A community health nurse is assisting at a field triage station established near the epicenter of a major earthquake. Using the START (Simple Triage and Rapid Treatment) algorithm, which of the following non-ambulatory adult casualties should the nurse classify as Immediate (Red tag)? Select all that apply.
- A casualty who is initially apneic but begins taking 14 breaths per minute after the nurse manually opens the airway.Answer
- A casualty who is breathing 24 times per minute, has a palpable radial pulse, but stares blankly and cannot follow the command to squeeze the nurse's hand.Answer
- A casualty with blunt head trauma who is breathing 36 times per minute.Answer
- DA casualty with an obvious lower leg deformity who is breathing 22 times per minute, has a palpable radial pulse, and appropriately answers questions about their identity.
- EA casualty with massive thoracic trauma who remains completely apneic after the nurse manually opens the airway.
Answer
The casualties that should be tagged as Immediate (Red) are the one who begins breathing after airway repositioning, the one with an altered mental status who cannot follow commands, and the one with a respiratory rate over 30 breaths per minute.
The START algorithm prioritizes casualties based on Respirations, Perfusion, and Mental Status (RPM). A Red tag is given if the respiratory rate is > 30, if breathing only occurs after airway repositioning, if perfusion is compromised (absent radial pulse or delayed cap refill), or if the client cannot follow simple commands. The correct choices reflect clients meeting the respiratory (> 30 breaths/min or requiring airway repositioning) and mental status (unable to follow commands) criteria.
Step-by-Step Solution
Key Concept
START Adult Disaster Triage Algorithm