1. Is the patient dying 2. Is this a pt who shouldn’t wait ? 3. How many resources does this pt need ? 4. VS

Triage Flashcards by Helmi Olsen

4 decision points

Is the patient dying
Is this a pt who shouldn’t wait ?
How many resources does this pt need ?
VS

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ESI 1

Does the person need immediate saving intervention?
Airway
Breathing or
Circulation

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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)

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Examples of immediate life saving airway/breathing

BVM
Emergent cpap bipap
Surgical airway
Intubation

Not life saving - nc and nonrebreather

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Electrical life saving

Defib
Cardioversion
Pacing

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Procedures (lifesaving )

Chest needle decompression
Open thoracotomy
Pericardiocentesis
IO

Non life saving - diagnostics

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Hemodynamics

IV resusc (significant )
Blood admin
Control of major bleeding

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Life saving meds

Narcan 
Adenosine 
D50
Dopamine
Atropine

Not lifesaving - asa heparin abx RT tx IV nitro pain meds

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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

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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 ?

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ESI 2 cardiac

Suspicion of ACS

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EENT esi 2

Epiglottitis
Peritonsillar abscess
(High risk situation )
Inhalation injury

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Genitourinary esi 2

Testicular torsion
Dialysis pt not able to be dialyzed
Inability to urinate and needing Cath

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Mental health esi 2

Danger to self or others
Si/ hi / psychotic / violent /elopement risk

Intoxication alone is not esi 2

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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

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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 ```