EMERGENCY AND DISASTER

TRIAGE EXERCISES
EDN TRIAGE EXERCISES

IDENTIFY THE APPROPRIATE

TRIAGE COLOR FOR THE
IDENTIFIED PATIENT.
EDN TRIAGE EXERCISES

 1. Male in his 30s, complains of pain in his left

leg (obviously fractured), Respirations 24,
pulse strong, CRT 1 second, no excessive
bleeding.
 This patient is tagged YELLOW: needs care but will
not die if there is a reasonable (2-4 hour) delay.
Respirations are within acceptable range (less than
30), pulse and CRT normal. Complains of pain, and is
communicating where it hurts, so mental status
probably normal.
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 2. Female in her 50s, bleeding from nose,

ears, and mouth. Trying to sit up but can’t,
respirations 20, pulse present, CRT 1 second,
not responding to your commands.
 As her mental status is impaired, tag RED (immediate).
This victim may have a significant head injury, but is stable
from the standpoint of respirations and perfusion.
EDN TRIAGE EXERCISES

 3. Teenage girl bleeding heavily from her right

thigh, respirations 32, pulse thready, CRT 2.5
seconds, follows commands.
 Tagged as RED. This victim is seriously hemorrhaging,
one of the reasons to treat during triage. Respirations
elevated and perfusion impaired. Apply pressure by
placing her hands on the bleeding and applying
pressure, preferably using his shirt or bandanna as a
“dressing”.
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 4. Another teenage girl, small laceration

on forehead, says she can’t move her
legs. Respirations 20, pulse strong, CRT 1
second.
 Probable spinal injury but otherwise stable and can
communicate. Tagged as YELLOW
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 5. Male in his 20s, bleeding head wound,

respirations absent. Airway repositioned,
still no breathing.
 If not breathing, you will reposition his head and
place an airway. In this case, this fails to restart
breathing. This patient is deceased for all intents
and purposes. Tagged as BLACK, move on.
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 7. Teenage boy, multiple cuts and abrasions

but not hemorrhaging, says he can’t breathe,
respirations 34, radial pulse present, CRT 2.5
seconds.
 Tagged as RED (respirations over 30, impaired perfusion)
This victim doesn’t look so bad but is having trouble
breathing and has questionable perfusion. Mental status is
unimpaired, but he likely has other issues, perhaps internal
bleeding.
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 8. Female in her 20s, burns on neck and face,

respirations 22, pulse present, CRT 1 second,
asks to get up and can walk, although with a
limp.
 Obviously injured, this young woman is otherwise
stable and communicating. With assistance, she is
able to stand up, and can walk by herself. She
becomes another of the walking wounded, tag
GREEN.
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 9. Elderly woman, bleeding profusely from an

amputated right arm at the elbow,
respirations 36, pulse on other wrist absent,
CRT 3 seconds, unresponsive.
 Obviously in dire straits, you use your shirt as a tourniquet
and sacrifice your remaining helper to apply pressure on
the bleeding area. Tagged as Red.
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 10. Male child, multiple penetrating injuries,

respirations absent. Airway repositioned, starts
breathing. Radial pulse absent, CRT 2 seconds,
unresponsive.
 You initially think this child is deceased, but you follow
protocol and reposition his airway by tilting his head back.
He starts breathing even without an oral airway, to your
surprise, tagged as RED. If he is bleeding heavily from his
injuries, you apply pressure and wait for the –
additional help you requested on initial survey of the MCI to
arrive.
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 11. School aged boy standing in the middle of

the room. Pale, shaking, and crying out loud.
No obvious injuries. Doesn’t respond when
talked to, but seems alert and aware, and
follows your gestures.
 Tagged as Green – doesn’t need urgent medical care.
Possible hearing loss from explosion. Might not speak
English. Where are his parents?
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 12. Teenage boy in shorts with blistered

reddened skin covering both legs. No evidence
of burns above the legs. Alert and talking but
has severe pain. No breathing complaints, RR
20. Pulse strong and mildly fast at 110. Good
capillary refill. No other injuries.
 Tagged as Yellow – Passes breathing, circulation,
mental status. Has major stage 2 burns, but can
probably wait several hours for treatment as long
as closely monitored to make sure he remains stable.
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 13. Young woman, obviously very pregnant.

Complains of shortness of breath. RR 38, shallow,
strained. Skin pale, cool and dry, capillary
perfusion > 2 seconds. Conscious, alert, but very
agitated. Attempts to answer but has trouble
understanding.
 Tagged as Red – Respiration over 30 and trouble
answering. Type of underlying injury unclear. Could have
blast lung or inhalation injury. Could have unrelated illness.
Monitor for pregnancy complication or premature
delivery.
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 14. Disheveled adult male, poorly groomed.

Wandering around without purpose, mumbling.
Some scratches and abrasions, but no obvious
injury. No breathing difficulties. He tells you his
name and where he lives, but speech is bizarre. He
thinks terrorists are nearby and will shoot him if he
leaves. He admits having a psychiatric history.
 Tagged as Green – walking. No physical injury, but psychotic
either from stress or from underlying mental health
problems.
EDN TRIAGE EXERCISES

 15. Elderly male in a wheelchair. Complains of

severe chest pain, radiating to jaw, with nausea
and light-headedness. Alert. RR mildly rapid at
28. Sweaty and pale. Pulse weak, 120. No signs
of injury.
 Tagged as Red – probable MI. START triage doesn’t
work as well for medical problems as it does for injuries.
Heart attacks need urgent care, so even if he passed
circulation (pulses OK), I would still tag red. On the other
hand, if his heart stopped, do not do CPR in this setting.
EDN TRIAGE EXERCISES

 16. Teen age girl trapped under an overturned

piece of furniture. Only obvious injuries are
scrapes, bruises, and a “goose egg” on her
forehead. RR 34, pulse 120 and strong, good
capillary perfusion. Dazed and confused,
unable to help free herself or answer
questions, speech garbled.
 Tagged as Red – unable to answer simple questions.
Assume closed head injury.
EDN TRIAGE EXERCISES

 17. Middle aged male. Unconscious. Large

areas of red blistered burns on arms, chest,
and face, with singed hair on face and head.
Horrible burnt flesh smell. Respiration is
shallow, irregular and very slow at 4-5/min.
 Tagged as Black. This breathing pattern is a near-death
sign. Treat it like someone who is not breathing at all. His
lungs probably look like his skin – even with a ventilator,
prognosis is dismal.
EDN TRIAGE EXERCISES

 18. Healthy appearing senior female on floor

with severe leg pain and light-headedness.
Alert and able to answer questions. No
respiratory complaints, RR 24. Pulse strong
and mildly rapid at 120. Leg has deformity
and open wound with bone sticking out.
Some ongoing bleeding.
 Tagged as Yellow – open leg fracture needs medical
attention today, but OK to delay a few hours.
EDN TRIAGE EXERCISES

 19. Young woman, face down. Large bloody

wound on the back of her head, with visible
blood leaking through clothes in many spots.
When you roll her over, she is limp and
completely unresponsive. When you open her
eyes, one pupil is large and fixed. Breathing is
slow and irregular at 14, pulse is 20.
 Tagged as Black – not expected to survive with this
level of coma. Description suggests severe open head
injury. Typical pupils for severe brain swelling
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 20. Infant girl about a year old, found under

victim #19. Crying loudly, moving arms and
legs, has blood on her, but with close
examination, no evidence of injury. No
breathing distress, RR 28. Squirming too
much to find a pulse, but good capillary refill.
 Tagged as Green – no evidence of injury (shielded by
deceased mother).
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 21. Preschool aged girl, sitting near other

victims and Crying and holding her arm which
is obviously deformed. Several small cuts.
Able to tell you her arm hurts, and wants to
know where her mother and sister are. RR 24,
pulse 100. No other obvious injury.
 Tagged as Green – closed arm fractures don’t need urgent
medical intervention, just first aid.
EDN TRIAGE EXERCISES

 22. Obese late middle-aged male on floor,

confused and mumbling. Responds
somewhat to shaking, but not making sense.
No obvious trauma. Skin is pale and sweaty,
and has tremors. RR 30. Pulse 140 but strong.
A Med Alert tag on his neck says he has
diabetes.
 Tagged as Red – might be low blood sugar instead of
injury.
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 23. 25 year old woman, spurting blood from

neck injury. Respirations at 30 bpm, radial
pulse present, awake.
 Tagged as RED – Arterial bleeding present, respiratory
distress.
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 24. 13 year old confused asking the words

over and over again “What happened?”.
Respirations at 35 bpm, CRT of 2.
 Tagged as red – IMMEDIATE, Impaired mental status,
respiratory concerns
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 25. A three month old infant with no visible

injury. Unresponsive, no respirations, absent
radial pulse.
 Tagged as BLACK – No RR, No PR. Client is deceased.
EDN TRIAGE EXERCISES

 26. 10 year old male with a broken arm

walking around the scene looking for his
parents who was separated from him during
the explosion.
 Tagged as GREEN – Patient is walking around the scene
with what appears to be an isolated extremity injury.
Patient is a walking wounded.
EDN TRIAGE EXERCISES

 27. A responsive 35 year old female, pale,

moist skin and respirations of 32 breaths per
minute.
 Tagged as RED – Patient is having rapid respirations, signs
of shock are observed on this patient.
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 28. An unresponsive male patient with

snoring respirations. His breathing improves
when you open his airway.
 Tagged as RED – Patient is having airway problems and
responds to minimal interventions.
EDN TRIAGE EXERCISES

 29. A 50 year old man has bilateral fractured

femurs. He has a faint radial pulse and a
respiratory rate of 33.
 Tagged as RED – Patient is having shock (faint radial pulse)
secondary to his injury.
EDN TRIAGE EXERCISES

 30. A 57 year old female has a deformed tibia

and fibula. She is oriented with respirations of
20 and a pulse of about 100.
 Tagged as YELLOW – Patient doesn’t fall into walking
wounded, doesn’t have outward signs of shock, elevated
respirations or an altered mental status.
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 31. A 19 year old male with 2nd and 3rd degree

burns over about 80 percent of his body.
Respirations 24 and pulse about 120
 Tagged as YELLOW – Patient is critical and might not
survive. He doesn’t fit the criteria for green or red. While it
seems contradictory, yellow is a spot that meets the triage
criteria and doesn’t take the resources for a more
salvageable red tagged patient.
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 32. A 42 year old woman with no obvious

injuries and without a carotid pulse.
 Tagged as BLACK – Patient is deceased. Resuscitation isn’t
performed in a multiple casualty situation.
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 33. A 19 year old woman, unable to walk,

respirations at 25, A&O x 3, obeys commands.
Tagged as YELLOW – Patient is non-ambulatory,
responsive, may delay treatment..
EDN TRIAGE EXERCISES

 34. A young man with lacerations on face and

neck, nonresponsive, no pulse, no
respirations.
 Tagged as BLACK – Patient is deceased. No respirations
even with minimal repositioning.
EDN TRIAGE EXERCISES

 35. A 22 year old with impaled stick in right

chest, responsive to questions, respirations at
25 bpm and CRT 2 seconds.
 Tagged as YELLOW – Delayed interventions, no
abnormalities according to criteria.
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END