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

In the START triage system, any compromise in airway or breathing is the highest priority for intervention.
A patient with breathing difficulty is classified as Red (Immediate) because they require life-saving interventions to secure their airway and prevent respiratory arrest.
The goal of START is to quickly identify patients who will die without immediate care, and this patient fits that criteria.
While the pinpoint pupils suggest a possible underlying cause (like an opioid overdose), the respiratory compromise itself is the deciding factor for immediate triage.

Option A: In an MCI, a patient with 80% Total Body Surface Area (TBSA) burns has a very low chance of survival. Resources are directed to patients with a higher likelihood of recovery.
Option C: Under START triage protocols, patients who are apneic (not breathing) and pulseless are classified as Black (Deceased/Expectant).
Option D: The first step of START triage is to identify the 'walking wounded.' Any patient who can walk is automatically classified as Green (Minor), as their injuries are not immediately life-threatening.

Clinical Relevance

Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing START Triage in Mass Casualty Incidents (MCI) in acute care settings.
Nurses must be able to rapidly and accurately apply triage principles in an MCI to do the greatest good for the greatest number of people.
Accurate triage prevents the misallocation of limited resources, such as personnel, equipment, and treatment space, to less critical patients, thereby improving overall outcomes.
What if? If the patient with breathing difficulty had a respiratory rate of 20/min, was perfusing well, but was unable to follow commands, they would still be triaged as Red (Immediate) based on their altered mental status.

How to Approach the Question

First, identify the core task: Apply the START triage system to a mass casualty scenario.
Recall the START algorithm's flow, which begins by identifying the 'walking wounded' (Green).
For remaining patients, assess RPM: Respiration, Perfusion, and Mental Status.
Evaluate each option against the algorithm: A patient with breathing difficulty immediately flags a problem with 'Respiration,' making them a top priority (Red).
A patient who is walking is Green. A patient with no pulse is Black. A patient with injuries incompatible with life in an MCI setting (like 80% burns) is also Black.
By systematically applying the START rules, you can determine that the patient with respiratory compromise is the only one who fits the Red (Immediate) category.

Concept Tested & Keywords

Concept Tested: START Triage in Mass Casualty Incidents (MCI)
Stem keywords: emergency department, accident, START triage, Red, immediate priority
Lead-in keywords: identify which patient
Clinical cues: 20 victims arrive after an accident (indicates a Mass Casualty Incident)
Negative lead-in flag: false

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E6 Nelson Textbook of Pediatrics(2024) — Volume 1 p. 617-619

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