Triage Nursing

SANE Nursing

nurse that does forensics. Rape Kit for rape victims. Specialized training.

Trauma Center Level 1

Regional resource capable of providing highest level of trauma care

Trauma Center Level 2

Reside in community hospital and provides the vast majority of trauma care.

Trauma Center Level 3

Provides stabilization for lower level injuries and patient transfers for more complicated trauma.

Trauma Center Level 4

in remote settings patients are stabilized to the best degree possible and then transferred

Capnography CO2

Reflects Ventilation and Depicts Respiration, Should be used in conjunction with Pulse Oximetry

normal capnography

30-40 mmHg

SpO2

Reflects oxygenation

30 to 60 second lag in detecting apnea or hypoventilation

Should be used with capnography

Immediate Life Saving Measures

Airway

• Intubation

• Surgical airway (trach)

• CPAP, emergency BiPAP

• Bag Valve Mask Ventilation

Immediate Life Saving Measures

Spinal Cord Injuries

Cervical Spine Stabilization (1st then oxygenation/airway)

Other Immediate Life Saving Measures

Defibrillation

External Pacing

Chest needle decompression

Hemodynamics

• Significant IV fluid resuscitation

Blood administration

IV medications/Vasopressors/Anti-arrhythmic Rx

Control of major arterial bleeding

Overdose therapy

Vasopressors

act to increase blood pressure

examples:

Anti-arrhythmic

prevents/controls abnormal heart rhythms

Examples:

ESI level 1

Without Interventions Death will Occur

Resucitation

ESI Level 1

Cardiac/Respiratory Arrest

ESI Level 1

Overdose with a RR<8

ES1 Level 1

Severe Respiratory Distress with agonal or gasping respiration

ESI Level 1

Acute SOB with decreased oxygen sat. <90

ESI Level 1

anaphylactic shock with a BP< of 70 by palpation

ESI Level 1

Flaccid Baby

ESI Level 1

Gun Shot wound to the Abdomen with a BP<88 by palpation

ESI Level 1

Chest Pain, Pale, Diaphoretic

ESI Level 1

Dizziness, Recent LOC, HR=40/min

ESI Level 1

Unresponsive with a strong odor of ETOH

ESI Level 1

Severe stroke needing airway protection

ESI Level 1

Abnormal V/S

ESI Level 1

Examples of ESI Level 2

Emergent

Patient with Severe flank pain

ESI Level 2

Vomiting with a HX of renal colic

ESI Level 2

Patient with burns to both arms

ESI Level 2

Patient with a dislocated shoulder, pain rated as 10/10, diaphoretic, tearful

ESI Level 2

Psychiatric Patient who is screaming obscenities

ESI Level 2

Oncology patient with breakthrough pain

ESI Level 2

New onset of confusion in an elderly patient? Sepsis

ESI Level 2

Male with a known brain tumor whose wife/family reports confusion

ESI Level 2

Adolescent found confused and disorientated

ESI Level 2

3 month old who's parent report their baby sleeping all day

ESI Level 2

Reporting acute onset uni-lateral abdominal pain and is 6 weeks pregnant (ectopic pregnancy)

ESI Level 2

Abnormal VS

ESI Level 2

ESI Level 3

Urgent

30-40% of patients seen in the ED.

Require in-depth length of stay

Utilize 2 or more resources

Before assuming a patient is a Level 3 you must consider the patients vital signs (if significantly out of range, move them to ESI Level 2)

Fractured Ankle

ESI Level 3

Migraines

ESI Level 3

Abdominal Pain

ESI Level 3

Cold Manifestations

ESI Level 3

Rashes

ESI Level 3

Minor Injuries

ESI Level 3

ESI Level 4

Stable, Can safely wait hours to be seen. Care by mid-level providers in fast track or express care. Requires a physical exam and utilizes 1 resource

Healthy teen with sore throat and fever

ESI Level 4

Healthy female with a UTI, denies vaginal discharge

ESI Level 4

Healthy 45 year old ma, stubbed his toe and thinks it's broken

ESI Level 4

Healthy 12 year old with minor thumb laceration

ESI Level 4

Elder from SNF (skilled nursing facility) after accidentally pulling out G-tube

ESI Level 4

Abscessed Tooth

ESI Level 4

ESI Level 5

Non-urgent

Patient requires no resources

Physical exam

PO meds

Discharge Instructions

Tetanus Booster

Healthy 10 year old w/ poison Ivy

ESI Level 5

Healthy man who ran out his blood pressure meds. yesterday

ESI Level 5

Young adult involved in a car accident yesterday, but claims nothing hurts

ESI Level 5

Middle aged man who arrives for 3rd dose of rabies vaccines after a squirrel bite

ESI Level 5

# 1 reason people go the emergency room

Pain

#2 reason people go to the emergency room

Injury

ABCD

Airway, Breathing, Circulation, Disability

Signs of internal bleeding include:

Bruising, swelling, and pain over vital organs; painful, swollen, or deformed extremities

Collins Sign- bruising around the umbilicus

Signs of shock

Decreased blood pressure; rapid, weak pulse; mottled to gray skin color; changes in mental status

hypothermia symptoms

Change in mental status

Shivering

Cool abdomen

Low core body temperature

Hypothermia interventions

Goal is to stop further heat loss. Passive warming done first (remove patient from cold environment, remove wet/cold clothing, turn up heat, warm blankets). Active rewarming (hot packs on armpits and groin, warm IV fluids)

hyperthermia (heat stroke)

A life-threatening condition in which core body temperature increases beyond normal limits in an uncontrolled manner

Heat Stroke Interventions

Prehospital

ABC

Rapid cooling after ensuring patent airway

Hospital Care

Oxygen therapy

IV NS

Aggressive cooling and core temperature monitoring

Foley catheter to monitor I&O

Labs

Muscle relaxant if shivering occurs

Slow cooling interventions when core temp is 102

AVPU-

A-Alert?

V-Responsive to Voice? Verbal

P- Responsive to Pain?

U-Unresponsive

EFGH Secondary Survey

E: Enviorment/Expose- unwrap and expose, looking for obvious external trauma.

F:Fahrenheit: Assess body temperature. Hypothermia?

G: Get Vitals, Quick Set

H:History-Present History-Events related to current events

Shock symptoms

-Pale, Cold, Clammy Skin

-Rapid Pulse, Low BP

-Increased, Shallow Breathing Rate

-Expressionless Face/Staring Eyes

Helical (Spiral) CT

In one breath hold, the tube can go all the way around the patient and get a scan. Shows small densities in the the thoracic region

Normal pH of blood

7.35-7.45

Normal PCO2

35-45

Normal HCO3

22-26

Normal SaO2

95-100%

A patient asks why he is being put on heparin?

Heparin will help prevent any new clots from developing

Normal PTT range

25-35 seconds

To be therapeutic and effective, you want it to be at least 1.5-2.5 X the normal.

Is Trauma gun shot wounds mandatory to report

Yes

Nursing interventions for gun shot/chest wound

Set up a thoracotomy tray and chest drainage system in trauma room.

Prepare blood warmers and patient warming lights.

Have intubation equipment ready

Make sure high-flow IV tubing is present with 0.9% NACL

Set up arterial line and Central Venous Cath.

Set up Nasogastric tube (NGT) and urinary catheter insertion; ensure suction is working.

What do you have to do to blood if you are giving it fast?

Warm it up, better received by the body

1 unit of blood raises the HGB/HCT how much?

1g/3%

elevated D-dimers can be due to...

thrombosis, PE, DVT