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Difficulty: HardEmergency Response Plan

A localized tornado strike has caused massive structural damage to a community center during a crowded event, resulting in numerous casualties. The first-responding nurse is applying the Simple Triage and Rapid Treatment (START) algorithm to prioritize care. Which individual should the nurse classify as requiring immediate, life-saving intervention (Red tag)?

  1. An individual who is unable to stand, has a respiratory rate of 24 breaths per minute, lacks a palpable radial pulse, and has a capillary refill time of 4 secondsAnswer
  2. B
    An individual with an open abdominal wound exposing intestines, who cannot walk, has a respiratory rate of 28 breaths per minute, a strong radial pulse, and answers questions appropriately
  3. C
    An individual who limped independently to the triage area with metal shrapnel embedded in their shoulder, crying loudly in pain
  4. D
    An individual with a severe traumatic head injury who is unresponsive, not breathing, and remains apneic after manual repositioning of the airway

Answer

The individual who is unable to stand, has a respiratory rate of 24, lacks a palpable radial pulse, and has delayed capillary refill.
The correct answer identifies a client who fails the perfusion step of the START triage algorithm. Although their respiratory rate is adequate, the absence of a radial pulse and delayed capillary refill indicate compromised circulation, warranting an immediate (Red) tag.

Step-by-Step Solution

1
Evaluate ambulatory status.
Determine if the client can walk. If yes, tag Green (Minor). If no, proceed to respiratory assessment.
Ambulatory status quickly identifies clients with adequate physiological reserves.
2
Assess respiratory rate (Breathing).
If apneic, open airway. If still apneic, tag Black. If breathing starts, tag Red. If spontaneous rate is > 30/min, tag Red. If < 30/min, proceed to perfusion.
Airway and breathing are the most critical determinants of immediate survival.
3
Assess perfusion.
Check for a palpable radial pulse or capillary refill. If pulse is absent or refill > 2 seconds, tag Red. If pulse is present, proceed to mental status.
Adequate circulation is required to maintain tissue viability and prevent shock.
4
Assess mental status.
Ask the client to follow a simple command (e.g., 'squeeze my hand'). If unable, tag Red. If able, tag Yellow (Delayed).
Inability to follow commands indicates significant neurological impairment or severe hypoxia.

Key Concept

Simple Triage and Rapid Treatment (START) Algorithm
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Topics

Emergency Response Plan

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