Multi-Casualty Arrival: Triage, Tags, and a Suspected Release

The case

11:52. A community hospital emergency department with 14 treatment bays and 6 nurses on shift receives notice that an unidentified white powder was released inside a warehouse two miles away.

12:04. Fourteen people arrive within 9 minutes. Nine walk in. Five arrive on stretchers. Two of the walk-ins came by private vehicle straight to the ambulance bay and have not been decontaminated. Several report burning eyes and throat.

12:07. Rapid assessment of five non-ambulatory patients:

• Patient A, age 41, respirations 34, radial pulse present, follows commands.
• Patient B, age 58, respirations 12, radial pulse absent, capillary refill 4 seconds, confused.
• Patient C, age 29, respirations 18, radial pulse present, cannot state the year or follow a simple command.
• Patient D, age 63, apneic. Airway opened by head-tilt chin-lift. Still apneic after repositioning.
• Patient E, age 8, apneic. Airway opened. Still apneic; a carotid pulse is present.

12:15. The department has not been locked down. Incident command has not been notified.

CUE · Recognize cues. Which finding at 12:04 is the most significant?

1. Several patients report burning eyes.
2. Fourteen people from one location present within 9 minutes with similar complaints.
3. Nine of the fourteen are ambulatory.
4. Two patients arrived by private vehicle.

ANA · Analyze cues. The nurse must separate two questions that candidates merge. Which statement is accurate?

1. Contamination is on the patient; transmission is from the patient. Decontamination and isolation are different decisions.
2. Any patient needing decontamination also needs airborne precautions.
3. Isolation replaces decontamination once the agent is identified.
4. Decontamination is deferred until the agent is named.

PRI · Prioritize hypotheses. Using the mass-casualty algorithm, how is Patient D tagged?

1. Immediate, because apnea is the most life-threatening finding present.
2. Delayed, because an airway maneuver was already attempted.
3. Expectant, because the patient does not breathe after the airway is opened.
4. Minor, because no other injury is documented.

SOL · Generate solutions. Which plan is correct for the nine ambulatory arrivals?

1. Direct them into the department for assessment and tag after triage.
2. Direct them away from the treatment area, tag them minor, and decontaminate before entry.
3. Discharge them, since ambulatory patients are not injured.
4. Place them all in airborne precautions.

ACT · Take action. Which action comes first for the two private-vehicle arrivals?

1. Stop them outside the department and decontaminate before entry.
2. Escort them to a treatment bay and remove clothing there.
3. Obtain a history of exposure duration.
4. Give them surgical masks and seat them in the waiting room.

EVA · Evaluate outcomes. At 12:40, Patient A's respirations are 40 and the radial pulse is now absent. What does the nurse do?

1. Leave the delayed tag in place, since tags are assigned once.
2. Re-triage and re-tag the patient as immediate.
3. Move the patient to the expectant area.
4. Wait for the next scheduled reassessment round.

Keyed answers: CUE 2 · ANA 1 · PRI 3 · SOL 2 · ACT 1 · EVA 2.

The pediatric variant. Patient E is the reason the pediatric branch exists. In the pediatric algorithm, an apneic child with a palpable pulse receives rescue breaths before the expectant decision is made. If breathing resumes, the child is tagged immediate.

Tag colors

• Green, minor. Ambulatory, walking wounded, directed away from the treatment area.
• Yellow, delayed. Injured, but breathing, perfusing, and following commands.
• Red, immediate. A failure in respirations, perfusion, or mental status that a rapid intervention can correct.
• Black, expectant. No respirations after the airway is opened, under the adult algorithm.

Category A bioterrorism strip

Memory hookWalking, breathing, bleeding, thinking.

Watch outIn a mass casualty the sickest patient is not the first patient. Spending three nurses on Patient D costs the four immediate patients their intervention window.

Margin noteThe tag is a snapshot.

TakeawayDisaster triage optimizes for the population, and that single change reverses the priority rule practiced everywhere else.

Prioritization frameworks belong to → BOOK 03 · P6.

Verify at reprint: triage criteria, the tag color set, and the pediatric variant against current federal mass-casualty triage guidance. Verify decontamination sequence and PPE for an unidentified agent against current CDC and OSHA guidance for hospital first receivers. Verify every agent-to-precaution pairing individually against current CDC agent-specific isolation guidance.