Triage

Triage, a French word meaning “to sort,” refers to the process of rapidly determining patient acuity. It is one of the most important assessment skills needed by emergency nurses.4,5 Most often, you will confront multiple patients who have a variety of problems. The triage process works on the premise that patients who have a threat to life must be treated before other patients.

A triage system identifies and categorizes patients so that the most critical are treated first. The ENA and American College of Emergency Physicians support the use of a five-level triage system.⁶ The Emergency Severity Index (ESI) is a five-level triage system that incorporates concepts of illness severity and resource utilization (e.g., electrocardiogram [ECG], laboratory work, radiology studies, IV fluids) to determine who should be treated first⁵ (Table 69-2). The ESI includes a triage algorithm that directs you to assign an ESI level to patients coming into the ED. (The triage algorithm can be found in the ESI Implementation Handbook available at www.ahrq.gov/research/esi.) Initially, assess the patient for any threats to life (ESI-1) (e.g., Is the patient dying?) or presence of a high-risk situation (ESI-2) (e.g., Is this a high-risk patient who should not wait to be seen?). Next, evaluate patients who do not meet the criteria for ESI-1 or ESI-2 for the number of anticipated resources they may need. Assign patients to ESI level 3, 4, or 5 based on this determination. Normal vital signs are required for patients assigned to ESI level 3. Patients with abnormal vital signs may be reassigned to ESI level 2.⁵ (For practice using the ESI triage system, see the ESI Implementation Handbook available at www.ahrq.gov/research/esi.)

After you complete the initial focused assessment to determine the presence of actual or potential threats to life, proceed with a more detailed assessment. A systematic approach to this assessment decreases the time needed to identify potential threats to life and limits the risk of overlooking a life-threatening condition. A primary and secondary survey is the approach used for all trauma patients. For nontrauma patients, the primary survey is followed by a focused assessment. (Focused assessments are discussed in Chapter 3.)

Primary Survey

The primary survey (Table 69-3) focuses on airway, breathing, circulation (ABC), disability, and exposure or environmental control. It aims to identify life-threatening conditions so that appropriate interventions can be started. You may identify life-threatening conditions related to ABCs (Table 69-4) at any point during the primary survey. When this occurs, start interventions immediately, before moving to the next step of the survey.

TABLE 69-3

EMERGENCY ASSESSMENT: PRIMARY SURVEY

Assessment	Interventions
Airway With Simultaneous Cervical Spine Stabilization and/or Immobilization
• Assess for respiratory distress. • Assess airway for patency. • Check for loose teeth or foreign bodies. • Assess for bleeding, vomitus, or edema.	• Open airway. • Use jaw-thrust maneuver. • Remove or suction any foreign bodies. • Insert oropharyngeal or nasopharyngeal airway, endotracheal tube, cricothyroidotomy. • Immobilize cervical spine using rigid cervical collar and cervical immobilization device. Secure forehead to backboard.
Breathing
• Assess ventilation. • Scan chest for signs of breathing. • Look for paradoxic movement of the chest wall during inspiration and expiration. • Note use of accessory muscles or abdominal muscles. • Observe and count respiratory rate. • Note color of nail beds, mucous membranes, skin. • Auscultate lungs. • Assess for jugular venous distention and position of trachea.	• Give supplemental O2 via appropriate delivery system (e.g., non-rebreather mask). • Ventilate with bag-valve-mask with 100% O2 if respirations are inadequate or absent. • Prepare to intubate if severe respiratory distress (e.g., agonal breaths) or arrest. • Have suction available. • If absent breath sounds, prepare for needle thoracostomy and chest tube insertion.
Circulation
• Check carotid or femoral pulse. • Palpate pulse for quality and rate. • Assess skin color, temperature, and moisture. • Check capillary refill. • Assess for external bleeding. • Measure blood pressure.	• If absent pulse, initiate cardiopulmonary resuscitation and advanced life-support measures. • If shock symptoms or hypotensive, start two large-bore (14- to 16-gauge) IVs and initiate infusions of normal saline or lactated Ringer’s solution. • Control bleeding with direct pressure and pressure dressings, if appropriate. • Administer blood products if ordered. • Consider autotransfusion if isolated chest trauma. • Consider use of a pneumatic antishock garment or pelvic splint in the presence of pelvic fracture with hypotension. • Obtain blood samples for type and crossmatch.
Disability
Brief Neurologic Assessment
• Assess level of consciousness by determining response to verbal and/or painful stimuli (e.g., AVPU, Glasgow Coma Scale). • Assess pupils for size, shape, equality, and reactivity.	• Periodically reassess level of consciousness, mental status, pupil size and reactivity.
Identify Deformities
• Inspect extremities for any obvious deformities. • Determine range of movement and strength in extremities.	• Immobilize (e.g., splint) any obvious deformities.
Brief Pain Assessment
• Assess pain (e.g., PQRST [see Table 34-7]).	• Periodically reassess pain using standardized pain scale.
Exposure and Environmental Control
• Assess full body for additional or related injuries	• Remove clothing for adequate examination. • Keep patient warm with blankets, warmed IV fluids, overhead lights to prevent heat loss, if appropriate. • Maintain privacy.

AVPU, A = alert, V = responsive to voice, P = responsive to pain, and U = unresponsive.

TABLE 69-4

POTENTIAL LIFE-THREATENING CONDITIONS FOUND DURING PRIMARY SURVEY*

Airway

• Inhalation injury (e.g., fire victim) • Obstruction (partial or complete) from foreign bodies, debris (e.g., vomitus), or tongue • Penetrating wounds and/or blunt trauma to upper airway structures

Breathing

• Anaphylaxis • Flail chest with pulmonary contusion • Hemothorax • Pneumothorax (e.g., open, tension)

Circulation

• Direct cardiac injury (e.g., myocardial infarction, trauma) • Pericardial tamponade • Shock (e.g., massive burns, hypovolemia) • Uncontrolled external hemorrhage • Hypothermia

Disability

• Head injury • Stroke

^*List is not all-inclusive.

A = Airway With Cervical Spine Stabilization and/or Immobilization.

Nearly all immediate trauma deaths occur because of airway obstruction. Saliva, bloody secretions, vomitus, laryngeal trauma, dentures, facial trauma, fractures, and the tongue can obstruct the airway. Patients at risk for airway compromise include those who have seizures, near-drowning, anaphylaxis, foreign body obstruction, or cardiopulmonary arrest. If an airway is not maintained, obstruction of airflow, hypoxia, and death will result.

Primary signs and symptoms in a patient with a compromised airway include dyspnea, inability to speak, gasping (agonal) breaths, foreign body in the airway, and trauma to the face or neck. Airway maintenance should progress rapidly from the least to the most invasive method. Treatment includes opening the airway using the jaw-thrust maneuver (avoiding hyperextension of the neck) (Fig. 69-1), suctioning and/or removal of foreign body, insertion of a nasopharyngeal or an oropharyngeal airway (in unconscious patients only), and endotracheal intubation. If intubation is impossible because of airway obstruction, an emergency cricothyroidotomy or tracheotomy is performed (see Chapter 27). Ventilate patients with 100% O₂ using a bag-valve-mask (BVM) device before intubation or cricothyroidotomy.⁷

Rapid-sequence intubation is the preferred procedure for securing an unprotected airway in the ED. It involves the use of sedation (e.g., midazolam [Versed]) or anesthesia (e.g., etomidate [Amidate]) and paralysis (e.g., succinylcholine [Anectine]). These drugs aid intubation and reduce the risk of aspiration and airway trauma.⁷ (See Chapter 66 for more information on intubation.)

Suspect cervical spine trauma in any patient with face, head, or neck trauma and/or significant upper chest injuries. Stabilize the cervical spine (head maintained in a neutral position) and/or immobilize during assessment of the airway. At the scene of the injury, the cervical spine is immobilized with a rigid cervical collar (C-collar) and a cervical immobilization device (CID) (also known as “head blocks”). Finally, secure the patient’s forehead to the backboard. Do not use sandbags because the weight of the bags could move the head if the patient is logrolled.

B = Breathing.

Adequate airflow through the upper airway does not ensure adequate ventilation. Many conditions cause breathing changes, including fractured ribs, pneumothorax, penetrating injury, allergic reactions, pulmonary emboli, and asthma attacks. Patients with these conditions may have a variety of signs and symptoms, including dyspnea (e.g., pulmonary emboli), paradoxic or asymmetric chest wall movement (e.g., flail chest), decreased or absent breath sounds on the affected side (e.g., pneumothorax), visible wound to chest wall (e.g., penetrating injury), cyanosis (e.g., asthma), tachycardia, and hypotension.

Every critically injured or ill patient has an increased metabolic and oxygen demand and should have supplemental O₂. Administer high-flow O₂ (100%) via a non-rebreather mask and monitor the patient’s response. Life-threatening conditions (e.g., flail chest, tension pneumothorax) can severely and quickly compromise ventilation. Interventions may include BVM ventilation with 100% O₂, needle decompression, intubation, and treatment of the underlying cause.

C = Circulation.

An effective circulatory system includes the heart, intact blood vessels, and adequate blood volume. Uncontrolled internal or external bleeding places an individual at risk for hemorrhagic shock (see Chapter 67). Check a central pulse (e.g., carotid) because peripheral pulses may be absent due to direct injury or vasoconstriction. If you feel a pulse, assess the quality and rate. Assess the skin for color, temperature, and moisture. Altered mental status and delayed capillary refill (longer than 3 seconds) are common signs of shock. Take care when evaluating capillary refill in cold environments because cold delays refill.

Insert IV lines into veins in the upper extremities unless contraindicated, such as in a massive fracture or an injury that affects limb circulation. Insert two large-bore (14- to 16-gauge) IV catheters and start aggressive fluid resuscitation using normal saline or lactated Ringer’s solution (see Chapter 67 for more information on hypovolemic shock and fluid resuscitation).

Apply direct pressure with a sterile dressing followed by a pressure dressing to any obvious bleeding sites. Obtain blood samples for typing to determine ABO and Rh group. Give type-specific packed red blood cells if needed. In an emergency (life-threatening) situation, give uncrossmatched blood if immediate transfusion is warranted. Pelvic splints or belts for pelvic fracture may be used for bleeding with hypotension.⁸

D = Disability.

Conduct a brief neurologic examination as part of the primary survey. The patient’s level of consciousness is a measure of the degree of disability. Determine the patient’s response to verbal and/or painful stimuli to assess level of consciousness. A simple mnemonic to remember is AVPU: A = alert, V = responsive to voice, P = responsive to pain, and U = unresponsive. In addition, use the Glasgow Coma Scale (GCS) to determine the level of consciousness (see Table 57-5). Finally, assess the pupils for size, shape, equality, and reactivity.

E = Exposure or Environmental Control.

Remove all trauma patients’ clothing to perform a thorough physical assessment. This often requires cutting off the patient’s clothing. Be careful not to cut through any area that may provide forensic evidence (e.g., bullet hole). Once the patient is exposed, use warming blankets, overhead warmers, and warmed IV fluids to limit heat loss, prevent hypothermia, and maintain privacy.

Secondary Survey

The secondary survey begins after addressing each step of the primary survey and starting any lifesaving interventions. The secondary survey is a brief, systematic process that aims to identify all injuries⁹ (Table 69-5).

TABLE 69-5

EMERGENCY ASSESSMENT: SECONDARY SURVEY

Assessment	Interventions
Full Set of Vital Signs
Establish baseline vital signs	• Obtain vital signs: temperature, heart rate, respiratory rate, oxygen saturation, BP bilaterally.
Focused Adjuncts
Determine need for additional procedures	• Initiate continuous ECG, O2 saturation, and end-tidal carbon dioxide monitoring. • Insert urinary catheter (if not contraindicated). • Insert gastric tube. • Obtain blood for laboratory studies. • Arrange for diagnostic studies (e.g., chest x-ray). • Provide tetanus prophylaxis, if appropriate.
Facilitate Family Presence
Determine caregiver’s desire to be present during invasive procedures and/or cardiopulmonary resuscitation	• Assign team member to support caregivers.
Give Comfort Measures
Assess, treat, and reassess for pain, anxiety	• Provide emotional support to patient and caregiver. • Provide additional comfort measures as appropriate (e.g., distraction, ice, position of comfort, warm blanket, analgesia).
History and Head-to-Toe Assessment
History	• Obtain details of the incident/illness, mechanism and pattern of injury, length of time since incident occurred, injuries suspected, treatment provided and patient’s response, level of consciousness. • Use the mnemonic AMPLE to determine Allergies, Medication history, Past health history (e.g., preexisting medical/psychiatric conditions, last menstrual period), Last meal, and Events/Environment preceding illness or injury.
Head, Neck, and Face	• Note general appearance, including skin color. • Examine face and scalp for lacerations, bone or soft tissue deformity, tenderness, bleeding, and foreign bodies.
	• Inspect eyes, ears, nose, and mouth for bleeding, foreign bodies, drainage, pain, deformity, ecchymosis, lacerations. • Palpate head for depressions of cranial or facial bones, contusions, hematomas, areas of softness, bony crepitus. • Examine neck for stiffness, pain in cervical vertebrae, tracheal deviation, distended neck veins, bleeding, edema, difficulty swallowing, bruising, subcutaneous emphysema, bony crepitus.
Chest	• Observe rate, depth, and effort of breathing, including chest wall movement and use of accessory muscles. • Palpate for bony crepitus, subcutaneous emphysema. • Auscultate breath sounds. • Obtain 12-lead ECG and chest x-ray. • Inspect for external signs of injury: petechiae, bleeding, cyanosis, bruises, abrasions, lacerations, old scars.
Abdomen and Flanks	• Look for symmetry of abdominal wall and bony structures. • Inspect for external signs of injury: bruises, abrasions, lacerations, punctures, old scars. • Auscultate for bowel sounds. • Palpate for masses, guarding, femoral pulses. • Note type and location of pain, rigidity, or distention of abdomen.
Pelvis and Perineum	• Gently palpate pelvis. • Assess genitalia for blood at the meatus, priapism, ecchymosis, rectal bleeding, anal sphincter tone. • Determine ability to void.
Extremities	• Inspect for signs of external injury: deformity, ecchymosis, abrasions, lacerations, swelling. • Observe skin color and palpate skin for pain, tenderness, temperature, and crepitus. • Evaluate movement, strength, and sensation in arms and legs. • Assess quality and symmetry of peripheral pulses.
Inspect Posterior Surfaces	• Logroll and inspect and palpate back for deformity, bleeding, lacerations, bruises.

F = Full Set of Vital Signs, Focused Adjuncts, Facilitate Family Presence.

Obtain a full set of vital signs, including blood pressure (BP), heart rate, respiratory rate, O₂ saturation, and temperature after the patient is exposed. If the patient has sustained or is suspected of having sustained chest trauma, or if the BP is abnormally high or low, obtain the BP in both arms.

At this point, determine whether to proceed with the secondary survey or to perform additional interventions. The input of other health care team members often influences this decision. The following focused adjuncts are considered for patients who sustain significant trauma or require lifesaving interventions during the primary survey:

• Continuously monitor ECG for heart rate and rhythm.

• Continuously monitor O₂ saturation and end-tidal carbon dioxide (if appropriate) (see Chapter 66).

• Obtain portable chest x-ray to confirm exact placement of tubes (e.g., endotracheal, gastric).

• Insert an indwelling catheter to decompress the bladder, monitor urine output, and check for hematuria. Do not insert an indwelling catheter if blood is present at the urinary meatus (e.g., urethral tear) or if scrotal hematoma or perineal ecchymosis is present. Men with a high-riding prostate gland on rectal examination are at risk for a urethral injury. The physician may order a retrograde urethrogram before inserting a catheter.

• Insert orogastric or nasogastric tube to decompress and empty the stomach, reduce the risk of aspiration, and test the contents for blood. Place an orogastric tube in a patient with significant head or facial trauma, since a nasogastric tube could enter the brain.

• Facilitate laboratory and diagnostic studies (e.g., type and crossmatch, complete blood count and metabolic panel, blood alcohol, toxicology screening, arterial blood gases [ABGs], coagulation profile, cardiac markers, pregnancy [urine], x-rays, computed tomography [CT] scans, ultrasound).

• Determine the need for tetanus prophylaxis.

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