does the patient require immediate life saving intervention? airway obstructed or partially...
TRANSCRIPT
![Page 1: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/1.jpg)
EMERGENCYSEVERITY
INDEX
REVIEW
![Page 2: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/2.jpg)
requires immediate life-saving intervention?
A
high risk situation?or
confused/lethargic/disoriented?or
severe pain/distress? B
How many different resources are needed?---------------------------------------------------------------------------------------
none one many C
Danger zone vitals? Age HR RR< 3 mo > 180 > 503m-3y > 150 > 403y- 8y > 140 > 30> 8 y > 100 > 20
SaO2<92%
D
ESI Triage Algorithm
5 4
2
3
1Yes
No
Consider
No
Yes
![Page 3: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/3.jpg)
DECISION POINT A Does the patient require immediate life
saving intervention?Airway
Obstructed or partially obstructed Unable to protect their own airway
Breathing Apneic Intubated prehospital Severe respiratory distress SpO2 less than 90%
![Page 4: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/4.jpg)
DECISION POINT A Cont.
Circulation Pulseless or concerned about rate, rhythm or
qualityDrugs
Hemodynamic interventions Immediate IV medications to correct
hemodynamic instability
![Page 5: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/5.jpg)
DECISION POINT A Does this patient have an acute mental
status change that requires immediate life saving intervention?Hypoglycemia needs glucoseHeroin OD needs narcanSubarachnoid bleed needs airway
protection Is this patient a P or U on the AVPU scale
![Page 6: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/6.jpg)
LEVEL 1 EXAMPLES Cardiac or respiratory arrest Overdose with a RR of 8 Severe respiratory distress Acute SOA with SpO2 < 90% Anaphylactic shock Critically injured trauma patient Chest pain, pale, diaphoretic Chest palpitations, HR 180+ Unresponsive with strong odor of
alcohol Severe stroke needs airway
protection
![Page 7: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/7.jpg)
AGGRESSIVE LIFE SAVING INTERVENTIONSWILL THIS INTERVENTION SAVE THIS PERSONS LIFE?
Airway and breathing IntubationSurgical airwayCPAP, BiPAPBag valve mask
Defibrillation External pacing Chest needle decompression
HemodynamicsSignificant IV fluid resuscitationBlood administration IV medications
Vasopressors
Control of major bleeding
![Page 8: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/8.jpg)
Immediate Life-saving Interventions
Life-saving Not life-saving
Airway breathing BVM ventilationIntubation Surgical airway Emergent CPAPEmergency BiPAP
Oxygen administrationNasal cannulaNon-rebreather
Electrical Therapy Defibrillation Emergent cardioversion External pacing
Cardiac Monitor
Procedures Chest needle decompressionPericardiocentesis Open thoracotomy Intraoseous access
Diagnostic testsECGLabs UltrasoundFAST (focused abdominal scan for trauma)
Hemodynamics Significant IV fluid resuscitation Blood administration Control of major bleeding
IV access Saline lock for medications
Medications Naloxone D50 Dopamine Atropine Adenocard
ASA IV nitroglycerin Antibiotics Heparin Pain medications Respiratory treatments with beta agonists
![Page 9: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/9.jpg)
3 QUESTIONS USED TO DETERMINE WHETHER THE PATIENT MEETS LEVEL 2
Is this a high risk situation?
Is this patient confused, lethargic or disoriented?
Is this patient in severe pain or distress?
The triage nurse obtains pertinent subjective and objective information to quickly answer these questions
![Page 10: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/10.jpg)
Decision Point B: Should the patient wait?
High risk situation?or
confused/lethargic/disoriented?or
severe pain/distress? B
2
Yes
![Page 11: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/11.jpg)
DECISION POINT BIS THIS A HIGH RISK SITUATION?
Determination is based on a brief patient interview, gross observations, “sixth sense”
Do not require a full set of vital signs Unsafe for the patient to wait
Suggestive of a condition that could easily deteriorate
Symptoms of a condition that’s treatment is time sensitive
Potential for major life or organ threat
![Page 12: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/12.jpg)
EXAMPLES OF “HIGH RISK” Episodes of chest pain, denies other
symptoms, known cardiac history R/O PE Newborn with a fever Rule out ectopic pregnancy Neutropenia with a fever Suicidal/homicidal
![Page 13: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/13.jpg)
DECISION POINT BIS THE PATIENT CONFUSED, LETHARGIC OR DISORIENTED?
Is there an acute change in level of consciousness?
Is this situation where the brain is structurally or chemically compromised?
![Page 14: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/14.jpg)
EXAMPLES New onset of confusion in an elderly
patient 30 y.o. with a known brain tumor whose
wife reports that he is confused Adolescent found confused and
disoriented
![Page 15: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/15.jpg)
DECISION POINT BIS THE PATIENT IN SEVERE PAIN OR DISTRESS?
Is the patient currently in Pain?Pain intensity ratingChief complaintPMH, medicationsVS, physical assessment findings
Assign ESI level 2 if and only if:Self reported 7/10 or greaterAND
RN cannot intervene AND they require immediate intervention
Does this patient need your last bed?
![Page 16: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/16.jpg)
ESI LEVEL 2 PAIN EXAMPLES ? Kidney stone
Severe flank pain, vomiting Burn victim
Burns to both arms Oncology patient Possible dislocated shoulder
Rates pain 10+, diaphoretic, tearful ? Compartment syndrome
![Page 17: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/17.jpg)
IS THIS PATIENT IN DISTRESS?PHYSIOLOGICAL OR PSYCHOLOGICAL
Sexual assault victim Combative patient Homicidal/suicidal patient Bipolar patient who is manic Acute grief reaction Known alcohol use with head injury
![Page 18: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/18.jpg)
DECISION POINT C
![Page 19: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/19.jpg)
DECISION POINT CHOW MANY RESOURCES? Determined by the experienced ED RN
at triage Based on the standard of care Independent of type of hospital,
location, physician on duty, acuity of the department
![Page 20: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/20.jpg)
WHAT IS A RESOURCE?Resources: Labs ECG X-ray CT, MRI IV fluids IV, IM meds & nebs Specialty Consult Simple procedure=1(lac repair, foley cath) Complex procedure=2(conscious sedation)
Not Resources: History and Physical Pelvic Point of care testing Saline or heplock PO medications Tetanus shot Prescription refills Phone call to PCP Simple wound care Crutches, gel splints, slings
![Page 21: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/21.jpg)
ESI LEVEL 5 No Resources Examples
-Healthy 10y.o. with “poison ivy”-Healthy 52y.o. Who ran out of his
BP med recently-22y.o. involved in an MVC 2 days
ago, just wants to get checked-46y.o. with a cold
![Page 22: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/22.jpg)
ESI LEVEL 4 Stable, can safely wait for hours to be
seen Care by mid-level providers in a fast
track or urgent care setting Requires a physical exam and one
resource
![Page 23: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/23.jpg)
ESI LEVEL 4 Examples:
-Healthy 19y.o. with a sore throat and fever
-Healthy 29y.o. with a UTI, denies abdominal pain-Healthy 43y.o. with a stubbed toe-Healthy 12y.o. with a minor thumb laceration
![Page 24: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/24.jpg)
ESI LEVEL 3 30-40% of patients seen in the ED Need 2 or more resources Require in-depth evaluation Long length of stay Before assigning a patient to ESI level 3
the nurse must consider the patients vital signs
![Page 25: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/25.jpg)
DECISION POINT D
WHAT ARE THE PATIENTS VITAL SIGNS?
CONSIDER THE VITAL SIGNS:ARE THEY OUTSIDE OF THE ACCEPTABLE PARAMETERS FOR AGE?DO THEY FIT WITH ILLNESS, SUCH AS HR ELEVATED DUE TO FEVER?IF UNACCEPTABLE CONSIDER UP-TRIAGE TO ESI LEVEL 2
![Page 26: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/26.jpg)
ESI LEVEL 3, 4 & 5 EXAMPLES ESI level 3
Fractured ankleAbdominal painMost migraines
ESI level 4Sprained ankleAbscess
ESI level 5Toothache
![Page 27: Does the patient require immediate life saving intervention? Airway Obstructed or partially obstructed Unable to protect their own airway Breathing](https://reader033.vdocuments.net/reader033/viewer/2022061520/56649ebf5503460f94bca480/html5/thumbnails/27.jpg)
TRIAGE CASE
REVIEWS