護理師在急診進行檢傷分類。哪位病人應優先評估？
A nurse is conducting a triage assessment in an emergency department. Which client should be evaluated first?
- AA client with a superficial laceration on the forehead額頭有淺層撕裂傷的病人
- BA 55-year-old presenting with crushing substernal chest pain✓ 正解呈現胸骨後 crushing 性胸痛的 55 歲病人
- CAn adolescent with a fever of 101.5°F and a sore throat發燒 101.5°F 且有喉嚨痛的青少年
- DA child with a fractured radius with no neurovascular compromise橈骨骨折且無神經血管受損的兒童
檢傷分類（Triage）必須遵循危急程度排序，優先處理危及生命（Life-threatening）或器官功能的狀況。胸痛（Substernal chest pain）強烈暗示急性冠心症（ACS）或心肌梗塞，這是心臟供氧不足的臨床表徵，若不立即介入，病人可能迅速演變為心律不整或心臟驟停，因此必須列為最高優先級。
Crushing substernal chest pain is a classic sign of acute coronary syndrome or myocardial infarction, representing a life-threatening emergency that requires immediate intervention to prevent cardiac arrest. In triage, clients with potential cardiovascular instability take precedence over those with stable fractures, minor infections, or superficial injuries.
美國急診檢傷多採用 Emergency Severity Index (ESI) 系統。台灣與美國在檢傷邏輯上一致，但美國護理師在急診對於疑似 ACS 病人有高度的自主權，通常會依據 Protocol 直接啟動心電圖與給予 Aspirin，無需等待醫師指令。