policy and procedures Flashcards
when to escalate vital signs to dr?
changes in breathing pattern
- o2 if sob, tachypnea, desaturation
abnormal VS: SBP<100, HR<60 or >=100, spo2 <=93 (<88 for COPD)
new onset fever T>=37.5
NEWSII 3 in single parameter, 5-6, if 7 or more then resus
if GCS deteriorates, check with senior first
- inform if 2 or more, change in pupil size and reflex, limb strength deteriorates
- to resus if 4 or more
indications for CLC
NL/NES as primary or secondary dx
AMS including AI
describe the GCS scale and scoring
E1 = none, E2 = pain, E3 = voice, E4 = spontaneous, EC = closed
V1 = none, V2 = incomprehensible sound, V3 = inappropriate words, V4 = confused, V5 = orientated, VT = trachy
M1 = none, M2 = abnormal extension, M3 = abnormal flexion, M4 = flexion, M5 = localises pain, M6 = obeys commands
describe the scoring for pupil reflex and limb strength
pupil size: 1-8mm
pupil shape: round, irregular
pupil reflex: brisk, sluggish, fixed, EC, NT
power 0 = none, 1 = minimal, 2 = AG, 4 = mild weakness, 5 = normal
indications for NVA
MSK injury, post-orthopedic procedure +/- application of restrictive cast
describe the NVA and scoring
pain = pain score
color (pallor) = pink, pale, blue, mottled
motor (paralysis) = active, flicker, absent
> UL: thumbs up, oppose thumb/pinky, adduction of fingers
> LL: dorsi/plantarflexion
sensation (paraesthesia) = hyper, normal, reduced, absent, NA
> UL: web of 1st/2nd, tip of index/middle finger, fat pad of pinky
> LL: tip of 2nd toe, distal-proximal midsole
poikilothermia = warm, cool, cold
pulse = strong, weak, absent, NA
> UL: radial, brachial
> LL: dorsalis pedis, posterior tibialis
swelling = absent, slight, moderate, severe
CRT = <3s, >3s, NA
what is the indication of lung auscultation at triage?
SOB
signs upon auscultation that indicates to go resus
- accessory muscle use
- aggression
- silent chest
- stridor
- spo2 < 90%
- speech: unable to speak full sentence in one breath
- exhausted/confused
- RR > 30
- HR > 120
what is the indications of stroke scale at triage?
unilateral weakness/numbness
new neurological sx with past stroke hx
slurred speech
headache 8-10/10
ataxia (poor coordination, gait)
giddiness with confusion
vertiginous giddiness
describe the stroke scale and the relevant documentation
pronator drift, speech, facial palsy
- document ONLY positive domains, unless all positive
what are the inclusion and exclusion criterion for stroke activation?
include: presentation of stroke symptoms within 6h of discovery
exclude: poor premorbids (ie. bedbound/uncommunicative), TIA, hypoglycemia (sx resolved after), pure sensory sx (ie. only numbness)
what is symptom discovery time vs. last seen well?
symptom discovery is when the symptoms are first noted by pt/nok
last seen well is when nok last saw patient asymptomatic (made inaccurate if patient went to sleep)
what are the indications of ECG at triage
bradycardia (<60)
tachycardia (>100)
hypokalemia (<2.5)
hyperkalemia (>6)
epigastric pain (>20yo)
chest pain (>20yo)
chest trauma
seizure
syncope
palpitations
what are the indications of UC10 at triage
flank/loin/lower abdominal pain
urinary symptoms
SBP 200 or more, DBP 120 or more
referred by OPS for HTN
HC ‘HI’
what are the indications of HC at triage
DM
AMS, giddy, seizure (syncope), weakness
lumps, bumps, abscess, chronic wounds, skin infections
what are the indications of UPT at triage
F/9-60yo + lower abdominal pain/require XR at triage, unsure if pregnant
amenorrhea
menorrhagia
what are the indications of blood taking at triage
FBC = dengue review clinic
CK = rhabdo review clinic
what are the indications of CXR at triage, and what views are indicated?
CXR PA/AP = isolated chest trauma within MCL, cough x1/52, creps, referral for dengue
CXR PA + oblique = isolated chest trauma lateral to MCL
what are the indications of limb XRs, and what XRs can be ordered?
limb inflammation, isolated blunt/penetrating injury TRO fracture/dislocation and FB respectively
> UL: shoulder, elbow, wrist, hand
> LL: knee, ankle, foot
what are the contraindications to ordering XRs at triage?
FFH, pregnant, multi-site injury
what are the XRs for foot FB (if unanswered in question 12)
foot AP/lateral, foot true lateral
what are the XRs for throat FB (if unanswered in question 12)
neck lateral
describe the hip fracture protocol at triage, and how you will assess if patient can be included
include if: isolated hip pain post trauma, external rotation and shortening of hip joint
- XR hip and pelvis
- consult Dr for IM/IV tramadol + maxalon if needed
what are the inclusion criteria for ‘Direct to Subspecialty: Eye’?
c/o ONLY red eye or floaters
referred by OPS
isolation level 0
stable vitals
time: M-F 8am-3pm; sat 8am-11am
what are the inclusion criteria for CRAO workflow?
sudden unilateral LOV presenting within 4.5h + no ARI
what are some examples of P2 uptriage cases?
symptomatic ARU
testicular pain/swelling <25yo
brought in on NRM
HI + anticoagulant usage (or unsure)
GPFirst
what are some examples of P2 cases?
testicular pain/swelling >=25yo
ARU, comfortable
abdominal pain >50yo
chest pain > 25yo
R shoulder/elbow dislocation: to resus
long/deep lacerations
UL: all dislocation/closed #
LL: hip/tibia/fibula/foot closed #
in lung auscultation, what are the breath sounds you can anticipate?
rhonchi: expiratory
wheeze: expiratory, musical
stridor: inspiratory, harsh
creps: inspiratory, fine/coarse popping/crackles
diminished
action if patient has wheeze/rhonchi ONLY
MDI salbutamol 6 puffs + PEFR, PAC 1 EDX
action if patient has wheeze/rhonchi with creps
consult sr dr TRO APO
action if patient has creps ONLY
CXR
action if patient has unilateral diminished/absent breath sounds
consult sr dr TRO PTX
inclusion and exclusion criteria for paracetamol
age 16 and above, pain 6-10 NOT epigastric /T 38 and above
exclude if:
- allergy to paracet
- last admin <6h ago
- cannot swallow (ie. nausea, NGT)
inclusion and exclusion criteria for ketorolac
age 16-64, pain 6-10 NOT epigastric
exclude if:
- allergy to aspirin, cox-2 inhibitors, NSAIDs, paracetamol
- anticoagulant/steroid use
- asthma, BGIT, cardiac/renal failure
- coagulation disorders (coagulopathy, dengue, thrombocytopenia), cancer, post-hemodialysis
inclusion and exclusion criteria for diclofenac
age 16-64, pain 6-10 NOT epigastric
exclude if:
- allergy to aspirin, cox-2 inhibitors, NSAIDs, paracetamol
- anticoagulant/steroid use
- asthma, BGIT, cardiac/renal failure
- coagulation disorders (coagulopathy, dengue, thrombocytopenia), cancer, post-hemodialysis
- unable to swallow
if patient is allergic to paracetamol, can you give any other analgesia at triage?
no
signs of airway compromise
stridor, swallow impairment + drooling, speech: hot potato, hoarse, unable, swelling of face, neck, tongue, ligatures (encircling/anterior), elevation of tongue, cyanosis, tracheal deviation
signs of breathing compromise
accessory muscle use, agonal/shallow breathing, breathlessness, cyanosis, distress (tripod + ICS muscle use), desaturation, nasal flaring, pursed lip breathing, unable to speak in full sentences
tachy/brady/apnea
signs of circulation compromise
active bleeding - hemorrhage/spurters, cold/clammy peripheries, giddiness, pallor, hypotension, tachycardia, diaphoresis
signs of disability compromise
AMS +/- HI, decreased/loss of consciousness, combativeness, confusion, gcs<12
