Emergency Nursing and Triage Lecture

Vocabulary flashcards covering key emergency nursing, triage, assessment, and airway management terms from the lecture notes.

Triage

The rapid process of sorting and prioritizing patients according to illness or injury severity and urgency of care required.

Emergent (Three-Tier Triage)

Highest-priority category; patients need immediate treatment within minutes or they may die (e.g., airway compromise, severe bleeding).

Urgent (Three-Tier Triage)

Intermediate-priority; serious but not immediately life-threatening conditions that can wait up to 2 hours for care.

Non-Urgent (Three-Tier Triage)

Lowest-priority; non-life-threatening issues likely needing only one resource and able to wait >2 hours (e.g., dysmenorrhea).

Resuscitation – ESI Level 1 / Five-Tier Level 1

Requires immediate life-saving intervention (e.g., cardiopulmonary arrest, severe respiratory distress).

Emergent – ESI Level 2 / Five-Tier Level 2

High-risk or potentially life-threatening presentation needing rapid assessment and treatment (e.g., chest pain, stroke).

Urgent – ESI Level 3 / Five-Tier Level 3

Needs quick attention but can wait ≤30 min; likely to use two or more resources (e.g., fever, moderate pain).

Less Urgent – ESI Level 4 / Five-Tier Level 4

Can safely wait up to 1 hour; expected to require one resource (e.g., earache, chronic back pain).

Nonurgent – ESI Level 5 / Five-Tier Level 5

Can wait up to 2 hours; requires no resources other than exam (e.g., sore throat, menstrual cramps).

Emergency Severity Index (ESI)

Five-level triage tool that combines patient acuity with anticipated resource use to prioritize ED care.

Danger-Zone Vital Signs (ESI)

Abnormal vitals that may upgrade an ESI-3 patient to ESI-2 (e.g., RR, HR, BP outside age norms).

Pediatric Fever Rule (ESI)

Fever >38 °C in infants ≤28 days → ESI-2; consider ESI-2 for 1–3 mo if >38 °C; consider ESI-3 for 3 mo–3 yr if >39 °C or incomplete immunizations.

Simple Procedure (ESI)

One-resource intervention such as lac repair, simple wound dressing, Foley insertion.

Complex Procedure (ESI)

Two-resource intervention such as conscious sedation, chest tube insertion.

Color Code – Red (Immediate)

Priority I in mass casualty; life-threatening injuries needing urgent resuscitation within 2 hours.

Color Code – Yellow (Delayed)

Priority II; serious injuries requiring early treatment/ surgery but can wait up to 6 hours.

Color Code – Green (Minor)

Priority III; “walking wounded” with minor injuries who can self-aid or wait for care.

Color Code – Black (Expectant)

Priority IV; deceased or injuries incompatible with survival given available resources; provide comfort care.

Category I Obvious Emergency (Hospital)

Treatable life-threatening condition such as cardiac arrest, severe bleeding, shock.

Category II Strong Potential Emergency

Serious but not immediately life-threatening (e.g., burns without airway issues, multiple fractures).

Category III Potential Emergency

Possible evolving emergency (e.g., abdominal pain, high fever).

Category IV No Emergency

Minor conditions appropriate for outpatient care (e.g., mild URTI, sore throat).

Primary Survey (ABCDEFG)

First assessment sequence to find and manage life-threats: Airway/Alertness, Breathing, Circulation, Disability, Exposure, Facilitate adjuncts/Family, Get resuscitation adjuncts.

Airway Obstruction Signs

Dyspnea, inability to speak, gasping respirations, foreign body, facial/neck trauma.

Jaw-Thrust Maneuver

Airway-opening technique used when cervical spine injury is suspected; avoids neck hyperextension.

Rapid Sequence Intubation (RSI)

Preferred ED method for securing an unprotected airway using sedatives and paralytics in quick succession.

7 P’s of RSI

Preparation, Pre-oxygenation, Pre-treatment, Paralysis with induction, Protection (Sellick), Placement, Post-intubation management.

AVPU Scale

Simple neurologic check: Alert, responds to Voice, responds to Pain, Unresponsive.

Glasgow Coma Scale (GCS)

Neurologic tool scoring eye, verbal, and motor responses (3–15) to quantify level of consciousness.

Secondary Survey

Head-to-toe assessment after life-threats controlled, including vitals, history, and detailed exam.

SAMPLE History

Trauma mnemonic: Symptoms, Allergies, Medications, Past history, Last meal/menses/tetanus, Events/environment.

PQRST Pain Assessment

Provokes, Quality, Radiation, Severity, Time – systematic evaluation of pain characteristics.

MIVT Pre-hospital Report

Mechanism of injury, Injuries sustained, Vital signs, Treatment given prior to ED arrival.

Focused Assessment with Sonography for Trauma (FAST)

Bedside ultrasound to detect intra-abdominal or pericardial hemorrhage.

Targeted Temperature Management (TTM)

Controlled cooling (≈32–36 °C for ≥24 h) after cardiac arrest to improve neurologic outcomes.

Family-Focused Intervention

ED practice of keeping family informed, encouraging bedside presence, and supporting coping, especially after sudden death.

Expectant Care

Palliative focus for patients tagged black in mass casualty or deemed nonsurvivable given resources.

Rapid Diagnostic Turnaround

ED goal of providing lab or imaging results quickly to reduce time to diagnosis and treatment.

Optimal Nurse Staffing

Adequate number and skill mix of nurses to ensure safe, timely emergency care.

Code Blue

Hospital alert indicating adult cardiopulmonary arrest requiring resuscitation team response.

Sellick’s Maneuver

Cricoid pressure applied during RSI to minimize aspiration risk and improve glottic view.

Dangerous Mechanism of Injury

High-energy events (e.g., major trauma, head injury) that automatically escalate triage level due to high risk.

Compartment Syndrome

Limb-threatening condition of increased pressure within a closed muscle compartment requiring urgent recognition.

Battle’s Sign

Post-auricular bruising suggestive of basilar skull fracture.

Raccoon Eyes

Periorbital ecchymosis indicating anterior basilar skull fracture.

Time-Lapse Assessment

Reevaluation months after initial assessment to compare current status with baseline data.

Problem-Focused Assessment

Ongoing assessment targeting a previously identified issue (e.g., hourly urine output in ICU).

Emergency Assessment

Rapid evaluation during physiologic or psychological crisis to identify life-threats (e.g., ABCs in cardiac arrest).

Expectant Triage Tag (Black)

Indicates victim unlikely to survive; priority is pain relief and comfort measures.

Immediate Triage Tag (Red)

Indicates victim needs medical attention within 60 minutes to survive.

Delayed Triage Tag (Yellow)

Indicates serious injuries that can tolerate delayed transport and treatment.

Minor Triage Tag (Green)

Indicates minor injuries; patient likely ambulatory and stable.

Obstructed Airway – Complete

Total blockage preventing any air movement; brain injury or death occurs within 3–5 minutes without intervention.

Obstructed Airway – Partial

Incomplete blockage causing hypoxia and hypercarbia that can progress to respiratory and cardiac arrest if untreated.

Mass Casualty Incident (MCI)

Event in which patient volume exceeds available resources, necessitating altered standards of triage and care.

Get Resuscitation Adjuncts (LMNOP)

Labs, Monitor ECG, Nasogastric tube, Oxygenation assessment, Pain management – completed during primary survey.