TRIAGE

 TRIAGE Triage is the process of determining the priority of patients' treatments by the severity of their condition or likelihood of recovery with and without treatment. In the Emergency department, sequence of treatment of patients is determined by patient’s triage category and not first cum first serve basis. In case of large number of patients and longer waiting times, periodic reassessment & re-triaging of patients is important.  Triage categories: RED, YELLOW & GREEN RED   First priority   Require immediate assessment & care  Compromised primary survey A - Noisy breathing/ Stridor/ Pooling of secretions       Angioedema involving face B - RR < 10 or > 24/minute, SpO2 < 94% Increased work of breathing , audible wheeze C - HR < 50 or >120 (without fever)        SBP < 90 or >200 , DBP >110       Shock index (pulse rate/SBP >1)        Presence of active bleeding D – GCS < 13 ; Responding only to Pain or Unresponsive        Patient with ongoing seizure Time sensitive Emergencies  Acute Chest Pain < 24hr duration (?ACS)  Suspected Stroke < 24 hr (in window period)  Drowning/hanging/electrocution/ trauma with dangerous mechanism of injury  Acute limb ischemia <48 hr duration  Acute scrotal/inguinal pain in Young male  Sudden onset abdominal pain or pain with vaginal bleeding  Toxin ingestion / Bites & stings   Any evaluation suggestive of Sepsis  Pregnancy in third trimester with pain abdomen or bleeding per vagina  Severe pain anywhere in body (Pain score >7)  H/o syncope  Sudden onset severe headache (?SAH)  Agitated/ violent patient  Acute urinary retention  Fever Temperature > 39oC with any one of - Aplastic Anaemia - Acute Leukaemia - H/o Chemotherapy in last 14 days  Outside reports of S.Potassium > 5.5mEq/L  Priority Red  even without above criteria AIIMS EHS patient YELLOW  Second Priority   Require emergent care, however can withstand some delay in comparison to Red triaged patients Stable primary survey  Patent Airway  RR 10 to 24/min ; SpO2 > 95%  SBP >90  without tachycardia or bradycardia  GCS >13  Vulnerable population / Risk for early deterioration  Patients with stable primary survey with   Chronic Liver disease  Chronic Kidney disease  Uncontrolled Diabetes Mellitus  h/o Fever with Immune suppression  Post ictal patient  Elderly or paediatric or pregnant patient  Persistent vomiting/ decreased urine output  GREEN  Require minimum or OPD based care  Patients with stable primary survey  & No risk factors for deterioration 

Sample Format for initial documentation in the Emergency Medicine case sheet                         Case Seen by Dr ABC (Write your Name & Designation) Date & Time at which patient is examined  Previous known co-morbid illness of the patient  Chief complaint of the patient (with duration) Primary Survey (with steps for stabilisation) A-Airway:  Patent/ Threatened/Obstructed  intervention B-Breathing RR:      SpO2                        Bilateral Air Entry C- Circulation Pulse rate:  /min (Regular. Irregular)                           BP:          Capillary refill time/ peripheral perfusion D- Disability GCS E V M     If any Focal neurologic deficit present     Pupil examination/ meningeal signs/plantar reflexes E- Exposure Temperature                      Salient Head to examination findings   Brief history as per the presenting complaint   Relevant Negative history  Relevant focussed systemic examination finding POC Investigation  Write the investigation sent with Time at which sent   Mention salient investigation findings such as ECG, Blood gas findings   RBS Instructions regarding shifting the patient to specific area as per triage category Yellow/ Red & handover note Consultations if informed any with time at which informed Documentation of Emergency Treatment advised/given 1) Inj. Paracetamol 1g i.v.  stat  Number the drugs  Mention the name of the medication, formulation, dose and route  of administration clearly Mention if any other intervention done such NG lavage, Foleys catheterisation etc     Other specific documentation Ex: Blood product arrangement, important investigation to be reviewed etc   *If Patient has any known allergies to any specific drug mention on the front sheet in Capital letters   

Assessment of a patient with Chest Pain in ED Salient history to be taken Salient clinical examination Point of care Investigation Basic initial management  Site of pain – Localised or not  Onset & duration of pain  Radiation of pain: Jaw, arm, epigastrium, neck, back, Inter-scapular region  Aggravating factors: Exertion, post prandial  Relieving factors: Rest, Medication  Associated- Nausea, vomiting, sweating, palpitation, syncope, any limb weakness  H/o Recent surgery/ immobilisation /any limb swelling/ prolonged travel/ trauma  H/o Fever/ cough/ expectoration, breathing difficulty/ Hemoptysis  Co-morbid illness: Diabetes, Hypertension, Coronary artery disease, Chronic Kidney disease, Malignancy  Medication history: Patient previously continuing & medications if any given at the referring healthcare facility  Compete primary assessment   Measure Blood pressure in both upper limbs  JVP, Pedal oedema  Chest auscultation to look for air entry, wheeze, crepitation  Cardiac auscultation for any systolic murmur  Quick Neurologic assessment to look for limb weakness, slurring of speech Investigations to be done based on probable clinical diagnosis. “*” marked investigations to be discussed with Senior Resident before proceeding.   Expedite ECG (within 10 minutes of patient presentation to ED)   Point of care USG – Lung & cardiac & vascular USG  Baseline CBC & Renal function Test  Blood gas (when indicated clinically)  Troponin I*  D- dimer*  Chest X-ray *Always discuss with the Senior Resident on shift before proceeding with any of the following management  Shift to Red area if Red flags present  Loading dose of medications: Tab Aspirin 325mg Tab Clopidogrel 300mg Tab Atorvastatin 80mg  Tab Sorbitrate 5mg  sublingual stat  Refer “medications in ED” section at page no. 31 for contraindications and other details   RED FLAG SIGNS  Patient has associated profuse sweating/ persistent vomiting  Unstable primary assessment  ECG Showing ST elevation or depression in any leads