Triage Flashcards
1
Q
Primary goal of triage in the ED:
A
rapid identifications of urgent, life-threatening conditions
2
Q
Complementary Goals
A
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
3
Q
Triage Systems
A
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
4
Q
Triage RN Skills
A
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
5
Q
Triage Categories Level 1
A
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
6
Q
Level 2
A
Requires immediate nursing assessment and rapid treatment
Prevent loss of life / permanent disability
Chest pain
Head Injuries
Stroke
Asthma
7
Q
Level 3
A
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
8
Q
Level 4
A
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
9
Q
Level 5
A
Requires non-urgent care Minor injury or condition / not life-threatening URI’s Earache Minor lacerations Sprain / strain
10
Q
First Priority is
A
to protect yourself from exposure to blood and body fluids by using mandatory standard precautions.
11
Q
The primary survey is
A
a rapid assessment to:
Identify life-threatening injuries/ symptoms that must be treated before continuing the assessment
12
Q
ABCDE
A
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
13
Q
A = Airway and Cervical Spine
A
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
14
Q
B = Breathing
A
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
15
Q
C = Circulating
A
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
16
Q
D = Disability (neuro check)
A
Evaluate LOC Pupil response Gross sensory/motor Protect Cervical Spine GCS This can be affected by traumatic as well as toxic and metabolic causes
17
Q
E = Expose all injuries
A
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
18
Q
Secondary Survey is…
A
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
19
Q
Secondary Survey “SAMPLE”
A
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
20
Q
Physical Assessment
A
Head Neck Chest Limbs Back Perineum Genitalia
21
Q
Secondary Survey Interviewing Techniques
A
PQRST
Provokes Quality Radiation Severity Time
Skills
Open ended vs closed ended questions
Active listening
Non judgmental
22
Q
Gerontological Considerations
A
Emergencies may be more difficult to assess/ detect due to: Atypical presentation Chronic illness Altered response to treatment Greater risk of developing complications
23
Q
Pediatric Considerations
A
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.
24
Q
Specific Injuries - Assessment and Management
A
Abdominal Trauma Poisonings Environmental Emergencies Hemorrhage Tetanus Prophylaxis
25
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
26
Blunt Trauma
MVC, falls, blows or explosions
Injuries may be hidden/difficult to detect
Can lead to major blood loss into peritoneal cavity
27
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
```
28
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
29
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
30
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
31
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
32
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
```
33
Corrosive materials
Alkaline
lye, drain cleaners, bleach, oven cleaners, batteries
Acid
toilet bowel cleaners, pool cleaners, metal cleaners, rust removers, battery acid
34
Poison Management
Support vital organ systems
Determine poison
Remove or inactivate toxin before it is absorbed
Give specific antidote
35
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
36
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
37
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
```
38
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
39
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
40
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
```
41
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
42
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
```
43
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”
```
44
Hypothermia Management
```
Move to a warm environment
Removal of wet clothing
Rewarming
Continuous monitoring
Supportive care
Warmed IV fluids
```
45
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
46
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
47
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
```
48
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
49
Fresh water aspiration
```
Surfactant Destroyed
Protein rich plasma moves into alveoli
Atelectasis occurs
Pulmonary edema
Hypoxemia
```
50
Salt water aspiration
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Hypertonic water / osmotic force
Fluid from pulmonary capillaries pulled into alveoli
Atelectasis occurs
Pulmonary edema
Hypoxemia
```
51
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
52
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
53
Black Widow Spider
abd cramping, more systemic complaints- nausea- widespread pain
54
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
55
Deer Ticks
remove completely as quick as possible-risk of lyme disease and rocky mt fever
56
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
57
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
58
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
59
Tetanus
```
Systemic infection caused by Clostridium Tetani spores found in:
Soil / garden moss
Human / animal excrement
Incubation: 2 – 30 days
Tetanus Prophylaxis
```
60
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
61
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
62
First Aid - Sprains and Strains
Rest
Ice
Compress
Elevate
63
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
64
Minor Wounds
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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
```
65
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
66
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
67
Avulsed Tooth
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If tooth is dirty – gently rinse with water
Place in:
Tooth socket
Between gum and cheek
Clean gauze
Milk
Normal Saline
See dentist
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