# Situation: A strong typhoon has caused flooding in a low-lying municipality. The public health nurse of the Rural Health Unit (RHU) is a member of the municipal health emergency response team. At a collapsed footbridge, the nurse triages adult casualties using Simple Triage and Rapid Treatment (START). None of the four casualties below can walk, and each is breathing spontaneously. Which casualty should be tagged YELLOW (delayed)?

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> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: A strong typhoon has caused flooding in a low-lying municipality. The public health nurse of the Rural Health Unit (RHU) is a member of the municipal health emergency response team.

At a collapsed footbridge, the nurse triages adult casualties using Simple Triage and Rapid Treatment (START). None of the four casualties below can walk, and each is breathing spontaneously. Which casualty should be tagged YELLOW (delayed)?

## 보기

1. Breathing 32/min; radial pulse present; follows simple commands
2. Breathing 24/min; capillary refill 3 seconds; follows simple commands
3. Breathing 20/min; radial pulse present; cannot follow simple commands
4. Breathing 28/min; radial pulse present; follows simple commands **✔ 정답**

**정답: 4**

## 해설

In START, a casualty who cannot walk is tagged Red if the respiratory rate is more than 30 per minute, if the radial pulse is absent or capillary refill is more than 2 seconds, or if the casualty cannot follow simple commands. A rate of 28 per minute does not exceed the cut-off, and this casualty's perfusion and mental status are adequate, so this casualty is Yellow. Each of the others meets one Red criterion.

## 심화 해설

START triage in a mass casualty incident

In a flooding disaster, the public health nurse must rapidly sort casualties so that limited transport and hospital resources go first to those who need immediate life-saving intervention. The Simple Triage and Rapid Treatment (START) algorithm uses four sequential assessments: ability to walk, respiratory rate, perfusion, and mental status. Because all four casualties in this scenario cannot walk and are breathing spontaneously, the decision moves to the next steps.

START assigns a Red (immediate) tag when any one of the following is present: respiratory rate above 30/min, absent radial pulse or capillary refill longer than 2 seconds, or inability to follow simple commands. A casualty who fails none of these Red criteria but cannot walk is tagged Yellow (delayed) [1].

Casualty 4 has a respiratory rate of 28/min, a present radial pulse, and can follow simple commands. None of the three Red criteria is met, so this casualty is correctly classified as Yellow. The respiratory rate of 28/min is elevated but remains below the START threshold of 30/min, and perfusion and mental status are intact.

The other three casualties each meet one Red criterion. Casualty 1 has tachypnea at 32/min, which exceeds the respiratory cutoff. Casualty 2 has a capillary refill of 3 seconds, indicating delayed perfusion. Casualty 3 cannot follow simple commands, reflecting altered mental status. Each of these findings alone is sufficient for a Red tag under START [1][2].

A key clinical point is that START is designed for speed and simplicity, not diagnostic precision. The respiratory rate cutoff of 30/min and the capillary refill cutoff of 2 seconds are deliberately conservative thresholds intended to identify casualties who may be deteriorating and need immediate intervention. The protocol sacrifices some specificity to ensure high sensitivity for critical illness, which is appropriate in a mass casualty incident where overtriage is more acceptable than undertriage [2][3].

Watch out! A respiratory rate of 28/min is not normal, but in START it does not trigger a Red tag by itself. Do not upgrade a casualty to Red based on clinical concern alone; follow the algorithm’s explicit cutoffs.

Key point! The order of assessment matters. In START, you check walking first, then breathing, then perfusion, then mental status. Once a Red criterion is found, you stop and tag Red — you do not continue to the next step. Casualty 4 passes all steps and is therefore Yellow.

| Casualty | Respiratory rate | Perfusion | Mental status | Red criterion met | START tag |
| --- | --- | --- | --- | --- | --- |
| 1 | 32/min | Radial pulse present | Follows commands | Tachypnea >30/min | Red |
| 2 | 24/min | Capillary refill 3 sec | Follows commands | Delayed capillary refill >2 sec | Red |
| 3 | 20/min | Radial pulse present | Cannot follow commands | Altered mental status | Red |
| 4 | 28/min | Radial pulse present | Follows commands | None | Yellow |

The rationale for using a simple, reproducible tool like START is supported by field experience. In a train crash disaster, START triage levels were compared with actual clinical outcomes, and the system performed well in identifying the most critically injured patients for priority transport [2]. Although START was originally developed for prehospital use, its principles also inform hospital-based triage during mass casualty surges, where rapid categorization remains essential [3].References (research sources)

- [1]START triage: does it work?Research articleGebhart ME, Pence R (2007) · DOI: 10.1016/j.dmr.2007.05.002

- [2]Does START triage work? An outcomes assessment after a disaster.Research articleKahn CA, Schultz CH, Miller KT, Anderson CL (2009) · DOI: 10.1016/j.annemergmed.2008.12.035

- [3]A review of mass casualty incident triage tools for hospital-based triage.Research articleAbdul-Nabi SS, Hitti E. (2025) · DOI: 10.4103/tjem.tjem_77_25

## 임상 시나리오

START Triage in Flood ResponseRapid sorting of non-ambulatory casualties
In START triage, a non-ambulatory casualty is tagged Red if any one of these is present: respiratory rate >30/min, absent radial pulse or capillary refill >2 seconds, or inability to follow simple commands.

A casualty with respiratory rate 28/min, palpable radial pulse, and intact mental status meets no Red criteria and is tagged Yellow (delayed).

CautionDo not upgrade to Red for tachypnea below the 30/min cutoff. Reassess casualties periodically, as Yellow patients can deteriorate while awaiting transport.

## 핵심 개념

- **START triage** — Simple Triage and Rapid Treatment; a mass casualty triage algorithm using ambulation, respiratory rate, perfusion, and mental status to assign color tags.
- **Red tag (Immediate)** — Assigned when a non-ambulatory casualty has RR >30/min, absent radial pulse or CRT >2 seconds, or cannot follow simple commands.
- **Yellow tag (Delayed)** — Assigned to casualties who cannot walk but do not meet any Red criteria; their care can be delayed while Red casualties are treated first.
- **Capillary refill time (CRT)** — A perfusion assessment; in START, a refill time longer than 2 seconds indicates shock and warrants a Red tag.
- **Mass casualty incident (MCI)** — An event such as a typhoon or flood that overwhelms local resources, requiring triage to prioritize care and transport.

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