A nurse is triaging victims of a multiple motor-vehicle crash. The nurse assesses a client trapped under a car who is apneic and has a weak pulse at 120/min. After repositioning his upper airway, the client remains apneic. Which of the following actions should the nurse take?
A.
Place a black tag on the client’s upper body and atempt to help the next client in need.
B.
Start CPR
C.
Place a red tag on the client’s upper body and obtain immediate help from other personnel.
D.
Reposition the client’s upper airway a second time before assessing his respirations.
The correct answer and Explanation is :
The correct answer is A. Place a black tag on the client’s upper body and attempt to help the next client in need.
In a mass casualty incident (MCI), the principles of triage focus on doing the greatest good for the greatest number of people. Triage in such situations is based on a color-coded tagging system:
- Red: Immediate care required to save life (high priority).
- Yellow: Delayed care; serious but not immediately life-threatening injuries (medium priority).
- Green: Minor injuries; ambulatory patients (low priority).
- Black: Deceased or expected to die despite best efforts (no priority).
In this case, the client is apneic (not breathing) with a weak pulse. The nurse has already attempted to open the airway, and the client remains apneic, which means the individual is not breathing despite airway repositioning. Under these circumstances in an MCI, the patient is considered to be in a critical condition with very poor prognosis, and resources like CPR or ventilation should not be utilized, as they are reserved for those with a higher chance of survival.
Performing CPR or continuing airway repositioning in this scenario would not follow the guidelines for MCI triage, which focuses on the efficient allocation of limited resources. The nurse must make difficult decisions in these situations and prioritize those who can benefit most from intervention. Therefore, tagging the patient with a black tag (indicating expectant or deceased) and moving on to other victims who may have a better chance of survival is the appropriate action.
This strategy aims to maximize the number of lives saved in situations where there are many victims and limited personnel or resources available to care for them all.