Download Triage Priority

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
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• http://www.trauma.or
g.tw
• AIS System and ISS
scoring
– ISS>4 需要登錄