•1/3 of hospital care begins in the emergency department
• The majority of ED patients require immediate care
• In 2003, 114 million visits to Emergency Rooms occurred
• Since 1993, there has been a 14-percent decrease in the number of
Emergency Departments nationwide.
• In the 1990’s, hospitals lost 103,000 staffed inpatient
medical/surgical beds and 7,800 ICU beds.
• In 2004, nearly 70 percent of urban hospitals went on diversion to
ambulances citing lack of critical care beds.
American Hospital Association (2006). Prepared to care: The 24/7 standby role of America’s full service hospitals. Retrieved September
28, 2009 from http://www.aha.org/aha/research-and-trends/AHA-policy-research/PreparedToCareIndex.html
American College of Emergency Physicians (2004). Report from a roundtable discussion: Meeting the challenge of emergency
department overcrowding/boarding. Retrieved September 28, 2009, from
http://www.acep.org/workarea/downloadasset.aspx?id=34350
• Level One: Resuscitation – patients require immediate evaluation
and management
• Level Two: Emergent – patients require evaluation within 15
minutes for potential threats to life or limb
• Level Three: Urgent – patients have conditions that cause
significant discomfort and should be evaluated within 30-60 minutes
• Level Four: Less Urgent – patients do not require rapid
intervention, but should be evaluated within 60 minutes
• Level Five: Non-urgent – patients may be seen in a delayed
fashion and could be referred to other areas of the health care system
Prah Ruger, J., Lewis, L.M., & Richter, C.J. (2007). Identifying high-risk patients for triage and resource allocation in the
ED. American Journal of Emergency Medicine. 25, 794-798.
• Assessed while maintaining Cervical Spine
• Signs and symptoms of compromised airway
• Jaw Thrust Maneuver
• Causes
• Assessment
• Treatment
•
Central Pulse is Checked
• Color, Temperature, Moisture
AMS and delayed
capillary refill are the most
•
significant signs of shock
• 2 large bore IV’s with NS or LR
• Level of Consciousness
• Glasgow Coma Scale
• Pupil Size
Expose – remove all clothing (special consideration for forensics)
Full Set of Vital Signs
Family Presence
Five Interventions
Give Comfort
History and Head to Toe Assessment
 Trauma victims are
often victims or
perpetrators of crime
 Work
collaboratively with
law enforcement
 Maintain the chain
of evidence
• Blood type and cross
• Blood alcohol level
• Urine drug screen
• Pregnancy test
• What others can you think of ?
• X-Ray, CT, MRI
• Diagnostic Peritoneal
Lavage (DPL)
• Abdominal Ultrasound Focused Assessment with
Sonography for Trauma
(FAST)
Blood, crystalloids –NS or LR, volume expanders Hespan
Inotropic drugs after IV fluids
Dopamine, dobutamine, isoproterenol
Vasopressors
dopamine, epinephrine
Opioids - pain control
Tetanus prophylaxis
Antibiotics
Mannitol
• Atypical presentations
• Cognitive Impairment
• Co-morbidities
• Polypharmacy – Coumadin,
Beta-blockers, Anti-hypertensives
Hwang, U., Richardson, L.D., Sonuyi, T.O., & Morrison, R.S. (2006). The Effect of emergency
department crowding on the management of pain in older adult with hip fracture. Journal of the
American Geriatric Society. 54, 270-275.
 Crosses all socioeconomic and sociocultural barriers
 1.5 million women and 834,000 men treated at ED’s have been
battered by persons known to them
 Make referrals, provide emotional support, inform victims
about their options, ensure patient safety
 Suspected abuse of elders, persons with disabilities and
children MUST be reported by law. It is not an option to assume
the social worker or doctor will report.
 Assessments conducted in less
than 15
seconds…
 System of colored tags to determine seriousness of
injury and likelihood of survival
 Total number of casualties a hospital can expect is
estimated by doubling the number of casualties that
arrive in the first hour.
• Injury identification-rapid assessment at scene
• Penetrating injuries to abdomen, pelvis, chest, neck or
head
• Spinal cord with deficit
• Crushing injury to head, chest or abdomen
• Major burns
• Critical interventions
• providing life support, immobilizing the cervical spine,
managing the airway, and treating hemorrhage and shock
• Rapid transport-ASAP to regional trauma center
MIEMSS
A V P U
A V P U
A V P U
•
Patient Information
•
Triage Status
•
Tourniquet @ _______
Chief Complaint
Extremity Splint
Gauge
HOSP NOTIFIED
•
Transportation
•
Peel - off Bar Codes
•
Transport Record
•
Vital Signs
•
History
•
Treatment
PASG
Inflated at _______________
Gross Decon.
Final Decon.
TRIAGE TAG
Maryland Emergency
Medical Services
Maryland Department
of Transportation
• Major obvious injuries or illness can be circled
• Indicate injuries on the human figure
• Additional information is added on the comments line
• Paramedics
communicate with ED
• Brief report about client
with ETA
• Severity of condition
determines ED
response
• Champion Revised
Trauma Scoring
System
Nursing Diagnosis
• Ineffective airway clearance
• Altered tissue perfusion
• Impaired gas exchange
• Risk for infection
• Impaired physical mobility
• Spiritual distress
• Risk for post-trauma syndrome
• Risk for patients and caregivers
• Emotions range from fear, anger
denial and shock.
• May experience flashbacks and
nightmares
• Recognition of our own values and perceptions
• Need for evidenced based practice
• Continuing education through inservices and online training
• Department specific policies – no more than 8 hours in triage
• Use of a different triage ranking system such as ESI where
specific complaints are automatic level assignments