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Difficulty: HardEmergency Response Plan

A triage nurse is the first medical responder at the scene of a structural collapse at a crowded stadium. Using the START (Simple Triage and Rapid Treatment) algorithm for mass casualty incidents, which client must the nurse categorize as "Immediate" (Red tag)?

  1. A non-ambulatory client with a closed head injury who has a respiratory rate of 26 breaths/min, a palpable radial pulse, and stares blankly without following the command to squeeze handsAnswer
  2. B
    A client who self-extricated and walked to the triage point, now clutching their chest and reporting sudden, severe substernal chest pain
  3. C
    A non-ambulatory client with a partial leg amputation, a respiratory rate of 24 breaths/min, a capillary refill of 1.5 seconds, and intact orientation
  4. D
    A non-ambulatory client with severe maxillofacial trauma who remains apneic after the nurse manually positions the airway

Answer

The non-ambulatory client with the closed head injury who cannot follow the command to squeeze hands.
In a mass casualty incident, the START triage method evaluates clients based on Respirations, Perfusion, and Mental status (RPM). Clients who cannot follow simple commands (such as squeezing a hand) due to an altered mental status are categorized as 'Immediate' (Red tag). This client has adequate respirations (under 30) and perfusion (palpable radial pulse), but fails the mental status assessment, indicating a critical need for immediate intervention.

Step-by-Step Solution

1
Assess the ambulatory status of all victims.
The client walking with severe chest pain is categorized as Green.
In a mass casualty incident, the 'walking wounded' are initially categorized as Minor (Green), regardless of presenting symptoms, to quickly clear the area and allocate resources to immobile victims.
2
Assess the respiratory status of the remaining non-ambulatory clients.
The apneic client remains apneic after the airway is opened and is categorized as Black. The remaining clients have respirations under 30 breaths/min.
Clients requiring massive resources (such as continuous manual ventilation or CPR) are classified as Expectant (Black) in a disaster to preserve resources for salvageable clients.
3
Assess perfusion in clients with adequate respirations (under 30 breaths/min).
Both the client with the head injury and the client with the amputation have palpable radial pulses or capillary refill times under 2 seconds.
Adequate perfusion means these clients bypass the perfusion trigger for a Red tag and move to the final assessment step.
4
Assess mental status in clients with adequate respirations and perfusion.
The client with the amputation is oriented (Yellow tag). The client with the head injury cannot follow simple commands (Red tag).
Failure to follow simple commands indicates impending neurological compromise or airway loss, requiring Immediate (Red) life-saving intervention.

Key Concept

START (Simple Triage and Rapid Treatment) Algorithm
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Topics

Emergency Response Plan

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