Emergency department An Emergency Department (ED), also known as Accident & Emergency (A&E), Emergency Room (ER), Emergency

Ward (EW), or Casualty Department is a medical treatment facility, specialising in acute care of patients who present without prior appointment, either by their own means or by ambulance. The emergency department is usually found in a hospital or other primary care center. Due to the unplanned nature of patient attendance, the department must provide initial treatment for a broad spectrum of illnesses and injuries, some of which may be life-threatening and require immediate attention. In some countries, emergency departments have become important entry points for those without other means of access to medical care. The emergency departments of most hospitals operate 24 hours a day, although staffing levels may be varied in an attempt to mirror patient volume. As patients can present at any time and with any complaint, a key part of the operation of an emergency department is the prioritization of cases based on clinical need. This is usually achieved though the application of triage. Triage is normally the first stage the patient passes through, and most emergency departments have a dedicated area for this to take place, and may have staff dedicated to performing nothing but a triage role. In most departments, this role is fulfilled by a nurse, although dependant on training levels in the country and area, other health care professionals may perform the triage sorting, including paramedics or doctors. Most patients will be assessed and then passed to another area of the department, or another area of the hospital, with their waiting time determined by their clinical need. However, some patients may complete their treatment at the triage stage, for instance if the condition is very minor and can be treated quickly, if only advice is required, or if the emergency department is not a suitable point of care for the patient. Conversely, patients with evidently serious conditions, such as cardiac arrest, will bypass triage altogether and move straight to the appropriate part of the department. The resuscitation area is key in most departments and the most serious patients will be dealt with in this area, and it contains the equipment and staff required for dealing with immediately life threatening illnesses and injuries. Patients whose condition is not immediately life threatening will be sent to an area suitable to deal with them, and these areas might typically be termed as a majors or minors area. Such patients may still have been found to have significant problems, including fractures, dislocations, and lacerations requiring suturing. Children can present particular challenges in treatment and some departments have dedicated pediatrics areas and some departments employ a play therapist whose job is to put children at ease to reduce the anxiety caused by visiting the emergency department, as well as provide distraction therapy for simple procedures. Many hospitals have a separate area for evaluation of psychiatric problems. These are often staffed by psychiatrists and mental health nurses and social workers. There is typically at least one room for people who are actively a risk to themselves or others (e.g. suicidal). Fast decisions on life-and-death cases are critical in hospital emergency rooms. As a result, doctors face great pressures to overtest and overtreat. The fear of missing something often leads to extra blood tests and imaging scans for what may be harmless chest pains, run-of-the-mill head bumps, and non-threatening stomachaches, with a high cost on the Health Care system.[2] [edit] Nomenclature During the 1990s, an effort began to change previous naming conventions to the more accurate term Emergency Department

(ED), which is a term increasingly used by members of the speciality internationally. Historic terminology still exists across the world, especially in vernacular usage. For instance, terms such as the previously accepted formal term 'Accident and Emergency' or 'A&E' are still widely known in countries such as the United Kingdom and its former territories, as are common informal terms such as 'Casualty', or 'Casualty Department'. The same applies to 'Emergency Room' or 'ER' in North America, originating when emergency facilities were provided in a single room of the hospital. In the cases of both 'ER' in North America and 'Casualty' in the United Kingdom, the continued prevalence can be to some extent linked to the existence of long running television dramas bearing those respective names. See ER (TV series) and Casualty (TV series). The term "Urgency" instead of "Emergency" is used in some Latin American countries. Emergency Departments are known as "Servicios de Urgencia" and they function in a similar fashion to European Emergency Departments. [edit] Signage

An example of California hospital signage Regardless of naming convention, there is a widespread usage of directional signage in white text on a red background across the world, which indicates the location of the emergency department, or a hospital with such facilities. Signs on emergency departments may contain additional information. In some American states there is close regulation of the design and content of such signs. For example, California requires wording such as "Comprehensive Emergency Medical Service" and "Physician On Duty",[3] to prevent persons in need of critical care from presenting to facilities that are not fully equipped and staffed. In some countries, including the United States and Canada, a smaller facility that may provide assistance in medical emergencies is known as a clinic. Larger communities often have walk-in clinics where people with medical problems that would not be considered serious enough to warrant an emergency department visit can be seen. These clinics often do not operate on a 24 hour basis. Critical conditions handled [edit] Cardiac arrest Cardiac arrest may occur in the ED/A&E or a patient may be transported by ambulance to the emergency department already in this state. Treatment is basic life support and advanced life support as taught in advanced life support and advanced cardiac life support courses. This is an immediately life-threatening condition which requires immediate action in salvageable cases. [edit] Heart attack See main article: Myocardial infarction

Patients arriving to the emergency department with a myocardial infarction (heart attack) are likely to be triaged to the resuscitation area. They will receive oxygen and monitoring and have an early ECG; aspirin will be given if not contraindicated or not already administered by the ambulance team; morphine or diamorphine will be given for pain; sub lingual (under the tongue) or buccal (between cheek and upper gum) glyceryl trinitrate [nitroglycerin] (GTN or NTG) will be given, unless contraindicated by the presence of other drugs, such as drugs that treat erectile dysfunction. An ECG that reveals ST segment elevation or new left bundle branch block suggests complete blockage of one of the main coronary arteries. These patients require immediate reperfusion (re-opening) of the occluded vessel. This can be achieved in two ways: thrombolysis (clot-busting medication) or percutaneous transluminal coronary angioplasty (PTCA). Both of these are effective in reducing significantly the mortality of myocardial infarction. Many centers are now moving to the use of PTCA as it is somewhat more effective than thrombolysis if it can be administered early. This may involve transfer to a nearby facility with facilities for angioplasty. [edit] Trauma Main article: Physical trauma Major trauma, the term for patients with multiple injuries, often from a road traffic accident or a major fall, is sometimes handled in the Emergency Department. However, trauma is a separate (surgical) specialty from emergency medicine (which is a medical specialty, and has certifications in the United states from the American Board of Emergency Medicine). Trauma is treated by a trauma team who have been trained using the principles taught in the internationally recognized Advanced Trauma Life Support (ATLS) course of the American College of Surgeons. Some other international training bodies have started to run similar courses based on the same principles. The services that are provided in an emergency department can range from simple x-rays and the setting of broken bones to those of a full-scale trauma center. A patient's chance of survival is greatly improved if the patient receives definitive treatment (i.e. surgery or reperfusion) within one hour of an accident (such as a car accident) or onset of acute illness (such as a heart attack). This critical time frame is commonly known as the "golden hour". Some emergency departments in smaller hospitals are located near a helipad which is used by helicopters to transport a patient to a trauma center. This inter-hospital transfer is often done when a patient requires advanced medical care unavailable at the local facility. In such cases the emergency department can only stabilize the patient for transport. [edit] Mental illness Some patients arrive at an emergency department for a complaint of mental illness. In many jurisdictions (including many U.S. states), patients who appear to be mentally ill and to present a danger to themselves or others may be brought against their will to an emergency department by law enforcement officers for psychiatric examination. The emergency department conducts medical clearance rather than treats acute behavioral disorders. From the emergency department, patients with significant mental illness may be transferred to a psychiatric unit (in many cases involuntarily). [edit] Asthma and COPD Acute exacerbations of chronic respiratory diseases, mainly asthma and chronic obstructive pulmonary disease (COPD), are assessed as emergencies and treated with oxygen therapy, bronchodilators, steroids or theophylline, have an urgent chest X-ray and arterial blood gases and are referred for intensive care if necessary. Non invasive ventilation in the ED has reduced the requirement for tracheal intubation in many cases of severe exacerbations of COPD.

[edit] Special facilities, training, and equipment An ED requires different equipment and different approaches than most other hospital divisions. Patients frequently arrive with unstable conditions, and so must be treated quickly. They may be unconscious, and information such as their medical history, allergies, and blood type may be unavailable. ED staff are trained to work quickly and effectively even with minimal information. ED staff must also interact efficiently with pre-hospital care providers such as EMTs, paramedics, and others who are occasionally based in an ED. The pre-hospital providers may use equipment unfamiliar to the average physician, but ED physicians must be expert in using (and safely removing) specialized equipment, since devices such as Military Anti-Shock Trousers ("MAST") and traction splints require special procedures. Among other reasons, given that they must be able to handle specialized equipment, physicians can now specialize in emergency medicine, and EDs employ many such specialists. ED staff have much in common with ambulance and fire crews, combat medics, search and rescue teams, and disaster response teams. Often, joint training and practice drills are organized to improve the coordination of this complex response system. Busy EDs exchange a great deal of equipment with ambulance crews, and both must provide for replacing, returning, or reimbursing for costly items. Cardiac arrest and major trauma are relatively common in EDs, so defibrillators, automatic ventilation and CPR machines, and bleeding control dressings are used heavily. Survival in such cases is greatly enhanced by shortening the wait for key interventions, and in recent years some of this specialized equipment has spread to pre-hospital settings. The best-known example is defibrillator's, which spread first to ambulances, then in an automatic version to police cars, and most recently to public spaces such as airports, office buildings, hotels, and even shopping malls. Because time is such an essential factor in emergency treatment, EDs typically have their own diagnostic equipment to avoid waiting for equipment installed elsewhere in the hospital. Nearly all have an X-ray room, and many now have full radiology facilities including CT scanners and ultrasonography equipment. Laboratory services may be handled on a priority basis by the hospital lab, or the ED may have its own "STAT Lab" for basic labs (blood counts, blood typing, toxicology screens, etc.) that must be returned very rapidly. [edit] Non-emergency use Metrics applicable to the ED can be grouped into three main categories, volume, cycle time, and patient satisfaction. Volume metrics including arrivals per hour, percentage of ED beds occupied and age of patients are understood at a basic level at all hospitals as an indication for staffing requirements. Cycle time metrics are the mainstays of the evaluation and tracking of process efficiency and are less widespread since an active effort is needed to collect and analyze this data. Patient satisfaction metrics, already commonly collected by physician groups and hospitals, are useful in demonstrating the impact of changes in patient perception of care over time. Since patient satisfaction metrics are derivative and subjective, they are less useful in primary process improvement. In many Primary Care Trusts there may be out of hours doctor services sometimes known as Keydoc or something similar (varying by area) provided by volunteer General Practitioners. Patients attending the ED for minor complaints do not contribute significantly to the overall workload of the department.[citation needed] (Despite the level of complaints in the general public and by health staff.) Studies, in Australia at least, have shown that improved after-hours GP access has no effect on ED workload or waiting times. In the United States, and many other countries, hospitals are beginning to create areas in their emergency rooms for people with minor injuries. These are commonly referred as fast track or Minor Care units. These units are for people with non life-threatening

injuries. The use of these units within a department have been shown to significantly improve the flow of patients through a department and to reduce waiting times. Urgent care clinics are another alternative, where patients can go to receive immediate care for non-life-threatening conditions. Triage is defined as sorting and allocating treatment to patients based upon the severity of their conditions. Patients are sorted by a system which sets priorities designed to increase the number of people who survive. Triage protocols are often used in cases of combat or disaster situations when a large number of patients require treatment at once. The Importance of Triage o Triage is required for the effective management of an emergency situation. This means patients are not seen according to when they arrive at the hospital, but are seen according to guidelines which determine who needs care most urgently and where care is most likely to be successful. In order to remove confusion and misgivings, guidelines are in place which help health care professionals to know how to prioritize. The importance of this discipline can never be overstated, when one takes into consideration the fact that in 2008, nearly 120 million emergency department visits were made to hospitals in the US. Triage Guidelines

order and priority of emergency transport, or the transport destination for the patient. Triage may also be used for patients arriving at the emergency department, or to telephone medical advice systems,[3] among others. This article deals with the concept of triage as it occurs in medical emergencies, including the prehospital setting, disasters, and during emergency room treatment. Triage originated in World War I by French doctors treating the battlefield wounded at the aid stations behind the front. Much is owed to the work of Dominique Jean Larrey during the Napoleonic Wars. Until recently, triage results, whether performed by a paramedic or anyone else, were frequently a matter of the 'best guess', as opposed to any real or meaningful assessment.[4] At its most primitive, those responsible for the removal of the wounded from a battlefield or their care afterwards have divided victims into three categories:

Those who are likely to live, regardless of what care they receive; Those who are likely to die, regardless of what care they receive; Those for whom immediate care might make a positive difference in outcome.[5]

Typically in an Emergency Room, or what is called an Emergency Department (ED), triage guidelines begin with general policies including registration, documentation and referrals. When the actual triage work starts, guidelines are given to classify patients into priority levels I, II, III and IV based on factors relating to medical needs, social service needs, mental health needs and substance abuse needs. When a caregiver gets several patients at the same time, the guidelines have to be adhered to and a response has to be undertaken. A lot depends on the judgment the caregiver makes of the situation. The triage level may be changed if the caregiver feels the need to do so, but this usually has to be done in consultation with the doctor.

For many Emergency medical services (EMS) systems, a similar model can sometimes still be applied. However once a full response has occurred and many hands are available, paramedics will usually use the model included in their service policy and standing orders. In the earliest stages of an incident, however, when one or two paramedics exist to twenty or more patients, practicality demands that the above, more "primitive" model will be used. Modern approaches to triage are more scientific. The outcome and grading of the victim is frequently the result of physiological and assessment findings. Some models, such as the START model, are committed to memory, and may even be algorithm-based. As triage concepts become more sophisticated, triage guidance is also evolving into both software and hardware decision support products for use by caregivers in both hospitals and the field.[6]

Classifying Patients

The ailments that qualify for Priority Level I medical needs include profuse bleeding, acute chest pains, unconsciousness and other severe conditions. Patients who get admitted with such needs are classified as priority Level I and need to be attended to first. This is followed by priority level II, cases which include abscesses, a 2nd or 3rd trimester of pregnancy with no prenatal care or a situation in which the patient has run out of seizure or other life saving medications. Level III ailments include less serious conditions such as unexplaind coughing, or pain that could suggest the need for treatment but that does not indicate a lifethreatening condition. Level IV ailments are minor ailments such as non-life threatening conditions, small cuts and bruises or other conditions that neither cause great pain nor threaten overall health and well-being.

Triage ( /tri/) is the process of determining the priority of patients' treatments based on the severity of their condition. This rations patient treatment efficiently when resources are insufficient for all to be treated immediately. The term comes from the French verb trier, meaning to separate, sort, sift or select.[1] Two types of triage exist: simple and advanced.[2] Triage may result in determining the order and priority of emergency treatment, the

[edit] Advanced triage Contents [hide] In advanced triage, doctors may decide that some seriously injured people should not receive advanced care because they are unlikely to survive. Advanced care will be used on patients with less severe injuries. Because treatment is intentionally withheld from patients with certain injuries, advanced triage has ethical implications. It is used to divert scarce resources away from patients with little chance of survival in order to increase the chances of survival of others who are more likely to survive. In Western Europe, the criterion used for this category of patient is a trauma score of consistently at or below 3. This can be determined by using the Triage Revised Trauma Score (TRTS), a medically-validated scoring system incorporated in some triage cards.[10] Another example of a trauma scoring system is the Injury Severity Score (ISS). This assigns a score from 0 to 75 based on severity of injury to the human body divided into three categories: A (face/neck/head), B(thorax/abdomen), C(extremities/external/skin). Each category is scored from 0 to 5 using the Abbreviated Injury Scale, from uninjured to critically injured, which is then squared and summed to create the ISS. A score of 6, for "unsurvivable", can also be used for any of the three categories, and automatically sets the score to 75 regardless of other scores. Depending on the triage situation, this may indicate either that the patient is a first priority for care, or that he or she will not receive care due to the need to conserve care for more likely survivors. The use of advanced triage may become necessary when medical professionals decide that the medical resources available are not sufficient to treat all the people who need help. The treatment being prioritized can include the time spent on medical care, or drugs or other limited resources. This has happened in disasters such as volcanic eruptions, thunderstorms, and rail accidents. In these cases some percentage of patients will die regardless of medical care because of the severity of their injuries. Others would live if given immediate medical care, but would die without it. In these extreme situations, any medical care given to people who will die anyway can be considered to be care withdrawn from others who might have survived (or perhaps suffered less severe disability from their injuries) had they been treated instead. It becomes the task of the disaster medical authorities to set aside some victims as hopeless, to avoid trying to save one life at the expense of several others. If immediate treatment is successful, the patient may improve (although this may be temporary) and this improvement may allow the patient to be categorized to a lower priority in the short term. Triage should be a continuous process and categories should be checked regularly to ensure that the priority remains correct. A trauma score is invariably taken when the victim first comes into hospital and subsequent trauma scores taken to see any changes in the victim's physiological parameters. If a record is maintained, the receiving hospital doctor can see a trauma score time series from the start of the incident, which may allow definitive treatment earlier.

1 Types of triage o 1.1 Simple triage

o o o o o o

1.2 1.3 1.4 1.5 1.6 1.7

1.1.1 S.T.A.R.T. model Advanced triage Continuous integrated triage Practical applied triage Reverse triage Labelling of patients Undertriage and overtriage

2 Regional variation o 2.1 United States military o 2.2 Canada o 2.3 United Kingdom o 2.4 Finland o 2.5 France o 2.6 Germany o 2.7 Israel o 2.8 Japan 3 Triage outcomes o 3.1 Evacuation o 3.2 Alternative care facilities o 3.3 Secondary (in-hospital) triage o 3.4 Hospital triage systems in the United States 4 Bioethical implications in triage o 4.1 Ventilator rationing 5 See also 6 References

[edit] Types of triage [edit] Simple triage Simple triage is usually used in a scene of a "mass-casualty incident" (MCI), in order to sort patients into those who need critical attention and immediate transport to the hospital and those with less serious injuries. This step can be started before transportation becomes available. The categorization of patients based on the severity of their injuries can be aided with the use of printed triage tags or colored flagging.[7] [edit] S.T.A.R.T. model Main article: Simple triage and rapid treatment S.T.A.R.T. (Simple Triage and Rapid Treatment) is a simple triage system that can be performed by lightly trained lay and emergency personnel in emergencies.[8] It is not intended to supersede or instruct medical personnel or techniques. It has been (2003) taught to California emergency workers for use in earthquakes. It was developed at Hoag Hospital in Newport Beach, California for use by emergency services. It has been field-proven in mass casualty incidents such as train wrecks and bus accidents, though it was developed for use by community emergency response teams (CERTs) and firefighters after earthquakes. In 2009, the Newport Beach Fire Department gave approval for a bilingual version of the S.T.A.R.T. system to be included in a series of books called Emergency Language SystemsEMSpaol,[9] produced by Emergency Language Systems Triage separates the injured into four groups:

Typical triaging systems

The deceased who are beyond help The injured who can be helped by immediate transportation The injured whose transport can be delayed Those with minor injuries, who need help less urgently

SMART TAG system. Note the bar code for patient tracking.

[edit] Practical applied triage During the early stages of an incident, first responders may be overwhelmed by the scope of patients and injuries. One valuable technique, is the Patient Assist Method (PAM); the responders quickly establish a casualty collection point (CCP) and advise ; either by yelling, or over a loudspeaker, that "anyone requiring assistance should move to the selected area (CCP)". This does several things at once, it identifies patients that are not so severely injured, that they need immediate help, it physically clears the scene, and provides possible assistants to the responders. As those who can move, do so, the responders then ask, "anyone who still needs assistance, yell out or raise your hands"; this further identifies patients who are responsive, yet maybe unable to move. Now the responders can rapidly assess the remaining patients who are either expectant, or are in need of immediate aid. From that point the first responder is quickly able to identify those in need of immediate attention, while not being distracted or overwhelmed by the magnitude of the situation. Using this method assumes the ability to hear. Deaf, partially deaf or victims of a large blast injury may not be able to hear these instructions. [edit] Reverse triage In addition to the standard practices of triage as mentioned above, there are conditions where sometimes the less wounded are treated in preference to the more severely wounded. This may arise in a situation such as war where the military setting may require soldiers be returned to combat as quickly as possible, or disaster situations where medical resources are limited in order to conserve resources for those likely to survive but requiring advanced medical care.[13] Other possible scenarios where this could arise include situations where significant numbers of medical personnel are among the affected patients where it may be advantageous to ensure that they survive to continue providing care in the 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 in warm water if given immediate basic life support and often those who are rescued and able to breathe on their own will improve with minimal or no help.[14] [edit] Labelling of patients

METTAG system in Japanese.

Even simple tape can be used as a last resort.

ET Light Picture 352 X 240 [edit] Continuous integrated triage Continuous Integrated Triage is an approach to triage in mass casualty situations which is both efficient and sensitive to psychosocial and disaster behavioral health issues that affect the number of patients seeking care (surge), the manner in which a hospital or healthcare facility deals with that surge (surge capacity) [11] and the overarching medical needs of the event. Continuous Integrated Triage combines three forms of triage with progressive specificity to most rapidly identify those patients in greatest need of care while balancing the needs of the individual patients against the available resources and the needs of other patients. Continuous Integrated Triage employs:

Many triage systems are now computerized Upon completion of the initial assessment by medical or paramedical personnel, each patient will be labelled with a device called a triage tag. This will identify the patient and any assessment findings and will identify the priority of the patient's need for medical treatment and transport from the emergency scene. Triage tags may take a variety of forms. Some countries use a nationally standardized triage tag,[15] while in other countries commercially available triage tags are used, and these will vary by jurisdictional choice.[16] The most commonly used commercial systems include the METTAG,[17] the SMARTTAG,[18] E/T LIGHT tm[19] and the CRUCIFORM systems.[20] More advanced tagging systems incorporate special markers to indicate whether or not patients have been contaminated by hazardous materials, and also tear off strips for tracking the movement of patients through the process. Some of these tracking systems are beginning to incorporate the use of handheld computers, and in some cases, bar code scanners. At its most primitive, however, patients may be simply marked with coloured tape, or with marker pens, when triage tags are either unavailable or insufficient.

Group (Global) Triage (i.e., M.A.S.S. triage)

[12]

Physiologic (Individual) Triage (i.e., S.T.A.R.T.) Hospital Triage (i.e., E.S.I. or Emergency Severity Index)

However any Group, Individual and/or Hospital Triage system can be used at the appropriate level of evaluation.

[edit] Undertriage and overtriage Undertriage is the process of underestimating the severity of an illness or injury. An example of this would be categorizing a Priority 1 (Immediate) patient as a Priority 2 (Delayed) or Priority 3 (Minimal). Historically, acceptable undertriage rates have been deemed 5% or less. Overtriage is the process of overestimating the level to which an individual has experienced an illness or injury. An example of this would be categorizing a Priority 3 (Minimal) patient as a Priority 2 (Delayed) or Priority 1 (Immediate). Acceptable overtriage rates have been typically up to 50% in an effort to avoid undertriage. Some studies suggest that overtriage is less likely to occur when triaging is performed by hospital medical teams, rather than paramedics or EMTs.[21] [edit] Regional variation [edit] United States military Triage in a non-combat situation is conducted much the same as in civilian medicine. A battlefield situation, however, requires medics and corpsmen to rank casualties for precedence in MEDEVAC or CASEVAC. The triage categories (with corresponding color codes), in precedence, are:

Class IV Patients requiring such extensive care beyond medical personnel capability and time.

Triage Principles: Mettag: RED Priority I Immediate attention. Identifier is a Mettag torn to the red stripe or Roman numeral I placed on the forehead or back of left hand. First priority casualties are those that have life-threatening injuries that are readily correctable. For purposes of priority for dispatch to the hospital, however, a second sorting or review may be necessary so only those transportable cases are taken early. Some will require extensive stabilization at the scene before transport may be safely undertaken. A red tag may be used as an additional means of identification. Mettag: YELLOW Priority II Delayed attention. Identifier is the Mettag torn to the yellow stripe or Roman numeral II placed on the forehead or back of left hand. Delayed category casualties are all those whose therapy may be delayed without significant threat of life or limb and those for whom extensive or highly sophisticated procedures are necessary to sustain life. Mettag: GREEN Minor injuries. Casualties with minor injuries will receive minimum first aid treatment. They will not be transported to hospitals until all Priority I and II patients have received care. They will be sent from the triage area to a designated area away from the disaster scene in order to reduce confusion. If they are capable, they may also be used as litter bearers or first aid providers. Mettag: BLACK Dead. Identifier is the Mettag torn up to the black stripe or an X on the forehead and covered with a sheet, blanket or other opaque material as soon as possible. Unless absolutely necessary, they should be left in place until released by the coroner. The temporary morgue should be an area away from the scene of the triage area. Persons who are psychologically disturbed, who interfere with casualty handling, should be isolated from the incident scene as quickly as possible. Campus Police will be requested to escort individuals to a designated area away from the disaster scene. TRIAGE CATEGORY GUIDELINES For multiple casualty incidents involving up to 80 victims: RED: IMMEDIATE (Priority I) 1. Asphyxia 2. Respiratory obstruction from mechanical causes 3. Sucking cheat wounds

Immediate: The casualty requires immediate medical attention and will not survive if not seen soon. Any compromise to the casualty's respiration, hemorrhage control, or shock control could be fatal. Delayed: The casualty requires medical attention within 6 hours. Injuries are potentially life-threatening, but can wait until the Immediate casualties are stabilized and evacuated. Minimal: "Walking wounded," the casualty requires medical attention when all higher priority patients have been evacuated, and may not require stabilization or monitoring. Expectant: The casualty is expected not to reach higher medical support alive without compromising the treatment of higher priority patients. Care should not be abandoned, spare any remaining time and resources after Immediate and Delayed patients have been treated.[22]

Afterwards, casualties are given an evacuation priority based on need:

Urgent: evacuation is required within two hours to save life or limb. Priority: evacuation is necessary within four hours or the casualty will deteriorate to "Urgent". Routine: evacuate within 24 hours to complete treatment.

4. Tension pneumothorax 5. Maxillofacial wounds in which asphyxia exists or is likely to develop 6. Shock caused by major external hemorrhage 7. Major internal hemorrhage 8. Visceral injuries or evisceration 9. Cardio/pericardial injuries 10. Massive muscle damage 11. Severe burns over 25% 12. Dislocations 13. Major fracture 14. Major medical problems readily correctable 15. Closed cerebral injuries with increasing loss of consciousness Simple Treatment and Rapid Treatment (START): Quick identifiers for Red

In a "naval combat situation", the triage officer must weigh the tactical situation with supplies on hand and the realistic capacity of the medical personnel. This process can be ever-changing, dependent upon the situation and must attempt to do the maximum good for the maximum number of casualties.[23] Field assessments are made by two methods: primary survey (used to detect & treat life-threatening injuries) and secondary survey (used to treat non-life threatening injuries) with the following categories:

Class I Patients who require minor treatment and can return to duty in a short period of time. Class II Patients whose injuries require immediate life sustaining measures. Class III Patients for whom definitive treatment can be delayed without loss of life or limb.

Ventilation > 30/min

Perfusion <> Mental status: unable to follow simple directions

12. Injuries of the eye 13. Maxillofacial injuries without asphyxia

YELLOW: DELAYED (Priority II)

14. Complicated major medical problems* 15. Minor medical problems

1. Vascular injuries requiring repair 2. Wounds of the genitourinary tract 3. Thoracic wounds without asphyxia 4. Severe burns under 25% 5. Spinal cord injuries requiring decompression 6. Suspected spinal cord injuries without neurological signs 7. Lesser fractures 8. Injuries of the eye 9. Maxillofacial injuries without asphyxia 10. Minor medical problems 11. Victims with little hope of survival under the best of circumstances of medical care For multiple casualty incidents with an overwhelming number of survivors or over 80 victims:

16. Victims with little hope of survival under the best of circumstances of medical care *Conditions which have changed categories http://wacebnm.curtin.edu.au/workshops/Triage.pdf Cardiac Monitor - The cardiac monitor is a device that shows the electrical and pressure waveforms of the cardiovascular system for measurement and treatment. Parameters specific to respiratory function can also be measured. Because electrical connections are made between the cardiac monitor and the patient, it is kept at the patient's bedside. Purpose The cardiac monitor continuously displays the cardiac electrocardiogram (EKG) tracing. Additional monitoring components allow cardiovascular pressures and cardiac output to be monitored and displayed as required for patient diagnosis and treatment. Oxygen saturation of the arterial blood can also be monitored continuously. Most commonly used in emergency rooms and critical care areas, bedside monitors can be interconnected to allow for continual observation of several patients from a central display. Continuous cardiovascular and pulmonary monitoring allows for prompt identification and initiation of treatment.

RED: IMMEDIATE (Priority I)

1. Asphyxia 2. Respiratory obstruction from mechanical causes 3. Sucking cheat wounds 4. Tension pneumothorax 5. Maxillofacial wounds in which asphyxia exists or is likely to develop 6. Shock caused by major external hemorrhage 7. Dislocations 8. Severe burns under 25%* 9. Lesser fractures* 10. Major medical problems that can be handled readily YELLOW: DELAYED (Priority II) 1. Major fractures (if able to stabilize)* 2. Visceral injuries or evisceration* 3. Cardio/pericardial injuries* 4. Massive muscle damage* 5. Severe burns over 25%* 6. Vascular injuries requiring repair 7. Wounds of genitourinary tract 8. Thoracic wounds without asphyxia 9. Closed cerebral injuries with increasing loss of consciousness* 10. Spinal cord injuries requiring decompression 11. Suspected spinal cord injuries without neurological signs

Description The monitor provides a visual display of many patient parameters. It can be set to sound an alarm if any parameter changes outside of an expected range determined by the physician. Parameters to be monitored may include, but are not limited to, electrocardiogram, noninvasive blood pressure, intravascular pressures, cardiac output, arterial blood oxygen saturation, and blood temperature. Equipment required for continuous cardiac monitoring includes the cardiac monitor, cables, and disposable supplies such as electrode patches, pressure transducers, a pulmonary artery catheter (SwanGanz catheter), and an arterial blood saturation probe.

Preparation As the cardiac monitor is most commonly used to monitor electrical activity of the heart, the patient can expect the following preparations. The sites selected for electrode placement on the skin will be shaved and cleaned causing surface abrasion for better contact between the skin and electrode. The electrode will have a layer of gel protected by a film, which is removed prior to placing the electrode to the skin. Electrode patches will be placed near or on the right arm, right leg, left arm, left leg, and the center left side of the chest. The cable will be connected to the electrode patches for the measurement of a five-lead electrocardiogram. Additional configurations are referred to as three-lead and 12-lead electrocardiograms. If noninvasive blood pressure is being measured, a blood pressure cuff will be placed around the patient's arm or leg. The blood pressure cuff will be set to inflate manually or automatically. If manual inflation is chosen, the cuff will only inflate at the prompting of the health care provider, after which a blood pressure will be displayed. During automatic operation, the blood pressure cuff will inflate at timed intervals and the display will update at the end of each measurement.

Disposable pressure transducers require a reference to atmosphere, called zeroing, which is completed before monitoring patient pressures. This measurement will

arterial blood saturation probe should be expect to remain attached until discharge is imminent. How to Set Up Emergency Department Patient Rooms By Elizabeth Otto, eHow Contributor

Cardiac monitors display such vital signs as heart rate, pulse, and blood pressure for patients in the intensive care unit. ( Photograph by Hank Morgan. Science Source/Photo Researchers. Reproduced by permission. ) occur once the patient is comfortably positioned since the transducer must be level with the measurement point. The pressure transducer will then be connected to the indwelling catheter. It may be necessary for as many as four or five pressure transducers to be connected to the patient. The arterial blood saturation probe will be placed on the finger, toe, ear, or nasal septum of the patient, providing as little discomfort as possible, while achieving a satisfactory measurement.

Print this article Emergency department patient rooms are designed with the needed equipment and supplies to provide urgent care to the sick and injured. Essentially, all rooms include basic patient care supplies. However, specialty rooms, such as surgical suites, may be set up in the emergency department as well. Follow the patient care standards for your emergency department when deciding how to expand the set up of patient care rooms beyond the basics. Difficulty:

Moderate Instructions Things You'll Need

Medical supplies

o 1 Place the bed in a center position, ensuring the patient is easily reached from both sides. Do not place the bed against a wall as this will limit access to the patient. Ensure that any ceiling-mounted privacy drapes will easily close between the bed and the door, allowing privacy for the patient from anyone coming in and out of the room. o 2 Place portable light stands, intravenous poles and rolling trays against the walls, or in a corner to keep them easily accessible, but out of the way. Ensure that all overhead lighting, outlets, electronic call buttons and medical ports, such as oxygen, are installed and working properly. o 3 Stock commonly used medical supplies in drawers, such as tongue depressors, bandages, scissors and gauze. Place commonly used equipment, such as an otoscope and opthalmoscope, blood pressure cuff and stethoscope within easy reach, such as on a counter top or wall mount. Consider dedicating one drawer or cabinet for culture supplies, such as wound and Pap smear cultures, or place them in a portable container. o 4 Place an emergency cart in the patient room, which contains non-pharmaceutical emergency medical equipment such as intubation supplies, bag-valve-masks, suction tubing and CPR masks. Consider placing emergency equipment in dedicated drawer space if a cart is not available. o 5 Ensure that oxygen supplies, such as nasal cannulas and masks are readily available next to the oxygen port in the room, as well as portable oxygen units. Place suction tubing with both wall mounted and portable suction units, as well. o 6 Add a variety of necessities such as patient gowns, drapes, shorts and slippers in a cabinet or drawer, and include both pediatric and adult sizes. Stock a supply of linens such as blankets, sheets and wash cloths, as well as bags for patient belongings, emesis basins, biohazard bags and laboratory transport bags. Include other linens and functional supplies as needed.

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Aftercare After connecting all equipment, the health care provider will observe the monitor and evaluate the quality of the tracings, while making size and position adjustments as needed. The provider will confirm that the monitor is detecting each heartbeat by taking an apical pulse and comparing the pulse to the digital display. The upper and lower alarm limits should be set according to physician orders, and the alarm activated. A printout may be recorded for the medical record, and labeled with patient name, room number, date, time, and interpretation of the strip. Maintenance and replacement of the disposable components may be necessary as frequently as every eight hours, or as required to maintain proper operation. The arterial saturation probe can be repositioned to suit patient comfort and to obtain a tracing. All connections will be treated in a gentle manner to avoid disruption of the signal and to avoid injury to the patient. Normal results The monitor will provide waveforms and/or numeric values associated with the patient status. These may include, but are not limited to, heart rate, arterial blood pressure, central venous pressure, pulmonary artery pressure, pulmonary capillary wedge pressure, left atrial pressure, cardiac output, arterial blood saturation, and blood temperature. Furthermore, these values can be used to calculate other values, or parameters, or used to diagnose and treat the patient's condition. Patient movement may cause measurement errors; the patient will be requested to remain motionless. Depending on the mobility of the patient, assistance should be provided by the health care provider prior to changing from a laying down position to sitting or standing. As the patient's condition improves, the amount of monitoring equipment may be decreased. However, the electrocardiogram and