Triage- Tillman - Lecture notes 1 PDF

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Triage ...

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Emergency, Terrorism, and Diaster Nursing Emergency Nursing ● Patients with life-threatening or potentially life-threatening problems enter the hospital through the emergency department (ED) ○ Without insurance→ treat as primary care provider ○ Aging= sicker ○ Discharged sooner than should be→ will come back ○ Mental health patients ●

Triage- “to sort” ○ Process of rapidly determining patient acuity ○ Represents a critical assessment skills

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Triage system ○ Categorizes patients so most critical are treated first ■ ESI= triage algorithm

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Primary survey= the first step ○ Focuses on airway, breathing, circulation, disability, exposure (ABCDE) ■ Identify life threatening conditions ■ Exposure= exposure to chemicals, environment, toxins: cold temperatures, hot temperatures, stabbed with metal, impaled with objects (do not remove. Stabilize and leave it in place→ may be occluding the blood vessels and preventing shock) ○ Identifies life-threatening conditions ■ Primary survey: If you identify a problem, you fix it before you move on (ABCDE): Been in the cold? → warm them up with lights and blankets ○ If life-threatening conditions related to ABCD are identified during primary survey, interventions are started IMMEDIATELY and before proceeding to the next step of the survey ■ Privacy

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Airway with cervical spine stabilization and/or immobilization (until able to clear it) ■ Goal= STABILIZE (ABCDE) ○ signs/symptoms in patient with compromised airway ■ Dyspnea ■ Inability to vocalize= can not speak (may be caused by edema) ■ Presence of foreign body in airway ● Adventitious lung sounds: stridor= airway is obstructed and airway is escaping around the object ● Wheezing= constricted (whistle) ■ Trauma to face or neck

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Burn patient can sustain airway obstruction (causing swelling and edema→ obstructing the airway) ● Motor vehicle accident ● Saliva, bloody secretions, dentures, facial trauma, fractures At risk: drowning, anaphylaxis, seizures, body obstructions (younger kids due to curiosity- placing in mouth or nose), cardiopulmonary arrest

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Maintain airway: least to most invasive method ○ Open airway using the jaw-thrust maneuver (cause soft palate to open up) ○ Suction and/or remove foreign body (pull saliva or bloody secretions) ○ Insert nasopharyngeal/oropharyngeal airway (no cuts. Just passing through naso, oropharyngeal, or endo trachea) ○ Endotracheal intubation ○ Primary survey: ABCDE ■ Identity problem? FIX IT→ then move on to the next letter

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Jaw Thrust Maneuver ○ Supine position ○ Rescuer is kneeling at the top of the head (NOT THE SIDE: risk of moving the head): keep head stable (Do not tilt: risk of compromise)

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Rapid Sequence Intubation ○ Preferred procedure for unprotected airway ■ Involves sedation or anesthesia and paralysis

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Stabilize/ Immobilize Cervical Spine ○ Face, head, or neck trauma and/ or significant upper torso injuries ○ Placed in a C spine cast ○ Immobilized during assessment of the airway

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Breathing ○ Assess for dyspnea, cyanosis (late sign) paradoxical/asymmetric chest wall movement (pneumothorax, fractured ribs, atelectasis), decreased/absent breath sounds (swelling or edema), tachycardia (due to O2 is low) → hypotension ■ Fractured ribs: lead to respiratory failure (Hypercapnia due to not able to fully expand their lungs and blow off CO2→ Respiratory acidosis) ■ Anaphylaxis causes edema ■ Penetration ■ PE (HYPOXIA- respiratory failure) ■ Asthma→ constricting (wheezing) and CO2 trapping→ respiratory failure (hypercapnia) ■ Majority will die due to airway problem

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Administer high-flow O2 via a non rebreather mask ■ First thing to do ■ PE will not change due to obstruction but still place O2 on patient to hyperoxygenate the blood able to pass Bag-valve-mask (BVM) ventilation with 100% O2 and intubation for lifethreatening conditions ■ Open up the bag (it does come collapse at first) ■ Not able to move or immobilize? May need intubation due to obstruction ■ Life threatening= pneumothorax Monitor patients response

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Circulation ○ Check central pulse (peripheral pulses may be absent because of injury or vasoconstriction) ■ NUMBER ONE= Carotid (due to being a central pulse) ■ Assess quality and rate ■ Capillary refill (< 2 seconds, >3 seconds= we have a problem) ■ Skin color= pale, gray, ashy, dry ■ temp=will drop ■ Decrease in all= poor circulation= high risk of shock (loss of blood flow in vascular space) ■ Bleeding? Put pressure on the site ■ Pulses are absent due to blood loss→ vasoconstrict (compensation) to get blood to major organs quickly ■ Decreased circulation due to decrease in fluids→ give them fluids ○ Insert two large bore IV catheters ■ Want as large as you can get so you can give blood ● Preferably an 18 ● Aggressive fluid resuscitation ● Isotonic solution (NS and LR) ● Placement= brachial vessel (utilize upper veins) ○ Unless patient has massive fractures (swelling, edema → could occlude vessel) ○ Place pressure dressing around the sites of trauma: at risk for shock and DIC ⇒ bleeding around IV sites ○ Labs= Type and cross for blood products if needed ○ Initiate aggressive fluid resuscitation using normal saline or lactated ringers solution

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Disability ○ Measured by patients level of consciousness ■ AVPU ● A= alert ○ Talking without any stimuli

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Exposure/environmental control ○ Remove clothing to perform physical assessment ○ Prevent heat loss ■ Covered in chemicals ● First step= place gloves on ○ protect yourself and others (isolation) ● Know what it is!!! Brush off excess (dust or powder), rinse them off (liquid- chemical spill) ■ In water→ get them out of the water ■ Remember privacy ■ ■ ■

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V= responsive to voice ○ Answers when you call their name ● P= responsive to pain ○ May not be able to talk, but they do respond to pain ○ Sternal rub ● U= unresponsive ○ Most critical Glasgow Coma Scale ● A grading score Pupils ● Response to light: fixed, dilated?

Warming blankets Overhead lamps Warmed IV fluids & fluid resuscitation at the same time

Triage example

Secondary Survey- brief, systematic process to identify all injuries ● Primary= stabilize & did not treat injuries *SAVE THEM FIRST ●

Full set of vital signs/five interventions/facilitate family presence ○ Complete set of vital signs ■ BP (bilaterally due to possible injury) ■ HR ■ RR ■ O2 ■ Temp ■ Make the decision if we are going to continue the survey and continue interventions ■ Did the intervention work? ■ SAMPLE ● S= system ○ Identify issues

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A= allergies M= medication history =medication P= past health history L=last PO (may need surgery- risk of aspiration) E= events or environmental factors leading to the injury ○ Any other exposures they had ■ Head to toe ● Head, neck, face ● Abdomen= guarding, bruising, rigid→ risk of internal bleeding ○ Aneurysms ● Pelvis, peri ○ Fractures or crushes→ risk of bladder damage ● Complete go down anteriorly → then log roll to inspect posteriorly ○ Keeping C spine Initiate EKG monitoring Initiate pulse oximetry Insert indwelling catheter Insert orogastric/nasogastric tube Collect blood for laboratory studies ■ Primary only asked for the type of cross for immediate care Family presence: family members who wish to be present during invasive procedures/resuscitation view themselves as participants in care ■ Encourage this. Presence should be supported ■ They were able to see everything that we could do to save the patient ■ Maintain C Spine, reduce anxiety (uses O2) → family member presence can decrease anxiety Their presence should be supported

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Give Comfort Measures ○ Pain management strategies ○ Combination of ■ Pharmacologic measures ■ Nonpharmacologic measures

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History and Head to Toe ○ Obtain history of events, illness, injury from patient, family, and emergency personnel ■ EMT ● How was the patient found at the scene ■ Head to toe assessment for all body systems ■ Chief complaint? ● Subjective complaints? To internalize interventions

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Patients report of pain level Description of pain ○ ACS= dull chest pain ○ Aneurysm= Sharp ○ Location ○ Duration ○ Quality ■ Witness description ● What did they do right before the injury ● What did they sound like ■ Health history ● SAMPLE Perform head to toe assessment to obtain information about all other body systems

Inspect the posterior surfaces ○ Logroll patient (while maintaining cervical spine immobilization) to inspect the posterior surfaces ■ Abrasions ■ Puncture wounds ■ Gun shot wounds (matching exit wounds? Bullet may be in the body) ■ Pain in lower portions of the spine→ clear upper area ○ Palpate the spin to search for misalignment Evaluate need for tetanus prophylaxis ○ Does your patient have any exposures where they would benefit from these prophylaxis Provide ongoing monitoring and evaluate patient’s response to interventions ○ We have identified the problem, but they should be maintaining progress or improvement ○ Based off of the interventions provided Prepare to ○ Transport for diagnostic tests (x-ray, CT) ○ Admit to general unit, telemetry, or ICY ■ Increased cardiac factors? → cath lab ○ Transfer to another facility ■ Does your hospital have the unit that your patient needs ● PEDS, burn unit ■ Nurse might accompany the patient during the transfer

Case study ● 32-year-old man arrives in ED via paramedics. Neighbor found him lying on the rocks in the rock garden. He had fallen off the roof while fixing the shingles on his house. His femur is protruding through the skin. The paramedics report that he was found in large pool of blood. Unresponsive, BP 60/42, HR 168

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Life threatening injuries= Hypovolemic shock, DIC, head trauma, TBI, abdominal injury, cushing ulcer, internal bleeding Interventions ■ Type and cross, fluid resuscitation

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Death in the emergency department ○ Must recognize the importance of hospital rituals in preparing the bereaved to grieve (e.g. collecting belongings, viewing the body) ○ Determine if the patient could be a candidate for non-heart beating donation ■ Tissues and organs (e.g. corneas, heart valves, skin, bone, kidneys) can be harvested from patients after death ● Be cautious when approaching the family about organ donation ○ Really up to the doctor so you shouldnt have to ask ○ Doctor’s responsible ○ Nurses suggest to medical team ■ Show comfort and compassion to the family ● Do not put their personal belongings in a urine specimen cup ● Clean up the body before bringing in the family

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Gerontologic considerations ○ Emergency care ■ Older adults are at high risk for injury-primarily from falls ■ Causes ● Generalized weakness ● Environmental hazards ● Orthostatic hypotension ■ Important to determine whether physical findings may have caused fall or may be due to fall ● Diabetic who did not eat this morning due to BG dropping ● Getting out of shower before they fell ● Got really dizzy and weak→ fell→ still feeling weak? ● Fracture can cause a fall due to arthritis, osteoarthritis ● Fall causes fracture

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Emergency and Mass Casualty Incident Preparedness ○ When an emergency of MCI occurs first responders (e.g. police, emergency medical personnel are dispatched) ○ Triage of casualties differs from usual ED triage and is conducted in...