Triage Flashcards
4 decision points
- Is the patient dying
- Is this a pt who shouldn’t wait ?
- How many resources does this pt need ?
- VS
ESI 1
Does the person need immediate saving intervention?
Airway
Breathing or
Circulation
Criteria for meeting esi 1
Need immediate airway, medication or hemodynamic intervention Already intubated Apneic Pulseless Severe resp distress Spo2 <90% Acute mental status changes Unresponsive (nonverbal and not following commands acutely or req noxious stimuli)
Examples of immediate life saving airway/breathing
BVM
Emergent cpap bipap
Surgical airway
Intubation
Not life saving - nc and nonrebreather
Electrical life saving
Defib
Cardioversion
Pacing
Procedures (lifesaving )
Chest needle decompression
Open thoracotomy
Pericardiocentesis
IO
Non life saving - diagnostics
Hemodynamics
IV resusc (significant )
Blood admin
Control of major bleeding
Life saving meds
Narcan Adenosine D50 Dopamine Atropine
Not lifesaving - asa heparin abx RT tx IV nitro pain meds
Examples of esi 1
Cardiac arrest, resp arrest , spo2 <90, trauma unresponsive , od rr <6 , anaphylaxis , hypoglycemia with ams , hypovolemia with pale , diaphoretic, no <70/palp, hr 30 weak and dizzy, severe Brady/tachy with signs of hypoperfusion
Decision point B
Would I use my last open bed for this pt?
Can this pt wait to be seen?
Is this a high risk situation?
Or
Is this patient confused, lethargic, or disoriented ? New onset or chronic ?
Or
Is this pt in severe pain or distress ?
ESI 2 cardiac
Suspicion of ACS
EENT esi 2
Epiglottitis
Peritonsillar abscess
(High risk situation )
Inhalation injury
Genitourinary esi 2
Testicular torsion
Dialysis pt not able to be dialyzed
Inability to urinate and needing Cath
Mental health esi 2
Danger to self or others
Si/ hi / psychotic / violent /elopement risk
Intoxication alone is not esi 2
Neuro esi 2
Severe headache with mental status changes , high bp, fever, lethargy, or rash
Sudden onset speech deficits or weakness
No hx ha with sudden onset ha concerning for subarachnoid
On/gyn
Esi 2
Late pregnancy: abruptio placentae and placenta previa
Early pregnancy:
Ectopic pregnancy
Postpartum heavy vag bleed
Abruptio placentae s/sx
Bleeding, contractions, fetal distress
In second half of pregnancy
Placenta previa s/sx
Painless vag bleeding
Most likely 3rd trimester
Ectopic pregnancy s/sx
Amenorrhea
Vag bleeding
Abd pain
Less classic sx : painful fetal movements , nausea , dizziness/weakness, fever , flu sx , vomiting , syncope, cardiac arrest
Ortho esi 2
Compartment syndrome
Inj with neurovasc impairment
Partial / complete amputations
Trauma mech with high accel or decel mech
Pelvis , femur and hip can present with a lot of blood loss
Peds ESI 2
Seizures Sepsis Dehydration DKA Burns Child abuse Head trauma Accidental OD (even vitamin) Infant <28 days with fever >100.4
Resp esi 2
Resp distress - asthma , PE, pleasurable effusion, pneumo, aspiration of fb , smoke inhalation , sob with cp
Other esi 2 (high risk situations )
DKA hyper or hypoglycemia Sepsis Syncope or near syncope Electrolyte disturbances
Abd high risk situation examples
Abd pain in elderly
GIB
Cardiac esi 2 examples
CP, arterial occlusion , cp with prior stent , pericarp effusion
Infective endocarditis
General esi 2
Immunocompeomised
Organ transplant
Onc pts
Esi 2 GU examples
Testicular torsion (sudden onset testicular pain) Renal failure unable to be dialyzed
Gyn esi 2 examples
Ectopic
Spontaneous abortion
Mental health esi examples
SI
HI
Combative , hostile , hysterical, etoh w trauma
Any sexual assault
Neuro esi 2 examples
Rule out meningitis (h/a, fever, lethargy)
Hx multiple cva
Acute ischemic stroke (motor or speech deficits )
Peds esi 2 examples
V/d unable to eat , asthma attack
Resp esi 2 ex
Acute epiglottitis (drooling) Severe asthma (severe sob) Pleural effusions (severe sob) Spontaneous pneumo (sudden onset sob)
Trauma esi 2 ex
Mva with transient loc
Stab to groin
Esi pain
7 or higher is severe
What is an esi resource ?
Labs
ECG , X-ray, CT, US, MRI
IV fluids (lock not a resource )
Meds (IV IM or nebs)- tetanus excluded
Specialty consult (not pcp)
Simple procedure = 1 (lac repair, Foley Cath)
Complex procedure = 2 (conscious sedation)
What is not a resource ?
Lock Po med Tetanus vaccine Wound care Dressing , splint , sling crutches Poc tests Pelvic exam Cardiac monitoring
