Triage Priority Wang, Tzong-Luen, MD, PhD, FESC, FACC.

Triage PriorityTriage PriorityTriage PriorityTriage PriorityWang, Tzong-Luen, MD, PhD, FESC, FACCWang, Tzong-Luen, MD, PhD, FESC, FACC

Class I Class I (( 立即處理立即處理 ))• 意識程度下降• 生命現象：

– 收縮壓： <80mmHg或 >220mmHg– 心跳： >150bpm或 <50bpm– 呼吸： >30rpm或 <8rpm– 體溫： >41℃或 <32℃

• 內科：異物阻塞 ;已插氣管內管或胸管者 ;呼吸窘迫 ;發紺 ;心因性胸痛 ;正在抽搐 ;內出血併生命現象不穩定者

• 外科：外傷出血無法控制者 ;大於 5cm的開放性傷口 ;疑呼吸道(顏面 )灼傷 ;電灼傷 ;化學性灼傷 ;三度 TBSA>10 ;﹪ 二度TBSA>15 ;﹪ 骨盆或股骨骨折 ;開放性骨折 ;疑頸椎骨折 ;頭部嚴重畸形 ;腦組織外露 ;內臟外露 ;皮下氣腫 ;胸腹開放性傷口 ;毒蛇 ;虎頭蜂咬傷 ;槍傷或穿刺傷

• 婦產科：急產 ;性侵害• 精神科：攻擊性行為

Class II Class II (( 十分鐘內處理十分鐘內處理 ))• 生命現象：

– 收縮壓： 180-220mmHg– 呼吸： 20-30rpm– 體溫： 39-41℃或 32-35℃

• 內科：呼吸喘 ;呼吸困難 ;胸痛原因不明者 ;疼痛併嚴重症狀者 (劇痛、臉色蒼白 );暈眩 (Vertigo);突發性神經症狀 ;內出血併HR>100bpm;吐血 ;嘔吐、腹瀉、脫水致 HR>100bpm

• 外科：小於 5cm的開放性傷口 ;疑有骨折 ;關節腫脹 ;疑頭骨骨折 ;其他昆蟲、動物咬傷 ;急性尿滯留 (>6小時 )

• 精神科：自殺行為或傾向• 眼科：眼內異物• 耳鼻喉科：耳鼻喉道內異物

Class III Class III (( 三十分鐘內處三十分鐘內處理理 ))

• 生命現象：– 體溫： 38-39℃

• 內科：抽搐已停止者 ;疼痛但無嚴重症狀者 ;頭暈(dizziness);血便、黑便、咳血但生命徵象穩定者 ;嘔吐、腹瀉但生命徵象穩定者 ;疑似或輕微中風

• 外科：無傷口之軟組織傷害 ;動物抓傷 ;血尿 ;尿路結石 ;解尿困難

• 精神科：失眠

Class IV Class IV (( 可延後處理可延後處理 ))• 不符合急診以上條例，如：

– 頭痛、喉痛、咳嗽、流鼻水等感冒症狀。– 中風後遺症。– 中風已數日，在別處已處理過，來本院等住院者。– 已知癌症的病患，其主訴顥然與癌症有關者，且生命徵象正常。

– 自門診轉來做常規檢查的治療者。– 自門診轉來等住院者，但生命徵象正常者。– 主訴某種症狀已有相當時日，但生命徵象正常者。

大量傷患分類

一、極危險、第一優先一、極危險、第一優先 (( 紅紅色色 ))

1. 呼吸停止或呼吸道阻塞。2. 被目擊的心臟停止。3. 動脈斷掉或無法控制之出血。4. 穩定性的頸部受傷。5. 嚴重的頭部受傷且意識昏迷。6. 開放性胸部或腹部傷害。7. 大型或併發性燙傷。8. 嚴重休克。9. 呼吸道燙傷或灼傷。10.壓力性氣胸。11.內科醫療疾病的併發症。12.關節骨折且遠端無脈搏。13.股骨骨折。

二、危險、第二優先二、危險、第二優先 (( 黃色黃色 ))1. 背部受傷 (不論是否有脊椎受傷 ) 。2. 中度的流血 (少於二處 ) 。3. 嚴重燙傷。4. 開放性或多處骨折。5. 穩定的腹部傷害。6. 眼部傷害。7. 穩定性的藥物中毒。

三、輕傷、最低優先、延後處三、輕傷、最低優先、延後處理理 (( 綠色綠色 ))

1. 小型的挫傷或軟組織傷害。2. 小型或簡單型骨折。3. 肌肉扭傷。4. 凡是由於受傷過於嚴重 (如：頭部外傷且腦組織外露，三級灼傷且超過體表面積百分之四十以上 )且存活機會不太大者。

四、死亡四、死亡 (( 黑色黑色 ))1. 頭部不見。2. 沒有脈搏超過二十分鐘，除了冷水溺水或極度低體溫者。

3. 軀幹分離。4. 從高度落下且具有多處的受傷與骨折，沒有呼吸者。

5. 肉臟外脫。

Triage Decision Triage Decision Scheme (Trauma)Scheme (Trauma)

• STEP 1: Measure Vital Signs and Level of Consciousness– GCS<14– RR<10 or >29– SBP<90– RTS<11– PTS<9

Triage Decision Triage Decision SchemeScheme

• STEP 2: Anatomic and Physiologic Approach– Flail chest– Two or more proximal long-bone fractures– Amputation proximal wrist/ankle– All penetrating trauma to head, neck, torso, and

extremities proximal to elbow and knee– Limb paralysis– Pelvic fractures– Combination trauma with burns


• STEP 3: Trauma Mechanisms– Ejection from auto– Death in same passenger compartment– Pedestrian thrown or run over– High-speed auto crash

• Initial speed >40mph (64 kph)• Major auto deformity >20 inches (50cm)• Intrusion into passenger compartment >12 inches (30cm)• Extrication time > 20 minutes• Falls > 20 ft• Roll over• Auto-pedestrian injury with > 5mph (8kph) impact• Motorcycle crash > 20 mph (32 kph) or with separation of rider and

bike


• STEP 4: Underlying Conditions– Age <5 or >55 – Pregnancy– Immunosuppressed patients– Cardiac disease; respiratory disease– Insulin-dependent diabetes; cirrhosis;

morbid obesity; coagulopathy

Revised Trauma Revised Trauma ScoreScore

• Respiratory Rate– 10-29 score 4 – >29 score 3– 6-9 score 2– 1-5 score 1– 0 score 0


• Systolic BP– >89 score 4 – 76-89 score 3– 50-75 score 2– 1-49 score 1– 0 score 0


• GCS Score Conversion– 13-15 score 4 – 9-12 score 3– 6-8 score 2– 4-5 score 1– <4 score 0

Pediatric Trauma Pediatric Trauma ScoreScore

• Weight– >20Kg (44 lb) score +2 – 10-20Kg (22-44 lb) score +1– <10 Kg (22 lb) score –1

• Airway– Normal score +2– Oral or nasal airway; O2 score +1– Intubated; cricothyroidtomy score –1 tracheostomy


• Systolic Blood Pressure– >90mmHg; good peripheral pulse; score +2 perfusion– 50-90mmHg; carotid/femoral score +1 pulses palpable– <50mmHg; weak or no pulses score –1

• Level of Consciousness– Awake score +2– Obtunded or any LOC score +1– Coma; unresponsive score –1


• Fracture– None seen or suspected score +2 – Single, closed score +1– Open or multiple score –1

• Cutaneous– None visible score +2– Contusion, abrasion; laceration score +1

<7cm; not thru fascia– Tissue loss; any GSW/SW; score –1

thru fascia

Detailed Adult Detailed Adult CriteriaCriteriaGCS < 12 = RED

AIRWAY

ACTIVE airway assistance required (i.e., more than supplemental O2 without airway adjunct)

Sustained respiratory rate > 30

Detailed Adult Detailed Adult CriteriaCriteria

CIRCULATION

No radial pulse AND heart rate > 120

OR

BP < 90 systolic

Sustained heart rate > 120 with radial pulse and BP > 90 systolic


BEST MOTOR RESPONSE

BMR < 4

OR

Paralysis, loss of sensation, suspicion of spinal cord injury

BMR = 5

Detailed Adult CriteriaDetailed Adult Criteria

CUTANEOUS

Amputation proximal to wrist or ankle

OR

> 15 % BSA 2nd and 3rd degree burns

OR

Penetrating injury to head, neck, torso, excluding superficial wounds

Degloving injury or flap avulsion > 5 inches


LONGBONE FRACTURE

Multiple longbone fracture sites

Single longbone fracture site due to MVC

OR

Single longbone fracture site due to fall from > 10 feet


AGE

Age > 55

MECHANISM OF INJURY

Ejection from vehicle (excludes open vehicles)

OR

Driver with deformed steering wheel

Notes on Peds CriteriaNotes on Peds Criteria• Applicable to age 15 or less• Size component is based on Broslow color

zone or weight• Any airway maintenance beyond

supplemental O2 and one-time need for suctioning = RED

• Any altered mental status other than amnesia = RED criteria

• Paralysis, loss of sensation, or suspicion of spinal cord injury = RED criteria under “Consciousness” category

Notes on Peds Notes on Peds Criteria (cont.)Criteria (cont.)

• Any reliable hx of LOC = BLUE• Fracture criteria are also based on

longbones (same as adults).• Open long bone or multiple

longbone fx/dislocations = RED • > 10 % BSA 2nd and 3rd degree

burn = RED

Detailed Peds CriteriaDetailed Peds Criteria

SIZE

Weight < 10 Kg (< 22 lbs..) or RED or PURPLE Broslow Tape Zone

AIRWAY

ACTIVE airway assistance required (i.e., more than supplemental O2/one-time suctioning without airway adjunct)

Detailed Peds Detailed Peds CriteriaCriteria

CONSCIOUSNESS

Patient not awake and appropriate

OR

Paralysis, loss of sensation, or suspected spinal cord injury

Amnesia

OR

Reliable history of loss of consciousness

Detailed Peds CriteriaDetailed Peds Criteria

CIRCULATION

No palpable pulsesOR

Weak carotid or femoral pulseOR

Systolic BP < 50

Good carotid or femoral pulse with absent distal pulses

OR

Systolic BP 50-90


LONGBONE FRACTURE

Any open longbone fracture

OR

Multiple closed longbone fracture sites or dislocations

Single closed long bone fracture site


CUTANEOUS

Degloving injury, major flap avulsionOR

Amputation proximal to wrist or ankleOR

> 10% BSA 2nd and 3rd degree burnsOR

Penetrating injury to head, neck or torso

Practice Case #1Practice Case #1• 68 yo female

pedestrian struck• GCS 14, BMR 5• Patent airway• HR 100, BP

120/94, RR 20• Abrasions• Unstable pelvis

BLUE

BLUE

POSITIVE

TRAUMA

ALERT

Practice Case #2Practice Case #2• 21 yo male• Stab wound to left

chest• Airway patent• GCS 15• BS on left• BP 90/P, HR 130

RED

RED

POSITIVE TRAUMA ALERT

Practice Case #3Practice Case #3• 4 year old near-

drowning in pool• No signs of trauma• Intubated• Normal skin signs• Normal brachial

pulse• Responsive to deep

pain

Drowning is not considered trauma

unless injury accompanies it!

Practice Case #4Practice Case #4• 6 yo female fell 10 ft.

from tree• 22 kg weight• amnestic for event,

o/w alert• airway patent• obvious closed

forearm fx• nl vital signs

BLUE

BLUE


Practice Case # 5Practice Case # 5• 6 month old male

(purple)• child abuse• multiple cigarette

burns & contusions• abdomen rigid• strong palpable

carotid pulse only• does not cry with

exam

BLUE

BLUE

RED


Trauma BlueTrauma Blue1. Glasgow Coma Scale <14 2. Systolic Blood Pressure <90 3. Respiratory rate <10 or >29 4. Revised Trauma Score <11 5. Pediatric Trauma Score <9 6. Penetrating injuries to: head, neck, torso, and/or

extremities proximal to the knee and/or elbow 7. Flail Chest 8. Combination Trauma with burns or inhalation injury 9. Two or more proximal long bone injuries 10. High energy pelvic fractures 11. Limb paralysis 12. Amputation proximal to the wrist or ankle13. Trauma patient pregnant past 2nd trimester

Another Example

Trauma BlueTrauma Blue1. Ejection from automobile 2. Death in same passenger compartment 3. Prolonged extrication (>20 minutes) 4. Falls >20 feet 5. Roll-over 6. High speed auto crash

a. Initial speed >40mph b. Major auto deformity >20 inches c. Intrusion into passenger compartment >12 inches

7. Auto-Pedestrian injury with significant impact (>5 mph) 8. Pedestrian thrown or run over 9. Motorcycle crash > 20 mph or with separation of bike and rider 10. Patients age <5 or >55 11. Pregnancy past 1st trimester

Killip ClassificationKillip Classification• Killip I: Rales and S3 absent• Killip II: Rales over <50% of lung• Killip III: Rales over >50% of lung fields

(pulmonary edema)• Killip IV: Shock

Subset I: Normal hemodynamics; PCWP<18; CI>2.2Subset II: Pulmonary congestion: PCWP>18; CI<2.2Subset III: Peripheral hypoperfusion; PCWP>18; CI>2.2Subset IV: Pulmonary congestion and peripheral hypoperfusion; PCWP>18; CI<2.2

Goldman CriteriaGoldman Criteria• Age > 70 yrs (5)• CAD: MI within 6 months (10)• CHF: S3 or JVE (11)• Rhythm:

– other than NSR/PACs on most recent ECG (7); – > 5 PVCs/min any time preoperatively (7)

• Valvular Disease: important aortic stenosis (5)• General Medical condition (5)

– PaO2 <60 or PaCO2 >50, K <3.0, or HCO3 <20, BUN >50 or Cr >3.0, abnormal AST, signs of chronic liver disease, bedridden from noncardic causes

• Surgery: intraperitoneal, thoracic, aortic surgery (3)

emergent surgery (4)

Goldman CriteriaGoldman CriteriaClass

Total Score No or Minor Complication

s

Life Threatenin

g

Cardiac Deaths

I 0-5 99% 0.7% 0.2%

II 6-12 93% 5% 2%

III 13-25 86% 11% 2%

IV >25 22% 22% 56%

Revised Goldman Revised Goldman CriteriaCriteria

• High risk type of surgery• History of ischemic heart disease• History of heart failure• History of CVA• Preoperative treatment with insulin• Preoperative serum creatinine > 2.0

mg/dL

Rates: 0.4% with no risk; 0.9% with 1 risk; 7% with 2 risks; 11% with 3 or more risks

Detsky CriteriaDetsky Criteria• Age > 70 yrs (5)• CAD:

– MI within 6 months (10)– MI >6 months (5)– CCS angina class III (10)– CCS angina class IV (20)– Unstable angina past 3 months (10)

• CHF: – Pulmonary edema within 1 week (10)– Pulmonary edema, ever (5)

• Rhythm: – other than NSR/PACs on last preop ECG (5); – > 5 PVCs/min any time preoperatively (5)

• Valvular Disease: suspected critical aortic stenosis (5)• General Medical condition (5)

– PaO2 <60 or PaCO2 >50, K <3.0, or HCO3 <20, BUN >50 or Cr >3.0, abnormal AST, signs of chronic liver disease, bedridden from noncardic causes

• Surgery: emergent surgery (10)

Revised Detsky Revised Detsky CriteriaCriteria

• High risk type of surgery• History of ischemic heart disease• History of heart failure• History of CVA• Preoperative treatment with insulin• Preoperative serum creatinine > 2.0 mg/dL• unstable angina within 3 months of surgery or

stable angina occurring with minimal exertion or recent pulmonary edema (HIGH RISK)

Rates: 0.4% with no risk; 0.9% with 1 risk; 7% with 2 risks; 11% with 3 or more risks or HIGH RISK

Goldman and Goldman and Detsky CriteriaDetsky Criteria

• May UNDERESTIMATE the Cardiac Risk in Vascular Patients …

Eagle CriteriaEagle Criteria• Access 5 significant clinical predictors

1.Q waves on EKG 2.History of angina 3.History of ventricular ectopy requiring

treatment 4.Diabetes mellitus requiring therapy other

than diet 5.Age > 70

• Rate of postoperative ischemic events: 3.1% if no predictors, 15% if 1-2 predictors and up to 50% if 3 or more predictors.

Perioperative Perioperative ßß--BlockerBlocker

• Known CAD or 2+ CRF then : Perioperative atenolol 5 mg IV q 5min

x 2 recommended 30 min preop & immediately postop

Atenolol 50-100 mg po qd postop day 1 until d/c.

• [1 yr mortality 3% vs 14% for placebo]

Ranson’s criteria Ranson’s criteria (alcoholic)(alcoholic)

• Admission– Age > 55yr– WBC >

16,000/cmm– Glucose > 200

mg/dL– LDH > 350 IU/L– GOT > 250 IU/L

• 48 Hours– Hct drop > 10%– PaO2 < 60 mmHg– Ca < 8 mg/dL– Base deficit > 4

mEq/L– BUN rise > 5 mg/dL– Estimated fluid

sequestration > 6L

Ranson’s criteria Ranson’s criteria (non-alcoholic)(non-alcoholic)

• Admission– Age > 70yr– WBC >

18,000/cmm– Glucose > 220

mg/dL– LDH > 400 IU/L– GOT > 440 IU/L

• 48 Hours– Hct drop > 10%– PaO2 < 60 mmHg– Ca < 8 mg/dL– Base deficit > 5

mEq/L– BUN rise > 2 mg/dL– Estimated fluid

sequestration > 6L

Glascow criteria (<48 Glascow criteria (<48 hours)hours)

• Age > 55yr• Glucose > 180 mg/dL• Albumin < 3.2 g/dL• PaO2 < 60 mmHg• WBC > 15,000/cmm• LDH > 600 IU/L• BUN > 45 mg/dL• Ca < 8 mg/dL

Prediction Model for Prediction Model for PneumoniaPneumonia

Patient characteristic Points assigned_______________Demographic factors Age: o Males: Age (in years) o Females: Age (in years) -10 Nursing home resident: +10Comorbid illnesses Neoplastic disease: +30 Liver disease: +20 Congestive heart failure: +10 Cerebrovascular disease: +10 Renal disease: +10


Physical examination findings

Altered mental status: +20

Respiratory rate 30/minute

or more: +20

Systolic blood pressure <90

mmHg: +20

Temperature <35 degrees C

or 40 degrees C or more: +15

Pulse 125/minute or more: +10


Laboratory findings

pH <7.35: +30

BUN >10.7 mmol/L: +20

Sodium <130 mEq/L: +20

Glucose >13.9 mmol/L: +10

Hematocrit <30 percent: +10

PO2 <60 mmHg (2): +10

Pleural effusion: +10

_______________________________________

(1) A risk score (total point score) for a given patient is obtained by summing the patient age in years (age minus 10 for females) and the points for each applicable patient characteristic.(2) Oxygen saturation <90 percent also was considered abnormal.

Risk Stratification Risk Stratification for Pneumoniafor Pneumonia

Risk Class

Low I Algorithm

Low II 70 or fewer points

Low III 71-90 total points

Moderate IV 91-130 total points

High V >130 total points

Asthma SeverityAsthma SeverityFactor

Severe asthma (FEV1 <1.0 L)

Pulse rate (beats/min) ≥120, but may be less with equally severe asthma

Respiratory rate (breaths/min)

≥40, but most are >20, therefore nondiscriminating

Pulsus paradoxus (mm Hg)

≥10, but may be absent with equally severe asthma in 50% of cases

Pulse rate ≥120, respiratory rate ≥20, pulsus paradoxus ≥10

If all three abnormal, 90% with severe asthma, but only 40% with FEV1 <1.0 L have all three abnormal

Use of accessory muscles of respiration

If present, may indicate severe asthma; if absent, may have equally severe asthma in 50% of cases

ABG analysis (mm Hg) PaO2 ≤60 or PaCO2 ≥42 indicates severe asthma; all

other values difficult to interpret unless PEFR or FEV1 known Pulmonary function

studiesPEFR and FEV1 measure directly the degree of

airflow obstruction; most useful in assessing severity and guiding treatment decisions

Asthma SeverityAsthma Severity1. Past history of sudden severe exacerbations 2. Prior intubation for asthma 3. Prior asthma admission to an intensive care unit 4. Two or more hospitalizations for asthma in the past year 5. Three or more ED care visits for asthma in the past year 6. Hospitalization or an ED care visit for asthma within the

past month 7. Use of >2 MDI short-acting β2 agonist canisters per

month 8. Current use of or recent withdrawal from systemic

corticosteroids 9. Difficulty perceiving severity of airflow obstruction 10. Comorbidities such as cardiovascular diseases or other

systemic problems 11. Serious psychiatric disease or psychosocial problems 12. Illicit drug use, especially inhaled cocaine and heroin

Asthma SeverityAsthma SeverityMild Intermittent Asthma Symptoms Symptoms <2 times a week

Asymptomatic and normal PEFR between exacerbations Exacerbations brief (from a few hours to a few days); intensity may vary Nighttime

<2 times a month Lung Function FEV1 or PEFR >80% predicted

PEFR variability <20%

Asthma SeverityAsthma Severity

Mild Persistent Asthma Symptoms Symptoms >2 times a week but <1

time a day Exacerbations may affect activity Nighttime

>2 times a month Lung Function FEV1 or PEFR >80% predicted

PEFR variability 20-30%


Moderate Persistent Asthma Symptoms Daily symptoms

Daily use of inhaled short-acting beta2-agonist Exacerbations affect activity Exacerbations 2 or more times a week; may last days Nighttime symptoms

>1 time a week Lung Function FEV1 or PEFR >60%-<80% predicted

PEFR variability >30%


Severe Persistent Asthma• Symptoms• Continual symptoms

Limited physical activity Frequent exacerbations Nighttime Symptoms

• Frequent Lung Function• FEV1 or PEFR <60% predicted

PEFR variability >30%

Asthma SeverityAsthma SeverityCLASSIFICATION OF ASTHMA SEVERITY

Severity Prior to Initiation of Therapy

Mild Intermittent

Mild Persistent Moderate Persistent

Severe Persistent

Symptoms < or = 2 per week > 2 per week

daily symptoms continual symptoms

Nighttime symptoms < or = 2 per month > 2 per month

> 1 per week frequent

Lung function

< or = 80% predicted < or = 80%

predicted

> 60% -< or = 80%

< or = 60%

Peak flow variability

< 20% 20-30% > 30% > 30%

Scoring System for Scoring System for SARS (SSSS)SARS (SSSS)

• radiographic findings of multilobar or bilateral infiltrates (3 points)

• sputum monocyte predominance (3 points)• lymphocytopenia (2 points)• history of exposure (1 point)• lactate dehydrogenase >450U/L (1 point)• C-reactive protein> 5.0mg/dL (1 point)• activated partial prothrombin time> 40sec (1 point)

SSSS > 6 probable SARS

創傷登錄創傷登錄• 目前急診科已進行創傷登錄• http://

www.trauma.org.tw• AIS System and ISS

scoring– ISS>4 需要登錄

Triage Priority Wang, Tzong-Luen, MD, PhD, FESC, FACC.

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Transcript of Triage Priority Wang, Tzong-Luen, MD, PhD, FESC, FACC.