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Triage Priority Wang, Tzong-Luen, MD, PhD, FESC, FACC Class I (立即處理) • 意識程度下降 • 生命現象: – – – – 收縮壓:<80mmHg或>220mmHg 心跳:>150bpm或<50bpm 呼吸:>30rpm或<8rpm 體溫:>41℃或<32℃ • 內科:異物阻塞;已插氣管內管或胸管者;呼吸窘迫;發紺;心因性胸 痛;正在抽搐;內出血併生命現象不穩定者 • 外科:外傷出血無法控制者;大於5cm的開放性傷口;疑呼吸道(顏 面)灼傷;電灼傷;化學性灼傷;三度TBSA>10﹪;二度TBSA>15﹪;骨盆 或股骨骨折;開放性骨折;疑頸椎骨折;頭部嚴重畸形;腦組織外露;內 臟外露;皮下氣腫;胸腹開放性傷口;毒蛇;虎頭蜂咬傷;槍傷或穿刺傷 • 婦產科:急產;性侵害 • 精神科:攻擊性行為 Class II (十分鐘內處理) • 生命現象: – 收縮壓:180-220mmHg – 呼吸:20-30rpm – 體溫:39-41℃或32-35℃ • 內科:呼吸喘;呼吸困難;胸痛原因不明者;疼痛併嚴重症狀者(劇 痛、臉色蒼白);暈眩(Vertigo);突發性神經症狀;內出血併 HR>100bpm;吐血;嘔吐、腹瀉、脫水致HR>100bpm • 外科:小於5cm的開放性傷口;疑有骨折;關節腫脹;疑頭骨骨折; 其他昆蟲、動物咬傷;急性尿滯留(>6小時) • 精神科:自殺行為或傾向 • 眼科:眼內異物 • 耳鼻喉科:耳鼻喉道內異物 Class III (三十分鐘內處理) • 生命現象: – 體溫:38-39℃ • 內科:抽搐已停止者;疼痛但無嚴重症狀者;頭暈 (dizziness);血便、黑便、咳血但生命徵象穩定者;嘔 吐、腹瀉但生命徵象穩定者;疑似或輕微中風 • 外科:無傷口之軟組織傷害;動物抓傷;血尿;尿路結石; 解尿困難 • 精神科:失眠 Class IV (可延後處理) • 不符合急診以上條例,如: – – – – 頭痛、喉痛、咳嗽、流鼻水等感冒症狀。 中風後遺症。 中風已數日,在別處已處理過,來本院等住院者。 已知癌症的病患,其主訴顥然與癌症有關者,且生 命徵象正常。 – 自門診轉來做常規檢查的治療者。 – 自門診轉來等住院者,但生命徵象正常者。 – 主訴某種症狀已有相當時日,但生命徵象正常者。 大量傷患分類 一、極危險、第一優先(紅色) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 呼吸停止或呼吸道阻塞。 被目擊的心臟停止。 動脈斷掉或無法控制之出血。 穩定性的頸部受傷。 嚴重的頭部受傷且意識昏迷。 開放性胸部或腹部傷害。 大型或併發性燙傷。 嚴重休克。 呼吸道燙傷或灼傷。 壓力性氣胸。 內科醫療疾病的併發症。 關節骨折且遠端無脈搏。 股骨骨折。 二、危險、第二優先(黃色) 1. 2. 3. 4. 5. 6. 背部受傷(不論是否有脊椎受傷) 。 中度的流血(少於二處) 。 嚴重燙傷。 開放性或多處骨折。 穩定的腹部傷害。 眼部傷害。 7. 穩定性的藥物中毒。 三、輕傷、最低優先、延後處 理(綠色) 1. 2. 3. 4. 小型的挫傷或軟組織傷害。 小型或簡單型骨折。 肌肉扭傷。 凡是由於受傷過於嚴重(如:頭部外傷且腦組 織外露,三級灼傷且超過體表面積百分之四 十以上)且存活機會不太大者。 四、死亡(黑色) 1. 頭部不見。 2. 沒有脈搏超過二十分鐘,除了冷水溺水或極 度低體溫者。 3. 軀幹分離。 4. 從高度落下且具有多處的受傷與骨折,沒有 呼吸者。 5. 肉臟外脫。 Triage Decision Scheme (Trauma) • STEP 1: Measure Vital Signs and Level of Consciousness – – – – – GCS<14 RR<10 or >29 SBP<90 RTS<11 PTS<9 Triage Decision Scheme • STEP 2: Anatomic and Physiologic Approach – – – – Flail chest Two or more proximal long-bone fractures Amputation proximal wrist/ankle All penetrating trauma to head, neck, torso, and extremities proximal to elbow and knee – Limb paralysis – Pelvic fractures – Combination trauma with burns Triage Decision Scheme • STEP 3: Trauma Mechanisms – – – – Ejection from auto Death in same passenger compartment Pedestrian thrown or run over High-speed auto crash • Initial speed >40mph (64 kph) • Major auto deformity >20 inches (50cm) • Intrusion into passenger compartment >12 inches (30cm) • Extrication time > 20 minutes • Falls > 20 ft • Roll over • Auto-pedestrian injury with > 5mph (8kph) impact • Motorcycle crash > 20 mph (32 kph) or with separation of rider and bike Triage Decision Scheme • STEP 4: Underlying Conditions – – – – – Age <5 or >55 Pregnancy Immunosuppressed patients Cardiac disease; respiratory disease Insulin-dependent diabetes; cirrhosis; morbid obesity; coagulopathy Revised Trauma Score • Respiratory Rate – – – – – 10-29 >29 6-9 1-5 0 score score score score 4 3 2 1 score 0 Revised Trauma Score • Systolic BP – – – – – >89 76-89 50-75 1-49 0 score score score score 4 3 2 1 score 0 Revised Trauma Score • GCS Score Conversion – – – – – 13-15 9-12 6-8 4-5 <4 score score score score score 4 3 2 1 0 Pediatric Trauma Score • Weight – >20Kg (44 lb) – 10-20Kg (22-44 lb) – <10 Kg (22 lb) • Airway score +2 score +1 score –1 – Normal – Oral or nasal airway; O2 – Intubated; cricothyroidtomy tracheostomy score +2 score +1 score –1 Pediatric Trauma Score • Systolic Blood Pressure – >90mmHg; good peripheral pulse; perfusion – 50-90mmHg; carotid/femoral pulses palpable – <50mmHg; weak or no pulses score +2 score +1 score –1 • Level of Consciousness – Awake – Obtunded or any LOC – Coma; unresponsive score +2 score +1 score –1 Pediatric Trauma Score • Fracture – None seen or suspected – Single, closed – Open or multiple score +2 score +1 score –1 • Cutaneous – None visible score +2 – Contusion, abrasion; laceration score +1 <7cm; not thru fascia – Tissue loss; any GSW/SW; score –1 thru fascia Detailed Adult Criteria GCS < 12 = RED AIRWAY ACTIVE airway assistance required (i.e., more than supplemental O2 without airway adjunct) Sustained respiratory rate > 30 Detailed Adult Criteria CIRCULATION No radial pulse AND heart rate > 120 OR BP < 90 systolic Sustained heart rate > 120 with radial pulse and BP > 90 systolic Detailed Adult Criteria BEST MOTOR RESPONSE BMR < 4 OR Paralysis, loss of sensation, suspicion of spinal cord injury BMR = 5 Detailed Adult Criteria CUTANEOUS Amputation proximal to wrist or ankle OR > 15 % BSA 2nd and 3rd degree burns OR Penetrating injury to head, neck, torso, excluding superficial wounds Degloving injury or flap avulsion > 5 inches Detailed Adult Criteria LONGBONE FRACTURE Multiple longbone fracture sites Single longbone fracture site due to MVC OR Single longbone fracture site due to fall from > 10 feet Detailed Adult Criteria AGE Age > 55 MECHANISM OF INJURY Ejection from vehicle (excludes open vehicles) OR Driver with deformed steering wheel Notes on Peds Criteria • Applicable to age 15 or less • Size component is based on Broslow color zone or weight • Any airway maintenance beyond supplemental O2 and one-time need for suctioning = RED • Any altered mental status other than amnesia = RED criteria • Paralysis, loss of sensation, or suspicion of spinal cord injury = RED criteria under “Consciousness” category Notes on Peds Criteria (cont.) • Any reliable hx of LOC = BLUE • Fracture criteria are also based on longbones (same as adults). • Open long bone or multiple longbone fx/dislocations = RED • > 10 % BSA 2nd and 3rd degree burn = RED Detailed Peds Criteria SIZE Weight < 10 Kg (< 22 lbs..) or RED or PURPLE Broslow Tape Zone AIRWAY ACTIVE airway assistance required (i.e., more than supplemental O2/one-time suctioning without airway adjunct) Detailed Peds Criteria CONSCIOUSNESS Patient not awake and appropriate OR Paralysis, loss of sensation, or suspected spinal cord injury Amnesia OR Reliable history of loss of consciousness Detailed Peds Criteria CIRCULATION No palpable pulses OR Weak carotid or femoral pulse OR Systolic BP < 50 Good carotid or femoral pulse with absent distal pulses OR Systolic BP 50-90 Detailed Peds Criteria LONGBONE FRACTURE Any open longbone fracture OR Multiple closed longbone fracture sites or dislocations Single closed long bone fracture site Detailed Peds Criteria CUTANEOUS Degloving injury, major flap avulsion OR Amputation proximal to wrist or ankle OR > 10% BSA 2nd and 3rd degree burns OR Penetrating injury to head, neck or torso Practice Case #1 • 68 yo female BLUE pedestrian struck • GCS 14, BMR 5 BLUE • Patent airway • HR 100, BP 120/94, RR 20 • Abrasions • Unstable pelvis POSITIVE TRAUMA ALERT Practice Case #2 • 21 yo male • Stab wound to left RED chest • Airway patent • GCS 15 RED • BS on left • BP 90/P, HR 130 POSITIVE TRAUMA ALERT Practice Case #3 • 4 year old neardrowning in pool • No signs of trauma • Intubated • Normal skin signs • Normal brachial pulse • Responsive to deep pain Drowning is not considered trauma unless injury accompanies it! Practice Case #4 • 6 yo female fell 10 ft. from tree • 22 kg weight • amnestic for event,BLUE o/w alert • airway patent BLUE • obvious closed forearm fx • nl vital signs POSITIVE TRAUMA ALERT Practice Case # 5 • 6 month old male BLUE (purple) • child abuse • multiple cigarette burns & contusions • abdomen rigid BLUE • strong palpable carotid pulse only RED • does not cry with exam POSITIVE TRAUMA ALERT Trauma Blue 1. 2. 3. 4. 5. 6. Glasgow Coma Scale <14 Systolic Blood Pressure <90 Respiratory rate <10 or >29 Revised Trauma Score <11 Pediatric Trauma Score <9 Penetrating injuries to: head, neck, torso, and/or extremities proximal to the knee and/or elbow 7. Flail Chest 8. Combination Trauma with burns or inhalation injury 9. Two or more proximal long bone injuries 10. High energy pelvic fractures 11. Limb paralysis 12. Amputation proximal to the wrist or ankle 13. Trauma patient pregnant past 2nd trimester Another Example Trauma Blue 1. 2. 3. 4. 5. 6. Ejection from automobile Death in same passenger compartment Prolonged extrication (>20 minutes) Falls >20 feet Roll-over High speed auto crash a. Initial speed >40mph b. Major auto deformity >20 inches c. Intrusion into passenger compartment >12 inches 7. Auto-Pedestrian injury with significant impact (>5 mph) 8. Pedestrian thrown or run over 9. Motorcycle crash > 20 mph or with separation of bike and rider 10. Patients age <5 or >55 11. Pregnancy past 1st trimester Killip Classification • Killip I: Rales and S3 absent • Killip II: Rales over <50% of lung • Killip III: Rales over >50% of lung fields (pulmonary edema) • Killip IV: Shock Subset I: Normal hemodynamics; PCWP<18; CI>2.2 Subset II: Pulmonary congestion: PCWP>18; CI<2.2 Subset III: Peripheral hypoperfusion; PCWP>18; CI>2.2 Subset IV: Pulmonary congestion and peripheral hypoperfusion; PCWP>18; CI<2.2 • • • • Goldman Criteria Age > 70 yrs (5) CAD: MI within 6 months (10) CHF: S3 or JVE (11) Rhythm: – other than NSR/PACs on most recent ECG (7); – > 5 PVCs/min any time preoperatively (7) • Valvular Disease: important aortic stenosis (5) • General Medical condition (5) – PaO2 <60 or PaCO2 >50, K <3.0, or HCO3 <20, BUN >50 or Cr >3.0, abnormal AST, signs of chronic liver disease, bedridden from noncardic causes • Surgery: intraperitoneal, thoracic, aortic surgery (3) emergent surgery (4) Goldman Criteria Clas s Total Score No or Minor Life Complications Threatening Cardiac Deaths I 0-5 99% 0.7% 0.2% II 6-12 93% 5% 2% III 13-25 86% 11% 2% IV >25 22% 22% 56% Revised Goldman Criteria • • • • • • High risk type of surgery History of ischemic heart disease History of heart failure History of CVA Preoperative treatment with insulin Preoperative serum creatinine > 2.0 mg/dL Rates: 0.4% with no risk; 0.9% with 1 risk; 7% with 2 risks; 11% with 3 or more risks Detsky Criteria • • • • • • • Age > 70 yrs (5) CAD: – MI within 6 months (10) – MI >6 months (5) – CCS angina class III (10) – CCS angina class IV (20) – Unstable angina past 3 months (10) CHF: – Pulmonary edema within 1 week (10) – Pulmonary edema, ever (5) Rhythm: – other than NSR/PACs on last preop ECG (5); – > 5 PVCs/min any time preoperatively (5) Valvular Disease: suspected critical aortic stenosis (5) General Medical condition (5) – PaO2 <60 or PaCO2 >50, K <3.0, or HCO3 <20, BUN >50 or Cr >3.0, abnormal AST, signs of chronic liver disease, bedridden from noncardic causes Surgery: emergent surgery (10) • • • • • • • Revised Detsky Criteria High risk type of surgery History of ischemic heart disease History of heart failure History of CVA Preoperative treatment with insulin Preoperative serum creatinine > 2.0 mg/dL unstable angina within 3 months of surgery or stable angina occurring with minimal exertion or recent pulmonary edema (HIGH RISK) Rates: 0.4% with no risk; 0.9% with 1 risk; 7% with 2 risks; 11% with 3 or more risks or HIGH RISK Goldman and Detsky Criteria • May UNDERESTIMATE the Cardiac Risk in Vascular Patients … Eagle Criteria • Access 5 significant clinical predictors 1.Q waves on EKG 2.History of angina 3.History of ventricular ectopy requiring treatment 4.Diabetes mellitus requiring therapy other than diet 5.Age > 70 • Rate of postoperative ischemic events: 3.1% if no predictors, 15% if 1-2 predictors and up to 50% if 3 or more predictors. Perioperative ßBlocker • Known CAD or 2+ CRF then : Perioperative atenolol 5 mg IV q 5min x 2 recommended 30 min preop & immediately postop Atenolol 50-100 mg po qd postop day 1 until d/c. • [1 yr mortality 3% vs 14% for placebo] Ranson’s criteria (alcoholic) • Admission – Age > 55yr – WBC > 16,000/cmm – Glucose > 200 mg/dL – LDH > 350 IU/L – GOT > 250 IU/L • 48 Hours – – – – Hct drop > 10% PaO2 < 60 mmHg Ca < 8 mg/dL Base deficit > 4 mEq/L – BUN rise > 5 mg/dL – Estimated fluid sequestration > 6L Ranson’s criteria (nonalcoholic) • Admission – Age > 70yr – WBC > 18,000/cmm – Glucose > 220 mg/dL – LDH > 400 IU/L – GOT > 440 IU/L • 48 Hours – – – – Hct drop > 10% PaO2 < 60 mmHg Ca < 8 mg/dL Base deficit > 5 mEq/L – BUN rise > 2 mg/dL – Estimated fluid sequestration > 6L Glascow criteria (<48 hours) • • • • • • • • Age > 55yr Glucose > 180 mg/dL Albumin < 3.2 g/dL PaO2 < 60 mmHg WBC > 15,000/cmm LDH > 600 IU/L BUN > 45 mg/dL Ca < 8 mg/dL Prediction Model for Pneumonia Patient characteristic Points _______________ Demographic factors Age: o Males: o Females: Nursing home resident: Comorbid illnesses Neoplastic disease: Liver disease: Congestive heart failure: Cerebrovascular disease: Renal disease: assigned Age (in years) Age (in years) -10 +10 +30 +20 +10 +10 +10 Prediction Model for Pneumonia Physical examination findings Altered mental status: +20 Respiratory rate 30/minute or more: +20 Systolic blood pressure <90 mmHg: +20 Temperature <35 degrees C or 40 degrees C or more: +15 Pulse 125/minute or more: +10 Prediction Model for Pneumonia Laboratory findings pH <7.35: +30 BUN >10.7 mmol/L: +20 Sodium <130 mEq/L: +20 Glucose >13.9 mmol/L: +10 Hematocrit <30 percent: +10 PO2 <60 mmHg (2): +10 Pleural effusion: +10 _______________________________________ (1) A risk score (total point score) for a given patient is obtained by summing the patient age in years (age minus 10 for females) and the points for each applicable patient characteristic. (2) Oxygen saturation <90 percent also was considered abnormal. Risk Stratification for Pneumonia Risk Class Low I Algorithm Low II 70 or fewer points Low III Moderate IV 71-90 total points 91-130 total points High V >130 total points Asthma Severity Factor Pulse rate (beats/min) Respiratory rate (breaths/min) Pulsus paradoxus (mm Hg) Severe asthma (FEV1 <1.0 L) ≥120, but may be less with equally severe asthma ≥40, but most are >20, therefore nondiscriminating ≥10, but may be absent with equally severe asthma in 50% of cases Pulse rate ≥120, respiratory rate ≥20, pulsus paradoxus ≥10 Use of accessory muscles of respiration If all three abnormal, 90% with severe asthma, but only 40% with FEV1 <1.0 L have all three abnormal If present, may indicate severe asthma; if absent, may have equally severe asthma in 50% of cases ABG analysis (mm Hg) PaO2 ≤60 or PaCO Pulmonary function studies PEFR and FEV1 measure directly the degree of ≥42 indicates severe asthma; all other values difficult to interpret unless PEFR or FEV1 known 2 airflow obstruction; most useful in assessing severity and guiding treatment decisions Asthma Severity 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Past history of sudden severe exacerbations Prior intubation for asthma Prior asthma admission to an intensive care unit Two or more hospitalizations for asthma in the past year Three or more ED care visits for asthma in the past year Hospitalization or an ED care visit for asthma within the past month Use of >2 MDI short-acting β2 agonist canisters per month Current use of or recent withdrawal from systemic corticosteroids Difficulty perceiving severity of airflow obstruction Comorbidities such as cardiovascular diseases or other systemic problems Serious psychiatric disease or psychosocial problems Illicit drug use, especially inhaled cocaine and heroin Asthma Severity Mild Intermittent Asthma Symptoms Symptoms <2 times a week Asymptomatic and normal PEFR between exacerbations Exacerbations brief (from a few hours to a few days); intensity may vary Nighttime <2 times a month Lung Function FEV1 or PEFR >80% predicted PEFR variability <20% Asthma Severity Mild Persistent Asthma Symptoms Symptoms >2 times a week but <1 time a day Exacerbations may affect activity Nighttime >2 times a month Lung Function FEV1 or PEFR >80% predicted PEFR variability 20-30% Asthma Severity Moderate Persistent Asthma Symptoms Daily symptoms Daily use of inhaled short-acting beta2agonist Exacerbations affect activity Exacerbations 2 or more times a week; may last days Nighttime symptoms >1 time a week Lung Function FEV1 or PEFR >60%-<80% predicted PEFR variability >30% Asthma Severity Severe Persistent Asthma • Symptoms • Continual symptoms Limited physical activity Frequent exacerbations Nighttime Symptoms • Frequent Lung Function • FEV1 or PEFR <60% predicted PEFR variability >30% Asthma Severity CLASSIFICATION OF ASTHMA SEVERITY Severity Prior to Initiation of Therapy Mild Intermittent Mild Persistent Moderate Persistent Severe Persistent daily symptoms continual symptoms Symptoms < or = 2 per week > 2 per week Nighttime symptoms < or = 2 per month > 2 per month > 1 per week Lung function < or = 80% predicted < or = 80% predicted > 60% < or = 80% < or = 60% < 20% 20-30% > 30% > 30% Peak flow variability frequent Scoring System for SARS (SSSS) • radiographic findings of multilobar or bilateral infiltrates (3 points) • sputum monocyte predominance (3 points) • lymphocytopenia (2 points) • history of exposure (1 point) • lactate dehydrogenase >450U/L (1 point) • C-reactive protein> 5.0mg/dL (1 point) • activated partial prothrombin time> 40sec (1 point) SSSS > 6 probable SARS 創傷登錄 • 目前急診科已進行創傷 登錄 • http://www.trauma.or g.tw • AIS System and ISS scoring – ISS>4 需要登錄