Term
| What are some examples of triage cat 1 |
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Definition
-Multi-trauma
-unconscious &/or severe head injury
-status epilepticus
-extreme dysponea eg severe asthma or acute pulmonary oedema
-cardio-pulmonary arrest
-open chest wounds
-major burns- >10% full thickness
-severe haemorrhage |
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Term
| What are some examples of triage cat 2 |
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Definition
-Chest pain or other symptoms suggestive of myocardial ischaemia, PE or aortic dissection
-severe abdo pain or other symptoms suggestive of ruptured aortic aneurysm
-altered LOC
-Fever, rash, headache ect suggestive of sepsis or meningitis
-severe skeletal trauma (femoral fracture, dislocated knee, amputations ect)
-severe pain
-multiple fractured ribs
-fractured cervical spine
-acute spinal injury with neurological deficit
-eye injuries |
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Term
| What are some examples of triage cat 3 |
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Definition
-moderately severe pain not suggestive of critical illness
-severe laceration without active haemorrhage
-head injury with transient LOC
-PR/PV bleeding
-compound fractures without neurovascular compromise |
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Term
| What are some examples of triage cat 4 |
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Definition
-minor trauma (severe sprains)
-migraine headache (with history)
-Earache
-Gastroenteritis
-Colles fracture or simple fractures |
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Term
| What are some examples of triage cat 5 |
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Definition
-Chronic lower back pain
-URTI, flu
-dressings
-sprains
-rash |
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Term
| What is primary assessment |
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Definition
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Term
| What's involved in airway assessment? |
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Definition
observe for
-vocalisation
-tongue obstruction
-loose teeth or foreign objects
-bleeding
-vomitus or other secretions
-oedema |
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Term
| What are airway interventions |
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Definition
-position supine
-assume cervical spinal injury pressent until proven otherwise
-open and clear airway (jaw thrust/chin lift, removal of foreign bodies, suctioning), insertion of nasal or oral airway, consider intubation. |
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Term
| What's involved in breathing assessment? |
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Definition
Assess:
-spontaneous breathing
-chest rise and fall
-skin colour
-RR
-patterns of breathing
-soft tissue or bone injuries to chest wall
-use of accessory muscles
-bilateral breath sounds
-jugular veins and position of trachea |
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Term
| What are some breathing interventions? |
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Definition
Breathing present- O2 high flow mask (12-15L)
Breathing absent- +ve pressure ventilation, intubate, high flow O2.
Breathing ineffective: identify life threatening conditions |
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Term
| Examples of life threatening injuries that may compromise breathing: |
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Definition
Tension pneumothorax
open pneumothorax
flail chest with pulmonary contusion
hemothorax |
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Term
| What are some examples of life threatening injuries that may compromise airway? |
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Definition
partial or complete airway obstruction
obstruction by tongue
penetrating wounds
blunt trauma to larynx pr other upper airway structures |
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Term
| What is involved in circulatory assessment |
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Definition
-pulse quality, location and rate
-cap refill
-skin colour, temp and diaphoresis
-inspect for external bleeding
-assess LOC
-BP if adequate staff avaliable |
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Term
| What are circulatory interventions |
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Definition
no pulse: initiate CPR (BLS, ALS)
pulse ineffective: control external bleeding, recognise shock, 2 large bore cannulas, fluid replacement, transfer for definitive care or OT. |
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Term
|
Definition
response to bolus:
-rapid stabilization (<20% blood loss)
-transient response (20-40% blood loss, ongoing loss or inadequate fluid stabilization)
-No response (look for exsanguinating source, consider tamponade, myocardial contusion) |
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Term
| Examples of life threatening conditions in relation to circulation: |
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Definition
uncontrolled bleeding
shock from haemorrhage
massive burns
pericardial tamponade
direct cardiac injury |
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Term
| What's involved in disability assessment |
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Definition
AVPU (alert, responds to verbal, responds to pain, unresponsive)
Assess pupils for size, shape and reactivity to light
GCS |
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Term
| What are disability interventions |
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Definition
if decreased LOC conduct further assessment in secondary survey
if pt not alert or vocalising monitor for compromise to airway and breathing
if GCS <9 will need intubation
if GCS <13 consider transfer |
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Term
| What's involved in assessing exposure |
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Definition
| undress pt, maintain normothermia, warm fluids. After performing primary survey and correcting any life threatening conditions proceed with careful sexamination. |
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Term
| What is involved in secondary assessment? |
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Definition
-Obs, ECG, pulse oximetry, IDC, gastric tube, laboritory studies
-comfort measures (pain relief, verbal reassurance)
-History (allergies, meds, past illness, last meal, environment and events prior to injury)
-head to toe examination (inspection, auscultation, palpation) |
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Term
| What is tertiary examination |
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Definition
24hrs after admission
head to toe
collect and review results: xray, scan, blood tests |
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Term
|
Definition
-pedestrian hit >30km/hr
-MVC > 60km/hr
-Fall >3m
-kicked/fall from moving horse
-hanging
-thrown from vehicle
-thrown over handlebars of bike
-severe electrical shock
-diving injury
-direct force to head or neck
-multiple trauma
-significant injury above clavicles
-trauma and unexplained hypotension
-neck tenderness
-limitations of neck movement due to pain
-neurological deficit |
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Term
| NEXUS criteria for c-spinal injury clearance |
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Definition
fully alert- GCS 15
No posterior midline cervical spine tenderness
No motor or sensory deficit (weakness, numbness)
No evidence or intoxication |
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Term
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Definition
cat 1 (immediate)- definite danger to life (self or others)
cat 2 (10min)- probable risk of danger to self and others &/or physical restrained in ED &/or severe behavioural disturbances
Cat 3 (30min)possible danger to self, moderate behaviour disturbances, severe distress.
Cat 4 (60min)- moderate distress, semi-urgent mental health problem, under observation &/or no immediate threat to self or others
Cat 5 (120min)- no danger to self or others, no acute distress, no behavioural disturbances |
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