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Triage Manual
Cassandra McAvoy
Bryant & Stratton College
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Table of Contents
Topic
Page No.
Anaphylactic Reaction
4
Bleeding, Severe with Open Wound
5
Broken arm, probable
5
Burn, second degree
6
Chest Pain, Severe
7
Confusion, disorientation & slurred speech
8
Facial Paralysis, Partial
8
Fainting
9
Seizures, Myoclonic
9
Unresponsive, No pulse, No respirations
10
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Table of Severity
Severity
Topic
1
Unresponsive, No pulse, No respirations
2
Anaphylactic Reaction
3
Severe Chest Pain
4
Severe Bleeding with Open Wound
5
Confusion, disorientation & Slurred speech
6
Partial Facial Paralysis
7
Myoclonic Seizures
8
Second degree burn
9
Fainting
10
Probable broken arm
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Actions Taken to Control an Emergency
Some actions that are needed during an emergency are if the patient is conscious try
getting information about symptoms to try and identify the problem. Always check for a
universal emergency medical identification symbol, which is usually accompanied by an
identification card which tells you what life threaten health problems the person has. Observe the
patients skin color, size and dilation of the pupils. Also make sure to check pulses and blood
pressures. Always make sure (Lindh, Pooler, Tamparo, Dahl, Morris, 2014).
Anaphylactic Reaction
Immediate Actions of the Medical Assistant
If someone is having an anaphylactic reaction the medical assistant’s first action is to ask
if he or she is carrying an epi pen to treat the reaction. Have the person lie still on their back and
loosen any tight clothing they have on. Cover the person with a blanket and don’t give them
anything to drink. Apply CPR if the person is not responsive. Seek further emergency treatment
after an episode of anaphylaxis because it’s possible for it to recur (Mayo Clinic Staff 2015).
Assess the Equipment, Supplies and Medication Necessary
Equipment that is needed during the event of someone having anaphylactic reaction
would be a blood pressure cuff and stethoscope. Epinephrine will be needed and also gloves
while handling the patient. (Lindh, Pooler, Tamparo, Dahl, Morris, 2014).
Post Emergency Patient Education
Anaphylaxis is a severe disorder that can be life-threatening without prompt treatment.
Symptoms usually get better with the right therapy, so it is important to act right away. A
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medical assistant could inform the patient he or she needs to wear an identification bracelet and
to get a good epi pen that is not expired (U.S. National Library of Medicine. 2015).
Bleeding, Severe with Open Wound
Immediate Actions of the Medical Assistant
In the case someone is bleeding severely with an open wound any dirt or debris should be
removed from the wound. Never remove larger, deeply embedded objects from someone.
Immediately stop the bleeding by applying pressure, once cleaned have person lie down and
apply a bandage or tourniquet if necessary. Make sure to immobilize the part of the body that is
injured once bleeding has stopped (Mayo Clinic Staff 2015).
Assess the Equipment, Supplies and Medication Necessary
For a severe bleeding open wound the medical assistant would need to use gauze or a
bandage. Also they may need to use a tourniquet. Sterile bandages are going to be needed along
with a clean cloth. Also they may need a clean dressing and sterile gloves (Mayo Clinic Staff
2015).
Post Emergency Patient Education
The medical assistant should instruct the patient to keep sharp objects or knives
away or locked up. Also to keep them away from children, and to stay up to date with
vaccinations like the tetanus immunization. The patient should be instructed to keep the wound
clean with antibiotic creams and to change the sterile dressing daily (U.S. National Library of
Medicine. 2015).
Broken arm, probable
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Immediate Actions of the Medical Assistant
Standard care for someone who has a broken arm is to keep the person still and calm and
examine them for any other injuries. If the skin is broken it should be treated right away to
prevent infection. Also if needed stabilize the broken limb with a splint or sling, and apply an ice
pack to reduce pain and swelling. The medical assistant should also check the blood circulation
to reduce damage to tissues from lack of blood (U.S. National Library of Medicine. 2015).
Assess the Equipment, Supplies and Medication Necessary
Equipment necessary or that could be used for a broken arm could be a sling or splint.
Also an ice pack could be needed and possibly sterile bandages or solution. Gloves will be
needed along with a sterile drape. Meds like Tylenol, and Advil may also be needed (U.S.
National Library of Medicine. 2015).
Post Emergency Patient Education
Post patient education in this case would be to inform the patient to wear protective gear when
doing or participating in contact sports. If young children are getting hurt protect the home by
putting up gate and keeping windows closed. Also instruct the patient to keep the cast elevated to
reduce swelling for 24-72 hours. Tell them to never put anything down the cast and to keep water
out of the cast to prevent the skin from getting infected. (U.S. National Library of Medicine.
2015).
Burn, second degree
Immediate Actions of the Medical Assistant
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Immediate action that should be taken for a second degree burn is to cool the burn to help
soothe the pain, remove any jewelry from burned area, and never break open the blisters. The
medical assistant could apply aloe vera lotion or gel, or a small amount of hydrocortisone cream
to the burned area with a sterile dressing (Mayo Clinic Staff 2015).
Assess the Equipment, Supplies and Medication Necessary
The medical assistant may need to use a sterile towel and nonstick sterile bandages. They
may also need Aleve, Advil, or Motrin. (Mayo Clinic Staff 2015).
Post Emergency Patient Education
The medical assistant should inform the patient be careful around hot surfaces and to
keep the pans with handle on them facing inward on the stove to prevent spilling. They should
also tell them to check the smoke detectors in the house frequently and to keep lighters and
flammables out of reach of children. The patient should be instructed to change the sterile
dressing daily and to keep antibiotic creams on the wound (U.S. National Library of Medicine.
2015).
Chest Pain, Severe
Immediate Actions of the Medical Assistant
The MA should ask questions like where the pain is, on a scale how would they describe
the pain, and how does it happen or appear. Also find out how long the pain lasts, and make sure
to ask the patient if they have taken any angina meds like nitroglycerin or any antacids. Also the
MA will need to monitor the vital sings of the patient (U.S. National Library of Medicine. 2015).
Assess the Equipment, Supplies and Medication Necessary
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Very limited supplies are needed for someone with chest pain although the medical
assistant should use gloves and have a stethoscope and blood pressure cuff handy. Nitro might be
needed if they have not taken some already, and chewable aspirins (U.S. National Library of
Medicine. 2015).
Post Emergency Patient Education
Post emergency care should be to check up with his or hers physician, and to take any
heart meds they may have or look into getting some. Tell the patient about any symptoms they
may experience so they can try to catch it a head of time. Inform the patient they will have to
make lifestyle changes like stopping smoking or changing diets (U.S. National Library of
Medicine. 2015).
Confusion, disorientation & slurred speech
Immediate Actions of the Medical Assistant
When someone comes in who is having a stroke the MA should react quickly and
remembering to use FAST. FAST standing for face; does the face drop on one side while trying
to smile, arms; is one arm lower than the other, speech; can a sentenced be repeated without
strange or being slurred, and time; because every minute counts. As the MA vital sings should be
monitored (Mayo Clinic Staff 2015).
Assess the Equipment, Supplies and Medication Necessary
Supplies needed would be a blood pressure cuff and stethoscope (Mayo Clinic Staff
2015).
Post Emergency Patient Education
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The patient should be told to take post stroke rehabilitation to relearn any skills lost due
to the stroke. The patient should also be informed as to what a stroke really is by telling them
that a stroke is when the brain can’t get enough blood flow. (U.S. National Library of Medicine.
2015).
Facial Paralysis, Partial
Immediate Actions of the Medical Assistant
The medical assistant should ask if both sides of the face have been affected and if he or
she has recently been sick or injured. Also they should ask if they have had any symptoms like
drooling or excessive tears from the eyes. The medical assistant should also monitor vital sings.
(U.S. National Library of Medicine. 2015).
Assess the Equipment, Supplies and Medication Necessary
Gloves should be worn by the medical assistant while accessing the patient. A blood
pressure cuff is needed along with a stethoscope (U.S. National Library of Medicine. 2015).
Post Emergency Patient Education
Post care should be to take any medications instructed by the doctor. Patient should also
be informed of warning signs of a stroke which are sudden numbness in the face, arms, or legs.
Also sudden confusion or blurred vision are signs of a stroke (U.S. National Library of Medicine.
2015).
Fainting
Immediate Actions of the Medical Assistant
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The medical assistant should take the blood pressure of the patient and keep them calm
and relaxed. Also they should check the patient for heart arrhythmias (U.S. National Library of
Medicine. 2015).
Assess the Equipment, Supplies and Medication Necessary
A blood pressure cuff will be needed along with a stethoscope and gloves. Smelling salt
will also be needed (U.S. National Library of Medicine. 2015).
Post Emergency Patient Education
Instruct the patient to avoid doing things they know will trigger them to faint, also to get
up slowly from a sitting or laying position to prevent from fainting (U.S. National Library of
Medicine. 2015).
Seizures, Myoclonic
Immediate Actions of the Medical Assistant
The medical assistant should immediately protect them from injury, and don’t restrict
them. Also in a warm quiet room making sure the patient is at ease. Also the medical assistant
should never put anything in the patient mouth (Mayo Clinic Staff 2015).
Assess the Equipment, Supplies and Medication Necessary
Gloves may be needed along with some seizure medications or injections to relive any
symptoms (Mayo Clinic Staff 2015).
Post Emergency Patient Education
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Post emergency patient education should be to use therapies like injections, and to further be
checked out by a referred doctor. The patient should be taught on what a seizure is by telling
them that a seizure is an uncontrolled activity of the brain (Mayo Clinic Staff 2015).
Unresponsive, No pulse, No respirations
Immediate Actions of the Medical Assistant
Immediately look for responsiveness, if there is no responses perform CPR after laying
the person on their back. Open the airway and check the chest for movement (U.S. National
Library of Medicine. 2015).
Assess the Equipment, Supplies and Medication Necessary
An AED will be needed along with the regular PPE’s. Also needed will be a blood
pressure cuff and stethoscope.
Post Emergency Patient Education
Patient post emergency education should be to avoid activities that can cause or lead to
cardiac arrest. Exercise should be cooperated into the patient’s daily routine and should be
referred to see a doctor regularly. Also to avoid using any illegal drugs. A heart attack is similar
and happens when the vessels in the heart become blocked (U.S. National Library of Medicine.
2015).
Scope of Practice of the MA in the Emergency
As a medical assistant my scope of practice allows me to give vital signs, perform ECG’s, taking
laboratory specimens and blood work. In my scope of practice as a Medical Assistant I can make
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sure the patient is comfortable and relaxed and apply any bandages to wounds that may need it.
Making sure to keep the patient calm until the doctor or physician has arrived (American
Association of Medical Assistants. 2015).
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References
American Association of Medical Assistants. (2015). State Scope of Practice Laws. Retrieved
from: http://www.aama-ntl.org/employers/state-scope-of-practice-laws
Lindh, W.Q. Pooler, M.S. Tamparo, C.D. Dahl, B.M. Morris, J.A.(2014). Delmar’s
Comprehensive Medical Assisting Administration and Clinical Competencies(5th).
Clifton Park, NY: Cengage Learning.
Mayo Clinic Staff (2015). First aid. Retrieved from: http://www.mayoclinic.org/first-aid/firstaid-severe-bleeding/basics/art-20056661
U.S. National Library of Medicine. (2015). First aid. Retrieved from:
http://www.nlm.nih.gov/medlineplus/ency/article/000045.htm