Being A Triage Nurse

Triage

- Classifying victims according to the severity of the injury, urgency of treatment and place of treatment

- In an ER: classifying clients according to their need for care and establishing priorities of care, kind of illness, severity of illness and resources available

- Commonly used system: Three-Tier System

Triaging is done if there are more victims than health responders.

Reverse Triaging is done during Search and Rescue stage where the priority is to get as much people out of danger with the least effort.

 Triage Rating Systems

Five-Tier (Military Triage)

Victim is dead or will die

Emergent: life-threatening injuries but readily correctable

Urgent: victim must be treated within 1-2 hours

Non-urgent: Delayed; non-critical or ambulatory; victim has no injury and no treatment is necessary

No Injury

Four-Tier System

Immediate – Emergent; victim is seriously injured but has a reasonable chance of survival

Delayed – Non-Urgent; victim can wait for care after simple first aid

Expectant – victim is extremely critical and dying

Minimal – no impairment of function and can treat self or be treated by a non-professional

Three-Tier System – HEALTH CARE

Life-Threatening – Emergent – victim has life-threatening injuries but they are readily correctable

Urgent – victim must be treated within 1 – 2 hours

Non-Urgent – Delayed; victim has no injury, is non-critical or is ambulatory

Two-Tier System

Immediate:

victims who have life-threatening injuries that are readily correctable on the scene (emergent) and victims who must

be treated within 1-2 hours (urgent)

Delayed:

basically non-urgent; no injuries, non-critical injuries, are ambulatory are dying or are dead

Emergency Department Triage

Emergent (Red): Priority 1 *Highest Priority

life-threatening injuries; needs immediate attention, continuous evaluation; still possess a high probability for

survival once stabilized

Urgent (Yellow); Priority 2

Injuries have complications that require treatment but are not life-threatening; can be treated within 1-2 hours;

require continuous evaluation every 30-60 minutes

Non-Urgent (Green): Priority 3

classification given to clients with local injuries who do not have immediate complications and who can wait several

hours for medical treatment; requires evaluation every 1-2 hours

Emergent (Red)

trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, acute neurological deficits, chemical splashes to the eyes

Urgent (Yellow)

simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, client with renal stones

Non-Urgent (Green) – minor laceration, sprain or cold symptoms

THE PHILIPPINE NATIONAL RED CROSS
Community Health and Nursing Services

START (Simple Triage and Rapid Treatment)

The categories in START are:

-the deceased, who are beyond help

-the injured who could be helped by immediate transportation

-the injured with less severe injuries whose transport can be delayed

-those with minor injuries not requiring urgent care.

1st priority: Life-threatening- needs to be treated within 1-3 hours; Transport Immediately.

Example: obstruction/damage to airway, breathing disturbance (RR = 30/min or RR<10/min), Circulation disturbance (HR = 100/ min or weak pulses), altered level of consciousness, external bleeding with CVS collapse

2nd priority: Urgent- needs to be treated within 4-6 hours; Transport after Red Cases

Example: Major burns: involving hands, feet or face (excluding respiratory tract); complicated by major soft tissue trauma, spinal injuries; long bone or pelvic fractures, environmental injuries (heat/cold exposure)

3rd priority: Requires minor treatment or can be delayed, Transport after Red and Yellow

Example: Minor injuries not threatened by ABC instability, minor fractures, soft tissue injuries,minor burns

Last priority: Expectant- Dead or Non-salvageable given the available resources; Lowest transport priority

Example: Injuries so severe that survival cannot be expected even under the most ideal conditions; obviously

mortal wounds where death is certain, death or moribund state

THE TRIAGE TAG

Caring for the Deceased & Expectant Victims

Recognize the importance of family rituals and provide support to loved ones

Organ donation procedures of the health care agency need to be addressed if appropriate

Do initial care of the deceased, make sure to label the body for other members of the team to recognize

Clinical Assessment in the ER

Primary Assessment – to identify any client problem that poses an immediate or potential threat to life

E.G. – usage of ABCs

Secondary Assessment – follows primary assessment and after treatment for any problems identified

E.G. – full history taking and physical assessment

TRAUMA CARE

The Objectives

At the completion of this session you should:

Understand the priorities of trauma management

Be able to rapidly and accurately assess trauma patients needs

Be able to resuscitate and stabilize trauma patients

Know how to organize basic trauma care in your hospital/community.

Trauma in Perspective

BENEFITS

-the great distances over which casualties may have to be transported to reach

a medical facility

-the time taken for patients to reach medical care

-the absence of high-tech equipment and supplies

-the absence of skilled people to operate and service it.

PREVENTION

This depends on the location’s resources and factors such as:

culture

manpower

politics

health budget

training.

ABCDE of Trauma

The ABCDE survey (Airway, Breathing, Circulation, Disability and Exposure) is undertaken.

airway obstruction

chest injuries with breathing difficulties

severe external or internal hemorrhage

abdominal injuries.

Note: This primary survey must be performed in no more than 2–5 minutes.

Airway Management

Talk to the patient

Give oxygen (if available, via self-inflating bag or mask)

Assess airway

snoring or gurgling

stridor or abnormal breath sounds

agitation (hypoxia)

using the accessory muscles of ventilation/paradoxical chest movements

cyanosis.
need for advanced airway management
 persisting airway obstruction

penetrating neck trauma with haematoma (expanding)

apnea

hypoxia

severe head injury

chest trauma

maxillofacial injury.