In the emergency department, 20 victims arrive after an accident. Using START triage, identify which patient should be classified as Red (immediate priority):

Appeared in: NORCET 9 Prelims-2025

Explanation

The patient with breathing difficulty has a compromised airway, which is the highest priority under the Airway, Breathing, Circulation (ABC) principle used in triage.
In the START algorithm, any patient with respiratory distress (e.g., rate greater than 30/min, or requiring airway repositioning to breathe) is immediately tagged as Red (Immediate).
The pinpoint pupils may indicate an underlying cause (like an opioid overdose) that is causing respiratory depression, further cementing the need for immediate intervention to restore adequate breathing.

Option A: A patient with 80% Total Body Surface Area (TBSA) burns has a very low chance of survival in an MCI setting and requires extensive resources. Therefore, they are triaged as Black (Expectant) to prioritize salvageable patients.
Option C: In the START system, if a patient is found apneic and pulseless, and does not start breathing after a simple airway maneuver (like a head-tilt/chin-lift), they are tagged as Black (Deceased/Expectant). CPR is not initiated in the field during an MCI.
Option D: The first step of START triage is to ask all who can walk to move to a designated area. These patients are automatically classified as Green (Minor), or 'walking wounded,' and are the last to be treated.

Visual 1: Flowchart: A flowchart illustrating the step-by-step decision process of the START Triage algorithm (Respirations -> Perfusion -> Mental Status).
Visual 2: Infographic: An infographic showing the four color-coded triage categories (Red, Yellow, Green, Black) with key criteria and patient examples for each.

Clinical Relevance

Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Application of the START (Simple Triage and Rapid Treatment) system in a mass casualty incident (MCI) in acute care settings.
Nurses must be able to switch from standard triage (treating the most critical first) to MCI triage (doing the greatest good for the greatest number), which involves difficult ethical decisions.
Rapid and accurate triage is crucial to save the maximum number of lives and prevent the healthcare system from being overwhelmed during a disaster.
What if? If the patient with the fractured arm was unable to walk, but their respiratory rate was 22/min, capillary refill was less than 2 seconds, and they could obey commands, they would be triaged as Yellow (Delayed). Their inability to walk moves them out of the Green category, and their stable RPM parameters place them in Yellow.

How to Approach the Question

First, identify the question's context: a mass casualty incident (MCI) with 20 victims. This signals that standard emergency protocols do not apply.
Recall the specific triage system mentioned: START (Simple Triage and Rapid Treatment).
Systematically apply the START algorithm to each patient option. The algorithm follows the order of Respiration, Perfusion, and Mental Status (RPM).
Start with the simplest step: Identify the 'walking wounded' (Green). The patient with a fractured arm who is walking is immediately Green.
Next, assess breathing. The patient with 'breathing difficulty' immediately signals a problem with the 'R' in RPM, making them a high-priority candidate for the Red category.
Evaluate the remaining patients. A pulseless, non-breathing patient is Black. A patient with injuries incompatible with survival given the resources (80% burns) is also Black.

Concept Tested & Keywords

Concept Tested: Application of the START (Simple Triage and Rapid Treatment) system in a mass casualty incident (MCI).
Stem keywords: emergency department, accident, START triage, Red (immediate priority)
Lead-in keywords: identify
Clinical cues: Mass casualty scenario (20 victims) dictates using MCI triage principles, not standard ED triage.

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Attempt every question from this paper in a timed mock, then review the full solution for each one.