BCEN Triage Systems 2 — Questions and Answers
Question 1: In the START triage system, a patient with a respiratory rate of 10 breaths per minute is classified as:
- Immediate (Red) (Correct answer)
- Delayed (Green)
- Expectant (Black)
- Minor (Green)
Correct answer: Immediate (Red)
In START triage, a respiratory rate below 30 but present after repositioning the airway classifies the patient as Immediate (Red).
Question 2: Which triage system uses five levels and was developed specifically for emergency department use in the United States?
- Canadian Triage and Acuity Scale (CTAS)
- Emergency Severity Index (ESI) (Correct answer)
- Manchester Triage System (MTS)
- Australasian Triage Scale (ATS)
Correct answer: Emergency Severity Index (ESI)
The Emergency Severity Index (ESI) is a five-level triage tool developed in the US specifically for ED use, focusing on acuity and anticipated resource needs.
Question 3: A patient arrives after a mass casualty incident unable to follow commands, with a radial pulse absent but carotid pulse present. Using START triage, this patient is classified as:
- Delayed (Yellow)
- Minor (Green)
- Immediate (Red) (Correct answer)
- Expectant (Black)
Correct answer: Immediate (Red)
Absent radial pulse or capillary refill greater than 2 seconds in START triage indicates immediate (Red) category due to hemodynamic compromise.
Question 4: The ESI algorithm assigns level 2 to a patient who:
- Has minor lacerations requiring only simple wound care
- Is in a high-risk situation or has altered mental status or severe pain (Correct answer)
- Requires more than two resources but is hemodynamically stable
- Can wait safely and requires zero resources
Correct answer: Is in a high-risk situation or has altered mental status or severe pain
ESI level 2 is assigned to patients in high-risk situations, those with altered mental status, or those with severe pain/distress who should not wait.
Question 5: During a mass casualty event, a patient who is breathing but has injuries so severe that survival is unlikely even with treatment is tagged:
- Red
- Yellow
- Black (Correct answer)
- Green
Correct answer: Black
Black (Expectant) is assigned to patients with injuries incompatible with survival given available resources, including those who are already deceased.
Question 6: Which statement best describes the purpose of the triage acuity level in the ESI system?
- It determines the exact diagnosis before treatment begins
- It predicts the number of resources the patient will need and their acuity level (Correct answer)
- It identifies patients who can be discharged immediately
- It assigns the patient to a specific physician based on specialty
Correct answer: It predicts the number of resources the patient will need and their acuity level
ESI integrates both acuity and anticipated resource utilization to sort patients and guide staffing and bed allocation decisions.
Question 7: A child arrives to the ED with stridor, retractions, and oxygen saturation of 88%. Using ESI pediatric considerations, this child should be triaged as:
- ESI level 3
- ESI level 4
- ESI level 1 (Correct answer)
- ESI level 2
Correct answer: ESI level 1
Airway compromise with hypoxia in a child meets ESI level 1 criteria, requiring immediate life-saving intervention.
BCEN Triage Systems 2
In the START triage system, a patient with a respiratory rate of 10 breaths per minute is classified as: