Please enable JavaScript.
Coggle requires JavaScript to display documents.
Emergency department triage process (Triage 2 (Airway stridor or…
Emergency department triage process
The process:
According to the Ministry of Health New Zealand (2011) the emergency department will triage a person on arrival. This involves an assessment to decide how urgent a patients illness or injury is. In New Zealand, the triage process includes a triage scale between 1-5. Category 1 patients require urgent care, while category 5 patients require less urgent care.
Triage 1:
Immediately life- threatening
Immediately triage and treat
Triage 2:
Imminently life-threatening, time critical
Commence medical assessment and treatment within 10 minutes
Triage 3:
Potentially life-threatening
Commence medical assessment and treatment within 30 minutes
Triage 4:
Potentially serious
Commence medical assessment and treatment within 60 minutes
Triage 5:
Less urgent
Commence medical assessment and treatment within 120 minutes
Triage 1
Airway
Immediate risk
obstructed airway
Breathing
Extreme distress
unable to speak
cyanosis
altered conscious status
Paediatric
severe use of accessory muscles
Circulation
Cardiac arrest or uncontrolled bleeding
showing signs and symptoms of severe shock
absent peripheral pulses
skin pale moist and cool
BP < 80
Paediatric
significant bradycardia in children < 60 in infants
children who are showing severe haemodyamic compromise
tachycardia
absent peripheral pulses
pale, moist, cool, mottled skin
capillary refill < 4sec
Disability
GCS < 9
seizure activity
unresponsive or responds to pain only
Mental Health
violent behavior who requires restraint.
has a weapon at hand
Triage 2
Airway
stridor or drooling present
Breathing
moderate respiratory distress
moderate use of accessory muscles
speaking in words
pale skin
peripheral cyanosis
Paediatric
severe use of accessory muscles
severe retractions
speaking in single words
abnormal RR
skin pale
peripheral cyanosis
Circulation
symptoms of shock
cool, clammy
abnormal HR <50 or >150
altered peripheral pulse
Paediatric
circulation present
moderate haemodynamic compromise
tachycardia
weak thready
skin pale and cool
capillary refill 3-4 sec
signs of dehydration
Disability
GCS 9-13
severe decrease in activity
no eye contact
decreased muscle tone
lethargy
drowsy
decreased responsiveness
Mental health
extreme agitation
aggressive
attempt self harm
suicidal ideation
A triage 2 patient arrived by ambulance into ED. The ambulance staff had handed over that the patient was SOB and had a nebuliser on route. On arrival to the department, the patient remained SOB and tachypneic. They also had a GCS 13, SPO2 <92%, speaking in words, cyanosis on the lips, and was showing an increased work of breathing. This patient was extremely anxious. They were immediately placed on a dual nebuliser to help manage their respiratory distress
Triage 3
Airway
Patent
Paediatric
stridor with mild respiratory distress
Breathing
moderate distress
speaking in short sentences
minimal use of accessory muscles
skin pink
Paediatrics
abnormal RR
Moderate respiratory distress (same as above)
Circulation
Signs and symptoms of mild shock
Palpable peripheral pulses
skin pale, moist, cool
moderate blood loss
Paediatric
tachycardia
skin pale warm
capillary refill < 2 seconds
signs of moderate dehydration
Disability
GCS 14-15
moderate decrease in activity
eye contact when disturbed
lethargy
moderate altered senses
Mental health
agitated
restless
psychotic
A patient was brought into ED with a possible hand fracture. They were placed as a status 3 as the injury is potentially life-threatening. They had moderate pain, GCS 15,and all vitals were in normal range.
Triage 4
Airway
patent
Breathing
normal
nil respiratory distress
Paediatric
Mild respiratory distress
Circulation
circulation present
Nil signs of shock
skin, pink, warm, dry
Disability
GCS 15
mild decrease in activity
quiet but eye contact
interacts well
Mental health
co-operative
signs and symptoms of anxiety / depression
A 1 year old baby was brought into ED by their mother. The mother was concerned their baby may have asthma, however the vital signs were all within the normal range and the baby had not shown any signs of respiratory distress other than a cough. This patient is safe to wait in the waiting room for a period up to 60 minutes.
Triage 5
Airway
patent
Breathing
normal
Circulation
nil signs and symptoms of shock
Disability
GCS 15
no neurovascular compromise
Paediatrics
playing
smiling
Mental health
no acute signs
A child had arrived into the department by their grandmother who was worried that the child may have injured their R) little toe. The grandmother stated the injury took place the night prior when the child banged their foot on the table leg. Upon arrival, the child presented happy with nil signs and symptoms of distress nor pain. The child was unsure which toe was sore. This response indicates the child is safe to wait in the waiting room for a period up to 120 mins.