1 Triage Nursing

8/4/2019 1 Triage Nursing

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TRIAGENURSING


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General Objective:

After 2 hours lecture-demo the students willbe able to


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Specific Objectives:

After 2 hours lecture-demo the students

will be able to:

- define Triage and Triage Nursing.

- enumerate the qualifications of a TriageNurse.

- differentiate the two types of triage.


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Triage

- from the French verb trier, meaning "to sort, sift orselect."

-

is a process of prioritizing patients based on theseverity of their condition so as to treat as manyas possible when resources are insufficient for allto be treated immediately.

- Triage originated and was first formalized in WWIby French doctors treating the battlefield woundedat the aid stations behind the front.
http://en.wikipedia.org/wiki/French_languagehttp://en.wikipedia.org/wiki/French_language


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TRIAGE NURSING

A point which emergency care begins.

A brief clinical assessment that determines theurgency of treatment and time and sequence inwhich patients are seen in the ER

A tool for ensuring patients are seen in a timelymanner, commensurate with their clinical urgency.


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The Triage Nurse

A qualified RN who demonstrates and maintainsclinical expertise in emergency nursing.

Initiate appropriate nursing interventions andorganizational guidelines.

Demonstrates critical thinking skills and abilities.


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Types of triage

1. Simple triage

2. Advanced triage


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Simple Triage

Used in a scene of mass casualty

This step can be started before

transportation becomes available

Categorization of patients based on the severity of

their injuries

Use printed triage tags or colored flagging.
http://en.wikipedia.org/w/index.php?title=Mass_casualty&action=edit&redlink=1http://en.wikipedia.org/wiki/Triage_taghttp://en.wikipedia.org/wiki/Flagging_%28tape%29http://en.wikipedia.org/wiki/Flagging_%28tape%29http://en.wikipedia.org/wiki/Triage_taghttp://en.wikipedia.org/w/index.php?title=Mass_casualty&action=edit&redlink=1


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A Triage Tag is a quick and easy way to communicate a patient's priority to others
http://en.wikipedia.org/wiki/Image:SmartTag_TriageTag.jpg


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TRIAGE COLOR CODE SYSTEM

RED YELLOW GREEN BLACK

URGENCY

Most Urgent-

First Priority

Urgent-

Second Priority

Third

Priority

Dying

or Dead

INJURY TYPE

Lifethreatening

injuries

Injuries with

systemic effects

& complications

Minimalinjuries w/ no

systemiccomplications

Catastrophicinjuries

MAY DELAY

TREATMENT? NO 30-60 min. Several HoursNo hope for

survival- no Tx


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S.T.A.R.T.

(Simple Triage and Rapid Treatment)

a simple triage system that can be

performed by lightly-trained lay and

emergency personnel in emergencies.

It is not intended to supersede or instruct

medical personnel or techniques.


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S.T.A.R.T.(Simple Triage and Rapid Treatment)

developed at Hoag Hospital in NewportBeach, California for use by emergency

services.

field-proven in mass casualty incidentssuch as train wrecks and bus accidents,

though it was developed for use by CERTsand firemen after earthquakes.
http://en.wikipedia.org/wiki/Newport_Beach%2C_Californiahttp://en.wikipedia.org/wiki/Newport_Beach%2C_Californiahttp://en.wikipedia.org/wiki/Community_emergency_response_teamhttp://en.wikipedia.org/wiki/Firemenhttp://en.wikipedia.org/wiki/Firemenhttp://en.wikipedia.org/wiki/Community_emergency_response_teamhttp://en.wikipedia.org/wiki/Newport_Beach%2C_Californiahttp://en.wikipedia.org/wiki/Newport_Beach%2C_California


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S.T.A.R.T.(Simple Triage and Rapid Treatment)

First:Separate the walking wounded- move to safe area- Evaluate later/GREEN Tag.

Next:Three step evaluation of non-walking victims- ONE VICTIM AT A TIME

Assess RESPIRATIONS

> 30/min

RED Tag

Move to next victim

None

Reposition airway & reassess

Within Normal Limits

Yes

RED TagMove to next victim

No

BLACK Tag


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Assess CIRCULATION

Delayed capillary refillRED Tag

Move to next victim

Capillary refill WNL

Assess MENTAL STATUS

Cannot follow simple commandsRED Tag

Move to next victim

Can follow simple commands

YELLOW Tag

Move to next victim


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ADVANCED TRIAGE(Hospital Triage)

Secondary triage is typically implemented byparamedics, battlefield medical personnel or by skillednurses in the emergency departments of the hospitalduring disasters.

More complex than with simple triage.

A trauma score is invariably taken when the victim firstcomes into hospital and subsequent trauma scores takento see any changes in the victim's physiologicalparameters.


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Advanced Triage

Categories of severity:

1. Black / Expectant

2. Red / Immediate

3. Yellow / Observation

4. Green / Wait (walking wounded)5. White / Dismiss (walking wounded)


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Black / Expectant

- They are so severely injured that they will die oftheir injuries, possibly in hours or days (large-body burns, severe trauma, lethal radiation dose),

or in life-threatening medical crisis that they areunlikely to survive given the care available(cardiac arrest, septic shock, severe head orchest wounds); they should be taken to a holding

area and given painkillers as required to reducesuffering.
http://en.wikipedia.org/wiki/Cardiac_arresthttp://en.wikipedia.org/wiki/Septic_shockhttp://en.wikipedia.org/wiki/Painkillerhttp://en.wikipedia.org/wiki/Painkillerhttp://en.wikipedia.org/wiki/Septic_shockhttp://en.wikipedia.org/wiki/Cardiac_arrest


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Red / Immediate

- They require immediate surgery or otherlife-saving intervention, and have first

priority for surgical teams or transport toadvanced facilities; they "cannot wait" butare likely to survive with immediate

treatment.


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Yellow / Observation

- Their condition is stable for the moment butrequires watching by trained persons and

frequent re-triage, will need hospital care(and would receive immediate priority careunder "normal" circumstances).


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Green / Wait (walking wounded)

- They will require a doctor's care in severalhours or days but not immediately, may

wait for a number of hours or be told to gohome and come back the next day (brokenbones without compound fractures, many

soft tissue injuries).


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White / Dismiss (walking wounded)

- They have minor injuries; first aid and homecare are sufficient, a doctor's care is notrequired. Injuries are along the lines of cutsand scrapes, or minor burns.


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Note

Some crippling injuries, even if not life-threatening, may be elevated in priority

based on the available capabilities. Duringpeacetime, most amputations may betriaged "Red" because surgicalreattachment must take place within

minutes, even though in all probability theperson will not die without a thumb or hand.


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Reverse triage

In addition to the standard practices of triage as mentioned above,there are conditions where sometimes the less wounded are treated inpreference to the more severely wounded. This may arise in a situationsuch as war where the military setting may require soldiers be returnedto combat as quickly as possible, or disaster situations where medical

resources are limited in order to conserve resources for those likely tosurvive but requiring advanced medical care. Other possible scenarioswhere this could arise include situations where significant numbers ofmedical personnel are among the affected patients where it may beadvantageous to ensure that they survive to continue providing care inthe coming days especially if medical resources are already stretched.In cold water drowning incidents, it is common to use reverse triage

because drowning victims in cold water can survive longer than inwarm water if given immediate BLS and often those who are rescuedand able to breathe on their own will improve with minimal or no help.
http://en.wikipedia.org/wiki/Basic_life_supporthttp://en.wikipedia.org/wiki/Basic_life_support


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References:

Burstein, J. L. & Hogan, D. E. (2007).Disaster Medicine (2nd ed.). Philadelphia,

PA: Lippincott Williams & Wilkins.

http://en.wikipedia.org/wiki/Triage
http://en.wikipedia.org/wiki/Triagehttp://en.wikipedia.org/wiki/Triage


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THANK YOU!

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1 Triage Nursing