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Difficulty: HardEmergency Response Plan

An emergency medical response team arrives at the site of an overturned commuter bus on a major highway. The designated triage nurse begins evaluating victims using the adult START (Simple Triage and Rapid Treatment) algorithm. Which victim should the nurse classify as requiring IMMEDIATE (Red tag) care?

  1. An unconscious adult who is apneic upon initial assessment but begins breathing at 12 breaths per minute after the airway is manually repositionedAnswer
  2. B
    An adult with an open tibial fracture who is unable to stand, has a respiratory rate of 26 breaths per minute, a capillary refill of 1.5 seconds, and follows simple commands
  3. C
    An unresponsive adult trapped under heavy debris who remains apneic even after the nurse clears the mouth and performs a jaw-thrust maneuver
  4. D
    A confused adult who is wandering near the shoulder of the road, holding a severely bleeding laceration on the scalp, but is able to ambulate independently

Answer

The victim who is initially apneic but begins breathing after the airway is manually repositioned requires an Immediate (Red) tag.
According to the adult START algorithm, the first physiological assessment for a non-ambulatory victim is respirations. If a victim is found to be apneic, the nurse must manually open the airway. If spontaneous breathing resumes immediately, the victim is experiencing a critical, yet reversible, airway obstruction and must be tagged as Immediate (Red).

Step-by-Step Solution

1
Evaluate the victim's ability to ambulate independently.
Determine if the victim can walk away from the immediate scene.
All walking victims are initially categorized as Minimal (Green) to quickly separate them from non-ambulatory victims who require physiological assessment.
2
Assess the respiratory status of all non-ambulatory victims.
Check if the victim is breathing. If apneic, manually open the airway.
Determines if airway compromise is the primary cause of apnea and whether it is rapidly reversible.
3
Assign a triage tag based on the response to airway repositioning.
Tag as Red (Immediate) if spontaneous breathing resumes. Tag as Black (Expectant) if apnea persists.
Prioritizes immediate life-saving interventions for salvageable clients while withholding resources from unsalvageable clients during a mass casualty event.

Key Concept

Adult START (Simple Triage and Rapid Treatment) Algorithm Application
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Topics

Emergency Response Plan

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