專科兒科創傷護理師對一名無意識出血男童執行初級評估。下列哪個臨床發現要求立刻進行干預凌駕於一切？
An experienced pediatric trauma nurse executes a rigorous primary assessment on an unconscious bleeding 11-year-old child. Which finding demands immediate intervention over all others?
- AAn absent radial pulse on the uninjured left arm.✓ 正解未受伤左侧手臂桡动脉搏动消失
- BA distended bladder dull to percussion.膀胱膨胀且叩诊呈浊音
- CA superficial jagged laceration on the forehead bleeding moderately.额头上有中度出血的浅表锯齿状撕裂伤
- DAn extensively bruised closed right tibia fracture.右胫骨广泛瘀血的闭合性骨折
本題考驗護理師在創傷情境下，執行初級評估 (Primary Assessment) 並判斷最優先介入的生命威脅。初級評估遵循 ABCDE 原則：氣道 (Airway)、呼吸 (Breathing)、循環 (Circulation)、意識狀態 (Disability)、暴露/環境控制 (Exposure/Environment Control)。在創傷出血病患中，循環問題，特別是休克徵象，是極度危急的狀況。橈動脈 (radial pulse) 摸不到是低血容量休克 (hypovolemic shock) 的晚期徵象，代表收縮壓可能已低於 80 mmHg，病患處於生命危急狀態，需要立即的液體復甦 (fluid resuscitation) 或輸血來維持器官灌流。這比其他局部性傷害更具優先性。
An absent radial pulse is a late sign of decompensated hypovolemic shock, indicating critically low blood pressure and inadequate organ perfusion. This circulatory compromise takes precedence over other injuries as it poses an immediate threat to life.
橈動脈摸不到 = 血壓已低於 80 (或小於更低)，這是絕對的黃金休克指標。