Triage and Emergency Management

Associate Professor Mona Mayhob

Adult Health Nursing
BUE -2022- 20223
• Objectives
• By the end of this lecture the student will be
able to:
• Define different related terms.
• Explain Triage system.
• Discuss principles of Emergency management.
• Introduction
Emergency situation can occur anywhere. It is
important for all medical team to have
theoretical background and practical skills needed
for quick assessment, intervention, and safe
emergency management. Rapid and competent
emergency care is the key to rapid recovery and
prevention of complications.
• Definition of Emergency Health Case
• It is any sudden illness, condition or injury
that is perceived by the patient or
significant others, and it is always required
immediate intervention.
• The core difference between emergency medical
care and regular medical care is that in an
emergency, a patient struggles with sudden and
intense symptoms. They can manifest as severe
pains and/or obstruction of bodily functions.
Without an immediate response, people with
such symptoms can die or get harmed.
• Emergency Nursing is a specialty in which
nurses care for patients in the emergency or
critical phase of their illness or injury and are
skillful at differentiate between life-
threatening cases, prioritizing the urgency of
care, rapidly and effectively carrying out
resuscitative measures and other needed
interventions.
• Priorities of Emergency Management
▪ Treatment of the actual life threatening
problems.

▪ Life saving to restore the patient’s life.

▪ Stabilize pulmonary –cardio vascular, central

nervous systems to prevent further
deterioration.
• Principles of Emergency Management
▪ Maintain airway patent & provide adequate
ventilation.

▪ Control bleeding if any & restore cardiac

output.

▪ Prevent and treat shock if any.

▪ Carry out rapid initial assessment.

• Emergency Medical Team (EMT)
• Senior Physician

• Doctors, Nurses

• Radiologist

• Lab technician

• Porters, Workers
 Scope of Emergency Nursing

➢Provide immediate action to treat the patient.

➢Treat emergency condition irrespective of age

group.

➢Treat a wide variety of illness or injury

situations, ranging from sore throat to a heart
attack.
 Principles in Emergency Nursing

Documentation of consent.

Limiting exposure to health risks.

Providing holistic care.

 Emergency Action Steps

Check the patient:

- Is the patient
CHECK safe?
- What happened?
- How many people
CALL are injured?
- Are there
bystanders who can
CARE help?
 Components of Emergency Care

Order of Emergency Care in Priority

Patient’s triage (prioritizing).
In depth nursing assessment.
Diagnostic testing.
Formulation of diagnosis.
Outcome management.
Evaluation.
Disposition.
Documentation.
 Role of Emergency Nurse

• Identify patient problems in emergency

situation.
• Establish priorities, monitoring acutely ill
patient.
• Focus on health promotion and prevention of
further complications.
 Basic Procedures needed in Emergency
Situation

Venous/Arterial
Puncture

Administer Oxygen
Therapy Demonstrate
BLS
 Basic Procedures needed in Emergency
Situation

Administer Emergency
Medications Radiologist

Intubation
Use defibrillator
Emergency Room
• Emergency Room is one of the part in a

hospital designed and used for the treatment

of patients requiring immediate medical

attention, as victims of accidents or heart

attacks, or any threatening health condition.

Classification of Emergency Room
 Classification of Emergency Room

1) Triage Area

2) Medical Care Area

3) Observing Area
• Triage is French term means sorting, it is the
process of sorting patients based on their
needs for immediate medical treatment as
compared to their chance of benefiting from
such care. Triage is done in Triage room inside
emergency rooms. It is done to get the Right
patient to the Right place at the Right time
with the Right care provider.
• Triage where patients are classified into
one of three groups: those who could be
expected to live without medical care, those
who would likely die even with care, and
those who could survive if they received
care.
Triage Categories
Triage Categories
 Triage Levels

1- Resuscitation

2- Emergent

3- Urgent

4- Less urgent

5- Non urgent
 Triage Levels
1- Resuscitation – There is a life Threaten problem
IMMEDIATE nurse assessment
IMMEDIATE physician assessment
It should be done in the following cases:
• Cardiac and Respiratory Arrest.
• Major/multiple trauma.
• Active Seizure.
• Different types of shock.
• Status/Severe Asthmatics.
 Triage Levels (Cont.)
2- Emergent
Potential threats to life, or poor function of
any body system
Nurse Assessment Immediate, Physician <15
minutes if there any case from the following
✓Decreased level of consciousness.
✓Severe respiratory distress.
✓Drug over dose, severe abdominal pain.
✓G.I. Bleeding with abnormal vital signs.
 Triage Levels

3- Urgent
Condition with significant distress.

Time Nurse < 20 min, physician < 30 min

It could be done in the following Cases:

• Head injury without disturbance of LOC.

• Mild to moderate respiratory distress.

• G.I. Bleed not actively bleed.

 Triage Levels (Cont.)
4- Less Urgent
✓Conditions with mild to moderate discomfort.

✓Time for nurse and physician assessment <1h.

✓Head injury, but alert, no vomiting.

✓Chest pain, no distress, no cardiac suspected

serious complain.
 Triage Levels (Cont.)

5- Non urgent

✓Conditions can be delayed, patients have no

distress.

✓Time for nurse and physician assessment more

than 2hours.

✓In case of minor trauma, patent with body

temperature less than (< 39 C◦).
 Role of Triage Nurse

• Observe all incoming patients even while

interviewing others.

• Maintain good communication between triage

and treatment area.

• Use all resources to maintain high standard of

care.
 • Triage Assessment
• It includes:

• Primary survey.

• Secondary survey

• Physical examination
• Primary Survey
• It is an initial assessment which is done to
identify the following: Life threatening
conditions through assessing ABCDE.
In Primary Survey Assess ABCDE
ABCDE Assessment Primary Survey
Assessment of Conscious Level
Secondary Survey
• It includes the following:

✓Medical History (Present & Past History).

✓Medications.

✓Physical Examination.

✓Laboratory investigations.
• Laboratory Investigations include:
- Blood group and cross-matching.
- Complete Blood Count (CBC).
- Electrolytes.
- Coagulation Profile (Prothrombin Time (PT) and
Partial Thromboplastin Time (PTT).
- Arterial Blood Gas (ABG).
- Liver Function and Renal Function Tests
 Classification of Emergency Room (Cont.)
2) Medical Area (It is divided into 3 Zones)

1) Resuscitation Zone/Red Zone e.g. patient with

cardiac arrest.

2) Yellow Zone: acute patients / no needs for

resuscitation

3) Green Zone: non seriously sick patients

 Classification of Emergency Room (Cont.)

3) Observation Room/Area:

• In this room the patient is kept under

observation may be for hours, but under
observation.
Equipment used in Emergency Room
Equipment used in Emergency Room
• Video about Triage and Rapid Emergency Management

• https://www.youtube.com/watch?v=n8pQGVvIInA