Triage Priority

1
Triage Priority

• Wang, Tzong-Luen, MD, PhD, FESC, FACC

2
Class I (????)

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• ???lt80mmHg?gt220mmHg
• ??gt150bpm?lt50bpm
• ??gt30rpm?lt8rpm
• ??gt41??lt32?
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• ?????????????5cm??????????(??)????????????TB
  SAgt10???TBSAgt15?????????????????????????????
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3
Class II (??????)

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• ???180-220mmHg
• ??20-30rpm
• ??39-41??32-35?
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  ???????????HRgt100bpm???????????HRgt100bpm
• ????5cm?????????????????????????????????(gt6?
  ?)
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• ??????
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4
Class III (???????)

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• ??38-39?
• ???????????????????(dizziness)????????????????
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• ?????

5
Class IV (?????)

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6
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7
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8
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9
??????????????(??)

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10
????(??)

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11
Triage Decision Scheme (Trauma)

• STEP 1 Measure Vital Signs and Level of
  Consciousness
• GCSlt14
• RRlt10 or gt29
• SBPlt90
• RTSlt11
• PTSlt9

12
Triage Decision Scheme

• STEP 2 Anatomic and Physiologic Approach
• Flail chest
• Two or more proximal long-bone fractures
• Amputation proximal wrist/ankle
• All penetrating trauma to head, neck, torso, and
  extremities proximal to elbow and knee
• Limb paralysis
• Pelvic fractures
• Combination trauma with burns

13
Triage Decision Scheme

• STEP 3 Trauma Mechanisms
• Ejection from auto
• Death in same passenger compartment
• Pedestrian thrown or run over
• High-speed auto crash
• Initial speed gt40mph (64 kph)
• Major auto deformity gt20 inches (50cm)
• Intrusion into passenger compartment gt12 inches
  (30cm)
• Extrication time gt 20 minutes
• Falls gt 20 ft
• Roll over
• Auto-pedestrian injury with gt 5mph (8kph) impact
• Motorcycle crash gt 20 mph (32 kph) or with
  separation of rider and bike

14
Triage Decision Scheme

• STEP 4 Underlying Conditions
• Age lt5 or gt55
• Pregnancy
• Immunosuppressed patients
• Cardiac disease respiratory disease
• Insulin-dependent diabetes cirrhosis morbid
  obesity coagulopathy

15
Revised Trauma Score

• Respiratory Rate
• 10-29 score 4
• gt29 score 3
• 6-9 score 2
• 1-5 score 1
• 0 score 0

16
Revised Trauma Score

• Systolic BP
• gt89 score 4
• 76-89 score 3
• 50-75 score 2
• 1-49 score 1
• 0 score 0

17
Revised Trauma Score

• GCS Score Conversion
• 13-15 score 4
• 9-12 score 3
• 6-8 score 2
• 4-5 score 1
• lt4 score 0

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Pediatric Trauma Score

• Weight
• gt20Kg (44 lb) score 2
• 10-20Kg (22-44 lb) score 1
• lt10 Kg (22 lb) score 1
• Airway
• Normal score 2
• Oral or nasal airway O2 score 1
• Intubated cricothyroidtomy score 1
• tracheostomy

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Pediatric Trauma Score

• Systolic Blood Pressure
• gt90mmHg good peripheral pulse score 2
• perfusion
• 50-90mmHg carotid/femoral score 1
• pulses palpable
• lt50mmHg weak or no pulses score 1
• Level of Consciousness
• Awake score 2
• Obtunded or any LOC score 1
• Coma unresponsive score 1

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Pediatric Trauma Score

• Fracture
• None seen or suspected score 2
• Single, closed score 1
• Open or multiple score 1
• Cutaneous
• None visible score 2
• Contusion, abrasion laceration score 1
• lt7cm not thru fascia
• Tissue loss any GSW/SW score 1
• thru fascia

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Detailed Adult Criteria
GCS lt 12 RED
AIRWAY ? ACTIVE airway assistance required (i.e.,
more than supplemental O2 without airway
adjunct) ? Sustained respiratory rate gt 30
22
Detailed Adult Criteria
CIRCULATION ?No radial pulse AND heart rate gt
120 OR ?BP lt 90 systolic ?Sustained heart rate gt
120 with radial pulse and BP gt 90 systolic
23
Detailed Adult Criteria
BEST MOTOR RESPONSE ?BMR lt 4 OR ?Paralysis, loss
of sensation, suspicion of spinal cord
injury ?BMR 5
24
Detailed Adult Criteria
CUTANEOUS ?Amputation proximal to wrist or
ankle OR ?gt 15 BSA 2nd and 3rd degree
burns OR ?Penetrating injury to head, neck,
torso, excluding superficial wounds ?Degloving
injury or flap avulsion gt 5 inches
25
Detailed Adult Criteria
LONGBONE FRACTURE ?Multiple longbone fracture
sites ?Single longbone fracture site due to
MVC OR ?Single longbone fracture site due to fall
from gt 10 feet
26
Detailed Adult Criteria
AGE ?Age gt 55
MECHANISM OF INJURY ?Ejection from vehicle
(excludes open vehicles) OR ?Driver with
deformed steering wheel
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Notes on Peds Criteria

• Applicable to age 15 or less
• Size component is based on Broslow color zone or
  weight
• Any airway maintenance beyond supplemental O2 and
  one-time need for suctioning RED
• Any altered mental status other than amnesia
  RED criteria
• Paralysis, loss of sensation, or suspicion of
  spinal cord injury RED criteria under
  Consciousness category

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Notes on Peds Criteria (cont.)

• Any reliable hx of LOC BLUE
• Fracture criteria are also based on longbones
  (same as adults).
• Open long bone or multiple longbone
  fx/dislocations RED
• gt 10 BSA 2nd and 3rd degree burn RED

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Detailed Peds Criteria
SIZE ?Weight lt 10 Kg (lt 22 lbs..) or RED or
PURPLE Broslow Tape Zone
AIRWAY ?ACTIVE airway assistance required (i.e.,
more than supplemental O2/one-time suctioning
without airway adjunct)
30
Detailed Peds Criteria
CONSCIOUSNESS ?Patient not awake and
appropriate OR ?Paralysis, loss of sensation, or
suspected spinal cord injury ?Amnesia OR ?Reliab
le history of loss of consciousness
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Detailed Peds Criteria
CIRCULATION ?No palpable pulses OR ?Weak carotid
or femoral pulse OR ?Systolic BP lt 50 ?Good
carotid or femoral pulse with absent distal
pulses OR ?Systolic BP 50-90
32
Detailed Peds Criteria
LONGBONE FRACTURE ?Any open longbone
fracture OR ?Multiple closed longbone fracture
sites or dislocations ?Single closed long bone
fracture site
33
Detailed Peds Criteria
CUTANEOUS ?Degloving injury, major flap
avulsion OR ?Amputation proximal to wrist or
ankle OR ?gt 10 BSA 2nd and 3rd degree
burns OR ?Penetrating injury to head, neck or
torso
34
Practice Case 1

• 68 yo female pedestrian struck
• GCS 14, BMR 5
• Patent airway
• HR 100, BP 120/94, RR 20
• Abrasions
• Unstable pelvis

• BLUE
• BLUE
• ?

POSITIVE TRAUMA ALERT
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Practice Case 2

• RED
• RED

• 21 yo male
• Stab wound to left chest
• Airway patent
• GCS 15
• BS ? on left
• BP 90/P, HR 130

POSITIVE TRAUMA ALERT
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Practice Case 3

• 4 year old near- drowning in pool
• No signs of trauma
• Intubated
• Normal skin signs
• Normal brachial pulse
• Responsive to deep pain

Drowning is not considered trauma unless injury
accompanies it!
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Practice Case 4

• BLUE
• BLUE

• 6 yo female fell 10 ft. from tree
• 22 kg weight
• amnestic for event, o/w alert
• airway patent
• obvious closed forearm fx
• nl vital signs

POSITIVE TRAUMA ALERT
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Practice Case 5

• 6 month old male (purple)
• child abuse
• multiple cigarette burns contusions
• abdomen rigid
• strong palpable carotid pulse only
• does not cry with exam

• BLUE
• BLUE
• RED

POSITIVE TRAUMA ALERT
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Trauma Blue

• 1.      Glasgow Coma Scale lt14
• 2.      Systolic Blood Pressure lt90
• 3.      Respiratory rate lt10 or gt29
• 4.      Revised Trauma Score lt11
• 5.      Pediatric Trauma Score lt9
• 6.      Penetrating injuries to  head, neck,
  torso, and/or extremities proximal to the knee
  and/or elbow
• 7.      Flail Chest
• 8.      Combination Trauma with burns or
  inhalation injury
• 9.      Two or more proximal long bone injuries
• 10.  High energy pelvic fractures
• 11.  Limb paralysis
• 12.  Amputation proximal to the wrist or ankle
• 13. Trauma patient pregnant past 2nd trimester

Another Example
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Trauma Blue

• 1.      Ejection from automobile
• 2.      Death in same passenger compartment
• 3.      Prolonged extrication (gt20 minutes)
• 4.      Falls gt20 feet
• 5.      Roll-over
• 6.      High speed auto crash        a.   
  Initial speed gt40mph        b.    Major auto
  deformity gt20 inches        c.    Intrusion into
  passenger compartment gt12 inches
• 7.      Auto-Pedestrian injury with significant
  impact (gt5 mph)
• 8.      Pedestrian thrown or run over
• 9.      Motorcycle crash gt 20 mph or with
  separation of bike and rider
• 10.  Patients age lt5 or gt55
• 11. Pregnancy past 1st trimester

41
Killip Classification

• Killip I Rales and S3 absent
• Killip II Rales over lt50 of lung
• Killip III Rales over gt50 of lung fields
  (pulmonary edema)
• Killip IV Shock

Subset I Normal hemodynamics PCWPlt18
CIgt2.2 Subset II Pulmonary congestion PCWPgt18
CIlt2.2 Subset III Peripheral hypoperfusion
PCWPgt18 CIgt2.2 Subset IV Pulmonary congestion
and peripheral hypoperfusion PCWPgt18
CIlt2.2
42
Goldman Criteria

• Age gt 70 yrs (5)
• CAD MI within 6 months (10)
• CHF S3 or JVE (11)
• Rhythm
• other than NSR/PACs on most recent ECG (7)
• gt 5 PVCs/min any time preoperatively (7)
• Valvular Disease important aortic stenosis (5)
• General Medical condition (5)
• PaO2 lt60 or PaCO2 gt50, K lt3.0, or HCO3 lt20, BUN
  gt50 or Cr gt3.0, abnormal AST, signs of chronic
  liver disease, bedridden from noncardic causes
• Surgery intraperitoneal, thoracic, aortic
  surgery (3)
• emergent surgery (4)

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Goldman Criteria
Class Total Score No or Minor Complications Life Threatening Cardiac Deaths
I 0-5 99 0.7 0.2
II 6-12 93 5 2
III 13-25 86 11 2
IV gt25 22 22 56
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Revised Goldman Criteria

• High risk type of surgery
• History of ischemic heart disease
• History of heart failure
• History of CVA
• Preoperative treatment with insulin
• Preoperative serum creatinine gt 2.0 mg/dL
• Rates 0.4 with no risk 0.9 with 1 risk 7
  with 2 risks 11 with 3 or more risks

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Detsky Criteria

• Age gt 70 yrs (5)
• CAD
• MI within 6 months (10)
• MI gt6 months (5)
• CCS angina class III (10)
• CCS angina class IV (20)
• Unstable angina past 3 months (10)
• CHF
• Pulmonary edema within 1 week (10)
• Pulmonary edema, ever (5)
• Rhythm
• other than NSR/PACs on last preop ECG (5)
• gt 5 PVCs/min any time preoperatively (5)
• Valvular Disease suspected critical aortic
  stenosis (5)
• General Medical condition (5)
• PaO2 lt60 or PaCO2 gt50, K lt3.0, or HCO3 lt20, BUN
  gt50 or Cr gt3.0, abnormal AST, signs of chronic
  liver disease, bedridden from noncardic causes
• Surgery emergent surgery (10)

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Revised Detsky Criteria

• High risk type of surgery
• History of ischemic heart disease
• History of heart failure
• History of CVA
• Preoperative treatment with insulin
• Preoperative serum creatinine gt 2.0 mg/dL
• unstable angina within 3 months of surgery or
  stable angina occurring with minimal exertion or
  recent pulmonary edema (HIGH RISK)
• Rates 0.4 with no risk 0.9 with 1 risk 7
  with 2 risks 11 with 3 or more risks or HIGH
  RISK

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Goldman and Detsky Criteria

• May UNDERESTIMATE the Cardiac Risk in Vascular
  Patients

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Eagle Criteria

• Access 5 significant clinical predictors
• Q waves on EKG
• History of angina
• History of ventricular ectopy requiring treatment
  
• Diabetes mellitus requiring therapy other than
  diet
• Age gt 70
• Rate of postoperative ischemic events 3.1 if no
  predictors, 15 if 1-2 predictors and up to 50
  if 3 or more predictors.

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Perioperative ß-Blocker

• Known CAD or 2 CRF then
• Perioperative atenolol 5 mg IV q 5min x 2
  recommended 30 min preop immediately postop
• Atenolol 50-100 mg po qd postop day 1 until d/c.
• 1 yr mortality 3 vs 14 for placebo

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Ransons criteria (alcoholic)

• Admission
• Age gt 55yr
• WBC gt 16,000/cmm
• Glucose gt 200 mg/dL
• LDH gt 350 IU/L
• GOT gt 250 IU/L

• 48 Hours
• Hct drop gt 10
• PaO2 lt 60 mmHg
• Ca lt 8 mg/dL
• Base deficit gt 4 mEq/L
• BUN rise gt 5 mg/dL
• Estimated fluid sequestration gt 6L

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Ransons criteria (non-alcoholic)

• Admission
• Age gt 70yr
• WBC gt 18,000/cmm
• Glucose gt 220 mg/dL
• LDH gt 400 IU/L
• GOT gt 440 IU/L

• 48 Hours
• Hct drop gt 10
• PaO2 lt 60 mmHg
• Ca lt 8 mg/dL
• Base deficit gt 5 mEq/L
• BUN rise gt 2 mg/dL
• Estimated fluid sequestration gt 6L

52
Glascow criteria (lt48 hours)

• Age gt 55yr
• Glucose gt 180 mg/dL
• Albumin lt 3.2 g/dL
• PaO2 lt 60 mmHg
• WBC gt 15,000/cmm
• LDH gt 600 IU/L
• BUN gt 45 mg/dL
• Ca lt 8 mg/dL

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Prediction Model for Pneumonia
Patient characteristic Points assigned
_______________ Demographic factors Age o
Males Age (in
years) o Females Age
(in years) -10 Nursing home resident
10 Comorbid illnesses Neoplastic disease
30 Liver disease
20 Congestive heart failure 10
Cerebrovascular disease 10 Renal disease
10
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Prediction Model for Pneumonia
Physical examination findings Altered mental
status 20
Respiratory rate 30/minute or more
20
Systolic blood pressure lt90 mmHg
20
Temperature lt35 degrees C or 40 degrees C or
more 15 Pulse
125/minute or more 10
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Prediction Model for Pneumonia
Laboratory findings pH lt7.35
30 BUN gt10.7 mmol/L
20 Sodium lt130 mEq/L
20 Glucose gt13.9 mmol/L
10 Hematocrit lt30 percent
10 PO2 lt60 mmHg (2)
10 Pleural effusion
10 _______________________________________ (1
) A risk score (total point score) for a given
patient is obtained by summing the patient age in
years (age minus 10 for females) and the points
for each applicable patient characteristic.(2)
Oxygen saturation lt90 percent also was considered
abnormal.
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Risk Stratification for Pneumonia
Risk Class
Low I Algorithm
Low II 70 or fewer points
Low III 71-90 total points
Moderate IV 91-130 total points
High V gt130 total points
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Asthma Severity
58
Asthma Severity

1. Past history of sudden severe exacerbations
2. Prior intubation for asthma
3. Prior asthma admission to an intensive care unit
4. Two or more hospitalizations for asthma in the
   past year
5. Three or more ED care visits for asthma in the
   past year
6. Hospitalization or an ED care visit for asthma
   within the past month
7. Use of gt2 MDI short-acting ß2 agonist canisters
   per month
8. Current use of or recent withdrawal from systemic
   corticosteroids
9. Difficulty perceiving severity of airflow
   obstruction
10. Comorbidities such as cardiovascular diseases or
    other systemic problems
11. Serious psychiatric disease or psychosocial
    problems
12. Illicit drug use, especially inhaled cocaine and
    heroin

59
Asthma Severity

• Mild Intermittent Asthma
•  Symptoms
•   Symptoms lt2 times a week   Asymptomatic and
  normal PEFR between exacerbations  
  Exacerbations brief (from a few hours to a few
  days) intensity may vary  Nighttime
•   lt2 times a month  Lung Function
•   FEV1 or PEFR gt80 predicted   PEFR variability
  lt20

60
Asthma Severity

• Mild Persistent Asthma
•  Symptoms
•   Symptoms gt2 times a week but lt1 time a day  
  Exacerbations may affect activity  Nighttime
•   gt2 times a month  Lung Function
•   FEV1 or PEFR gt80 predicted   PEFR variability
  20-30

61
Asthma Severity

• Moderate Persistent Asthma
•  Symptoms
•   Daily symptoms   Daily use of inhaled
  short-acting beta2-agonist   Exacerbations
  affect activity   Exacerbations 2 or more times
  a week may last days  Nighttime symptoms
•   gt1 time a week  Lung Function
•   FEV1 or PEFR gt60-lt80 predicted   PEFR
  variability gt30

62
Asthma Severity

• Severe Persistent Asthma
•  Symptoms
• Continual symptoms   Limited physical activity
    Frequent exacerbations  Nighttime Symptoms
•   Frequent  Lung Function
•   FEV1 or PEFR lt60 predicted   PEFR variability
  gt30

63
Asthma Severity
64
Scoring System for SARS (SSSS)

• radiographic findings of multilobar or bilateral
  infiltrates (3 points)
• sputum monocyte predominance (3 points)
• lymphocytopenia (2 points)
• history of exposure (1 point)
• lactate dehydrogenase gt450U/L (1 point)
• C-reactive proteingt 5.0mg/dL (1 point)
• activated partial prothrombin timegt 40sec (1
  point)
• SSSS gt 6 ? probable SARS

65
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• http//www.trauma.org.tw
• AIS System and ISS scoring
• ISSgt4 ????