A triage nurse is performing field triage following a stage collapse at a large outdoor concert. Using the Simple Triage and Rapid Treatment (START) algorithm for a mass casualty incident, which clients should the nurse classify as "Immediate" (Red tag)? Select all that apply.
- A client with an open leg fracture and a capillary refill time of 4 secondsAnswer
- BA client who is apneic upon initial assessment and remains apneic after manual airway repositioning
- A client with a head injury who cannot follow simple commands and is breathing 22 times per minuteAnswer
- DA client unable to walk due to a closed femur fracture, who is alert and breathing 20 times per minute
- A client with a penetrating chest wound who is breathing 36 times per minuteAnswer
- FA client with a superficial facial laceration who is walking around the scene crying loudly
Answer
The clients who should be classified as Immediate (Red tag) are the one with a delayed capillary refill, the one unable to follow simple commands, and the one with a respiratory rate over 30 breaths per minute.
In a mass casualty incident using the START triage method, the "Immediate" (Red tag) category is assigned to clients who have life-threatening injuries but are salvageable with rapid intervention. To quickly identify these clients, nurses use the RPM (Respiration, Perfusion, Mental Status) assessment. A client is tagged Red if they meet ANY of the following: respirations greater than 30 breaths per minute, capillary refill longer than 2 seconds (or absent radial pulse), or an inability to follow simple commands. The clients with a 4-second capillary refill, an inability to follow commands, and a respiratory rate of 36 breaths per minute all independently meet the criteria for immediate, life-saving care.
Step-by-Step Solution
Key Concept
Disaster Triage Using the START Algorithm
Estimated Time:1m 30s