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Difficulty: MediumEmergency Response Plan

While attending an off-duty community event at a large indoor stadium, a structural collapse occurs, resulting in mass casualties. A nurse establishes a preliminary triage area for the victims. Based on the START (Simple Triage and Rapid Treatment) algorithm, which individual should the nurse classify as an immediate priority?

  1. A
    An individual with an open femur fracture who is screaming in pain, has a respiratory rate of 28 breaths/min, and a capillary refill of 1.5 seconds.
  2. B
    An individual with multiple superficial abrasions who is walking around the scene frantically asking about the location of their family members.
  3. An individual with a head contusion who has a respiratory rate of 26 breaths/min, a palpable radial pulse, but is unable to follow the command to open their eyes.Answer
  4. D
    An individual without spontaneous respirations who remains apneic after the nurse manually utilizes the jaw-thrust maneuver to open the airway.

Answer

The individual with a head contusion who has a respiratory rate of 26 breaths/min, a palpable radial pulse, but is unable to follow the command to open their eyes.
The correct answer identifies a client who fails the mental status component of the START (Simple Triage and Rapid Treatment) algorithm. After confirming the client is not ambulatory, the nurse assesses Respirations (RR < 30 is stable), Perfusion (palpable radial pulse is stable), and Mental Status. Because the client cannot follow simple commands, they require an immediate priority classification (red tag).

Step-by-Step Solution

1
Assess ambulatory status.
The individual who is walking around the scene is categorized as 'Green' (minor/minimal priority).
Ambulatory clients are directed away from the immediate scene to clear space and are considered the walking wounded.
2
Assess the respiratory effort of the remaining non-ambulatory victims.
The apneic victim remains without respirations after airway positioning and is tagged 'Black' (expectant). The other two victims have respiratory rates under 30 breaths/min.
Victims who do not breathe after airway maneuvers are deceased or expectant; resources cannot be expended on them during a mass casualty event. Respiratory rates over 30 require a 'Red' tag.
3
Assess perfusion in the victims breathing less than 30 times per minute.
Both remaining victims have adequate perfusion (capillary refill < 2 seconds or a palpable radial pulse).
Inadequate perfusion (capillary refill > 2 seconds or absent radial pulse) would require immediate hemorrhage control and a 'Red' tag.
4
Assess mental status in victims with adequate respirations and perfusion.
The victim with the femur fracture is alert (screaming/vocalizing) and receives a 'Yellow' tag. The victim with the head contusion cannot follow simple commands and receives a 'Red' tag.
An inability to follow simple commands indicates a significant neurological compromise or inadequate cerebral perfusion, categorizing the client as an immediate life threat requiring a 'Red' tag.

Key Concept

Disaster Triage and the START Algorithm (RPM Method)
Estimated Time:1m 15s
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Topics

Emergency Response Plan

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