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Difficulty: HardEmergency Response Plan

A catastrophic explosion has occurred at a multi-story indoor shopping complex, resulting in a mass casualty incident. A triage nurse is systematically evaluating victims at the scene using the Simple Triage and Rapid Treatment (START) algorithm. Which victim should the nurse classify as requiring an Immediate (Red) triage tag?

  1. A victim with a crushed lower extremity who is breathing 24 breaths per minute, correctly answers orientation questions, but has an absent radial pulse.Answer
  2. B
    A victim with a severe scalp avulsion that is bleeding profusely, who is breathing 20 breaths per minute, has a capillary refill of 1.5 seconds, and is able to follow commands.
  3. C
    A victim with massive chest trauma who is unresponsive and apneic, and remains apneic after the nurse manually opens the airway.
  4. D
    A victim with a visibly distorted, open fracture of the left arm who is ambulatory, pacing around the triage area, and crying hysterically.

Answer

The victim with a crushed lower extremity who has an absent radial pulse, despite exhibiting normal respirations and an intact mental status.
The correct answer identifies a victim who fails the perfusion parameter of the START algorithm. Although this victim's respirations (24/min) and mental status (oriented) are acceptable, the absent radial pulse is a definitive indicator of profound hypovolemic shock. In the stepwise START assessment, failing any single critical parameter (respirations >30, absent radial pulse, or unable to follow commands) immediately designates the client as an Immediate (Red) priority.

Step-by-Step Solution

1
Assess the victim's ability to walk.
Ambulatory victims are tagged Green (Minor). Non-ambulatory victims require further assessment.
Walking inherently indicates an adequate airway, breathing, and circulation.
2
Evaluate spontaneous respirations in non-ambulatory victims.
Victims who are apneic after airway repositioning are tagged Black. Those with a respiratory rate >30 are tagged Red. If breathing is <30, proceed to the next step.
This identifies immediate respiratory life threats versus non-salvageable cases.
3
Assess circulatory perfusion via radial pulse or capillary refill.
An absent radial pulse or capillary refill >2 seconds results in an Immediate (Red) tag. If normal, proceed to the final step.
An absent radial pulse signals decompensated shock (systolic BP roughly <80 mmHg) and impending circulatory collapse, requiring immediate lifesaving intervention like hemorrhage control.
4
Check mental status.
Inability to follow simple commands results in a Red tag. The ability to follow commands results in a Yellow tag.
Altered mental status can indicate severe hypoxia or traumatic brain injury.

Key Concept

Disaster Triage (START Algorithm)
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Topics

Emergency Response Plan

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