An off-duty nurse is the first responder at the scene of a severe multi-vehicle highway collision involving a commuter bus. Using the Simple Triage and Rapid Treatment (START) algorithm, which individual should the nurse classify as "Immediate" (red tag)?
- An individual lying on the embankment who has a respiratory rate of 24 breaths/minute, palpable radial pulses, and is unable to follow simple commands.Answer
- BAn individual walking near the wreckage with a visibly bleeding facial laceration and a respiratory rate of 28 breaths/minute.
- CAn unresponsive individual with severe head trauma who exhibits no spontaneous breathing after manual airway repositioning.
- DA conscious individual trapped in a seat who is breathing 20 times per minute, has a strong radial pulse, and correctly answers questions.
Answer
The individual lying on the embankment who has a respiratory rate of 24 breaths/minute, palpable radial pulses, and is unable to follow simple commands.
The correct answer identifies a client who requires immediate life-saving intervention based on the RPM (Respiration, Perfusion, Mental Status) criteria of the START triage method. Because this victim is not walking, is breathing fewer than 30 times per minute, and has adequate perfusion, their neurological status must be assessed. The inability to follow simple commands indicates compromised neurological function or impending shock, directly resulting in an 'Immediate' (red tag) classification.
Step-by-Step Solution
Key Concept
Disaster Triage Principles (START Algorithm)