TriagePriority专业知识课件

TriagePriorityWang,Tzong-Luen,MD,PhD,FESC,FACCClassI(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旳開放性傷口;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ClassII(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旳開放性傷口;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ClassIII(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ClassIV(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。已知癌症旳病患，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旳治療者。自門診轉來等住院者，但生命徵象正常者。主訴某種症狀已经有相當時日，但生命徵象正常者。大量傷患分類一、極危險、第一優先(紅色)呼吸停止或呼吸道阻塞。被目擊旳心臟停止。動脈斷掉或無法控制之出血。穩定性旳頸部受傷。嚴重旳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。內科醫療疾病旳併發症。關節骨折且遠端無脈搏。股骨骨折。二、危險、第二優先(黃色)背部受傷(不論是否有脊椎受傷)。中度旳流血(少於二處)。嚴重燙傷。開放性或多處骨折。穩定旳腹部傷害。眼部傷害。穩定性旳藥物中毒。三、輕傷、最低優先、延後處理(綠色)小型旳挫傷或軟組織傷害。小型或簡單型骨折。肌肉扭傷。但凡由於受傷過於嚴重(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)頭部不見。沒有脈搏超過二十分鐘，除了冷水溺水或極度低體溫者。軀幹分離。從高度落下且具有多處旳受傷與骨折，沒有呼吸者。肉臟外脫。TriageDecisionScheme(Trauma)STEP1:MeasureVitalSignsandLevelofConsciousnessGCS<14RR<10or>29SBP<90RTS<11PTS<9TriageDecisionSchemeSTEP2:AnatomicandPhysiologicApproachFlailchestTwoormoreproximallong-bonefracturesAmputationproximalwrist/ankleAllpenetratingtraumatohead,neck,torso,andextremitiesproximaltoelbowandkneeLimbparalysisPelvicfracturesCombinationtraumawithburnsTriageDecisionSchemeSTEP3:TraumaMechanismsEjectionfromautoDeathinsamepassengercompartmentPedestrianthrownorrunoverHigh-speedautocrashInitialspeed>40mph(64kph)Majorautodeformity>20inches(50cm)Intrusionintopassengercompartment>12inches(30cm)Extricationtime>20minutesFalls>20ftRolloverAuto-pedestrianinjurywith>5mph(8kph)impactMotorcyclecrash>20mph(32kph)orwithseparationofriderandbikeTriageDecisionSchemeSTEP4:UnderlyingConditionsAge<5or>55PregnancyImmunosuppressedpatientsCardiacdisease;respiratorydiseaseInsulin-dependentdiabetes;cirrhosis;morbidobesity;coagulopathyRevisedTraumaScoreRespiratoryRate10-29 score4>29 score36-9 score21-5 score10 score0RevisedTraumaScoreSystolicBP>89 score476-89 score350-75 score21-49 score10 score0RevisedTraumaScoreGCSScoreConversion13-15 score49-12 score36-8 score24-5 score1<4 score0PediatricTraumaScoreWeight>20Kg(44lb) score+210-20Kg(22-44lb) score+1<10Kg(22lb) score–1AirwayNormal score+2Oralornasalairway;O2 score+1Intubated;cricothyroidtomy score–1tracheostomyPediatricTraumaScoreSystolicBloodPressure>90mmHg;goodperipheralpulse; score+2perfusion50-90mmHg;carotid/femoral score+1pulsespalpable<50mmHg;weakornopulses score–1LevelofConsciousnessAwake score+2ObtundedoranyLOC score+1Coma;unresponsive score–1PediatricTraumaScoreFractureNoneseenorsuspected score+2Single,closed score+1Openormultiple score–1CutaneousNonevisible score+2Contusion,abrasion;laceration score+1<7cm;notthrufasciaTissueloss;anyGSW/SW; score–1thrufasciaDetailedAdultCriteriaGCS<12=

REDAIRWAYACTIVEairwayassistancerequired(i.e., morethansupplementalO2without airwayadjunct)Sustainedrespiratoryrate>30DetailedAdultCriteriaCIRCULATIONNoradialpulseANDheartrate>120ORBP<90systolicSustainedheartrate>120withradialpulse andBP>90systolicDetailedAdultCriteriaBESTMOTORRESPONSEBMR<4ORParalysis,lossofsensation,suspicionofspinalcordinjuryBMR=5DetailedAdultCriteriaCUTANEOUSAmputationproximaltowristorankleOR>15%BSA2ndand3rddegreeburnsORPenetratinginjurytohead,neck,torso,excluding superficialwoundsDeglovinginjuryorflapavulsion>5inchesDetailedAdultCriteriaLONGBONEFRACTUREMultiplelongbonefracturesitesSinglelongbonefracturesiteduetoMVCORSinglelongbonefracturesiteduetofallfrom >10feetDetailedAdultCriteriaAGEAge>55MECHANISMOFINJURYEjectionfromvehicle(excludesopen vehicles)ORDriverwithdeformedsteeringwheelNotesonPedsCriteriaApplicabletoage15orlessSizecomponentisbasedonBroslowcolorzoneorweightAnyairwaymaintenancebeyondsupplementalO2andone-timeneedforsuctioning=REDAnyalteredmentalstatusotherthanamnesia=RED

criteriaParalysis,lossofsensation,orsuspicionofspinalcordinjury=REDcriteriaunder“Consciousness”categoryNotesonPedsCriteria(cont.)AnyreliablehxofLOC=BLUEFracturecriteriaarealsobasedonlongbones(sameasadults).Openlongboneormultiplelongbonefx/dislocations=RED

>

10%BSA2ndand3rddegreeburn=REDDetailedPedsCriteriaSIZEWeight<10Kg(<22lbs..)or

RED

or

PURPLE

BroslowTapeZoneAIRWAYACTIVEairwayassistancerequired(i.e., morethansupplementalO2/one-time suctioningwithoutairwayadjunct)DetailedPedsCriteriaCONSCIOUSNESSPatientnotawakeandappropriateORParalysis,lossofsensation,orsuspected spinalcordinjuryAmnesiaORReliablehistoryoflossofconsciousnessDetailedPedsCriteriaCIRCULATIONNopalpablepulsesORWeakcarotidorfemoralpulseORSystolicBP<50Goodcarotidorfemoralpulsewithabsentdistal pulsesORSystolicBP50-90DetailedPedsCriteriaLONGBONEFRACTUREAnyopenlongbonefractureORMultipleclosedlongbonefracturesitesor dislocations

SingleclosedlongbonefracturesiteDetailedPedsCriteriaCUTANEOUSDeglovinginjury,majorflapavulsionORAmputationproximaltowristorankleOR>10%BSA2ndand3rddegreeburnsORPenetratinginjurytohead,neckortorsoPracticeCase#168yofemalepedestrianstruckGCS14,BMR5PatentairwayHR100,BP120/94,RR20AbrasionsUnstablepelvisBLUEBLUEPOSITIVETRAUMAALERTPracticeCase#221yomaleStabwoundtoleftchestAirwaypatentGCS15BSonleftBP90/P,HR130REDREDPOSITIVETRAUMAALERTPracticeCase#34yearoldnear-drowninginpoolNosignsoftraumaIntubatedNormalskinsignsNormalbrachialpulseResponsivetodeeppainDrowningisnotconsideredtraumaunlessinjuryaccompaniesit!PracticeCase#46yofemalefell10ft.fromtree22kgweightamnesticforevent,o/walertairwaypatentobviousclosedforearmfxnlvitalsignsBLUEBLUEPOSITIVETRAUMAALERTPracticeCase#56montholdmale(purple)childabusemultiplecigaretteburns&contusionsabdomenrigidstrongpalpablecarotidpulseonlydoesnotcrywithexamBLUEBLUEREDPOSITIVETRAUMAALERTTraumaBlue1.

GlasgowComaScale<14

2.

SystolicBloodPressure<90

3.

Respiratoryrate<10or>29

4.

RevisedTraumaScore<11

5.

PediatricTraumaScore<9

6.

Penetratinginjuriesto:

head,neck,torso,and/orextremitiesproximaltothekneeand/orelbow

7.

FlailChest

8.

CombinationTraumawithburnsorinhalationinjury

9.

Twoormoreproximallongboneinjuries

10.

Highenergypelvicfractures

11.

Limbparalysis

12.

Amputationproximaltothewristorankle13.Traumapatientpregnantpast2ndtrimester

AnotherExampleTraumaBlue1.

Ejectionfromautomobile

2.

Deathinsamepassengercompartment

3.

Prolongedextrication(>20minutes)

4.

Falls>20feet

5.

Roll-over

6.

Highspeedautocrash

a.

Initialspeed>40mph

b.

Majorautodeformity>20inches

c.

Intrusionintopassengercompartment>12inches

7.

Auto-Pedestrianinjurywithsignificantimpact(>5mph)

8.

Pedestrianthrownorrunover

9.

Motorcyclecrash>20mphorwithseparationofbikeandrider

10.

Patientsage<5or>55

11.Pregnancypast1sttrimester

KillipClassificationKillipI:RalesandS3absentKillipII:Ralesover<50%oflungKillipIII:Ralesover>50%oflungfields(pulmonaryedema)KillipIV:ShockSubsetI:Normalhemodynamics;PCWP<18;CI>2.2SubsetII:Pulmonarycongestion:PCWP>18;CI<2.2SubsetIII:Peripheralhypoperfusion;PCWP>18;CI>2.2SubsetIV:Pulmonarycongestionandperipheralhypoperfusion;PCWP>18;CI<2.2GoldmanCriteriaAge>70yrs(5)CAD:MIwithin6months(10)CHF:S3orJVE(11)Rhythm:otherthanNSR/PACsonmostrecentECG(7);>5PVCs/minanytimepreoperatively(7)ValvularDisease:importantaorticstenosis(5)GeneralMedicalcondition(5)PaO2<60orPaCO2>50,K<3.0,orHCO3<20,BUN>50orCr>3.0,abnormalAST,signsofchronicliverdisease,bedriddenfromnoncardiccausesSurgery:intraperitoneal,thoracic,aorticsurgery(3) emergentsurgery(4)

GoldmanCriteriaClassTotalScoreNoorMinorComplicationsLifeThreateningCardiacDeathsI0-599%0.7%0.2%II6-1293%5%2%III13-2586%11%2%IV>2522%22%56%RevisedGoldmanCriteriaHighrisktypeofsurgeryHistoryofischemicheartdiseaseHistoryofheartfailureHistoryofCVAPreoperativetreatmentwithinsulinPreoperativeserumcreatinine>2.0mg/dLRates:0.4%withnorisk;0.9%with1risk;7%with2risks;11%with3ormorerisksDetskyCriteriaAge>70yrs(5)CAD:MIwithin6months(10)MI>6months(5)CCSanginaclassIII(10)CCSanginaclassIV(20)Unstableanginapast3months(10)CHF:Pulmonaryedemawithin1week(10)Pulmonaryedema,ever(5)Rhythm:otherthanNSR/PACsonlastpreopECG(5);>5PVCs/minanytimepreoperatively(5)ValvularDisease:suspectedcriticalaorticstenosis(5)GeneralMedicalcondition(5)PaO2<60orPaCO2>50,K<3.0,orHCO3<20,BUN>50orCr>3.0,abnormalAST,signsofchronicliverdisease,bedriddenfromnoncardiccausesSurgery:emergentsurgery(10) RevisedDetskyCriteriaHighrisktypeofsurgeryHistoryofischemicheartdiseaseHistoryofheartfailureHistoryofCVAPreoperativetreatmentwithinsulinPreoperativeserumcreatinine>2.0mg/dLunstableanginawithin3monthsofsurgeryorstableanginaoccurringwithminimalexertionorrecentpulmonaryedema(HIGHRISK)Rates:0.4%withnorisk;0.9%with1risk;7%with2risks;11%with3ormorerisksorHIGHRISKGoldmanandDetskyCriteriaMayUNDERESTIMATEtheCardiacRiskinVascularPatients…EagleCriteriaAccess5significantclinicalpredictors

QwavesonEKG

Historyofangina

Historyofventricularectopyrequiringtreatment

Diabetesmellitusrequiringtherapyotherthandiet

Age>70

Rateofpostoperativeischemicevents:3.1%ifnopredictors,15%if1-2predictorsandupto50%if3ormorepredictors.Perioperativeß-BlockerKnownCADor2+CRFthen:Perioperativeatenolol5mgIVq5minx2recommended30minpreop&immediatelypostopAtenolol50-100mgpoqdpostopday1untild/c.

[1yrmortality3%vs14%forplacebo]Ranson’scriteria(alcoholic)AdmissionAge>55yrWBC>16,000/cmmGlucose>200mg/dLLDH>350IU/LGOT>250IU/L48HoursHctdrop>10%PaO2<60mmHgCa<8mg/dLBasedeficit>4mEq/LBUNrise>5mg/dLEstimatedfluidsequestration>6LRanson’scriteria(non-alcoholic)AdmissionAge>70yrWBC>18,000/cmmGlucose>220mg/dLLDH>400IU/LGOT>440IU/L48HoursHctdrop>10%PaO2<60mmHgCa<8mg/dLBasedeficit>5mEq/LBUNrise>2mg/dLEstimatedfluidsequestration>6LGlascowcriteria(<48hours)Age>55yrGlucose>180mg/dLAlbumin<3.2g/dLPaO2<60mmHgWBC>15,000/cmmLDH>600IU/LBUN>45mg/dLCa<8mg/dLPredictionModelforPneumoniaPatientcharacteristic

Pointsassigned_______________Demographicfactors

Age:oMales:Age(inyears)oFemales:Age(inyears)-10Nursinghomeresident:+10ComorbidillnessesNeoplasticdisease:+30Liverdisease:+20Congestiveheartfailure:+10Cerebrovasculardisease:+10Renaldisease:+10PredictionModelforPneumoniaPhysicalexaminationfindings

Alteredmentalstatus:+20Respiratoryrate30/minuteormore:+20Systolicbloodpressure<90mmHg:+20Temperature<35degreesCor40degreesCormore:+15Pulse125/minuteormore:+10PredictionModelforPneumoniaLaboratoryfindingspH<7.35:+30BUN>10.7mmol/L:+20Sodium<130mEq/L:+20Glucose>13.9mmol/L:+10Hematocrit<30percent:+10PO2<60mmHg(2):+10Pleuraleffusion:+10_______________________________________(1)Ariskscore(totalpointscore)foragivenpatientisobtainedbysummingthepatientageinyears(ageminus10forfemales)andthepointsforeachapplicablepatientcharacteristic.

(2)Oxygensaturation<90percentalsowasconsideredabnormal.

RiskStratificationforPneumoniaRiskClassLowIAlgorithmLowII70orfewerpointsLowIII71-90totalpointsModerateIV91-130totalpointsHighV>130totalpointsAsthmaSeverityFactorSevereasthma(FEV1

<1.0L)Pulserate(beats/min)≥120,butmaybelesswithequallysevereasthmaRespiratoryrate(breaths/min)≥40,butmostare>20,thereforenondiscriminatingPulsusparadoxus(mmHg)≥10,butmaybeabsentwithequallysevereasthmain50%ofcasesPulserate≥120,respiratoryrate≥20,pulsusparadoxus≥10Ifallthreeabnormal,90%withsevereasthma,butonly40%withFEV1

<1.0L

haveallthreeabnormalUseofaccessorymusclesofrespirationIfpresent,mayindicatesevereasthma;ifabsent,mayhaveequallysevereasthmain50%ofcasesABGanalysis(mmHg)PaO2

≤60orPaCO2≥42indicatessevereasthma;allothervaluesdifficulttointerpretunlessPEFRorFEV1known

PulmonaryfunctionstudiesPEFRandFEV1

measuredirectlythedegreeofairflowobstruction;mostusefulinassessingseverityandguidingtreatmentdecisionsAsthmaSeverityPasthistoryofsuddensevereexacerbationsPriorintubationforasthmaPriorasthmaadmissiontoanintensivecareunitTwoormorehospitalizationsforasthmainthepastyearThreeormoreEDcarevisitsforasthmainthepastyearHospitalizationoranEDcarevisitforasthmawithinthepastmonthUseof>2MDIshort-actingβ2agonistcanisterspermonthCurrentuseoforrecentwithdrawalfromsystemiccorticosteroidsDifficultyperceivingseverityofairflowobstructionComorbiditiessuchascardiovasculardiseasesorothersystemicproblemsSeriouspsychiatricdiseaseorpsychosocialproblemsIllicitdruguse,especiallyinhaledcocaineandheroinAsthmaSeverityMildIntermittentAsthma

Symptoms

Symptoms<2timesaweek

AsymptomaticandnormalPEFRbetweenexacerbations

Exacerbationsbrief(fromafewhourstoafewdays);intensitymayvary

Nighttime

<2timesamonth

LungFunction

FEV1