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安全與感染控制 · HARD · MCQ

護理師在多車連環事故現場進行檢傷分類。哪位傷者應被標記為『紅色標籤』(Red Tag)?

The nurse is triaging victims at the scene of a multi-vehicle accident. Which client should be assigned a 'Red Tag'?

  • AA client with an arterial bleed from the leg that is controlled with pressure
    腿部動脈出血且經加壓已控制的病人
  • BA client who is unconscious with an open head injury and no spontaneous respirations
    意識不清、有開放性頭部創傷且無自發呼吸的病人
  • CA client with a closed fracture of the right tibia and stable vital signs
    右脛骨閉鎖性骨折且生命徵象穩定的病人
  • DA client with a sucking chest wound and significant respiratory distress✓ 正解
    有吸吮性胸部傷口且呼吸困難嚴重的病人
Explanation · 中文詳解

在大量傷患(Mass Casualty)的 START 檢傷系統中,紅色標籤代表『立即性威脅生命但有救治機會』的傷患(Immediate)。胸部吸入性傷口(Sucking chest wound)會導致開放性氣胸與嚴重的呼吸窘迫,需立即介入處置(如封閉傷口、插管),否則會在短時間內死亡。選項 C 為綠色或黃色(延遲);選項 B 為黑色(死亡或無救治希望),因為在資源有限現場,無自發呼吸者優先權最低;選項 A 雖有動脈出血但已被控制且循環尚可,通常標為黃色。護理思路在於資源分配與挽救最多生命。

In mass casualty triage using the START system, a Red Tag indicates an immediate threat to life that is treatable. A sucking chest wound causes severe respiratory distress and requires urgent intervention to restore ventilation, making it a priority for immediate care.

✦ 台美臨床差異

美國災難護理廣泛使用 START (Simple Triage and Rapid Treatment) 模型;台灣則多採用修訂後的 START 或五級檢傷併行,但在大型災難現場,紅標的判定基準基本一致,皆以呼吸、循環、意識(RPM)為準。

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