A 35-year-old man and his 9-year-old son are brought to the emergency department following a high-speed motor vehicle collision. The father was the restrained driver. He is conscious. His pulse is 135/min and his blood pressure is 76/55 mm Hg. His hemoglobin concentration is 5.9 g/dL. His son sustained multiple body contusions and loss of consciousness. He remains unresponsive in the emergency department. A focused assessment of the boy with sonography is concerning for multiple organ lacerations and internal bleeding. The physician decides to move the man's son to the operating room for emergency surgical exploration. The father says that he and his son are Jehovah's witnesses and do not want blood transfusions. The physician calls the boy's biological mother who confirms this religious belief. She also asks the physician to wait for her arrival before any other medical decisions are undertaken. Which of the following is the most appropriate next step for the physician?

Transfuse packed red blood cells to the son but not to father

Seek a court order for medical treatment of the son

Proceed to surgery on the son without transfusion

Wait for the son's mother before providing further treatment

Consult hospital ethics committee for medical treatment of the son

A 35-year-old woman with no significant past medical history is brought in by ambulance after a major motor vehicle collision. Temperature is 97.8 deg F (36.5 deg C), blood pressure is 76/40, pulse is 110/min, and respirations are 12/min. She arouses to painful stimuli and makes incomprehensible sounds, but is unable to answer questions. Her abdomen is distended and diffusely tender to palpation. Bedside ultrasound shows blood in the peritoneal cavity. Her husband rushes to the bedside and states she is a Jehovah’s Witness and will refuse blood products. No documentation of blood refusal is available for the patient. What is the most appropriate next step in management?

In accordance with the husband's wishes, do not transfuse any blood products

Observe and reassess mental status in an hour to see if patient can consent for herself

Attempt to contact the patient’s parents for additional collateral information

Consult the hospital ethics committee

A 28-year-old soldier is brought back to a military treatment facility 45 minutes after sustaining injuries in a building fire from a mortar attack. He was trapped inside the building for around 20 minutes. On arrival, he is confused and appears uncomfortable. He has a Glasgow Coma Score of 13. His pulse is 113/min, respirations are 18/min, and blood pressure is 108/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows multiple second-degree burns over the chest and bilateral upper extremities and third-degree burns over the face. There are black sediments seen within the nose and mouth. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in management?

Intubation and mechanical ventilation

Insertion of nasogastric tube and enteral nutrition

Intravenous corticosteroid therapy

A 3-month-old boy is brought to the emergency department by his mom for breathing difficulty after a recent fall. His parents say that he rolled off of the mattress and landed on the hard wood floor earlier today. After an extensive physical exam, he is found to have many purplish bruises and retinal hemorrhages. A non-contrast head CT scan shows a subdural hemorrhage. He was treated in the hospital with full recovery from his symptoms. Which of the following is the most important follow up plan?

Inform child protective services

Provide parents with anticipatory guidance

Referral to genetics for further testing

Reassurance that accidents are common

A 67-year-old woman is brought by ambulance from home to the emergency department after she developed weakness of her left arm and left face droop. According to her husband, she has a history of COPD, hypertension, and hyperlipidemia. She takes hydrochlorothiazide, albuterol, and atorvastatin. She is not on oxygen at home. She is an active smoker and has smoked a pack a day for 20 years. Her mother died of a heart attack at age 60 and her father died of prostate cancer at age 55. By the time the ambulance arrived, she was having difficulty speaking. Once in the emergency department, she is no longer responsive. Her blood pressure is 125/85 mm Hg, the temperature is 37.2°C (99°F), the heart rate is 77/min, and her breathing is irregular, and she is taking progressively deeper inspirations interrupted with periods of apnea. Of the following, what is the next best step?

Start tissue plasminogen activator (tPA)

Obtain non-contrast enhanced CT of brain

Triage principles for USMLE Step 2 CK: High-Yield CCS Cases Lessons

Triage Fundamentals - Sorting the Chaos

Primary Goal: To do the greatest good for the greatest number of casualties, not to treat the most critically injured first.
Core Principle: Sorting based on injury severity, prognosis, and resource availability.
Standard Color Codes:
- Red (T1/Immediate): Critical, life-threatening injuries. Needs immediate care.
- Yellow (T2/Delayed): Serious, but not immediately life-threatening.
- Green (T3/Minor): "Walking wounded."
- Black (T4/Expectant): Deceased or injuries incompatible with life.

⭐ In a mass casualty incident (MCI), a patient with an open fracture and stable vitals is tagged Yellow, whereas a patient with respiratory distress is tagged Red.

START Triage - The 30-2-Can Do Rule

A rapid triage system for mass casualty incidents (MCI).
Assesses patients based on Respirations, Perfusion, and Mental Status (📌 RPM).
The core principle is the "30-2-Can Do" rule.

⭐ Exam Favourite: In START triage, if a patient is not breathing, you are only allowed to perform one simple intervention: opening the airway. If they remain apneic after this, they are classified as deceased/expectant (Black tag).

Triage Categories - Code Red, Code Black

🔴 Code Red (I, Emergent):
- Condition: Life-threatening injuries requiring immediate intervention.
- Principle: Greatest chance of survival with rapid treatment.
- Examples: Airway obstruction, shock, major hemorrhage, >30% BSA burns.
⚫ Code Black (0, Expectant/Deceased):
- Condition: Deceased or injuries so catastrophic that survival is impossible.
- Principle: Resources are not utilized; provide comfort care if conscious.
- Examples: Apnea, pulselessness, decapitation, massive cranial destruction.

⭐ Reverse Triage: In lightning strikes or hypothermia, victims in apparent cardiorespiratory arrest (often tagged Black) are prioritized first due to the potential for resuscitation with prolonged CPR.

IDME Mnemonic for Primary Triage

Pediatric Triage - JumpSTART Your Engines

Modified START triage for children <8 years or <45 kg. Assesses non-ambulatory patients in a mass casualty incident. Uses the same color codes.

📌 Mnemonic: RPM

Respirations
Perfusion
Mental Status

⭐ The key modification from adult START is giving 5 rescue breaths to an apneic child with a pulse. If breathing starts, they are triaged as RED (Immediate).

High‑Yield Points - ⚡ Biggest Takeaways

Triage Goal: Do the greatest good for the greatest number of casualties.

This often means not treating the most critical patient first if their prognosis is poor and resources are limited.

Red (Immediate): Life-threatening but salvageable injuries (e.g., airway obstruction, shock).

Yellow (Delayed): Serious injuries that are not immediately life-threatening (e.g., stable fractures).

Green (Minor): The "walking wounded."

Black (Expectant): Unsurvivable injuries or found pulseless/apneic.

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