Emergency Care

Question 1

Scope of practice of an ED nurse

Answer 1

1. Triage
2. Administer treatment and implement interventions
3. Evaluate response
4. Communicate with pts, fam, multidisciplinary team
5. Coordinate discharges and referrals
6. Patient advocate in end of life issues
7. Crisis intervention

Question 2

Other roles of ED nurses

Answer 2

1. Pandemic, hazmat and disaster preparedness planning
2. Research
3. Education

Question 3

Role of the observation medicine and clinical decision unit in ED

Answer 3

provides evaluation and management of selected pts who require further hospital care following ED visit

Question 4

Which grps of patients does the observation and clinical decision unit cater to?

Answer 4

1. Diagnosis unclear after initial ED evaluation
2. Selected emergency conditions requiring additional period of treatment or observation

Question 5

Definition of disaster

Answer 5

Disruption of the functioning of a community, which exceeds the ability of the society to cope using its own resources.

An event which overwhelms local capacity, necessitating external assistance.

Question 6

Disaster triage in Singapore (P0-P3)

Answer 6

P0: Unlikely to survive given the severity of injuries and require palliative care

P1: Require immediate intervention and transport to hospital due to compromise in A/B/C

P2: Can afford delayed transport to the hospital, have life threatening injuries but is not expected to deteriorate significantly over the next few hrs

P3: Victims with minor injuries that is unlikely to deteriorate over days

Question 7

Principles of triage

Answer 7

1. rapid collection of relevant subjective and objective data
2. complex complaint-based process of sorting patients
3. Intended to identify the most seriously ill patients with time dependent conditions to ensure that they receive rapid care
4. Accurate triage is the key to efficient operation of ED, to increase chance of survival for critically ill patients

Question 8

Process of triage

Answer 8

Visual assessment –> History Taking with VS –> POCT & PAC status

1. Visual assessment (begins when pt first step into ED, assess using sight, hearing and smell)
2. Obtain subjective data (presenting complaint using PQRST/OLDCARTS/SOCRATES framework)
3. Obtain objective data (VS, pertinent physical findings)
4. Past medical history
5. Drug history and allergies
6. Fall risk/clinical fragility scale

Question 9

Point of care testing (POCT) purpose

Answer 9

Enables more rapid clinical decision making in the process of diagnosis (rule-in or rule-out), treatment choice and management

Question 10

Examples of POCTs

Answer 10

1. Capillary blood glucose
2. Urinalysis (urine dipstick)
3. Urine pregnancy test (Urine HCG)
4. Visual acuity test
5. 12 lead ECG
6. Covid ART

Question 11

How many Patient Acuity Categories (PAC) are there?

Answer 11

PAC 1-4

Question 12

Role of an effective triage nurse

Answer 12

1. Able to estimate conditions from a short clinical history taking, VS and physical examination
2. Comprehensive knowledge of pathological presentations
3. Intuition developed through long-time experiences

Question 13

PAC 1

Answer 13

Critically ill and require resuscitation:
- state of cardiovascular collapse
- imminent danger of collapse , require immediate attention

e.g. Cardiac arrest, seizure, shock, acute stroke, poly trauma

Question 14

PAC 2

Answer 14

Major emergency:
- ill and non ambulant
- In severe distress
- Not in imminent collapse
- Requires early attention, if not likely early deterioration

e.g. Asthma, chest pain, pregnant with PV bleeding (vaginal), testicular pain, burns

Question 15

PAC 3

Answer 15

Minor emergency:
- Ambulant
- Acute mild to moderate symptoms
- Requires acute treatment which will result in resolution of symptoms over time

e.g. Laceration, sore throat, sprains, diarrhoea

Question 16

PAC 4

Answer 16

No emergency:
- NON emergency
- Should NOT be presenting to ED
- Pls go home

e.g. Flu symptoms, unspecific aches and chronic pain

Question 17

Identify the PAC score for the following scenario:

Graham is a 55-year-old man who presents to the ED accompanied by his partner. He states that he has been ‘bleeding from the back-passage’ since the previous night. He is very anxious about the bleeding and reports that it was ‘bright’ in colour and ‘filled the toilet bowl on two occasions. His blood pressure is 155/100 mmHg, heart rate is 102 beats per minute and his respiratory rate is 20 breaths per minute.

Answer 17

PAC2

Only PAC3 if haemorrhoidal bleeding (will NOT fill the ENTIRE toilet bowl)

Question 18

Identify the PAC score for the following scenario:

Louisa is a 24-year-old woman who presents to the ED with her friend after ‘fainting’ in the toilet at home. She is reporting left sided abdominal pain, which she has had ‘on and off’ for several months. She previously attended the ED two weeks ago for the same problem. An abdominal ultrasound was performed at that time but identified no abnormalities. She rates her pain as 6/10. Her respiratory rate is 18 breaths per minute, heart rate is 82 beats per minute and her blood pressure is 112/64 mmHg. Her skin is cool and dry. She looks pale and uncomfortable.

Answer 18

PAC2 (considering she is cold, dry, pale), unless pt has chronic anemia

Question 19

Identify the PAC score for the following scenario:

Fred, an 84-year-old man, presents to triage reporting palpitations and central chest pain. He has a history of ischemic heart disease, coronary artery by-pass grafts and atrial fibrillation. He takes his anti-arrhythmic medications regularly and normally manages well at home. Today his skin is pale, cool and moist. His respiratory rate is 26 breaths per minute, heart rate is 142 beats per minute and irregular and he reports chest pain of 4/10.

Answer 19

PAC 2: Chest pain

Question 20

Identify the PAC score for the following scenario:

Rae, a 24-year-old university student, comes to the ED with a friend. She has a four-hour history of generalised abdominal pain, now localised to the right iliac fossa. She has vomited twice and had one episode of diarrhoea about two hours ago. Her respiratory rate is 24 breaths per minute, heart rate is 92 beats per minute, blood pressure is 128/72 mmHg and her temperature is 38.2 °C. She rates her pain as 6/10

Answer 20

PAC3 (looks relatively well, hemodynamically stable + she has friend beside her who can alert HCPs if she suddenly unwell)

PAC2 if appendix already ruptured

PAC1 if compromised V/S + severe abdominal pain

Question 21

​​Identify the PAC score for the following scenario:

Sarai is a 38-year-old woman with a history of asthma. She has required two admissions to the intensive care unit for her asthma in the past 18 months. She presents to triage at 8.30pm following a 22-hour history of wheeze and shortness of breath. She has been self-administering salbutamol at home but has had a minimal response to this despite three nebulisers in the past hour. On arrival her respiratory rate is 26 breaths per minute, she is speaking in three-word sentences and has an audible wheeze. Her oxygen saturation is 91% on room air

Answer 21

PAC1 (has been trying salbutamol w no improvement, Spo2 is 91% - may deteriorate)
Might be PAC2 if pt speaking in phrases, has not had such extensive treatment like this patient can suddenly deteriorate very fast

Question 22

​​Identify the PAC score for the following scenario:

A restless 24-year-old man is shouting in the ED waiting area. He says, ‘God says everyone here is a sinner’. He stands up and kicks the seats, his fists are clenched, he is red in the face and breathing hard. He turns to face the waiting patients with his fists raised aggressively.

Answer 22

PAC2 (area is away from everyone else), bc PAC3 has the rest of the pts there. Security guards present at

PAC2 incase he harms himself. It’s the only way to control him/allow him to calm down. Give him anxiolytics (which have sedative effects which cannot be observed in PAC3)

Question 23

​​Identify the PAC score for the following scenario:

Vinh is a 74-year-old man who is brought to the ED by paramedics at 5.10am. He has acute shortness of breath and a history of left ventricular failure. His respiratory rate is 30 breaths per minute, with accessory muscle use. His Sp02 is 89%, but the pulse oximetry display is giving a poor trace. Oxygen is being administered at 100% via bag-valve-mask. His heart rate is 112 beats per minute and irregular, and his blood pressure is 180/100 mmHg. Vinh is trying to remove the oxygen mask and is very agitated.

Answer 23

PAC1; possible CVS collapse

Question 24

Information to gather upon arrival of the ambulance

Answer 24

AT MIST

A: Age of patient
T: Time of incident

M: Mechanism of injury
I: Injuries sustained/suspected
S: Signs and symptoms
T: Treatment/interventions performed