Triage Flashcards
Primary goal of triage in the ED:
rapid identifications of urgent, life-threatening conditions
Complementary Goals
Prioritize care needs
Determine most appropriate area for treatment
Regulate patient flow
Provide continued assessment/ reassessment
Provide information/ referrals to client/ family
Relieve client/ family anxiety
Enhance public perceptions
Triage Systems
Type I - Traffic Director (no longer used)
Type II - Spot Check (no longer used)
Type III - Comprehensive
3 Level - Emergent, Urgent, Non-urgent
5 Level - Based on Emergency Severity Index. Endorsed by ENA- most often used
Triage RN Skills
Experienced in skilled rapid assessment
-Determination of patient urgency
-Ability to recognize who needs immediate intervention
Excellent assessment / organizational skills
-Extensive knowledge of diseases / injuries
Ability to communicate with patient / staff
-Verbal
-Written
Triage Categories Level 1
Resuscitation - Requires immediate nursing and medical care.
Prevent loss of life / permanent disability
Cardiac Arrest- CAB- compressions and defibrillation
Major Trauma
Severe Respiratory Distress
Seizures- continuous
Level 2
Requires immediate nursing assessment and rapid treatment
Prevent loss of life / permanent disability
Chest pain
Head Injuries
Stroke
Asthma
Level 3
Must be seen within 30 minutes Serious – not life threatening Multiple ED resources (lab, x-ray, EKG, respiratory therapy) If left untreated for > 2-3 hours may cause permanent disability / death Signs of infection- infx wound Mild Respiratory distress Moderate pain Significant lacerations
Level 4
Must be seen within 1 hour- fast track
One ED resource (lab, x-ray, EKG, respiratory therapy)
If left untreated for > 2-3 hours may cause permanent disability / death
Signs of infection
Mild Respiratory distress
Moderate pain
Chronic Back Pain
Level 5
Requires non-urgent care Minor injury or condition / not life-threatening URI’s Earache Minor lacerations Sprain / strain
First Priority is
to protect yourself from exposure to blood and body fluids by using mandatory standard precautions.
The primary survey is
a rapid assessment to:
Identify life-threatening injuries/ symptoms that must be treated before continuing the assessment
ABCDE
Airway and Cervical Spine ALL patients with multiple trauma are considered to have a C-spine injury until proven otherwise : IMMOBILIZE NECK AND BACK AS NECESSARY Breathing Circulation Disability/Neurologic Exposure / Environment
A = Airway and Cervical Spine
Is the airway Open? Clear of any form of obstruction? To open airway use: Head Tilt / Chin lift (B) Jaw Thrust (A) for suspected Cervical Spine Injury Airway stabilization: Assist Intubate- think about what is going on with pt- know when this would be needed
B = Breathing
Assess Respiratory Rate Depth Inspect for chest wall injury Flail chest, open/sucking chest wound? Palpate for SQ emphysema Asymmetric chest expansion / use of accessory muscles for breathing Ascultate breath sounds Diminished / absent Abnormal Intervene
C = Circulating
Pulse - quality, rate, rhythm Cap refill? Skin color, temperature, moisture LOC Blood Pressure If able to palpate: don’t need to memorize carotid pulse = SBP is 60 femoral = SBP is 70 radial = SBP is 80 pedal pulse = SBP is 100. Identify and control bleeding Use direct pressure If this is not effective apply pressure over major arterial pulse points proximal to the bleeding site. Use a tourniquet as a last resort
D = Disability (neuro check)
Evaluate LOC Pupil response Gross sensory/motor Protect Cervical Spine GCS This can be affected by traumatic as well as toxic and metabolic causes
E = Expose all injuries
Completely undress every trauma patient
Cutting away clothing is usually best to minimize injury and pain
Medical patients need to be undressed for adequate assessment
Minimize heat loss / hypothermia
Use warmed blankets / warmed IV fluids
Protect patient’s privacy and dignity
Secondary Survey is…
detailed head to toe assessment.
“Tubes and fingers in every orifice”
Full set of vital signs
“SAMPLE” Hx
Physical Assessment
Mechanism of injury - circumstances and energy forces that produced the trauma
Blunt- auto accident, fall, fist, baseball bat
Penetrating- knife, gunshot, fall on something sharp
Look for:
Deformities
Contusions
Abrasions/lacerations
Punctures
Secondary Survey “SAMPLE”
S = Subjective data – what happened? A = Allergies M = Medication use P = Past medical history, Primary Physician? L = Last meal, Last tetanus shot (pediatric immunizations), Last menses E = Events or environment related to the injury – include history of abuse
Physical Assessment
Head Neck Chest Limbs Back Perineum Genitalia
Secondary Survey Interviewing Techniques
PQRST
Provokes Quality Radiation Severity Time
Skills
Open ended vs closed ended questions
Active listening
Non judgmental
Gerontological Considerations
Emergencies may be more difficult to assess/ detect due to: Atypical presentation Chronic illness Altered response to treatment Greater risk of developing complications
Pediatric Considerations
Children have smaller airways- more easily blocked by tongue or F.B.
Large head size can contribute to obstruction of airway
Obligate nose breather
Higher metabolic rate = higher O2 demand
Smaller blood volume/ compensatory vasoconstriction/ may see normal BP in presence of significant hypovolemia.
Specific Injuries - Assessment and Management
Abdominal Trauma Poisonings Environmental Emergencies Hemorrhage Tetanus Prophylaxis
Penetrating Abdominal Injuries
Gunshot wounds
Stab wounds
Most important factor is velocity the missile entered body and in what direction
Stab wounds managed more conservatively
Penetrating trauma of the abdomen– high incidence of injury to hollow organs
Penetrating Abdominal Wound
Penetrating Chest Wound
Think Abdomen
Abdominal Trauma
Blunt Trauma
MVC, falls, blows or explosions
Injuries may be hidden/difficult to detect
Can lead to major blood loss into peritoneal cavity
Abdominal Trauma
Assessment Obtain Hx Inspect Ascultate- first bc palpating can create more sounds Lab work / Tests CBC, Chemistries, Amylase, UA Abd xrays, CT scan, Ultra sound
Abdominal Trauma Managment
Initiate ABC’s
Immobilize C-spine
Cut away clothing
Monitor for S/S of shock-important to get baseline vitals
Avoid opiods –decrease respiration- can also mask symptoms in abdomen
Control bleeding
Insert IV, NG, Foley
Crush Injury
Occurs when a person is caught between two objects
Assessment
Hypovolemia- significant blood loss and damage to blood vessels
Paralysis and damage to the nerves
Erythema/ blistering of skin
Body part appears swollen, tense, hard- compartment syndrome
Renal dysfunction- due to myoglobinuria- input and output VERY important- needs to be very accurate
Crush Injury Management
Maintain ABC’s
Observe for acute renal insufficiency
Splint early to control bleeding, pain
Elevate extremity to decrease swelling, pressure—fasciotomy may be needed
Medicate for pain / anxiety
compartment syndrome- check distal pulses, extreme pain not relieved by pain meds
Multiple Trauma
Potential to affect every body system
Mortality is R/T severity of injuries / number of systems / organs involved
Requires team approach – pt/ot/etc
Sometimes less obvious injury is one that will cause death
Poisoning
1-800-222-1222
Poison - substance that injures the body by its chemical action Mode of entry: Inhaled Ingested Injected Absorbed: Skin / Mucous membrane
Corrosive materials
Alkaline
lye, drain cleaners, bleach, oven cleaners, batteries
Acid
toilet bowel cleaners, pool cleaners, metal cleaners, rust removers, battery acid
Poison Management
Support vital organ systems
Determine poison
Remove or inactivate toxin before it is absorbed
Give specific antidote
Poison Management cont’d.
Vomiting is never induced after the ingestion of a caustic substance or a petroleum distillate
Gastric lavage is performed on obtunded patients only after their airway is protected
Activated Charcoal is given if the poison is one that can be absorbed
A specific antidote may be given
Poisoning - Inhaled
Carbon Monoxide (CO) poisoning Exposure may occur during a house fire/ engine exhaust/ improperly vented stoves or heating systems Odorless/colorless
Affinity for hemoglobin 200 times greater than for oxygen
BEWARE: pulse oximetry may indicate adequate saturation—despite the hypoxia
Clinical Manifestations of CO Poisoning:
Cardiac dysrhythmias / myocardial ischemia CNS manifestations Headache Loss of memory / concentration Irritability/ personality changes May appear intoxicated Excessive fatigue / muscle weakness Palpitations/ dizziness Renal failure Skin color: Pink to cherry red to cyanotic and pale - Not a reliable sign
CO Management
Reverse cerebral/ myocardial hypoxia
Speed up elimination of CO
Remove patient from source ASAP
Cornerstone of Tx is 100% O2 to displace CO from hemoglobin
Hyperthermia
Hyperthermia - Occurs during heat waves with high humidity (especially with exercise)
Mild – heat cramps
Moderate – heat exhaustion- tired, HA, just generally feel “bad”
Severe – heat stroke
Core temperature exceeds 105 degrees F
Acute medical emergency
Mortality rate about 70%
Recent exposure to elevated ambient temperature or excessive exercise during heat waves with high humidity
Hyperthermia Symptoms
Confusion / delirium Bizarre behavior Loss of muscle coordination Coma Elevated body temperature => 105 degrees F Hot / dry skin Anhidrosis- lack of sweating Tachypnea Hypotension Tachycardia
Hyperthermia Management
Stabilize ABC’s
Monitor vital signs – including core temp
Reduce core temp to 102 as rapidly as possible- NO ICE BATHS
Tepid baths
Cooling blankets
Prevent shivering
Monitor fluid and electrolytes
Monitor renal function
Accurate I & O’s- catheter with temperature probe- to continually monitor both
Lab results- chemistries: electrolytes, CBC, kidney fx: BUN and creatinine
Hypothermia occurs as a result of:
Prolonged exposure to cold temperatures Near drowning in cold water Can be induced in patients: Cold IV fluids / blood products Unwarmed O2 Exposure during examination
Hypothermia Symptoms
Core temp below 95 degrees Apathy Poor judgment Ataxia Drowsiness Dysarthria Drowsiness Pulmonary edema Cardiac dysrhythmias Acid-base imbalance Coagulopathy-blood isn’t moving too quickly Coma Heartbeat / BP may be undetectable –“not dead till warm and dead”
Hypothermia Management
Move to a warm environment Removal of wet clothing Rewarming Continuous monitoring Supportive care Warmed IV fluids
Frostbite is:
Trauma from exposure to freezing temperatures
Causes freezing of tissue
Damage usually irreversible
Feet/ hands/ nose and ears most frequently affected- bc exposed and they are smaller areas
Frostbite Assessment
Frozen body part may be hard / cold / insensitive to touch / appear white or mottled
Determine environmental temperature / duration of exposure / humidity and presence of wet conditions
Frostbite Management
Goal--restore normal body temp – controlled warmth – no water over 104 degrees…a little bit above body temperature-around 99-100 Remove constrictive clothing/ jewelry No ambulation if lower extremities involved Controlled/ rapid warming Administer analgesic Massage contraindicated Risk for infection great Administer Tetanus prophylaxis Avoid refreezing
Environmental Emergency - Near Drowning
Defined - survival from potential drowning for at least 24 hours
Third leading cause of accidental death
Toddlers/ young children at highest risk-can drown in a very small amt of water
40% are younger than 5 years of age
Fresh water aspiration
Surfactant Destroyed Protein rich plasma moves into alveoli Atelectasis occurs Pulmonary edema Hypoxemia
Salt water aspiration
Hypertonic water / osmotic force Fluid from pulmonary capillaries pulled into alveoli Atelectasis occurs Pulmonary edema Hypoxemia
Near drowning Management
Establish patent airway – intubate, PEEP- bc want to keep alveoli open
ABG / pulse oximetry –pulse ox still not very reliable
Administer O2
IV’s, Foley, NG tube
Monitor vital signs – including temp.
Keep patient warm
Medications as ordered:
Corticosteroids- inflammation
Antibiotics- infx
Osmotic diuretics- reduce fluid overload, kidney perfusion
Bronchodilators- keep alveoli open/ clear
Bites and Stings
Snakes
Animals – wild or domestic
Spiders / ticks / scorpions / bees / wasps / hornets / fire ants
Lethality due to poisonous venom and stings/ secondary anaphylaxis
Black Widow Spider
abd cramping, more systemic complaints- nausea- widespread pain
Brown Recluse Spider
more localized, little red spot then progresses in 12-24 hours to blister…then can progress to deep flesh wound- tx is good wound care, with abx
Deer Ticks
remove completely as quick as possible-risk of lyme disease and rocky mt fever
Stinging Insects
Remove stinger- use a dull edged plastic to scrape out- example credit card
Cleanse site- good skin care
Ice application reduces swelling/ decreases absorption of venom
Oral antihistamine for puritis and swelling
If severe reaction-may include treatment for anaphylaxis (happens very quickly) rapid and deadly- can start with itchiness around wound then tongue starts to swell- tx epi pen, Benadryl, and monitoring
Snake Bite
Remove constrictive clothing / rings-draw a circle to monitor if it gets larger
Cleanse wound light sterile dressing/ immobilize body part below heart
DO NOT apply ice or tourniquet—can increase tissue damage
Determine if bite from venomous snake
Give antivenin if indicated
No corticosteroids in 1st 6 hours- can mask inflammation and swelling and you need to see how bad it is
Td as needed
Monitor closely
Systemic reactions
Local swelling, reddness
Would you rather be bitten by a dog or a human?
Harmful dog germs are usually harmless to humans
NOT rabies
Human germs can harm humans of course.
So a bite from a human mouth full of harmful bacteria may very well be more damaging than a dog bite
Good wound care, suture care
Tetanus Prophylaxis
Tetanus
Systemic infection caused by Clostridium Tetani spores found in: Soil / garden moss Human / animal excrement Incubation: 2 – 30 days Tetanus Prophylaxis
Tetanus S/S
Depression of respiratory center
Local joint stiffness
Trismus – “lock jaw”
Spasms and tonic contractions of all muscle groups
Tetanus Prophylaxis
Prevent tetanus by:
Administering immunization
Scrupulous wound care
Tetanus toxoid provides active immunization
Tetanus immune globulin (HyperTET) provides passive immunization –if you’re definite the pt has never been given an immunization
Tetanus should be given within 72 hours of injury
Tetanus prone wounds
More than 6 hours old
Stellate or avulsed deep, penetrating wounds
Caused by missile/ crushing mechanism/ heat/ cold
Obvious signs of infection
Contaminants such as dirt/ feces/ soil/ saliva
Tetanus Prophylaxis- q5 to 10 years
First Aid - Sprains and Strains
Rest
Ice
Compress
Elevate
Nosebleeds (epistaxis)
Compress the nostrils (apply direct pressure to the septal area)
Apply direct pressure continuously for at least five minutes, and for up to 20 minutes.
Tilt the head forward
prevents blood from pooling in the posterior pharynx,
prevents nausea and airway obstruction.
Fluid resuscitation should be initiated if volume depletion is suspected
Minor Wounds
Stop the bleeding Clean the wound Apply an antibiotic –bacitracin is better than Neosporin Cover the wound Change the dressing Deep, gaping or jagged wounds probably require suturing Watch for signs of infection Consider tetanus prophylaxis
Hyperventlation
Breathing faster and deeper than normal
Headache
Chest pains
Dizziness, tingling
Carpopedal spasm- hands start to curl in bc they have blown off their CO2- feet will as well
Can be caused by anxiety and causes respiratory alkalosis
Hyperventilation Management
Calm the person
Encourage slowing of respiratory rate - have them to breathe with you - follow your normal breathing rate.
If person does not calm, seek medical attention
Don’t want to give them more o2- they are not lacking it
Avulsed Tooth
If tooth is dirty – gently rinse with water Place in: Tooth socket Between gum and cheek Clean gauze Milk Normal Saline See dentist
