The Emergency Severity Index

Jassin M. Jouria, MD Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serve as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e- module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology.

Abstract

One of the main challenges encountered by emergency departments is determining how to appropriately triage patients. Although some systems only take into account a single determining factor, the Agency for Healthcare Research and Quality promotes a system that considers both the acuity of patients’ health care problems as well as the number of resources needed to treat them. This system provides emergency departments with a unique tool to ensure that the most at-risk patients are being seen and treated in the most efficient manner.

1 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Policy Statement

This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 3 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Pharmacology content 0.5 hours (30 minutes).

Statement of Learning Need

Statistics have shown that a majority of U.S. patients wait over 15 minutes in a waiting room and that there is crowding in emergency rooms. Triaging quickly and effectively is a way to avoid unsafe waits and to address needed resources. It is important for emergency department clinicians to be trained in triage in order to determine what patients cannot wait to be treated, and to know the difference between a time sensitive issue to treat a life- threatening condition and what can be assigned a lesser critical or urgent need for treatment.

Course Purpose

To provide health clinicians with knowledge of the Emergency Severity Index

2 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com guidelines and best practice principles for emergency triage. Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,

Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.

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1. Emergency department (ED) clinicians use the Emergency Severity Index (ESI) and its triage algorithm primarily to

a. eliminate all decision-making in the emergency room. b. rate their performance after a patient is discharged. c. rate the intensity of care needed for a patient. d. determine whether a patient should be admitted to the ED.

2. True or False: The Emergency Severity Index (ESI) rates patient acuity from level 1 to level 5, with level 5 being the least emergent.

a. True b. False

3. Level 1 of the Emergency Severity Index (ESI)

a. does not require immediate physician involvement. b. involves non-lifesaving intervention. c. a Level 1 patient is always conscious. d. requires immediate, lifesaving intervention.

4. An apneic condition refers to

a. an abdominal injury. b. the suspension of breathing that is external. c. a Level 2 rating on the ESI. d. a constant change in air volume in the lungs.

5. If gas exchange between the environment and lungs are impeded, permanent damage can occur to the ______in as few as three minutes without adequate ventilation.

a. heart b. vascular tissue c. brain d. lungs

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Introduction

The Emergency Severity Index is a tool that includes five levels for use in the triage of patients arriving to an emergency department. Emergency clinicians use the emergency severity index and its triage algorithm to rate the intensity of care needed for patients. This measurement of needed care is referred to as patient acuity. Patient acuity is rated from most emergent (level 1) to least emergent (level 5). The Emergency Severity Index guides evaluation of the resources needed relative to the acuity level. This makes it unique among other assessment tools used to evaluate patients in an emergency department. The Emergency Severity Index is a valuable tool to ensure that clinical care meets standards of patient safety, as well as to assist emergency staff to make good decisions and to effectively operate an emergency department based on clinical research and best practice.

ESI Triage Fundamentals

The Emergency Severity Index (ESI) triage algorithm has been developed to determine the acuity level or intensity of care needed for a patient.1,2 Funding for the initial development of the ESI index came from the Agency for Healthcare Research and Quality (AHRQ).3 The ESI consists of various levels of care (level 1 to level 5) relative to the severity of emergency conditions and interventions needed to lower morbidity and mortality.

Level 1

Level 1 of the ESI index requires immediate, lifesaving intervention. It can require emergency airway, medications, and hemodynamic interventions; and it can include any of the following conditions.4 • Already Intubated

5 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Apnea • Pulselessness • Severe Respiratory Distress • SPO2 Less Than 90 • Acute Mental Status Changes • Unresponsiveness

For the above conditions, intubation will be required to support resuscitation efforts. Intubation involves a process of inserting an endotracheal (ET) tube through the mouth and into the airway so that the patient can be placed on a ventilator for assistance with breathing. The ET tube is connected to a ventilator for breathes to be delivered since the patient is unable to breathe independently or without assistance.5

Apnea or an apneic condition refers to the suspension of breathing that is external. There is no movement of the muscles involved in respiration during apnea. The volume in the lungs does not change. Depending on the level of airway expansion, gas exchange between the environment and lungs could be impeded. Permanent damage can occur to the brain in as few as three minutes without adequate ventilation. Death can occur after a few more minutes unless ventilation is restored.6

When considering the ESI level it’s important for Emergency Department (ED) staff to understand its purpose. As mentioned, the ESI allows ED staff to evaluate resources needed relative to patient acuity in order to safely provide patient care. A triage team member (generally a nurse) starts by looking at the patient acuity level only. If a patient is not at a level 1 or 2 on the ESI, the triage team member goes on to evaluate expected resources needed. The determination is then made whether the patient is level 3, 4, or

6 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5. The use of the ESI should be by clinicians with experience in emergency department triage, and is meant for use by a clinician who has been trained to triage ED patients.7

Triage is a process where trained clinicians determine the priority of ED treatment for patients. It is based on the severity of patient condition. To triage effectively clinicians must attempt to use ED resources that may be insufficient for the number of patients requiring immediate treatment. The triage staff determine the priority of treatment in an ED.8 Triage staff are assigned to evaluate patient acuity by determining stability of vital functions and the potential threat to life, an organ or limb. An estimation is made of the need for resources based on previous experiences with patients who have similar complaints and injuries. Triage staff are trained to understand: 1) Resources needed to meet patient care requirements, 2) Resources needed based on admission, transfer, and discharge requirements of patient care, 3) The 5 ESI levels based on the ESI algorithm, and 4) That ESI levels do not overlap. A patient is in one and only one of the evaluation levels.

Evaluation at Level 1

Triage staff should be aware of other algorithms used in emergency care. A medical algorithm uses a systematic approach to a treatment and includes a decision tree. This means if symptom A or B is observed then a particular treatment is indicated. These algorithms can be tools that reduce uncertainty of evaluation and treatment in healthcare settings.9 The ESI algorithm uses an approach similar to other medical algorithms used in emergency care. These include algorithms involving basic life support and advanced cardiac life support. While moving through each step of the process of evaluation, clinicians must answer specific questions and gather particular data. A decision is then made relative to triage. The ESI algorithm shows major

7 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com decision points. When considering the ESI algorithm there are four decision points: A, B, C, and D.10 These are shown in the Tables below.

A: Immediate Intervention

Immediate intervention is focused on lifesaving measures. What is included is emergency medication or airway issues and hemodynamic intervention. Also included are conditions requiring intubation such as already intubated, apnea, SPO2 less than 90, pulseless, respiratory distress, unresponsive, and acute changes in mental health. What is not included is an intervention such as an IV, ECG, labs, supplemental O2, or monitors.

Unresponsiveness is defined as a patient who 1) is nonverbal plus not following commands, and 2) requires a stimulus.

B: High Risk Situation

Severe pain or distress is determined by observation and/or when a patient rates pain at equal to or greater than 7 on a 0-10 scale.

C: Resources

Individual tests are not counted, but the number of different resources needed is counted. For example, one resource would be a lab test that included electrolytes, CBC, and coagulation studies. Two resources would be a CT scan and a CBC.

Resource Not Resource Lab tests – blood, urine History ECG Physical testing (point of care) Xray CT MRI ultrasound angiography IV fluids for hydration Saline or heplock Specialty consultation Phone call to primary care physician IV or IM or nebulized medication Tetanus immunization Prescription refill Crutches Splints/Slings Simple wound care (dressings, recheck)

Simple procedure = 1 (Foley catheter) Simple procedure = 1 (laceration repair) Complex procedure = 2 (conscious sedation)

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D: Danger Zone Vital Signs Can place patient into level 2 if exceeding any vital sign evaluation. Pediatric fever conditions include these considerations.

Age of patient Level

1 to 28 days 2 if temperature is higher than 38.0 degrees C/100.4 degrees F 1 to 3 months 2 if temperature is higher than 38.0 degrees C/100.4 degrees F 3 months to 3 years 3 if temperature is higher than 39.0 degrees C/100.2 degrees F

Consider the procedure of Foley catheter insertion, for example, which is counted as a resource and considered as a simple procedure. Information about 1) the basic steps to initiate a Foley catheter must be included when 2) triaging according to the ESI.11 Foley catheter insertion is reviewed below.

Foley Catheter:

• It is a thin and sterile tube. It is inserted into the bladder for draining urine. • Indwelling catheter is another term used as typically the catheter is left in place for some time. • A balloon on one end holds the catheter in place. The balloon is filled with sterile water. This keeps the catheter from being removed from the bladder. Urine drains into a tube and in the bag. • Catheterization is the process to insert the catheter.

Some of the disorders, problems and necessary procedures considered during Triage that may require a Foley catheter are listed below.

• Obstruction of urethra due to a condition such as prostate cancer, narrowing of the urethra, or prostate hypertrophy.

9 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Urine monitoring of a critically ill person. • Urine retention due to straining to urinate, urinary hesitancy, decrease in force of the urinary stream, interruption of urinary stream, and sensation of incomplete emptying. • Collection of sterile urine specimens for diagnoses • Bladder dysfunction that is nerve related as after spinal trauma

The example of Foley catheter insertion is just one example of how emergency interventions influence decisions and triage levels. Given any patient injury or diseased condition, as ED clinicians go through each step of the ESI process specific questions are answered and information gathered. A decision can then be made about the triage level.

Using the decision points of A, B, C, and D a patient is placed into a triage level. These levels range from 1 to 5. The experienced triage clinician starts at the top of the algorithm of the ESI and can often move quickly from one decision point to the next. Four key decision questions are shown below.9

A: Does the patient require immediate intervention that is lifesaving? B: Is this a patient who should not wait? C: How many resources does this patient need? D: What are the vital signs for the patient?

As the triage clinician answers the questions, the right ESI level is arrived at for the patient. The Decision Points are further explained below.

Decision Point A: Immediate Intervention?

The first question is straightforward; the patient is asked if an intervention is needed, and determination is made whether the needed intervention is

10 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com lifesaving. A “yes” answer at level 1 indicates a lifesaving intervention is needed.

The triage clinician is required to answer the question of whether the patient is dying. Level 1 is determined by asking the following questions to determine whether the patient requires an immediate lifesaving intervention.

Is There A Patent Airway?

A patent airway can be crucial to the health of a patient, and increases survival rates. A patent airway means the patient can inhale oxygen and exhale CO2. The airway is open and clear. Alternatively, the patient could have trouble breathing. In that case, clinicians should administer oxygen to the patient if needed. If a person is talking, there is likely a patent airway. If needed, the patient can use a face mask, nebulizer, or other device to help breathe.12

The next questions to ask are listed below. 1. Is the patient breathing? 2. Does the patient have a pulse? 3. Is there a concern about the pulse rate, quality, and rhythm? 4. Was the patient intubated before coming to the hospital? Was this due to issues such as maintaining a patent airway, adequate oxygen saturation, or spontaneous breathing? 5. Are there concerns about the patient being able to deliver oxygen adequately to tissues? 6. Does the patient need medication immediately? 7. Does the patient need volume replacement of blood or other hemodynamic intervention?

11 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com The clinician should also ask whether the patient meets criteria of: 1) Already intubated, 2) Apneic, 3) Pulseless, 4) Experiencing severe respiratory distress, 5) SpO2 under 90 percent, 6) Acute mental status changes, and 7) Unresponsive.

A triage clinician can predict the need of lifesaving intervention that is immediate. When a patient is apneic there is suspension of breathing. The muscles involved in inhalation do not move during apnea. Airways could be blocked, and there might not be gas exchange in the lungs.13 When apnea exists and in some cases during rapid sequence intubation, an option can be apneic oxygenation.14

With an SpO2 level below 90 percent there is a concern of hypoxemia. This refers to oxygen saturated hemoglobin as compared to total hemoglobin. The body needs a specific amount of oxygen in the blood. Normally, this should be at 95-100 percent. If the level goes below 80 percent, brain, heart, and other organ function could suffer. Lifesaving interventions that may be initiated are 1) secure an airway, 2) support circulation, 3) maintain breathing, and 4) address a change in the level of consciousness that is major.15 An intervention that is not considered lifesaving includes those that are either therapeutic and/or diagnostic.

Clinicians are trained to understand that in an ESI level 1 the patient is arriving at the emergency department in a condition that is unstable, and that without immediate care the patient could die. Emergency clinical help must therefore be immediate. Clinical staffing is needed to be able to provide critical care. Immediate lifesaving and non-lifesaving interventions that ED staff are trained to provide are listed below.16

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Airway/Breathing

Lifesaving: • Bag-valve-mask ventilation • Intubation • Surgical airway • Emergent Continuous positive airway pressure (CPAP) • Emergent Bi-level positive airway pressure (BiPAP)

Non-lifesaving: • Oxygen administration • Nasal cannula • Non-rebreather

Electrical Therapy

Lifesaving: • Defibrillation • Emergent cardioversion • External pacing

Non-lifesaving: Cardiac monitor

Procedures

Lifesaving: • Chest needle decompression • Pericardiocentesis • Open thoracotomy

13 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Intraosseous access

Non-lifesaving: • Diagnostic Tests • ECG • Labs • Ultrasound • FAST (Focused abdominal scan for trauma)

Hemodynamics

Lifesaving: • Significant IV fluid resuscitation • Blood administration • Control of major bleeding

Non-lifesaving: • IV access • Saline lock for medications

Ventilation

Bag-valve-mask (BVM) ventilation is an emergency skill that is essential as a basic airway management technique. It allows for ventilation and oxygenation of patients until a more definitive airway is established.17 It is an option when endotracheal intubation is not possible. It can be the only option for airway management for an emergency medical clinician. For prehospital airway support for a pediatric application, BMV can be the best option. It is also used for ventilation in an operating room when no intubation is required.

14 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Noninvasive ventilation involves the use of CPAP and BiPAP. CPAP refers to continuous positive airway pressure and BiPAP refers to bi-level positive airway pressure. This ventilation modality supports breathing with a patient who has undergone surgery and intubation. Noninvasive ventilation is used for adult respiratory management. It is seen in emergency department and intensive care unit settings. It is also seen in pediatric applications of treatment.18 With noninvasive ventilation the adverse effect of invasive ventilation is avoided. Patient comfort is an advantage. An artificial airway is not inserted yet mechanically assisted breaths are delivered. It provides ventilator support both in- and outside of an Intensive Care Unit (ICU). Two techniques are negative pressure and positive pressure ventilation. CPAP and BiPAP each provide positive pressure ventilation that is continuous.

With high flow nasal cannula therapy, a patient uses an air/oxygen blender, active humidifier, heated circuit, and nasal cannula. It delivers medical air that is heated and humidified. Delivery is at 60 L/min of flow. It can be a respiratory support technique for patients who are critically ill.19

A nonrebreather mask – also known as a nonrebreather and non-breather facemask – helps with delivery of oxygen therapy to patients. When in use, a patient can breathe unassisted. A nasal cannula can be set at low flow while the non-breather mask provides a higher oxygen concentration. Information and instructions for use about this mask is listed below.20

• The mouth and nose of a patient are covered by the mask. • The mask attaches through an elastic cord around the head of the patient. • The mask has an attached reservoir bag, typically, with a capacity of 1 liter that connects to a bulk oxygen system or external oxygen tank.

15 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Before placing the mask on a patient, the reservoir bag is inflated to more than 2/3 oxygen. A rate of 15 L/minute is used. • About a third of the air is depleted from the reservoir as a patient inhales, and then the air is replaced from the oxygen supply.

Cardiac Defibrillation and Cardioversion

The heart's electrical system controls the timing of a person’s heartbeat by sending an electrical signal through the heart cells. The signals that determine heartbeat start at the upper right heart chamber. With atrial fibrillation, a very fast and irregular signal through both upper heart chambers occurs, resulting in a fast irregular heart rhythm.

Cardioversion is a way to restore a regular heart rhythm if a heart has an irregular rhythm (arrhythmia) or is beating too fast. An arrhythmia can prevent proper blood circulation to the brain or heart. Cardioversion can help in treating atrial flutter, ventricular tachycardia, and atrial tachycardia. Medication may be used to bring back a regular heartbeat, also known as pharmacologic (or chemical) cardioversion.

Cardiac Defibrillator:

Use of a cardiac defibrillator for a life-threatening arrhythmia can be lifesaving. The defibrillator provides an electric current – sometimes called a counter shock – to the heart to end the dysrhythmia. When the heart muscle is shocked, depolarization of a large section of heart muscle occurs; and, the cardiac pacemaker then reestablishes the normal rhythm.

Types of defibrillators include external, implanted (cardio-defibrillator) and tranvenous.34

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Electrical cardioversion also involves an electric shock.21 But with cardioversion the shock is synchronized with the cardiac cycle, whereas with defibrillation synchronization is not needed. Cardioversion is used to end a cardiac dysrhythmia with poor blood perfusion. An example would be supraventricular tachycardia.

Needle Chest Decompression and Pericardiocentesis

Needle chest decompression may be used to relieve intrathoracic pressure. The procedure involves needle thoracentesis. It is a lifesaving procedure that may be given for the following reasons.22

• Accumulation of air under pressure located in pleural space • When injured tissue forms a 1-way valve and allows air to enter the pleural space with prevention of air escaping naturally • Tension pneumothorax • A condition that can progress to cardiovascular collapse and, if untreated, death

With pericardiocentesis, aspiration of fluid from the pericardial space (surrounding the heart) is done. If a patient has cardiac tamponade the procedure of pericardiocentesis can be lifesaving. This is true even if it complicates an acute aortic dissection and when the option of cardiothoracic surgery is not available. Aspects of cardiac tamponade are that it 1) is a life- threatening and time sensitive condition, 2) requires prompt management, 3) can include hypotension, a quiet heart, and increased venous pressure, and 4) can include acute intrapericardial hemorrhage.

17 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com The emergency bedside thoracotomy is an effort to save the life of patients with a chest injury. It has been in use since 1900 in emergency departments. Some statistics show it has over 50% survival rate.24

Complications after a chest injury can include shock due to the condition of the heart vasculature, tension pneumothorax, and cardiac tamponade. Some reasons for performing a thoracotomy are control of hemorrhage, management of cardiac tamponade, preventing air embolism, repairing a cardiac injury, repairing a pulmonary injury.25

Intraosseous Vascular Access

Intraosseous vascular access was introduced in the 1920’s for intravenous catheter access through a bone marrow cavity. By 1980, intraosseous (IO) vascular access was used for rapid fluid infusion during resuscitation. It is used for children and adults. Use with newborns could be faster than access via umbilical veins. The technique is recommended for children after two attempts at intravenous access that is not successful or during circulatory collapse. It is recommended if venous access is not reliable and quick.26

Electrocardiogram and Sonogram

An electrocardiogram (ECG) is a test that records the electrical activity of the heart. When the procedure is completed, electrodes are placed to the arms, chest, and legs. Generally, hair is clipped or shaved to make the electrodes adhere. The number of patches could vary to display an ECG graph and test result. The ECG image will help clinicians to identify a normal versus abnormal QRS complex.27

A sonogram, which is an ultrasound scan, can be used to detect problems in the heart, liver, kidney, abdomen, and womb. An ultrasound device uses

18 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com high frequency sound waves. These waves create an image of the inside of the body. It uses no radiation and is considered safe. An ultrasound scan can also be helpful for a surgeon in performing a biopsy in certain situations.28

FAST

The term FAST means focused assessment with sonography for trauma. It originally meant ‘focused abdominal scan for trauma’ when originally coined to describe ultrasound exams to evaluate a patient who was injured. Ultrasound can provide an initial screen exam in a trauma patient, and also describes a standard set of exams. An ultrasound is used in addition to other imaging studies. These other studies can help identify injuries in patients with, for example, thoracic or abdominal issues. A FAST ultrasound evaluation, in addition to an initial evaluation, may be invaluable during resuscitation efforts for a trauma patient.

Emergency scenarios where other diagnostic imaging studies might be incorporated into patient care include: 1) if a patient is unstable, has no visible source of bleeding, and initial ultrasound has shown no intraperitoneal fluid, an angiography may be useful, 2) ultrasound of a pelvic fracture may not show as much as another imaging modality can in a case of pelvic bleeding, and 3) if a patient is stable, an additional CT scan can help with a diagnosis.29

Pharmacological Intervention

Medications typically used in an emergency room are listed here. Some are considered lifesaving and some non-lifesaving.

19 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Lifesaving: • Naloxone • D50 • Dopamine • Atropine • Adenocard

Non-lifesaving: • ASA • IV nitroglycerin • Antibiotics • Heparin • Pain medications • Respiratory treatments with beta agonists

For drugs that can be lifesaving and used in an emergency room, clinicians need to be readily able to access drug information about the medication. A general reference of emergency drugs is included below.30-33

Adenocard

Generic Name: adenosine Brand Name: Adenocard and Adenoscan

Adenocard is used for treating irregular heartbeat. Certain brands are used during a stress test. Adenocard is a nucleoside and antiarrhythmic. It works to treat irregular heartbeat and slows the electrical conduction in the heart, normalizing heart rhythm, or slowing heart rate. It can help during a stress test as it improves blood flowing to the heart.

20 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Reasons not to use Adenocard include if a patient has 1) breathing problems such as asthma, 2) an allergy to an ingredient in Adenocard, 3) second or third degree heart block plus do not have an artificial pacemaker, and 4) sinus node disease such as sick sinus syndrome plus do not have an artificial pacemaker.

Before using Adenocard, it should be known whether the patient has certain medical conditions that may contraindicate use of or interact with the drug, such as pregnancy or planning to become pregnant, breast-feeding, taking any prescription or nonprescription medication, taking herbal preparation or dietary supplements, allergies to medication, food or other substances, history of seizures, blood vessel problems, heart problems, low blood volume, and lung or breathing problems (such as emphysema, bronchitis).

Some medications can interact with Adenocard, such as: • Aminophylline (the risk of seizures may be increased) • Beta-blockers (such as metoprolol) • Digoxin, diltiazem, or verapamil (the risk of irregular heartbeat • may be increased) • Carbamazepine or dipyridamole (they may increase the risk of Adenocard's side effects) • Methylxanthines (such as caffeine, theophylline because they may decrease Adenocard's effectiveness)

Adenocard is given as an injection. Some recommendations and safety concerns include: • Bad and even deadly heart problems such as irregular heartbeat after giving the drug.

21 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Avoiding drinks and food with caffeine before taking the drug. This includes coffee, tea, cocoa, cola, and chocolate. • While using the drug a patient should have blood pressure measures, ECGs, and lab tests. The test helps monitor the condition of the patient and checks for side effects. • Side effects can include stomach pain, dizziness, flushing, headache, and lightheadedness. • Several side effects can include severe allergic reaction, chest pain, fainting, confusion, fast heartbeat, slow heartbeat, irregular heartbeat, seizure, one sided weakness, shortness of breath, wheezing, speech problems, throat pain, and vision problems. Severe allergic reaction can include itching, hives, rash, difficulty breathing, tightness of the chest or throat, swelling of the tongue, face, lips, or mouth.

Dopamine

Generic Name: dopamine (injection) Brand Names: Intropin

Dopamine is a medication form of a chemical that occurs naturally in the body. Improvement of the heart pump strength and blood flow to the kidneys is how the medication works.

Dopamine is injected intravenously into the body. It is used to treat conditions such as low pressure when a patient is in shock that could be caused by a serious medical condition such as kidney failure, heart failure, heart attack, trauma, and surgery.

22 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Before the patient receives dopamine, clinicians should record any of the following conditions. • pheochromocytoma - tumor of the adrenal gland • history of blood clots • hardening of arteries • circulation problems • diabetes • frostbite • asthma • sulfite allergy • Buerger’s disease

All the prescription and over-the-counter medications used be recorded, including use of an MAO inhibitor such as furazolidone (Furoxone), isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam, Zelapar), or tranylcypromine (Parnate).

It is not known if Dopamine harms an unborn baby or passes into breast milk or harms a nursing baby.

When administered intravenously, the clinician should be alert to whether the patient is having any burning, pain, or swelling around the IV needle when dopamine is injected. Additionally, while receiving dopamine, the patient should be observed closely including vital signs, breathing, blood pressure, kidney function, and oxygen levels. To check for harmful effects, blood cells and kidney function should be tested often.

Dopamine side effects can include an allergic reaction such as difficulty breathing, hives, and swelling of the face lips, tongue, or throat. As

23 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com mentioned, serious side effects include burning and pain, as well as localized swelling, pounding heartbeat, chest pain, swelling of ankles or feet, urinating less than usual, painful urination, cold feeling, numbness, weak or shallow breathing, and skin changes in the feet or hands. Other side effects could include nausea, vomiting, chills, and feeling anxious.

The usual adult dose of Dopamine for nonobstructive oliguria includes: • Initial dose: 1 to 5 mcg/kg/min by continuous IV infusion. • Titrate to desired response; administration at rates greater than 50 • mcg per kg per minute have been used safely in serious situations.

The usual adult dose of Dopamine for shock includes: • Initial dose: 1 to 5 mcg/kg/min by continuous IV infusion. • Titrate to desired response; administration at rates greater than 50 • mcg/kg/minute have been used safely in serious situations.

The usual pediatric dose for nonobstructive oliguria includes: • Age less than 1 month: 1 to 20 mcg/kg/min by continuous IV infusion, • titrated to desired response. • Age 1 month or older: 1 to 20 mcg/kg/min by continuous IV infusion, titrated to desired response. Maximum dose 50 mcg/kg/min.

The hemodynamic effects of dopamine are dose dependent: • Low dosage: 1 to 5 mcg/kg/minute, increased renal blood flow and urine output

24 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Intermediate dosage: 5 to 15 mcg/kg/minute, increased renal blood flow, heart rate, cardiac contractility, cardiac output, and blood pressure • High dosage: greater than 15 mcg/kg/minute, alpha-adrenergic effects begin to predominate, vasoconstriction, increased blood pressure

The usual pediatric dose for shock includes: • Age less than 1 month: 1 to 20 mcg/kg/min by continuous IV infusion, • titrated to desired response • Age 1 month or older: 1 to 20 mcg/kg/min by continuous IV infusion, • titrated to desired response. Maximum dose 50 mcg/kg/min

Medications the patient may be taking should be noted, such as: • droperidol (Inapsine) • epinephrine (EpiPen, Adrenaclick, Twinject, and others) • haloperidol (Haldol) • midodrine (ProAmatine) • phenytoin (dilantin) • vasopressin (Pitressin) • diuretic medication • an antidepressant such as amitriptyline (Elavil, Vanatrip, Limbitrol), • doxepin (Sinequan, Silenor), nortriptyline (Pamelor), and others • a beta blocker such as atenolol (Tenormin, Tenoretic), carvedilol (Coreg), labetalol (Normodyne, Trandate), metoprolol (Dutoprol, Lopressor, Toprol), nadolol (Corgard), propranolol (Inderal, InnoPran), sotalol (Betapace), and others

25 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • cough or cold medicine that contains an antihistamine or decongestant • ergot medicine such as ergotamine (Ergomar, Cafergot, Migergot), dihydroergotamine (D.H.E. 45, Migranal), ergonovine (Ergotrate), or methylergonovine (Methergine) • a phenothiazine such as chlorpromazine (Thorazine), fluphenazine (Permitil, Prolixin), perphenazine (Trilafon), prochlorperazine (Compazine, Compro), promethazine (Pentazine, Phenergan, Anergan, Antinaus), thioridazine (Mellaril), or trifluoperazine (Stelazine)

Other drugs can interact with dopamine. Over the counter and prescription drugs patients may be taking should be known. This includes herbal products, vitamins, minerals, and over the counter drugs.

Atropine

Generic Name: Atropine sulfate Dosage Form: injection

The antispasmodic action of this drug can help in spastic conditions of the gastrointestinal (GI) tract and pylorospasm. For ureteral and biliary colic, atropine with morphine could be indicated. Atropine relaxes the colon and upper GI system during needed hypotonic radiography.

Small doses inhibit bronchial and salivary secretions. Moderate doses dilate the pupil, inhibit accommodation and increase the heart rate. Larger doses decrease motility of the urinary and GI system. Very large doses inhibit gastric acid secretion.

26 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Atropine sulfate injection can be given parenterally as a pre-anesthetic medication. This is for surgical patients to reduce bronchial and salivation secretions. It can also be used during inhalation anesthesia.

In poisoning such as with use of certain insecticides and chemical warfare nerve gas, large doses of atropine relieve muscarine-like symptoms and central system manifestations. It is used also as an antidote to mushroom poisoning due to muscarine in certain species.

Information about atropine includes: • It rarely occurs in plants. It must be prepared by synthesis. • It is usually used in the form of atropine sulfate. • Large doses may block nicotinic receptors at the neuromuscular junction.

Contraindications include patients with: • history of hypersensitivity to the drug. • narrow-angle glaucoma, and adhesions (synechiae) between the iris and lens of the eye. • tachycardia, and unstable cardiovascular status in acute hemorrhage. • GI issues such as obstructive disease (for example, achalasia, pyloroduodenal stenosis, or pyloric obstruction, cardiospasm), paralytic ileus, intestinal atony of the elderly or debilitated patient, severe ulcerative colitis, toxic megacolon complicating ulcerative colitis, and hepatic disease. • obstructive uropathy (for example, bladder neck obstruction due to prostatic hypertrophy), and renal disease. • myasthenia gravis.

27 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com A warning exists in the presence of high environmental temperature, as heat prostration can occur with anticholinergic drug use (fever and heat stroke due to decreased sweating). Diarrhea may be a symptom of incomplete intestinal obstruction, especially in patients with ileostomy or colostomy. Treatment of diarrhea with these drugs is not appropriate and is possibly harmful.

Situations where dosing, safety, and precautions should be considered includes:

• Elderly patients could react with excitement, agitation, drowsiness and other untoward manifestations to even small doses of anticholinergic drugs. • Use with a patient with gastric ulcer may produce a delay in gastric emptying time and may complicate such therapy (antral stasis). • Atropine may produce drowsiness, dizziness or blurred vision.

Use atropine with caution in the following conditions: • CNS: Autonomic neuropathy • Ocular: Glaucoma, light irides; if there is mydriasis and photophobia, dark glasses should be worn. Atropine should be used with caution in patients over 40 years of age because of the increased incidence of glaucoma. • GI: Hepatic disease, early evidence of ileus, as in peritonitis, ulcerative colitis (large doses may suppress intestinal motility and precipitate or aggravate toxic megacolon), hiatal hernia associated with reflux esophagitis (anticholinergics may aggravate it).

28 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • GU: Renal disease and prostatic hypertrophy; patients with prostatism can have dysuria may require catheterization • Endocrine: Hyperthyroidism • Cardiovascular: Coronary heart disease, congestive heart failure, cardiac arrhythmias, tachycardia, and hypertension. • Usage in biliary tract disease: The use of atropine should not be relied upon in the presence of complication of biliary tract disease. • Special risk patients: Atropine should be used cautiously in infants, small children and persons with Down’s syndrome, brain damage or spasticity. • Pulmonary: Debilitated patients with chronic lung disease, reduction in bronchial secretions can lead to inspissation and formation of bronchial plugs. Atropine should be used cautiously in patients with asthma or allergies.

Drug interactions include:

• Antihistamines, antipsychotics, antiparkinson drugs, alphaprodine, buclizine, meperidine, orphenadrine, benzodiazepines and tricyclic antidepressants may enhance the anticholinergic effects of atropine and its derivatives. • Nitrates, nitrites, alkalinizing agents, primidone, thioxanthenes, methylphenidate, disopyramide, procainamide and quinidine may also potentiate side effects. Monoamine oxidase inhibitors block detoxification of atropine, and thus, potentiate its actions. • Concurrent long-term therapy with corticosteroids or haloperidol may increase intraocular pressure. • Atropine may antagonize the miotic actions of cholinesterase inhibitors.

29 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • The bronchial relaxation produced by sympathomimetics is enhanced by Atropine.

Naloxone

Generic Name: naloxone Brand Names: Evzio, Narcan

Information about uses of Naloxone include: • Naloxone blocks or reverses the effects of opioid medication, including extreme drowsiness, slowed breathing, or loss of consciousness. An opioid is sometimes called a narcotic. • Naloxone is used to treat a narcotic overdose in an emergency situation. This medicine should not be used in place of emergency medical care for an overdose. • Naloxone is also used to help diagnose whether a person has used an overdose of an opioid.

Other precautionary information about the drug includes: 1) The clinician should know if the patient is pregnant or breast feeding, 2) Drinking alcohol can increase certain side effects of naloxone, 3) Naloxone may impair thinking or reactions, 4) If a patient is using naloxone and any narcotic pain medication, the pain, 5) Relieving effects of the narcotic will be reversed by receiving naloxone.

Additionally, the clinician should note whether the patient’s allergies, history of heart disease, and whether the patient is pregnant or nursing a baby.

Naloxone is injected into a muscle, under the skin, or intravenously.

30 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com The signs of an opioid overdose in the patient should be noted. Overdose symptoms may include:

• slowed breathing, or no breathing • very small or pinpoint pupils in the eyes • slow heartbeats • extreme drowsiness, especially if unable to wake the person from sleep

Atropine

Each medication auto-injector is for one use only. After one use the auto- injector should be thrown out, even if there is still some medicine left in it after injecting a dose.

Naloxone should be stored at room temperature away from moisture and heat. The auto-injector should be kept in its outer case until ready for use. The medicine should not be used if it has changed colors or has particles in it.

Naloxone side effects include an allergic reaction, such as hives, difficult breathing, swelling of the face, lips, tongue, or throat.

Because naloxone reverses opioid effects, this medicine may cause sudden withdrawal symptoms such as:

• nausea, vomiting, diarrhea, stomach pain • fever, sweating, body aches, weakness • tremors or shivering, fast heart rate, pounding heartbeats, increased blood pressure • feeling nervous, restless, or irritable

31 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • goosebumps, shivering • runny nose, yawning • in babies younger than 4 weeks old - seizures, crying, stiffness, overactive reflexes.

The usual adult dose for opioid overdose includes: • 0.4 to 2 mg/dose IV/IM/subcutaneously. May repeat every 2 to 3 minutes as needed. Therapy may need to be reassessed if no response is seen after a cumulative dose of 10 mg. • Continuous infusion: 0.005 mg/kg loading dose followed by an infusion of 0.0025 mg/kg/hr.

The usual pediatric dose for opioid overdose for infants, children, and adolescents include:

Opioid intoxication (full reversal):

• Is by intravenous (IV), the preferred route, or intraosseous (IO); may be administered intramuscularly (IM), subcutaneous (SQ), or by endotracheal tube (ET) route, but onset of action may be delayed, especially if patient has poor perfusion. ET preferred if IV or IO route not available; doses may need to be repeated. • Infants and Children less than or equal to 5 years or less than or equal to 20 kg: administer 0.1 mg/kg/dose, repeat every 2 to 3 minutes if needed, and may need to repeat doses every 20 to 60 minutes. • Children greater than 5 years or greater than 20 kg and Adolescents: 2 mg/dose, and, if no response, repeat every 2 to 3 minutes; may need to repeat doses every 20 to 60 minutes.

32 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Endotracheal (ET): the optimal endotracheal dose is unknown, and the current expert recommendations are 2 to 3 times the IV dose.

Manufacturer recommendations: IV (preferred), IM, Subcutaneous:

• Initial: 0.01 mg/kg/dose; if no response, a subsequent dose of 0.1 mg/kg may be given • If using IM or Subcutaneous route, dose should be given in divided doses.

Continuous IV infusion:

• Children: If continuous infusion is required, the initial dosage/hour should be calculated based on the effective intermittent dose used and duration of adequate response seen; the dose should be titrated, and a range of 2.5 to 160 mcg/kg/hour has been reported. Continuous infusion should be tapered gradually to avoid relapse.

Respiratory depression:

• Pediatric Advanced Life Support (PALS): Give IV: 0.001 to 0.005 mg/kg/dose; titrate to effect • Manufacturer recommendations: Initial: 0.005 to 0.01 mg/kg; repeat every 2 to 3 minutes as needed based on response.

Other drugs may interact with naloxone, including prescription and over-the- counter medicines, vitamins, and herbal products. Clinicians should be alert to all medicines used by patients.

33 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Level 1 Emergency Department Interventions

Level 1 of the ESI requires immediate medical involvement and evaluation is required to help the patient who is critically ill. Technical interventions that are immediate and lifesaving include obtaining oxygen saturation (spO2) and evaluating respiratory status. A patient can still be breathing with a SpO2 less than 90 percent or with severe respiratory distress. However, the patient needs an immediate intervention to maintain oxygenation status and an airway. Medical clinicians will need to order medication, such as for rapid sequence intubation or other interventions to maintain breathing and the airway.

Oxygen saturations are trended using a pulse oximeter. The measurement is designated as SpO2 or peripheral oxygen saturation. The pulse oximeter is a device that clips to the body, such as the finger, earlobe and infant’s foot.35

Rapid sequence intubation (also called rapid sequence induction) is used when a patient is at risk of airway compromise. Management of the airway is an important procedure for the emergency team. Failure to provide an airway can be fatal for the patient. A patient who needs intubation can have an inability to maintain airway patency, failure to ventilate, failure to oxygenate, or inability to protect against aspiration.36,37

For a patient with chest, pain level 1 considerations need to be kept in mind during clinical evaluation and determination of lifesaving intervention(s). A patient meets level 1 and requires immediate intervention that is lifesaving if in acute respiratory distress, showing pallor, diaphoretic (profusely perspiring), and hemodynamically unstable.

34 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Some patients with chest pain do not meet the level 1 consideration and should get a diagnostic ECG within 10 minutes of arrival to the ED. A hemodynamically unstable patient, however, will manifest hypotension, which may lead to tissue or cell death and organ failure. To determine if someone is hemodynamically unstable, the ED triage clinician needs to evaluate blood pressure and heart rate; and, in the ICU setting the pulmonary artery occlusion pressure, central venous pressure, cardiac output, and pulmonary artery pressure should be considered when evaluating hemodynamic stability of a patient.

Using the AVPU scale – Alert, Verbal, Pain, Unresponsive – a triage clinician can assess the level of responsiveness of a patient. The AVPU scale is used with the ESI algorithm. Patients who need immediate interventions are identified such as those having a sudden or recent change in their level of consciousness.

The scale is used to identify if a patient is nonverbal and needs painful stimuli to get a response. If a patient score is U or P on the AVPU scale, this translates to level 1 on the ESI scale.

A summary of the AVPU scale and level of consciousness is raised here. A is best. U is worst. Clinicians should work from A to U.38

Alert

The alert patient is awake, and generally the eyes are open. The patient will respond to voice but may be confused. A triage clinician can get information from talking to the patient. The patient has motor functions.

35 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Voice

The patient responds and opens the eyes when spoken to, and responds with a moan or slight movement. The patient may not be oriented to time and place.

Pain

The patient responds to a painful stimulus but not to voice. If someone is conscious they do not require a pain stimulus. The stimulus can be squeezing of the hand.

Unresponsive

Also called unconscious, the unresponsive person does not respond to even a painful stimulus. No response by voice or eyes to a stimulus is given.

A level 1 assessment happens in less than 5 percent of those who come to an emergency department. When a level 1 patient arrives in an emergency department, lifesaving interventions can be provided by the health team, nurse, or physician. Such a patient can end up being admitted to an intensive care unit. In some cases, the patient is discharged from the emergency department following treatment of the patient’s condition, such as in the case of alcohol intoxication, anaphylaxis (as with an allergic reaction to a bee sting), seizures, and hypoglycemia (also called low blood sugar or low blood glucose).39 Some case examples of level 1 include:40

• Cardiac or respiratory arrest • SpO2 at less than 90 percent • Trauma patient with a critical injury and appears unresponsive • Flaccid baby

36 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Child who fell and is unresponsive to stimuli • Patient who is dizzy and weak with a heart rate of 30 • Anaphylactic shock (as with an allergic reaction to a bee sting) • Drug overdose and respiratory rate of 6 • Patient who is unresponsive and has a strong odor of alcohol • Patient with hypoglycemia and a change in mental status • Respiratory distress that is severe with gasping • Trauma patient who needs immediate fluid resuscitation (crystalloid and colloid) • Intubated head bleed and unequal pupils • Low blood pressure (hypotension) with signs of decreased blood flow (hypoperfusion) • Heart beat that is too slow or too fast with signs of decreased blood flow (hypoperfusion) • Chest pain, profusely perspiring, blood pressure 70 systolic by palpation

If determining blood pressure by palpation only, a rough estimation of the systolic pressure is obtained. A pulse at three major arteries – carotid, femoral, and radial – is felt. If the pulse is felt at all three arteries, then the blood pressure is about 70-80 mmHg. If the carotid and femoral arteries are only felt the blood pressure is about 50-70 mmHg. If the carotid artery only is felt the blood pressure is about 40-50 mmHg.41

ESI Level 2

If a triage clinician determines the patient is not a level 1, moving on to the next decision point, determination is made whether a patient can wait to be seen. If waiting is not an option, the patient moves to level 2. As a high risk situation, Level 2 involves the kind of patient placed immediately into any

37 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com open ED bed due to the risks involved. The patient could be confused, lethargic, and disoriented. Severe pain and distress could be accompanying symptoms. This level includes danger zone vitals shown in the examples below, with many resources needed.54,55

Heart Rate: Less than 3 months/over 180 3 months – 3 years/over 160 3-8 years/over 140 Over 8 years/over 100

Respiratory Rate: Less than 3 months/over 50 3 months – 3 years/over 40 3-8 years/over 30 Over 8 years/over 20

SaO2 less than 92%

Pediatric Fever: 1-28 days, assign at least L2 if temp is over 100.4 °F 1-3 months, consider assigning L2 if temp is over 100.4 °F 3 months – 3 years, consider assigning L3 if temp is over 102.2 °F, incomplete immunizations, or no obvious source of fever

Some examples of ESI resources needed for Level 2 patients include:56,57 • Labs • ECG/X-rays • CT-MRI-Ultrasound-Angiography

38 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • IV Fluids • Intravenous and intramuscular medications/nebulized • Specialty Consultation • Simple Procedure (counts as 1 resource is uses only 1 resource) • Complex Procedure (counts as 2 resources with a procedure such as conscious sedation that requires 2 resources)

Oral medications are not considered a resource. Prescriptions are not considered a resource.

It can be challenging to determine a patient at level 2. A scenario of a Level 2 patient where the triage clinician may assign differently is described here.

A patient at level 2 rating due to long waits and a large number of other patients in the level 2 category is given a level 1 rating. The triage clinician is influenced by long ED waits and how crowded the ED is rather than how acute the situation is and how the patient condition fits the ESI algorithm.

The patient’s situation should be considered only and not conditions in the emergency room when determining an ESI level. If a triage clinician reports the wrong ESI level a patient could have a long wait and have a poor outcome – possibly resulting in complications and legal issues.

Decision Point B: High Risk Situation?

These questions should be used to determine whether a patient is at level 2.

• Is the patient in a high risk situation?

39 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Is the patient in severe distress or pain? • Is the patient disoriented, lethargic, or confused?

The triage clinician must quickly answer the questions. The clinician can get and use information that is objective and subjective. In contrast with level 1, Level 2 is determined by asking some specific questions, such as is the patient in a high risk situation?

The triage clinician can answer the above question based on the following assessment steps and actions.

• Interviewing the patient • Observing the patient • Working from experience • Knowing the age of the patient • Knowing the medical history of the patient • Determining whether the condition easily deteriorate • Understanding the time sensitive element

The triage clinician can recognize a high risk patient due to their experience and observations. The clinician can determine whether it is unsafe for the patient to be in the waiting room for long.

Level 2 patients are at high risk generally and very ill. They should be a high priority. Their treatment should be started as much as possible with no delay. The need is immediate.

A key difference in level 1 and level 2 is that with level 1 a physician should be immediately present. With level 2 the triage clinician notifies staff of a level 2 patient. The clinician can then start care without a physician at the

40 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com bedside immediately. The triage clinician knows that the patient must have interventions. But the clinician determines the condition will not get worse.

The clinician can do the following emergency interventions before a physician is needed:

• Obtain an ECG • Place a cardiac monitor on the patient • Provide supplemental oxygen • Start an IV (intravenous) access

Some examples of a patient in a high risk situation are highlighged here.42

• Signs of a stroke but not at a level 1 • Suicidal patient • Homicidal patient • Patient taking chemotherapy, showing a fever, immunocompromised • A needle stick for a health care worker • Possible ectopic pregnancy with stable blood flow • Active chest pain, stable, suspecting acute coronary syndrome, no immediate intervention needed that is lifesaving

Is the patient disoriented, confused, or lethargic?

With the question related to patient orientation and alertness, the clinician is looking for changes in consciousness that are acute. Examples of changes in level of consciousness include: • An adolescent who is disoriented and confused • An elderly patient with sudden confusion • An infant with a parent reporting the baby is sleeping all the time

41 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Is the patient in severe distress or pain?

The level of a patient’s pain is important to determine, and if the answer is ‘yes’, the triage clinician must determine the level of distress or pain. This can be determined by asking the patient of their pain level or through observation. If the patient reports pain at level 7 or higher on a 10-point scale with 10 being the most intense pain, the triage clinician could assign a level 2 rating. If the answer to the questions about severe distress or pain is ‘no’, the triage clinician can move to the next step.43

Not all patients who report pain at level 7 or above must be at level 1. For example, a twisted ankle may result in a pain rating of 8. In this case, the patient can possibly wait to be treated.

Some of the ways a patient can be assessed by observation include those listed below.

• Extreme perspiring • Crying • Facial expression • Body position • Vital sign changes as with hypertension • Vital sign changes as with rapid heart rate • Vital sign changes as with an increased respiratory rate

Another example would be a patient complaining of nausea and vomiting with a history of renal failure. In this case, a level 2 could be assigned.45

42 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com When severe distress is referenced this can by psychological or physical. This can include a victim of domestic abuse, an assault victim, or a combative person.

It was mentioned earlier that level 1 patients are less than 5 percent of those coming to an emergency department. Estimates show that 20 to 30 percent are at level 2. When a triage clinician identifies a patient as level 2, the clinician must make sure to care for the patient in a timely way. In such cases, it’s necessary to determine whether a family member could complete registration in the ED while the clinician arranges for the patient to have vital signs obtained, a comprehensive nursing assessment, and placement in a treatment area. About half of patients at level 2 will be admitted into the hospital.44,47 If the patient can wait, the next decision point is approached.

Decision Point C: Determining Resources

When moving to the decision point C, resources are determined. For each choice for resources, the clinician can answer ‘None’, ‘One’, or ‘Many’. For a physician to reach a decision on disposition, the triage clinician should ask how many resources a patient will need. The disposition could be to 1) Admit to the hospital, 2) Transfer to another institution, and 3) Admit to an observation unit. Considerations on determining resources include:

• Assessment provided by the patient • Assessment provided by the triage nurse • Past medical history • Age • Medications • Gender • What is typically done in this situation

43 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • What is the standard of care for an emergency department • Understanding of customary and prudent practices

Resources can include: • Procedures • Lab tests • Hospital services • Consultations • interventions • Simple interventions such as bandaging

The following list shows types of resources to help determine a level designation. As a reference point, two or more resources are needed for a level 3 designation. For a level 4 designation only one resource is needed. No resources are needed for a level 5.

Resources Not Resources

Labs (blood, urine) History & physical (including pelvic) ECG Point-of-care testing IV fluids (hydration) Saline or heplock X-rays and CT Prescription refills MRI, ultrasound, angiography Tetanus immunization IV, IM, or nebulized medications PO medications Specialty consultation Phone call to primary care physician Simple procedure = 1 (i.e., Foley Crutches catheter) Simple procedure = 1 (i.e., laceration Splints, slings repair) Complex procedure = 2 (i.e., sedation) Simple wound care (dressings, recheck)

Resources can include imaging such as X-Rays, CT scans, MRIs, ultrasound, and angiography.48

44 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Decision Point D: Vital Signs

When a triage clinician assigns a patient to level 3, patient vital signs should be obtained. The clinician must decide if the vital signs are such that there is concern. The clinician can put the patient at level 2 if vital signs are outside of acceptable parameters.

Predicting Resources: Levels 3,4, 5

To predict resources with a reference to levels 3, 4, and 5 in contrast to levels 1 and 2, the following criteria and example are considered.49

Level 5 – no resources • 12 year old, with poison ivy – needs an exam and prescription • 50 year old, did not take medication for blood pressure – has blood pressure of 150/92 – needs an exam and prescription

Level 4 – one resource • 20 year old with sore throat – needs an exam and throat culture – lab resource needed • 30 year old with a urinary tract infection – needs an exam and urine culture – lab resource needed

Level 3 – two or more resources • 20 year old with abdominal pain, nausea, no appetite – needs exam, IV fluid, lab studies, CT scan • 42 year old who is obese with swelling pain in the left leg – needs an exam, lab, and vascular study.

Vital signs are not part of a ESI level 1 or 2. Additional considerations include:50

45 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Taking the body temperature for a child under the age of 3 • Considering vital sign results a triage clinician can update a patient with a heart rate of 104 – to level 3 • A baby under the age of 1 with a respiratory rate of 48 and a cold could be triaged at a level 2 or 3

Getting vital signs is part of the assessment for level 3 and include data outlined below.

• Blood pressure – A high reading indicates strain on arteries and the heart, possibly contributing to a stroke or heart attack • Heart rate – Number of beats per minute, measuring the beating of the heart • Temperature – Measurement of temperature possibly indicates disease • Respiratory rate – Number of breaths per minute; how frequently the patient breathes • Oxygen saturation – Saturation of oxyhemoglobin, providing a possible warning of cardiovascular or pulmonary deterioration • Pain – Sensation transmitted by the nervous system, with perception modified by emotion and cognition

Further details on vital sign trends will be discussed elsewhere in this course.

Physical And Medical Conditions Influencing ESI Triage Categories

If a trauma patient arrives at an emergency room after a car accident, there may be corresponding organ complaints. The trauma patient may complain of pain in the right upper quadrant and have stable vital signs. The patient should be a level 2 because of the possibility of significant trauma such as a liver laceration.

46 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com In a trauma response level as used in an emergency department, both the triage level and trauma response level are important to how to treat a patient. For example, consider a patient involved in a car accident and having a blood pressure of 80 palpable. This patient should be at level 1.

Chest pain is another consideration for determining triage level for someone coming into an emergency department. If the patient is stable physiologically but has chest pain, it could be an acute coronary syndrome. This would be a level 2 patient. The patient does not need an immediate intervention that is lifesaving but may be a high risk patient. Acute coronary syndrome includes a heart attack and unstable angina. Acute coronary syndrome is a catch-all term for a condition where there is sudden blockage of blood to the heart muscle.51

In general, not everyone with chest pain is at a level 1. Getting vital signs is part of the assessment for level 3 and include the patient’s pulse, oxygen saturation and respiratory rate. Caring for someone with check pain is time sensitive, and that patient is not always at a level 1. A patient with chest pain should have an ECG within 10 minutes of arrival. The ECG is not lifesaving. It is diagnostic. The true level 1 patient needs immediate care that is lifesaving.

Some patients with chest pain are at level 1. If the blood pressure is 80 palpable and the patient is perspiring profusely, and is having chest pain, the patient is at level 1. Consider a patient who has signs of a stroke and complains of left arm weakness. A CT scan provides details that can help a stroke team. If the patient cannot maintain an airway, this is level 1.

47 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Another scenario to consider is a senior citizen who falls. They could fracture a hip as a result of the fall. Assume they arrive by car and report being in pain. This would be a level 3 patient. But the triage clinician could put the patient into a bed before another level 3 patient. Arriving by ambulance is not automatically a level 1 or 2. Instead the patient should go through the ESI algorithm.

A note of caution is when there is emergency department overcrowding.52 A triage clinician could have a level 2 patient and no open bed. The clinician should not just make the patient a level 3 in this situation. This clinician puts the patient at greater risk. The clinician should make the patient a level 2 and determine who in the level 2 is at greatest risk and could deteriorate. The clinician would place into a bed a patient with chest pain before a patient with a kidney stone.

Remember that level 1 is one of the five levels of the ESI triage system. The system divides patients up by resource needs and patient acuity. The clinician makes four decision points in the system. The patient is asked if they are dying, and the ESI clinician obtains vital signs, determines whether the patient waits, how many resources are needed. A triage clinician who has experience can quickly and appropriately triage patients when appropriately trained to use the ESI system.

Levels of the ESI triage system are shown in the table below.53

48 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Level Name Description Examples

Immediate, lifesaving intervention Cardiac arrest 1 Resuscitation required without delay Massive bleeding

High risk of deterioration, or signs Cardiac-related chest pain 2 Emergency of a time-critical problem Asthma attack Stable, with multiple types of resources needed to investigate Abdominal pain 3 Urgent or treat (such as lab tests plus X- High fever with cough ray imaging) Stable, with only one type of Simple laceration 4 Less urgent resource anticipated (such as only Pain on urination an X-ray, or only sutures) Stable, with no resources Rash 5 Non urgent anticipated except oral or topical Prescription refill medications, or prescriptions

The clinician should identify the lifesaving intervention needed, such as supporting circulation, maintaining the airway and addressing a major change in level of consciousness. Further, ED clinicians need to address time sensitive factors and whether a patient is: • In severe distress or pain • disoriented, lethargic, or confused • in a high risk age category, such as elderly • diagnosed with comorbid conditions (medical history) • At risk to easily deteriorate

Since Level 2 patients are at high risk generally and very ill, they should be a high priority. Their treatment should be started as much as possible with no delay. The need is immediate. The major determining factor should be if the condition could easily deteriorate. Characteristics of a Level 2-5 patient are outlined below.

49 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Level Name Description

High risk of deterioration, or signs of a time-critical 2 Emergency problem. Stable, with multiple types of resources needed to 3 Urgent investigate or treat (such as lab tests plus X-ray imaging). Stable, with only one type of resource anticipated 4 Less Urgent (such as only an X-ray, or only sutures). Stable, with no resources anticipated except oral or 5 Non Urgent topical medications, or prescriptions.

The qualifications for Level 2-5 on the ESI are additionally important to note and shown in the table below, which identifies resources needed.

Level Name Resources

2 Emergency Many 3 Urgent Two or more 4 Less Urgent One 5 Non Urgent None

When caring for pediatric patients in the ED, clinicians should be guided by the maximum temperatures for pediatric fevers. Pediatric fever conditions include the following considerations highlighted in the table below.

Age of Patient Level 1 to 28 days 2 if temperature is higher than 38.0 degrees C or 100.4 degrees F 1 to 3 months 2 if temperature is higher than 38.0 degrees C or 100.4 degrees F 3 months to 3 years 3 if temperature is higher than 39.0 degrees C or 100.2 degrees F

50 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Resources in these cases can include: • Procedures • Lab tests • Hospital services • Consultations • Interventions • Simple interventions

Resources to help determine a level designation are listed below. As a reference point, two or more resources are needed for a level 3 designation. For a level 4 designation only one resource is needed, and no resources is needed for a level 5.

Resources No Resources Labs (blood, urine) History & physical (including pelvic) ECG Point-of-care testing IV fluids (hydration) Saline or heplock X-rays and CT Prescription refills MRI, ultrasound, angiography Tetanus immunization IV, IM, or nebulized medications PO medications Specialty consultation Phone call to primary care physician Simple procedure = 1 Crutches (example, Foley catheter) Simple procedure = 1 Splints, slings (example, laceration repair) Complex procedure = 2 Simple wound care (dressings, recheck) (example, sedation)

Guidelines on what the triage clinician should do in working with the ESI system is further elucidated below. • Use the algorithm independent of how many patients come into the emergency room • Follow the institution’s requirements on level 2 and what types of patients to include

51 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Determine if a patient is at level 1 and needs, for example, immediate resuscitation • If a patient is not a level 1 determine if a patient can wait • Know that a level 2 patient needs help as soon as possible

Some questions the triage clinician should ask to follow the ESI algorithm are: • Is the patient in a high risk situation? • Does the patient have severe distress or pain? • Does the patient have unusual confusion, disorientation, or lethargy?

To identify a high risk patient, the triage clinician should look at: • The complaint of the patient • The symptoms and signs • Medical history • Demographics

The triage clinician does not make a diagnosis. Rather, he/she considers what could be a diagnosis based on patient complaints. Examples of situations that are high risk are listed here.

• Recognize a high risk patient. This should be done no matter what triage system is used. The ESI system recognizes that the triage clinician should rely on experience and expertise to determine if a patient is at risk. • Use scenarios to assess a patient as high risk. For example, a patient with chest pain, shortness of breath, and nausea. Another scenario of high risk is a person with a meningococcal rash, stiff neck, and fever.

52 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Vital signs can help only up to a point. Symptoms, signs, history, and complaints should be considered. These all help in determining if a condition is serious and could deteriorate rapidly. These are high risk. Vital signs may not be needed.

Examples of a level 2 patients that may not be as easily recognized by triage clinicians are highlighted here.

• A patient notes that they are allergic to peanuts. They were at a restaurant. They have throat tightening. They should be at level 2 as they are at high risk of anaphylaxis. They need quick evaluations but not at a level 1. They are at risk of anaphylaxis and could quickly deteriorate.

• An 80-year old patient has severe abdominal pain. Consider their age, medications, and history. They should be at level 2. They have a risk of mortality. Contrast this to the same symptoms of someone who is 20 years old with stable vital signs who would be at level 3.

Other examples of high risk situations to consider are elaborated on below. The experienced triage clinician in an emergency department will recognize these and help determine if a person is at high risk.

Abdominal and Gastrointestinal

The most frequent complaint in an emergency department is abdominal pain. How can the clinician tell if there is a high risk for a patient with abdominal pain? Some considerations include: • Patient demographics • History

53 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Current pain rating • Respiratory rate • Heart rate

If the condition is shock, symptoms to consider that put the patient at high risk include: 1. Respiratory distress 2. Tachycardia 3. Bloating 4. Pallor 5. Bleeding 6. General appearance 7. Hypotension 8. Several abdominal pain

If a patient is elderly and has severe abdominal pain that risk can be higher than with a younger person with higher mortality and mortality for the younger person. The elderly person could also have complications from gastrointestinal bleeding and bowel obstruction.58

To place a person into a high risk category here are more considerations, such as: 1. How the person describes their pain 2. Why the person came to the emergency department 3. How long has there been pain 4. Is there fever 5. Is there a loss of appetite 6. Is there dehydrations 7. Is there severe nausea, diarrhea, or vomiting

54 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com An abdominal aortic aneurysm is a consideration with these factors. An abdominal aortic aneurysm is a high risk condition at an ESI level of 2. It involves: 1. Pain that constant and severe 2. Pain that has a sudden onset 3. Abdominal pain radiation to the back 4. Hypertension in the patient history

Pancreatitis can have similar symptoms however is less life-threatening. With an abdominal aortic aneurysm, a patient has an enlarged area in the lower part of the aorta. This is the major blood vessel for supplying blood to the entire area. The aorta runs from the heart to the center of the chest and abdomen. A ruptured abdominal aortic aneurysm can cause bleeding that is life-threatening as the aorta is the main supplier of blood for the body.59

In the case of pancreatitis (inflammation of the pancreas), it can be acute and symptoms appear suddenly. Symptoms last for days. A patient can also have chronic pancreatitis, having it occur over years. A severe case of pancreatitis can lead to complications that are life-threatening.60,61 A patient can therefore start at a level 3 when they have abdominal pain. The triage clinician can change this to a higher risk if the other symptoms appear, such as tachycardia and elevated respiratory rate. Other factors to consider in a GI condition aside from vital signs would be any vomiting of blood or rectal bleeding.

A level 2 patient could be elderly, arrived by ambulance, have a heart rate of 117 and respiratory rate of 24. This patient is at high risk. A patient in their 30s with bright red blood in the rectum would not immediately placed at level 2.

55 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Cardiovascular

A common complaint of someone in an emergency department is chest pain. Some considerations include: • It can be difficult to determine acute coronary syndromes • AN ECG can help with the assessment • If a triage clinician asks for an ECG this can mean a level 2 classification and high risk for cardiac ischemia • If a patient has epigastric or chest discomfort they need an ECG as soon as possible to determine acute coronary syndromes and have a level 2 classification

With myocardial ischemia a patient has reduced blood flow to the heart. This prevents the heart from getting enough oxygen. This reduced blood flow can be the result of complete or partial blockage of the coronary arteries. This condition can damage heart muscle. It can also reduce the ability of the heart to efficiently pump. A severe and sudden blockage of a coronary artery can result in a heart attack. Abnormal heart rhythms can also result from myocardial ischemia. Some treatments for myocardial ischemia include:62 • Medication • Procedures to open blocked arteries • Bypass surgery

If a 55 year sold obese female had epigastric pain and fatigue this should be a level 2 patient. The clinician should consider gender and heart health risks when considering possible acute coronary syndromes.

Level 1 is the classification for a patient who is physiologically unstable, and requires immediate intubation and hemodynamic support or another immediate intervention.

56 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Not all chest pain means the patient should be at a level 1 or level 2. Consider the following two examples:

1. A patient who is 22-years old who has chest pain, cough, a 101 degrees F fever, and normal oxygen saturation. This is not a level 1 or 2. But if the patient notes they are using cocaine, the risk becomes higher. 2. A patient with chest pain, recent upper respiratory symptoms, no additional cardiovascular risk factors, and a cough with chest pain.

The triage clinician should look at each case individually when it comes to chest pain. Note there are other possible cardiovascular conditions that could be of a high risk, such as a case of acute vascular arterial occlusion, hypertensive crisis, or fever after a valve replacement

Nose and Throat

There could be impending airway loss if a patient is found to be drooling, and exhibits a wheezing and high pitched sound caused by disrupted airflow when breathing. The following are examples of very high risk conditions. These patients are at level 1. They need immediate intervention as there is danger of airway compromise, such as in cases of peritonsilar abscess, and epiglottitis (a foreign body in an airway or with a child a foreign body in the esophagus).

Epistaxis is often encountered in the ED, and some factors to consider include: • This can be caused by hypertension that is not controlled so the triage clinician should get a blood pressure reading even if the ESI algorithm does not call for one.

57 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • This can be a high risk situation if there is brisk bleeding (a nose bleed that is secondary to posterior) or with a patient using an anti- coagulant such as warfarin, which are all level 2 conditions.

Concerning a peritonsilar abscess, the abscess forms in throat tissue. This tissue is next to one of the tonsils. Abscesses are a collection of pus. It forms near an area of skin or other soft tissue that is infected. If severe it can cause blockage in the throat. The abscess can cause swelling and pain. With the throat blocked, it can become difficult for a patient to speak, swallow, or even breathe.

In a situation of a peritonsillar abscess, the following may occur.63 • It can result when tonsillitis spreads, causing infection in soft tissues. Tonsillitis is an infection of tonsils. • It is more likely to occur among older children, adolescents, and young adults. • The bacteria involved can be similar to what causes strep throat with the peritonsillar abscess being a complication of tonsillitis. • A common cause of the infection of soft tissue around tonsils is streptococcal bacteria. The tissue becomes invaded by anaerobes. These anaerobes live without oxygen. They enter through glands. • Risk factors include chronic tonsillitis, dental infection, infectious mononucleosis, calcium deposits in the tonsils, and chronic lymphocytic leukemia. • Symptoms include a sore throat, swelling, movement of the uvula, enlarged lymph glands, tender lymph glands, painful swallowing, fever, chills, spasms in the jaw, spasms in the neck, ear pain, muffled voice, and difficulty with swallowing saliva.

58 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com With acute epiglottitis, the patient has a potentially life-threatening condition that occurs when the tissue protecting the windpipe becomes inflamed. With acute epiglottitis in adults, the organisms that can cause it include Haemophilus influenzae, H parainfluenzae, streptococci, Staphylococcus aureus, mycobacteria, Escherichia coli, Neisseria meningitidis, herpes simplex virus (HSV), infectious mononucleosis, and Candida. Other (noninfectious) causes include smoking crack cocaine, head and neck chemotherapy, and ingestion of a bottle cap.64

Epistaxis as an acute hemorrhage that comes from a nasal cavity, nostril, or nasopharynx. We see this often as a complaint in an emergency department. It can cause significant anxiety in patients. Over 90 percent of those who have epistaxis and come to an emergency department are successfully treated.65

Respiratory

Concerning respiratory complaints and high risk, some level 1 and level 2 considerations are listed here. • Place at level 1 a patient who has respiratory distress that is severe and requires lifesaving intervention immediately including intubation • Place at level 2 patients • Once the clinician evaluates a patient with distress that is mild to moderate with determination of pulse oximetry and respiratory rate, level 2 should be considered as appropriate.

A patient is at high risk if they are oxygenating and ventilating properly but in respiratory distress. The condition could deteriorate rapidly. Related conditions could include:

59 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Asthma • Foreign body aspiration • Pulmonary embolus • Pleural effusion • Toxic smoke inhalation • Pneumothorax • Shortness of breath associated with chest pain

With pneumothorax, air leaks into the space between the chest wall and the lungs. Symptoms include shortness of break. When the pneumothorax is large, a tube or needle is inserted to remove excess air. The condition is a collapsed lunch; air pushes on the outside of the lung and makes it collapse. Only a portion of the lung collapses in many cases.

Some causes of a collapsed lung include:84 • Lung disease • Medical procedures • A penetrating chest injury

With pleural effusion, a patient has a buildup of fluid between the chest and tissues that line the lungs. Poor pumping of the heart or inflammation can cause fluid to accumulate around the lungs. Symptoms include shortness of breath, sharp chest pain, and cough. Some of the treatments include:85 • removal of fluid • water pills (diuretics) • antibiotics

With pulmonary embolism, the patient has a blockage in one of the pulmonary arteries of the lungs. Typically, blood clots cause a pulmonary

60 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com embolism. The clots travel to the lunch from the legs or other parts of the body. As clots can block blood flow to the lungs, this condition can be life- threatening. Prompt treatment reduces the risk of death.86

Toxicological

An ESI level of 1 is appropriate for a patient who is apneic and needing immediate lifesaving intervention. An ESI level of 2 is appropriate for other patients who admit to an overdose. Additional considerations include:

• Rapidly evaluate a patient who comes to the emergency department with an overdose condition as it represents a high risk • It can be challenging to determine quantities consumes and which drugs are involved

Other Medical Conditions

There are several medical complaints of a general nature the triage clinician should consider for being high risk. Included in these complications are: • Sepsis • Diabetic ketoacidosis • Hyperglycemia • Hypoglycemia • Various electrolyte disturbances • Syncope or near syncope

Syncope or Near syncope

Near syncope with light headedness and sense of near fainting with no loss of consciousness are conditions to carefully assess. They should be considered in light of past medical history and patient demographics.

61 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com With syncope comes a temporary loss of consciousness, also explained by patients and family as passing out or fainting. Typically, this is related to an insufficient flow of blood to the brain. This insufficient blood flow can be temporary. It can occur when blood pressure is low. The heart does not pump a supply of oxygen that is normally enough for the brain with this condition. It can be caused by pain, emotional stress, and pooling of blood in legs. This can come about due to changes in body position, dehydration, overheating, exhaustion, or heavy sweating.

Syncope can occur during coughing spells because of change in blood pressure. It can result from lung, metabolic, heart, neurological and other disorders. It can also be a side effect of medicine. Syncope with irregularities and palpitations of the heart can suggest a serious disorder.67

Diabetic Ketoacidosis

With diabetic ketoacidosis (DKA) the patient has is a serious condition. It can lead to the passing out that comes with a diabetic coma and even death. When cells do not get glucose as needed for energy, the body burns fat for energy. This produces ketones. Ketones are what the body creates when breaking down fat to use for energy. This happens where there is not enough insulin in the body to use glucose. Glucose is the source of energy normally used by the body. If there is a buildup of ketones in the blood, then the blood becomes more acidic. This is a warning sign that diabetes is out of control. It is a sign a person is getting sick.68

The body can be poisoned with a high level of ketones. With very high levels of ketones a person can develop diabetic ketoacidosis. Treatment for diabetic ketoacidosis typically happens in a hospital. Diabetic ketoacidosis can develop slowly but if vomiting occurs a life-threatening situation can

62 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com happen within a few hours. Ketoacidosis is a dangerous condition. If someone suspects they have the condition, they should contact a physician immediately or go to an emergency department. Early signs of diabetic ketoacidosis include: • Frequent urination • Thirst • Dry mouth • High blood sugar levels • High levels of ketones • Tired • Dry skin • Nausea • Vomiting • Abdominal pain • Difficulty breathing • Fruity odor on breath • Confusion

Both hyperglycemia and hypoglycemia can occur in a patient who has diabetes. With diabetes, the body does not product adequate insulin in Type 1 diabetes or cells stop responding to insulin in Type 2 diabetes.69

With hypoglycemia more insulin exists than is needed to balance energy expenditure and food intake for the patient. If not treated, the patient can become unconscious. If prolonged there can be irreversible damage. A patient who is hypoglycemic can appear to be drunk. Alcohol can induce hypoglycemia. A patient who looks drunk could be hypoglycemic. In most cases a patient under the influence of alcohol has their blood glucose level tested. This it to make sure they are not hypoglycemic.

63 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Hyperglycemia is a characteristic of a person with diabetes. If a physician sees a patient who complain of excessive thirst, hunger, and urination, the blood glucose level should be checked. They could be at 20 mmol/l while non diabetic readings are at 3.0 to 5.6 mmol/l. If a diabetic patient is hyperglycemic, they could have been ill for some hours.

With hyperkalemia a patient has an abnormally high level of potassium in the blood. This is an abnormality of electrolytes. It is a high risk condition. It can lead to serious dysrhythmia of the heart. You can suspect hyperkalemia in a renal dialysis patient. At very high levels this can lead to cardiac arrest and death. Severe hyperkalemia can result in a high mortality rate. Levels to know include:70 • Normal potassium levels are 3.5 to 5.0 milliequivalents per liter • Moderate levels are at 6.1 to 7.0 milliequivalents per liter • Severe levels are above 7.0 milliequivalents per liter

Sepsis

For an oncology patient with fever consider this patient immunosuppressed especially if they are undergoing chemotherapy. There could be a risk of sepsis here. Identify this patient as high risk to be evaluated as soon as possible.

Sepsis can be viewed in three stages. First is sepsis. Second is severe sepsis. Third is septic shock. The best option is to treat sepsis as early as possible before it becomes more life-threatening. A patient must show at least two of these symptoms and a confirmed or probable infection. 1. Heart rate at 90 beats a minute or higher 2. Respiratory rate at 20 breaths a minute or higher 3. Body temperature at above 101 F or below 96.8 F (above 38.3 C or

64 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com below 36 C)

With severe sepsis a patient will have at least one of the following symptoms and signs indicating that an organ could be failing.

• Decrease in urine output • Change in mental status • Decreased platelet count • Problems breathing • Abdominal pain • Abnormal pumping function of the heart

With septic shock the patient has the symptoms and signs of severe sepsis. Plus the patient has extremely low blood pressure. The pressure does not respond to simple fluid replacement.

Causes of sepsis can be any type of infection. This can be viral, bacterial, or fungal. Some likely varieties include: • Abdominal infection • Pneumonia • Kidney infection • Bloodstream infection (bacteremia)

Some reasons that incidence of sepsis appears to be increasing include: • Aging population • Drug resistant bacteria – types of bacteria that can resist the effect of antibiotics that at one time killed them. These antibiotic resistant bacteria are the root cause often of an infection that triggers sepsis. • Weakened immune system – This can be because of cancer treatments, HIV, or transplant drugs.

65 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com A patient is at greater risk of sepsis if they: • Are very young • Are very old • Have a compromised immune system • Are in the intensive care unit of a hospital • Already very sick • Have injuries or wounds such as burns • Have an intravenous catheter, breathing tube, or other invasive device

Possible complications include:71

• As sepsis gets worse blood flow can be impaired to organs such as kidneys, heart, and brain • Sepsis can cause blood clots to form within an organ and in toes, fingers, legs, and arms – leading to possible gangrene (tissue death) and organ failure • Mortality rate for septic shock is near 50 percent • One episode for severe sepsis increases the chance of a future infection

Genital and Urinary

For a renal dialysis patient who is not able to complete dialysis, know there can be electrolyte disturbances placing these patients at high risk. For testicular torsion the patient should not be placed in a waiting area. They must receive immediate attention. This is a life or limb condition with permanent organ loss. Males with several pain and testicular torsion require rapid pain control and surgical intervention.

66 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Obstetrical and Gynecological

Factors to consider for obstetrical and gynecological patients include: • Carefully assess all females with vaginal bleeding or abdominal pain • Take vital sign for all females with vaginal bleeding or abdominal pain if there is not an obvious level 1 condition • Determine pregnancy history • Determine last menstrual period if childbearing age • A patient may not know they are pregnant so a triage nurse should consider pregnancy a possibility

For an early pregnancy some considerations include: • Assess for an ectopic pregnancy • Assess for a spontaneous abortion • Assign a level 2 to all pregnant patients who have vaginal bleeding, discharge, or abdominal pain and at 14 weeks or over – plus seen by a doctor as soon as possible • Assign a level higher than 2 to a patient with bleeding and generalized cramping and stable vital signs

With an ectopic pregnancy, a fertilized egg implants other than the main cavity of the uterus. This fertilized egg cannot survive outside the uterus. If it continues to grow outside the uterus, it could damage nearby organs. It could also cause a loss of blood that is life-threatening. Symptoms of an ectopic pregnancy include vaginal bleeding and pelvic pain. If this is at a later stage of pregnancy, surgery may be needed. If it is at an early stage in pregnancy, medications may help.

The fertilized egg cannot survive outside the uterus. If left to grow, it may damage nearby organs and cause life-threatening loss of blood. Symptoms

67 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com include pelvic pain and vaginal bleeding. To prevent complications, treatment is needed. In the early stages, medications may be sufficient. Later stages require surgery. Normally an egg attaches to the lining of the uterus. Most often with an ectopic pregnancy this occurs in one of the fallopian tubes carrying the egg from the ovaries to the uterus. This is also called a tubal pregnancy. It can also occur in the cervix, ovary, or abdominal cavity. You cannot proceed normally with an ectopic pregnancy. The fertilized egg cannot survive.76

In the emergency room the triage clinician should look at symptoms and signs. Placental abruption (abruptio placentae) is a serious complication of pregnancy. With this condition the placenta peels away from the inner wall of the uterus. This peeling away is either complete or partial. The placenta develops during pregnancy in the uterus to feed the fetus. Placental abruption can deprive the baby of nutrients and oxygen and cause bleeding in the mother. This condition can happen suddenly. If it is untreated, it can put both baby and mother in danger.77

Placenta previa is a complication in pregnancy that can present as painless vaginal bleeding the in third trimester. An ultrasound scan can sometimes make this diagnosis earlier in pregnancy. The condition can be defined as complete and marginal previa. With a complete previa the placenta completely covers the cervical os. If an edge of the placenta is not fully covering it, this is a marginal previa. This can be a serious condition for the mother and fetus due to the risk of hemorrhage.78

For a patient who is postpartum some considerations include: • With heavy vaginal bleed assign a level 2 and have a doctor see the patient as soon as possible

68 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • With a hemodynamic instability and in need of lifesaving interventions place the patient at level 1

Ocular

Conditions that the triage clinician can tie to a complaint involving visual loss include: • Trauma • Retinal detachment • Acute narrow angle glaucoma • Central retinal artery occlusion • Chemical splash

With a central retinal artery occlusion, there can be a painless loss of monocular vision. With an ocular stroke the typical cause is an embolism of the retinal artery. An embolism can also travel to other branches of the retinal artery. A loss of just a section of the visual field can occur. Retinal artery occlusion is an emergency. A delay in treatment can result in loss of vision that is permanent. Immediate intervention improves the chances of a visual recovery. Retinal artery occlusion can also accompany other diseases that are systemic.79

With retinal detachment, you have an emergency. The retina is part of the eye, and it pulls away from supporting tissues. Tissues at the back of the eye pull away from the vessels that provide nourishment and oxygen hat is necessary. Symptoms can include floaters (debris), a shadow in the field of vision, or sudden flashes of light. Prompt treatment can save vision for the eye.80

69 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com With glaucoma a patient has an eye condition that damages the optic nerve which is needed for good vision. The damage could be caused by high pressure in the eye. It is a leading cause of blindness in the United States. It is more common in the elderly but can happen at any age. A common form of glaucoma has no warning signs. The effect is gradual.81

With a chemical splash in the eye the patient has an immediate threat to vision. It could result in a permanent condition. This is true with a splash that is: • Unknown • Base • Acid

If the chemical is alkali, flush immediately to stop damage to the cornea. This is a level 2 condition. Immediate irrigation should be started no matter what the condition is of available beds. Additional considerations include: • Eye trauma can cause a globe rupture • Eye trauma can cause hyphema • These conditions need immediate evaluation • These conditions need immediate treatment

With a hyphema, the patient has a collection of pooling of blood inside a chamber of the eye. This anterior chamber is the space between the cornea and the iris. Blood can cover all or most of the iris and pupil, blocking vision completely or partly. The condition includes the presence of blood in the aqueous fluid of the eye camber. A common cause of hyphema is trauma. After an injury accumulation of blood in the eye chamber is a challenging problem. Even a small hyphema due to injury can be traumatic. It can be associated with damage to vascular and other tissues. Complications can

70 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com result without prompt treatment. A blunt trauma to the eye can harm any of the following:82 • Iris • Cornea • Lens • Retina • optic nerve

Level 2 is the ESI evaluation as there could be further complications or deterioration. This is true for a patient with partial or full loss of vision that is sudden. Immediate care is needed to prevent permanent damage to the eye.

Orthopedic

For a patient with the symptoms and signs of compartment syndrome, some considerations include: • These patients are a high risk for extremity loss • These patients should be at level 2

With compartment syndrome a patient has a painful and dangerous condition caused by pressure buildup from internal bleeding or swelling of tissues. This pressure decreases blood flow. With decreased blood flow muscles and nerves do not get needed nourishment. For a severe case of compartment syndrome, a patient needs emergency surgery. Compartment syndrome happens when excessive pressure builds up within an enclosed muscle space. It usually results from swelling or bleeding after an injury. The high pressure is dangerous with this condition as blood flow to and from the affected tissues is impeded. This condition can be an emergency so there

71 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com is not permanent injury. Some of the symptoms include:83 • Weakness in the affected area • Sensation of pins and needles • Severe pain

Other high risk injuries include an extremity injury with: • Partial or complete amputation • Impacted neurovascular function • Trauma that is high risk due injury from a pedestrian struck by a car, gun shot, stab wound, acceleration, or deceleration

Level 1 is appropriate with the need for a lifesaving intervention, for example, a high level amputation and a hemodynamically unstable condition. Consider vital signs and carefully evaluate a patient with a possible fracture to: • Femur • Hip • Pelvis • Other extremity dislocation

Neurological

Consider high risk a patient with: • High blood pressure • Lethargy • Severe headache and changed mental status • Fever • Rash

A patient with sudden onset of motor weakness or speech deficit should be

72 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com at level 2. A patient with these symptoms needs immediate evaluation as they could be experiencing acute stroke. The time from onset of these symptoms is critically important in treating option selection.

With a stroke the supply of blood to part of the brain is reduced or interrupted. This deprives brain tissue of nutrients and oxygen. Brain cells start to die. This is a medical emergency. Treating promptly is important. Early action can minimize damage and complications. This poor blood flow to the brain causes cell death. Main kinds of stroke include ischemic due to lack of blood flow, and hemorrhagic due to bleeding.

These result in having part of the brain not work right. Symptoms and signs of a stroke can appear soon after the stroke happens. If symptoms last less than 1 to 2 hours, this is a mini stroke or transient ischemic attack. Signs and symptoms include:73 • Loss of vision on one side • Feeling like the world is spinning • Problems understanding • Problems speaking • Inability to move on one side of the body • Inability to feel on one side of the body • Severe headache with a hemorrhagic stroke

If a patient has no medical history of headaches and has the complaint of extreme headache should be considered high risk. There could be a subarachnoid bleed. With a subarachnoid hemorrhage you have bleeding in the area between the tissues that cover the brain and the brain itself. This is called the subarachnoid space. This bleeding can be caused by a bleeding disorder, bleeding from an aneurysm, a head injury, and use of blood

73 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com thinners. In the young this can be a result of car accident. In the elderly it can result typically after a fall.74

If patient complains of a seizure, some considerations include: • The patient could be in an altered state of consciousness after an epileptic seizure (postictal) • Place at level 2 all patients with a reported seizure and do not allow them to wait for a long period of time as they could have another seizure

With epilepsy, a patient has a neurological (central nervous system) disorder. This causes period of unusual behavior or seizures, sensations, and possible loss of consciousness. Seizures can vary. Some with a seizure stare blankly during a seizure for a few seconds. Other twitch legs and arms repeatedly. Here is more information about epilepsy.75

• About 1 in 25 people in the United States will develop a disorder with a seizure. • About 10 percent of people have a single seizure. • Two seizures are typically needed for an epilepsy diagnosis. • Even mild seizures can be dangerous. • Medications can control seizures in over 75 percent of people with epilepsy. • Some people outgrow epilepsy with age.

Mental Health

Consider to be high risk a patient who could harm others, themselves, or the environment and are:

74 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Suicidal • Homicidal • Violent • Psychotic

With intoxication considerations include: • No high risk exists without signs of trauma or risk of aspiration • Carefully assess the patient for trauma • Carefully asses the patient for behavioral issues

There could be a level 2 with such a patient under certain conditions considering past medical issue. Symptoms and signs of alcohol poisoning include: • Seizures • Confusion • Vomiting • Slow breathing at fewer than 8 breaths a minute • Irregular breathing with a gap between breaths of over 10 seconds • Pale or blue tinged skin • Low body temperature • Unconsciousness (passing out) and cannot be woken up

Note that a person with alcohol poisoning can be at risk of dying if they are unconscious and cannot be awakened. Alcohol poisoning is an emergency. Calling 911 can be in order. The person should not be left alone because of the gag reflex. Someone who has alcohol poisoning could choke on their vomit and not be able to breathe. If a person is vomiting they should be supported to sit up. If they must lie down turn, their head should be turned to the side to prevent choking. The triage clinician should try to keep the

75 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com person awake to prevent a loss of consciousness.

Ethyl alcohol (ethanol) is found in alcoholic drinks, cooking extracts, some medicines, and mouthwash. Alcohol poisoning comes usually from drinking many alcoholic beverages in a short time.

Toxic poisoning can also come from other forms of alcohol. This can include isopropyl alcohol in lotions and cleaning product. Another form of alcohol is methanol or ethylene glycol as found in paints, solvents, and antifreeze.72

Pediatric

Pediatric triage is challenging. This is especially true for infants. Factors to consider include: • Obtain a history • Evaluate the child’s activity level • If inconsolable, there is a high risk of serious illness • If withdrawn, there is a high risk of serious illness

Some high risk pediatric conditions include: • Severe dehydration • Severe sepsis • Seizures • Burns • Head trauma • Diabetic ketoacidosis • Ingestions including vitamins • Sickle cell condition • For an infant under 30 days of age – a fever of 100.4 F or 38 C or

76 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com higher

Transplant

If a patient is on a transplant list they are usually high risk. If a transplant patient has a non-transplant issue and comes to the emergency department, the triage clinician must assess the appropriate triage level, not necessarily a level 2, as with a cut to a finger. Typically, a patient who had an organ transplant is considered high risk and immunocompromised. A patient who has had an organ transplant can have complications including sepsis and organ rejection.

Trauma

A patient should be placed at level 2 if there is a high risk of injury. If a trauma patient has unstable vital signs they require immediate attention and should be at level 1. A traumatic event can involve injuries not seen immediately. Trauma can include being a victim of a: • Fall • Gunshot • Stab wound • Motorcycle accident • Car accident

These can cause penetrating and blunt trauma. These should be assessed carefully for serious injury. The following information should be obtained about the injury. • When the injury happened • Details of loss of consciousness • Patient age

77 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Distance patient fell • Type of injury • Speed of vehicles involved • Number of gunshots heard • Types of weapons • Location of injury • Head injury details including intracranial pressure, headache, vomiting

Level 2 could be appropriate. The triage clinician should rely on their knowledge and experience. Level 1 could be appropriate in some cases, such as a gunshot wound to the chest, head, neck abdomen, or groin. These typically need an immediate evaluation and intervention.

Considerations for an emergency department are highlighted here. • Use both trauma criteria and ESI triage • Treat the trauma and ESI triage criteria separately • Assign patients a value for trauma level and ESI level

As an example, a patient could be at level 1 for the trauma scale. On the ESI scale it could be level 2 because level 1 requires a lifesaving intervention.

Wound Management

The following should be considered as part of a high risk wound. • Uncontrolled bleeding • Partial or full amputations • Arterial bleeding

Level 2 is not appropriate for most wounds. Some considerations include:

78 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Level 1 is appropriate with uncontrolled bleeding where the patient need a lifesaving intervention that is immediate to stabilize the patient • Carefully assess a stab wound to see the neurovascular status

The clinician should consider whether the patient is experiencing new onset confusion, lethargy, or disorientation. To determine a level 2 status, the clinician should ask where a patient has new onset confusion, disorientation or lethargy.

Such a patient could be found with a friend or family member. The patient could have a change in the level of consciousness. This should not be confused with chronic confusion or chronic dementia. Keep in mind if a patient has a possible hip fracture and dementia, the symptoms of dementia should not be part of the evaluation of ESI level as it is not a sudden or new onset.

The cause of disorientation, lethargy, or confusion could be from a number of serious medical conditions. Some of them include: • Stroke • Transient ischemic attack • Other structural pathology to the brain • Electrolyte imbalance such as hyponatremia or hypoglycemia

With hyponatremia a patient has a condition that occurs when sodium level in the blood is too low. As an electrolyte, sodium helps to regulate the amount of water in and around cells. With hyponatremia the patient can have a medical condition causing it or may be drinking too much water during an endurance sport. This causes the sodium in the system to become too diluted. If this happens the water levels in the body rise. Cells start to

79 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com swell, and the consequences of the swelling can cause health problems that can be mild or life-threatening. In some cases, medications and intravenous fluids can help.87

Level 2 could be appropriate with the following examples. • A patient with diabetic ketoacidosis • A patient with an acute psychotic episode • A new onset of confusion for an otherwise healthy child or adult

The algorithm for the ESI level includes that with an unknown patient history a level 2 is appropriate if the patient is lethargic, disoriented, or confused. The triage clinician can assume the condition is new.

Level 1 is appropriate if the patient needs an immediate and lifesaving intervention. This would include difficulty maintaining an airway and a new onset of confusion.

Rapid treatment of pain is important, and the use of pain treatment in ESI should be considered. In determining a level 2 the triage clinician should consider whether the patient is experience severe distress or pain. Groups such as the American College of Emergency Physicians, Emergency Nurses Association, American Pain Society Board of Directors, and American Society of Pain Management Nursing have approved principles concerning pain management. An emergency department should adhere to these.

Pain

Level 2 could be appropriate for a patient who has a pain rating of 7/10 or higher. Assess a patient for the present of severe distress or pain. Level 2 is not appropriate for every patient at 7 or above on the pain scale but it

80 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com should be a consideration.

Level 2 could be appropriate if the triage clinician determines the pain rating plus clinical condition. An example would be if the patient complains of pain at a level of 10/10 because an object fell on his/her foot. The clinician could consider a possible fracture and severe pain. The ESI level would be 4. The resources would be an x ray. Proper care would require pain relief, and the clinician can give analgesics if an order is in place, elevation of the foot, and ice. The patient can wait to be seen. There are other scenarios where pain could be 10/10 and the ESL level is 2. This is where there is a rapid response to a condition such as cancer, renal colic, or sickle cell crisis.

The triage clinician should assess all these items when determining a triage level. • Pain intensity reported by patient • Complaint of the patient • Medical history • Patient’s physiologic appearance • What pain management triage can provide

Here is how to use severe pain as criteria to put a patient at a level 2. • An 80-year old female with abdominal pain, severe nausea, and a pain level of 7/10 • A patient writing in pain at 10/10 • A patient who is 30 years old with acute sickle cell pain crisis • An oncology patient who has severe pain • A burn that required pain control that is immediate • A patient with acute urinary retention

81 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com With a sickle cell crisis, red blood cells get stuck in small blood vessels. Red blood cells are normally round and soft, and circulate throughout the body easily. With sickle cell disease, some cells are curved and hard. These do not flow easily and become stuck or occlude vessels. These cells can slow blood flow, and can totally block blood flow.

Some parts of the body do not get the oxygen needed. This can cause intense pain, which can last from a few hours to a few weeks. The cells can get stuck in the small blood vessels of joints, the belly, and the chest. Symptoms may include:88 • Pain can be dull, throbbing, sharp, or stabbing • Severity varies from person to person • Duration of pain varies from person to person • Some people have pain every month • Some people have pain at no regular interval of time

Additional considerations concerning pain management in an emergency department include: • Assess all patients for pain • Ask a patient to rate their pain • Use a scale with the visual analog scale as an example • Use the pain rating as one factor in determining the ESI rating

A level of 2 could be appropriate for a patient who reports 7/10 or higher on the pain scale. The triage nurse also uses an objective and subjective assessment if the pain mean needing interventions beyond the scope of triage.

82 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Distress

To determine a level 2 for a patient, the triage clinician should assess for distress and how severe it is. This can be psychological or physiological. If a patient has respiratory distress that is severe plus pain, the level could be 2 for a disturbance that is physiological.

Some examples of distress that is psychological include: • Combativeness • Distraught due to a sexual assault • Behavioral outbursts • Victim of domestic violence • Acute grief reaction • Suicidal • Flight risk

The triage clinician should also consider not having these patients in a waiting room as the patient could cause agitation with other patients.

Environmental

A level 1 situation with a high risk for potential airway compromise can exist if the patient requires immediate intervention and airway distress coming from inhalation injuries due to smoke inhalation and chemical exposure.

For a third degree burn a patient should be at a level 2 and considered high risk. The patient should be transferred to a burn center for additional care that could be needed.

Burns can be a minor problem or life-threatening emergency. People pass

83 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com away from fire related burn. Chemicals and electricity can cause severe burns. Scalding liquids is a common cause of a burn for a child. Deep or widespread burns need immediate medical attention. For a severe burn, a person can require treatment at a burn center. They can need a skin graft to cover a large wound. A burn does not always impact the skin uniformly. A single injury could impact at varying depths. A minor burn is determined from a serious one by looking at the extent of damage to tissue.66

• A first degree burn has an impact on the epidermis (outer layer of skin). It can cause swelling, redness, and pain. It can heal without first aid in a few days to a week. An example is mild sunburn. • A second degree burn impacts the epidermis and dermis (second layer of skin). The skin can be red, white, or splotchy. There can be pain and swelling. The wound can look moist or wet. Blisters can appear. Scarring is possible • A third degree burn reaching to the layer beneath the skin. Areas that are burned can look charred black or white. The skin can look leathery or waxy. A patient with this burn can have difficulty breathing. There can also be carbon monoxide or smoke inhalation poisoning.

Special Situations

Factors to consider in special situations are highlighted here. • An emergency room can have an alert process. This process causes a team to address an issue in a timely way. • Examples of alerts are stroke alert, myocardial infarction alert, trauma alert, and sepsis alert. • These alerts are hospital specific. • With activation of such an alert the patient is at least at ESI level 2.

84 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com An example is a patient who complains of left side weakness. The patient is not a level 1. But the patient is at high risk for a stroke. The patient meets level 2 criteria. If there is deterioration, the patient would move to level 1.

Level 2 on the ESI triage scale has been considered here. Questions the triage clinician must ask and components of triaging were discussed. The triage clinician should ask questions of each patient, and be alert to those that are high risk.

Levels 3, 4, And 5 Compared

As stated above, Level 3 requires two or more resources. At Level 4, one resource required. At Level 5, no resources are required. The important step here is to determine a Level 3 and compare it to Levels 4 and 5.

The triage rating systems for an emergency department rely entirely on determining the acuity of the patient: How much care a patient must have? A high acuity patient needs care as without care the patient could die. These other rating systems look at an assessment of past medical history, vital signs, objective information, subjective information, allergies, and medication.

A triage clinician determines how sick the patient is. The clinician also determines how long the emergency department can wait before a patient sees a physician.89

85 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com The ESI system uses an approach that does not rely solely on patient acuity. The judgment of the clinician and the resources needed factor into the decision of which patient to see first.

The ESI approach is used to determine the needs for resources after a clinician determines whether a patient is not level 1 or level 2. At this point the clinician considers the resources a patient will need. The resources will determine what the disposition will be for the patient.

When first developing the ESI system, creators Wuerz and Eitel included the concept of resource as part of the triage decision. The creators wanted additional input other than patient acuity. They felt a triage clinician with experience could make a good prediction on resources such as interventions, tests, and consultations needed. This would be for the time that a patient is in the emergency department.

Studies have shown that trained triage clinicians are good at predicting resource needs for patients coming to an emergency room. This includes various kinds of institutions including learning and community hospitals plus those in rural and urban areas. Triage clinicians predicted accurately about three quarters of the time. This includes the need for resources through disposition of the patient; they can determine low versus high use of resources effectively, and can help streamline the flow of patients in an emergency department.

This is for patients who are at Levels 3, 4 or 5, not patients who are in a very high risk situation and in need of various degrees of immediate care. • First the triage clinician decides if there is a level 1 or 2 situation looking at patient acuity. Then the clinician looks at level 3 or higher

86 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com based in part on resource need, and looks at resource need for a level 3 or higher patient.

To identify resource needs in an emergency department, the triage clinician should: • Be familiar with the general standard of care expected in an emergency department • Be familiar with what is customer and prudent concern care in an emergency department • Be able to determine what resources an emergency department can provide to the kind of symptoms and complaints of a patient • Know what resources are needed to decide on the disposition for a patient concerning transfer, discharge, or admission into a hospital

A triage clinician can use the following information to make assessments about resources needed. • Age • Past medical history • Gender • Medications

As an example, if a person at the age of 21 comes in with a cut on their leg and has no medical conditions, the person will need sutures. If a person in their 80s comes in with a head injury plus has medical problems, the person will need a CT scan, ECG, blood tests, urine tests, consultations, and suturing. The resource needs are different for the two patients. A triage clinician can predict these resources as part of the ESI assessment starting at a level 3. Some guidelines include:

87 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • If a patient needs no resources, put them at level 5. • If a patient needs one resource, put them at level 4. • If a patient needs two or more resources, put them at level 3. • If a patient is at level 3 the chance of admission is higher than level 4 or 5. • If a patient is at level 3 the chance of a longer stay is greater than for level 4 or 5.

Identifying what is a resource versus not a resource Resource Not a resource Blood tests History Urine tests Physical ECG Point of care testing X rays, CT scans, MRI Angiography IV fluids for hydration Saline or heplock IV, IM, or nebulized medications PO medications Tetanus immunization Prescription refills Specialty consultation Phone call to primary care physician Simple procedure such as a Foley Simple wound care such as a dressing catheter Simple procedure such laceration repair Crutches Complex procedures required two Slings, splints resources such as conscious sedation

Summary

Emergency clinicians use the emergency severity index and its triage algorithm to rate the intensity of care needed for patients. The ESI guides evaluation of the resource(s) needed relative to patient acuity. It is a valuable tool to ensure that clinical care meets standards of patient safety, as well as to assist emergency staff to make good decisions and to effectively operate an emergency department based on clinical research and best practice.

88 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Level 1 of the ESI requires immediate medical involvement and evaluation is required to help the patient who is critically ill. Technical interventions are immediate and lifesaving. Level 2 patients are at high risk generally and very ill, and they should be a high priority. Their treatment should be started as much as possible with no delay. The need is immediate. The major determining factor should be if the condition could easily deteriorate. Characteristics of a Level 2-5 patient have been reviewed here.

Studies have shown that trained triage clinicians are good at predicting resource needs for patients coming to an emergency room. This includes the need for resources through disposition of the patient. Triage clinicians have been shown to be efficient in determining low versus high use of resources, and can help streamline the flow of patients in an emergency department.

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89 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1. Emergency department (ED) clinicians use the Emergency Severity Index (ESI) and its triage algorithm primarily to

a. eliminate all decision-making in the emergency room. b. rate their performance after a patient is discharged. c. rate the intensity of care needed for a patient. d. determine whether a patient should be admitted to the ED.

2. True or False: The Emergency Severity Index (ESI) rates patient acuity from level 1 to level 5, with level 5 being the least emergent.

a. True b. False

3. Level 1 of the Emergency Severity Index (ESI)

a. does not require immediate physician involvement. b. involves non-lifesaving intervention. c. a Level 1 patient is always conscious. d. requires immediate, lifesaving intervention.

4. An apneic condition refers to

a. an abdominal injury. b. the suspension of breathing that is external. c. a Level 2 rating on the ESI. d. a constant change in air volume in the lungs.

5. If gas exchange between the environment and lungs are impeded, permanent damage can occur to the ______in as few as three minutes without adequate ventilation.

a. heart b. vascular tissue c. brain d. lungs

6. Triage is a process where trained clinicians determine

a. the priority of ED treatment for patients. b. the severity of patient condition. c. whether a patient has suffered permanent injury. d. whether ESI applies to the patient.

90 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 7. True or False: The Emergency Severity Index (ESI) levels may overlap.

a. True b. False

8. When considering the Emergency Severity Index (ESI) algorithm

a. individual tests are counted. b. the number of different resources needed is counted. c. a temperature higher than 38.0˚ C/100.4˚ F is a Level 1. d. a phone call to primary care physician is the first step.

9. Noninvasive ventilation involves

a. adult respiratory management but is not used in pediatric applications. b. CPAP but does not include intubation. c. Level 3 through 5 ESI only. d. the use of CPAP and BiPAP.

10. Cardioversion is a way to restore a regular heart rhythm if a heart has an irregular rhythm (arrhythmia) and

a. medication may be used. b. electric shock may be used. c. it can be used for a patient with life-threatening arrhythmia. d. All of the above

11. True or False: A patient can still be breathing with a SpO2 less than 90 percent.

a. True b. False

12. Oxygen saturations are trended using

a. a CPAP. b. a BiPAP. c. a pulse oximeter. d. the AVPU scale.

91 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 13. ______is used when a patient is at risk of airway compromise.

a. An ECG b. Rapid sequence induction c. Cardioversion d. The AVPU scale

14. The pulse oximeter is a device that

a. requires intubation. b. is inserted into an artery. c. clips to a body part such as a finger. d. may control aspiration.

15. To determine if someone is hemodynamically unstable, before moving a patient to ICU, the emergency department triage clinical person needs to first

a. cardiac output. b. evaluate blood pressure and heart rate. c. pulmonary artery occlusion pressure. d. pulmonary artery pressure.

16. True or False: All patients with chest pain meet the Level 1 consideration and should get a diagnostic ECG within minutes of arrival to an emergency department.

a. True b. False

17. The AVPU scale

a. is part of the ESI algorithm. b. is a psychiatric test used to identify psychosis. c. can assess the level of responsiveness for a patient. d. measures oxygen levels.

92 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 18. One of the guidelines a triage clinician should follow when working with the ESI system in an emergency department is:

a. Use of the algorithm depends on the number of patients in the ED. b. Follow the institution’s requirements on level 2. c. Know that a level 2 patient can always wait. d. Determine if a patient is at level 1 but can still wait for intervention.

19. When determining blood pressure by palpation only, if the carotid artery only is felt, the blood pressure is

a. about 40-50 mmHg. b. about 50-70 mmHg. c. about 70-80 mmHg. d. indeterminate.

20. Some of the ways a patient can be assessed for pain by observation include

a. extreme perspiring. b. facial expression. c. body position. d. All of the above

93 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com CORRECT ANSWERS:

1. Emergency department (ED) clinicians use the Emergency Severity Index (ESI) and its triage algorithm primarily to

c. rate the intensity of care needed for a patient.

“The Emergency Severity Index [(ESI)] is a tool that includes five levels for use in the triage of patients arriving to an emergency department. Emergency clinicians use the emergency severity index and its triage algorithm to rate the intensity of care needed for patients.”

2. True or False: The Emergency Severity Index (ESI) rates patient acuity from level 1 to level 5, with level 5 being the least emergent.

a. True

“This measurement of needed care is referred to as patient acuity. Patient acuity is rated from most emergent (level 1) to least emergent (level 5).”

3. Level 1 of the Emergency Severity Index (ESI)

d. requires immediate, lifesaving intervention.

“Level 1 of the ESI index requires immediate, lifesaving intervention... and includes any of the following conditions.... Unresponsiveness.... A key difference in level 1 and level 2 is that with level 1 a physician should be immediately present.”

4. An apneic condition refers to

b. the suspension of breathing that is external.

“Apnea or an apneic condition refers to the suspension of breathing that is external. There is no movement of the muscles involved in respiration during apnea. The volume in the lungs does not change.”

94 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5. If gas exchange between the environment and lungs are impeded, permanent damage can occur to the ______in as few as three minutes without adequate ventilation.

c. brain

“Depending on the level of airway expansion, gas exchange between the environment and lungs could be impeded. Permanent damage can occur to the brain in as few as three minutes without adequate ventilation. Death can occur after a few more minutes unless ventilation is restored.”

6. Triage is a process where trained clinicians determine

a. the priority of ED treatment for patients.

“Triage is a process where trained clinicians determine the priority of ED treatment for patients. It is based on the severity of patient condition.”

7. True or False: The Emergency Severity Index (ESI) levels may overlap.

b. False

“ESI levels do not overlap.”

8. When considering the Emergency Severity Index (ESI) algorithm

b. the number of different resources needed is counted.

“When considering the ESI algorithm there are four decision points: ... Individual tests are not counted, but the number of different resources needed is counted.... Level 2 if temperature is higher than 38.0 degrees C/100.4 degrees F.... Not a resource: Phone call to primary care physician.”

95 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 9. Noninvasive ventilation involves

d. the use of CPAP and BiPAP.

“Noninvasive ventilation involves the use of CPAP and BiPAP. CPAP refers to continuous positive airway pressure and BiPAP refers to bi- level positive airway pressure. This ventilation modality supports breathing with a patient needing a surgical airway or intubation. Noninvasive ventilation is used for adult respiratory management. It is seen in emergency department and intensive care unit settings. It is also seen in pediatric applications.”

10. Cardioversion is a way to restore a regular heart rhythm if a heart has an irregular rhythm (arrhythmia) and

a. medication may be used. b. electric shock may be used. c. it can be used for a patient with life-threatening arrhythmia. d. All of the above

“Cardioversion is a way to restore a regular heart rhythm if a heart has an irregular rhythm (arrhythmia) or is beating too fast. Medication may be used to bring back a regular heartbeat, also known as pharmacologic (or chemical) cardioversion. Cardioversion uses an electric shock to restore a regular rhythm to the heart. More information on cardioversion is included below.... Defibrillation or cardioversion can be used in an emergency for a patient who has a sudden and life-threatening arrhythmia.”

11. True or False: A patient can still be breathing with a SpO2 less than 90 percent.

a. True

“A patient can still be breathing with a SpO2 less than 90 percent or with severe respiratory distress.”

12. Oxygen saturations are trended using

c. a pulse oximeter.

“Oxygen saturations are trended using a pulse oximeter.”

96 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 13. ______is used when a patient is at risk of airway compromise.

b. Rapid sequence induction

“Rapid sequence intubation (also called rapid sequence induction) is used when a patient is at risk of airway compromise.”

14. The pulse oximeter is a device that

c. clips to a body part such as a finger.

“Oxygen saturations are trended using a pulse oximeter. The measurement is designated as SpO2 or peripheral oxygen saturation. The pulse oximeter is a device that clips to the body, such as a(n) finger, earlobe and infant’s foot.”

15. To determine if someone is hemodynamically unstable, before moving a patient to ICU, the emergency department triage clinical person needs to first

b. evaluate blood pressure and heart rate.

“A hemodynamically unstable patient, however, will manifest hypotension, which may lead to tissue or cell death and organ failure. To determine if someone is hemodynamically unstable, the ED triage clinical person needs to evaluate blood pressure and heart rate; and, in the ICU setting the pulmonary artery occlusion pressure, central venous pressure, cardiac output, and pulmonary artery pressure should be considered when evaluating hemodynamic stability of a patient.”

16. True or False: All patients with chest pain meet the Level 1 consideration and should get a diagnostic ECG within minutes of arrival to an emergency department.

b. False

“Some patients with chest pain do not meet the level 1 consideration and should get a diagnostic ECG within 10 minutes of arrival to the ED.”

97 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 17. The AVPU scale

c. can assess the level of responsiveness for a patient.

“Using the AVPU scale – Alert, Verbal, Pain, Unresponsive – a triage clinician can assess the level of responsiveness for a patient. The AVPU scale is used with the ESI algorithm.”

18. One of the guidelines a triage clinician should follow when working with the ESI system in an emergency department is:

b. Follow the institution’s requirements on level 2.

“Guidelines on what the triage clinician should do in working with the ESI system is further elucidated below. Use the algorithm independent of how many patients come into the emergency room. Follow the institution’s requirements on level 2 and what types of patients to include. Determine if a patient is at level 1 and needs, for example, immediate resuscitation. If a patient is not a level 1 determine if a patient can wait. Know that a level 2 patient needs help as soon as possible.”

19. When determining blood pressure by palpation only, if the carotid artery only is felt, the blood pressure is

a. about 40-50 mmHg.

“If determining blood pressure by palpation only, a rough estimation of the systolic pressure is obtained. A pulse at three major arteries – carotid, femoral, and radial – is felt. If the pulse is felt at all three arteries, then the blood pressure is about 70-80 mmHg. If the carotid and femoral arteries are only felt the blood pressure is about 50-70 mmHg. If the carotid artery only is felt the blood pressure is about 40-50 mmHg.”

98 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 20. Some of the ways a patient can be assessed for pain by observation include

a. extreme perspiring. b. facial expression. c. body position. d. All of the above [correct answer]

“Some of the ways a patient can be assessed by observation include those listed below. Extreme perspiring. Crying. Facial expression. Body position. Vital sign changes as with hypertension. Vital sign changes as with rapid heart rate. Vital sign changes as with an increased respiratory rate.”

Reference Section

The reference section of in-text citations includes published works intended as helpful material for further reading. [These references are for a multi-part series on the Emergency Severity Index (ESI) and triage of patients arriving at an emergency department].

1. Gilboy, N., Tanabe, T., Travers, D., Rosenau AM. (2012). Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care, Version 4. Implementation Handbook 2012 Edition. AHRQ Publication No. 12-0014. Rockville, MD. Agency for Healthcare Research and Quality. Retrieved from http://www.ahrq.gov/professionals/systems/hospital/esi/index.html 2. American Sentinel University (2014). How to Use the Acuity Based Staffing Model in Nursing. Retrieved from http://www.americansentinel.edu/blog/2014/02/05/using-patient- acuity-to-determine-nurse-staffing/ 3. Gilboy, N., Tanabe, T., Travers, D., Rosenau AM. (2012). Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care, Version 4. Implementation Handbook 2012 Edition. AHRQ Publication No. 12-0014. Rockville, MD. Agency for Healthcare Research and Quality. Retrieved from http://www.ahrq.gov/professionals/systems/hospital/esi/index.html

99 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4. Gilboy, N., Tanabe, T., Travers, D., Rosenau AM. (2012). Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care, Version 4. Implementation Chapter 2 – Overview of the Emergency Severity Index. AHRQ Publication No. 12-0014. Rockville, MD. Agency for Healthcare Research and Quality. Retrieved from http://www.ahrq.gov/professionals/systems/hospital/esi/esi2.html 5. Whitlock, J. (2017) What Is Intubation and Why Is It Done? Retrieved from https://www.verywell.com/what-is-intubation-and-why-is-it- done-3157102 6. Young, G.B. (2017). Diagnosis of brain death. UpToDate. Retrieved online at https://www.uptodate.com/contents/diagnosis-of-brain- death?source=search_result&search=apnea%20and%20brain%20dea d&selectedTitle=2~150. 7. Gilboy, N., Tanabe, T., Travers, D., Rosenau AM. (2012). Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care, Version 4. Implementation Chapter 2 – Overview of the Emergency Severity Index. AHRQ Publication No. 12-0014. Rockville, MD. Agency for Healthcare Research and Quality. Retrieved from http://www.ahrq.gov/professionals/systems/hospital/esi/esi2.html 8. Gilboy, N., Tanabe, T., Travers, D., Rosenau AM. (2012). Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care, Version 4. Implementation Chapter 2 – Overview of the Emergency Severity Index. AHRQ Publication No. 12-0014. Rockville, MD. Agency for Healthcare Research and Quality. Retrieved from http://www.ahrq.gov/professionals/systems/hospital/esi/esi2.html 9. Dalawari, P., et al. (2015). Emergency severity index version 4 during the first year of implementation at an academic institution. Journal of Hospital Administration. 2016; Vol. 5, No. 2. 10. Gilboy, N., Tanabe, T., Travers, D., Rosenau AM. (2012). Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care, Version 4. Implementation Handbook 2012 Edition. AHRQ Publication No. 12-0014. Rockville, MD. Agency for Healthcare Research and Quality. Retrieved from http://www.ahrq.gov/professionals/systems/hospital/esi/index.html 11. Tangavelu-Veluswamy, A. (2016). Foley catheter. Retrieved from http://www.emedicinehealth.com/foley_catheter/article_em.htm 12. Woods, R. (2014) Basic Airway Assessment: It’s as easy as… 1-2-3. Retrieved from https://canadiem.org/basic-airway-assessment-easy- 1-2-3/ 13. Herth, F. (2017). Clinical presentation, diagnostic evaluation, and management of central airway obstruction in adults. UpToDate. Retrieved online at https://www.uptodate.com/contents/clinical- presentation-diagnostic-evaluation-and-management-of-central- airway-obstruction-in-

100 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com adults?source=search_result&search=blocked%20airway%20and%20 gas%20exchange&selectedTitle=1~150. 14. Sappenfield, J. (2013). The Ins and Outs of Apneic Oxygenation. Retrieved from http://airway.jems.com/2013/06/the-ins-outs-of- apneic-oxygenation/ 15. Walls, R. and Brown, C. (2017). The failed airway in adults. UpToDate. Retrieved online at https://www.uptodate.com/contents/the-failed- airway-in- adults?source=search_result&search=lifesaving%20intervention%20a nd%20blocked%20airway&selectedTitle=4~150. 16. Gilboy, N., Tanabe, T., Travers, D., Rosenau AM. (2012). Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care, Version 4. Implementation Chapter 2 – Overview of the Emergency Severity Index. AHRQ Publication No. 12-0014. Rockville, MD. Agency for Healthcare Research and Quality. Retrieved from http://www.ahrq.gov/professionals/systems/hospital/esi/esi2.html 17. Wittels, K. (2017). Basic airway management in adults. UpToDate. Retrieved online at https://www.uptodate.com/contents/basic-airway- management-in- adults?source=search_result&search=bag%20valve%20mask&selecte dTitle=1~96. 18. Pooboni, K. (2015). Emergent CPAP noninvasive ventilation procedures retrieved from http://emedicine.medscape.com/article/1417959- overview 19. Nishimura, M. (2015). High-flow nasal cannula oxygen therapy in adults. Journal of Intensive Care. Retrieved from https://jintensivecare.biomedcentral.com/articles/10.1186/s40560- 015-0084-5 20. Bailey, P. (2017). Continuous oxygen delivery systems for infants, children, and adults. UpToDate. Retrieved online at https://www.uptodate.com/contents/continuous-oxygen-delivery- systems-for-infants-children-and- adults?source=search_result&search=nonrebreather%20face%20mask &selectedTitle=1~59. 21. American Heart Association. (2016). Cardioversion. Retrieved from http://www.heart.org/HEARTORG/Conditions/Arrhythmia/PreventionTr eatmentofArrhythmia/Cardioversion_UCM_447318_Article.jsp - .WMYgAWW5CT8 22. Hawnwan, P., Kolinsky, C. (2015). EMSWorld, Evidence-Based EMS: Needle Decompression. Retrieved from http://www.emsworld.com/article/12041960/whats-the-best-site-for- needle-decompression 23. Hefner, A (2015). Emergency Pericardiocentesis. UpToDate. Retreived online at https://www.uptodate.com/contents/emergency-

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