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EMERGENCY NURSING
5-Tier
Triage Protocols
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EMERGENCY NURSING
5-Tier
Triage Protocols
All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted, in any
form or by any means—electronic, mechanical, photocopy, recording, or otherwise—without prior written permission of the publisher,
except for brief quotations embodied in critical articles and reviews and testing and evaluation materials provided by publisher to instruc-
tors whose schools have adopted its accompanying textbook. Printed in the United States of America. For information write Lippincott
Williams & Wilkins, 530 Walnut Street, Philadelphia PA 19106.
Materials appearing in this book prepared by individuals as part of their official duties as U.S. Government employees are not covered by
the above-mentioned copyright.
9 8 7 6 5
Briggs, Julie K.
Emergency nursing : 5-tier triage protocols / Julie K. Briggs, Valerie G. A. Grossman.
p. ; cm.
Includes bibliographical references and index.
ISBN 13: 978-1-58255-371-9
ISBN 1-58255-371-8 (alk. paper)
1. Emergency nursing--Handbooks, manuals, etc. 2. Triage (Medicine)--Handbooks, manuals, etc. I. Grossman, Valerie G. A.
II. Title.
Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However,
the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information
in this book and make no warranty, express or implied, with respect to the content of the publication.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in
accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in
government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the
package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly impor-
tant when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use
in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned
for use in his or her clinical practice.
RRC1009
LWW.com
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Contributor
Theresa Tavernero, RN, BSN, CEN, MHA
Nurse Consultant
Tacoma, Washington
Reviewers
Marge Bentler, RN, BSN, CEN Bret Lambert, MD, FACEP
Emergency Department Emergency Medicine
Good Samaritan Hospital Good Samaritan Hospital
Puyallup, Washington Puyallup, Washington
Clinical Assistant Professor of Medicine
Michael Brook, MD, FACEP University of Washington Medical Center
Emergency Medicine Seattle, Washington
Good Samaritan Hospital
Puyallup, Washington Theresa Tavernero, RN, BSN, CEN, MHA
Clinical Assistant Professor of Medicine Nurse Consultant
University of Washington Medical Center Tacoma, Washington
Seattle, Washington
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Preface
The Need for 5-Level Triage Protocols This protocol manual can help to achieve the fol-
Today, most emergency departments in the United lowing goals:
States, Canada, United Kingdom, Australia, and New
Zealand use some type of triage acuity system to ●
Provide consistency in triage decisions among dif-
determine how quickly a patient needs to be seen ferent nurses
and who can safely wait until rooms or resources are ●
Utilize healthcare resources in the most appropri-
available to provide the necessary care. While the ate manner
most common system has been the 3-tier system that ●
Set minimum expectations for triage decisions
rates patients as Emergent, Urgent, or Non-Urgent, ●
Guide the nurse in asking the right questions
the 5-tier triage system is rapidly gaining momen- ●
Assist the nurse in determining how soon the
tum as the system of choice. Studies have shown that patient needs to be seen
hospitals using a 5-tier system have reported greater ●
Remind the nurse of interventions to consider
consistency and accuracy in triage decisions. In 2002, ●
Serve as a reference for experienced nurses
the Emergency Nurses Association adopted a resolu- ●
Aid the less-experienced nurse in conducting the
tion promoting 5-level triage in the United States. triage assessment
In today’s rapidly changing health care environ- ●
Serve as a training tool in orientation
ment, an efficient emergency department is critical
to providing appropriate care at the appropriate time Protocol Components
in the appropriate setting. A 5-level triage system Each protocol has been developed to ensure accuracy
helps to ensure that patients are not over-triaged, and consistency among the different protocols. Each
which depletes scarce resources that may be needed protocol includes the following:
for a patient requiring immediate intervention, or
under-triaged, which puts the patient at risk for dete- Title: Protocols are arranged alphabetically and are
rioration while waiting to be seen. symptom-based. There are a few diagnosis-based
Emergency Nursing: 5-Level Triage Protocols will protocols, such as diabetic problems or asthma,
assist the triage nurse to function in a more consis- which are based on a known diagnosis or past his-
tent, reliable, and safe manner. The five levels are tory.
Resuscitation, Emergent, Urgent, Semi-Urgent, and Key Questions: These questions prompt the nurse
Non-Urgent, and they are based on patient acuity, to routinely ask for baseline and background infor-
severity of symptoms, the degree of risk for deterio- mation. To assist the nurse in meeting JCAHO and
ration while waiting, and the need for additional regulatory agency requirements, a prompt to ask
resources. In the protocols, ascending levels of about the pain scale and measure vital signs is
urgency are indicated by bolder headings and darker included in the Key Questions of all the protocols.
red icons and shading. The pain scale used is to be determined by each
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viii Preface
facility. Other key questions are protocol-specific waiting. Generally, this category of patient could be
and prompt the nurse to measure oxygen saturation seen in a lower acuity treatment area, and can safely
or ask about the mechanism of injury or tetanus wait. Each facility should determine acceptable wait-
immunization status. ing times if a room is not immediately available. In
Acuity Level/Assessment and Nursing Considerations: assigning this acuity, the nurse should consider that
The assessment is categorized from Level 1 through the patient may need only a simple exam. To improve
Level 5, with the most severe and life-threatening customer service, the nurse should reassess the wait-
symptoms listed first in Level 1. ing patient, per facility protocol, and offer comfort
Level 1—Resuscitation: This category is critical measures.
and the patient’s condition is life-threatening if not Nursing Considerations: In addition to assigning
managed immediately. In assigning this acuity, the acuity based on symptoms and resources needed, the
nurse should consider that the patient’s condition nurse is prompted when appropriate to initiate cer-
could quickly deteriorate and will require multiple tain nursing interventions. Nurses should initiate
staff at the bedside, mobilization of the resuscitation only those nursing interventions that have been
team, and many resources. approved by their facilities.
Level 2—Emergent: This category is high risk for Relevant Protocols: This section lists additional pro-
a patient waiting for treatment. The patient’s condi- tocols to consider that may assist in determining a
tion could deteriorate rapidly if treatment is delayed. more appropriate patient disposition.
In assigning this acuity, the nurse should consider
that the patient will require multiple diagnostic stud-
ies or procedures, frequent consultation with the Appendices
physician, and continuous monitoring. This section provides additional information to sup-
Level 3—Urgent: This category is moderate risk port the protocols, broaden the nurse’s scope of
for a patient waiting to be seen. The patient’s condi- knowledge, and prompt the nurse to look further in
tion is stable, but treatment should be provided as identifying potentially lethal conditions.
soon as possible to relieve distress and pain. Each Appendix A: The PQRSTT mnemonic assessment
facility should determine acceptable waiting times if a guide assists the nurse in asking the questions that will
room is not immediately available. In assigning this result in a comprehensive and high-quality interview.
acuity, the nurse should consider that the patient may Appendices B, C, D, E, F: Provide quick reference
need multiple diagnostic studies or procedures and charts to determine the appropriate dosages for
should be monitored for changes in condition while acetaminophen and ibuprofen, as well as weight and
waiting. temperature conversions.
Level 4—Semi-Urgent: This category is low risk
Appendices G, H, I: Provide additional information
for deterioration while the patient is waiting.
about three symptoms that are potentially life-threat-
Symptoms are less severe and the patient can safely
ening: abdominal pain, chest pain, and headaches.
wait for treatment. Each facility should determine
While nurses do not diagnose, it is important that
acceptable waiting times if a room is not immedi-
they understand the conditions and symptoms that
ately available. In assigning this acuity, the nurse
may be lethal.
should consider that the patient may need a simple
diagnostic study or procedure. Patients should be Appendices J, K, L, M, N: Address mechanism of
reassessed while waiting, per facility protocol. To injury (MOI) by age group. This handy guide
enhance customer service, the nurse should offer describes the types of injuries the nurse could antici-
comfort measures. pate based on age and MOI. This information will
Level 5—Non-Urgent: This category is a lower help to alert the nurse to potentially lethal conditions
risk for further deterioration while the patient is that initially could go undetected.
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Preface ix
Appendix O: A comprehensive reference tool on the impact the severity of symptoms, the appropriate
most commonly used, abused, and recreational triage disposition, and the triage experience:
drugs, their common names, and their effects. ●
Ages 65 and 1 month
Appendix P: A good reference on the signs and ●
Comorbidities, smoking, obesity, chronic disease,
symptoms of the most common types of poisoning. alcohol or drug use/abuse, immunosuppression,
Appendix Q: A handy reference on the biological hypertension, sedentary life style
and chemical agents most commonly anticipated to ●
Mechanism of injury (see appendices for age-
be used in a terrorist attack. The triage nurse may be specific guidelines)
the first to recognize the symptoms or a pattern and ●
Continued assessment while waiting
should report findings to the appropriate authority, ●
Potential EMTALA violations (all patients have a
per facility policy. right to a medical screening— review the facility’s
EMTALA policies)
Appendix R: A comprehensive chart describing the
most common communicable diseases, cold vs. flu In addition, the triage nurse should:
symptoms, and STDs. Includes modes of transmis-
sion, incubation periods, and contagious periods.
●
Develop and use standing orders to facilitate treat-
ment/diagnostic interventions at triage to improve
Appendix S: A triage assessment form to use as a patient satisfaction and throughput.
model in evaluating nurses’ interactions with ●
Keep patients informed while waiting—use this
patients. opportunity to continually reassess and improve
Appendix T: A set of training exercises to aid nurses customer satisfaction.
in identifying appropriate interventions at triage and ●
Monitor consistency in applying triage criteria and
identifying risk factors that might have an impact on assigning acuity.
assignment of acuity level. ●
Train staff in use of protocols with the 5-tier triage
system.
Additional Triage Guidelines ●
Create scenarios to rate consistency in the applica-
While every effort was made to design each protocol tion of triage protocols.
in the most comprehensive manner possible to be
age-specific and reflective of high-risk patients, the Julie K. Briggs, RN, BSN, MHA
triage nurse should be aware of the many factors that Valerie G. A. Grossman, BSN, CEN
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Acknowledgments
This has been a great experience and opportunity to work together from across the country in the creation of
this worthwhile project. We would like to express our gratitude and appreciation to Marge Bentler, RN, BSN,
CEN, Dr. Bret Lambert and Dr. Michael Brook for their thorough review and suggestions. We would also like to
extend a special thank you to Theresa Tavernero, RN, BSN, CEN, MHA, for her interest, contributions and
insightful suggestions for developing a quality product.
Julie Briggs and Valerie Grossman
Additionally, I would like to thank Valerie Grossman, my husband Worth, and my parents and friends for their
continued support and encouragement throughout this project, as I struggled to balance deadlines and life’s
unforeseeable challenges.
Julie
I am honored to have worked on this book with Julie, who has been a friend and mentor for many years. My
sincere appreciation goes to my daughters (Sarah and Nicole), my sister (Christina), and my parents (John and
Marie), who support my every project . . . and to Senior Chief Petty Officer Scott D. Grossman, US Navy, for
wherever he is in the world, he is always a role model for our family to emulate.
Valerie
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Contents
xiv Contents
Index, 255
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?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Associated Symptoms • Pain Scale
• Description and Location of the Pain • Vital Signs • Medications
1
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RELATED PROTOCOLS:
Diarrhea, Adult • Foreign Body, Ingestion • Menstrual Problems • Poisoning, Exposure or Ingestion
• Pregnancy, Abdominal Pain • Urination Problems • Vaginal Bleeding, Abnormal • Vomiting
See Appendix G: Differential Diagnosis of Abdominal Pain
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KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Associated Symptoms • Pain Scale
• Description and Location of the Pain • Vital Signs • Medications
3
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RELATED PROTOCOLS:
Constipation • Diarrhea • Foreign Body, Ingestion • Menstrual Problems • Poisoning, Exposure or
Ingestion • Pregnancy, abdominal pain • Urination Problems • Vaginal Bleeding • Vomiting
See Appendix G: Differential Diagnosis of Abdominal Pain
Notes
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KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Medications • Pain Scale • Vital Signs
• Drug or Drinking Habits • Amount and Frequency • Hours or Days Since Last Use or Drink
5
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RELATED PROTOCOLS:
Altered Mental Status • Anxiety • Chest Pain
See Appendix O: Drugs of Abuse
Notes
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Allergic Reaction
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity • Pain Scale • Suspected Cause
• Vital Signs • Oxygen Saturation • Medications
7
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8 Allergic Reaction
RELATED PROTOCOLS:
Asthma • Bee Sting • Breathing Problems • Hives
Notes
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?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity • Pain Scale
• Vital Signs • Oxygen Saturation
9
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RELATED PROTOCOLS:
Alcohol and Drug Use, Abuse, and Dependence • Breathing Problems • Chest Pain • Fever • Headache
• Head Injury
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?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity • Pain Scale • Vital Signs
11
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RELATED PROTOCOLS:
Extremity Injury
Notes
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Anxiety
(if chest pain is present, see Chest Pain)
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Medications • Severity • Pain Scale
• Vital Signs
13
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14 Anxiety
RELATED PROTOCOLS:
Breathing Problems • Chest Pain
Notes
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Asthma
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior Asthma History • Severity • Duration • Prior Treatment
• Medications • Pain Scale • Vital Signs • Oxygen Saturation • Peak Flow Meter Measurement
15
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16 Asthma
RELATED PROTOCOLS:
Allergic Reaction • Breathing Problems • Cough
Notes
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Back Pain
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity • Pain Scale • Vital Signs
• Medications
17
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18 Back Pain
RELATED PROTOCOLS:
Motor Vehicle Accident • Neck Pain • Urination Problems
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Bee Sting
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity • Pain Scale • Vital Signs
• Oxygen Saturation • Previous Bee Sting Reaction and Treatment
19
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20 Bee Sting
RELATED PROTOCOLS:
Allergic Reaction • Bites, Insect and Tick • Breathing Problems • Hives
Notes
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?
KEY QUESTIONS:
Name • Age • Onset • Location • Allergies • Prior History • Severity • Pain Scale
• Vital Signs • Tetanus Immunization Status
21
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RELATED PROTOCOLS:
Laceration • Puncture Wound • Wound Infection
Notes
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?
KEY QUESTIONS:
Name • Age • Onset • Location • Allergies • Prior History • Severity • Pain Scale
• Vital Signs • Type of Insect
23
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RELATED PROTOCOLS:
Allergic Reaction • Laceration • Wound Infection
Notes
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?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity • Pain Scale • Vital Signs
• Tetanus Immunization Status • Marine Animal Identification
25
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RELATED PROTOCOLS:
Allergic Reaction • Laceration • Puncture Wound • Wound Infection
Notes
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Bites, Snake
?
KEY QUESTIONS:
Name • Age • Onset • Location • Allergies • Prior History • Severity • Pain Scale
• Vital Signs • Tetanus Immunization Status • Type of Snake
27
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28 Bites, Snake
RELATED PROTOCOLS:
Allergic Reaction • Laceration • Wound Infection
Notes
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?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History (Including Infectious Diseases) • Severity
• Pain Scale • Vital Signs • Oximetry • Location of Body Art • Performed by Whom (Professional
Versus Amateur) • When Performed • Immunizations (dT, Hep B)
29
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RELATED PROTOCOLS:
Laceration • Wound Infection
Breast Problems
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity • Pain Scale • Vital Signs
35
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36 Breast Problems
RELATED PROTOCOLS:
Body Art Complications • Lacerations • Wound Infection
Notes
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Breathing Problems
?
KEY QUESTIONS:
Name • Age • Weight • Onset • Allergies • Prior History • Severity • Pain Scale
• Vital Signs • Oxygen Saturation • Medications
37
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38 Breathing Problems
RELATED PROTOCOLS:
Allergic Reaction • Asthma • Chest Pain • Foreign Body, Inhaled
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Burns
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Mechanism of Injury
• Severity • Pain Scale • Vital Signs • Last Tetanus Immunization • Size and Location of Burn
39
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40 Burns
RELATED PROTOCOLS:
Breathing Problems • Laceration • Poisoning, Exposure or Ingestion • Wound Infection
Notes
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Chest Pain
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Medications • Severity • Pain Scale
• Associated Symptoms • Vital Signs • Oxygen Saturation
41
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42 Chest Pain
RELATED PROTOCOLS:
Breathing Problems • Cold Symptoms
See Appendix H: Differential Diagnosis of Chest Pain
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KEY QUESTIONS:
Name • Age • Onset • Length and Time of Exposure • Body Temperature • Vital Signs
• Pain Scale • Medications • Tetanus Status
43
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Notes
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Cold Symptoms
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Associated Symptoms • Pain Scale
• Vital Signs • Oxygen Saturation • Medications
45
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46 Cold Symptoms
RELATED PROTOCOLS:
Breathing Problems • Fever • Sore Throat
Notes
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Confusion
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity • Pain Scale • Vital Signs
47
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48 Confusion
RELATED PROTOCOLS:
Altered Mental Status • Fever
Notes
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Contusion
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity • Pain Scale • Vital Signs
• Oxygen Saturation • Specifics of Injury • Medications
49
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50 Contusion
RELATED PROTOCOLS:
Extremity Injury
Bruise Assessment
Color of Bruise Age of Bruise
Red, reddish blue Less than 24 hr since time of injury
Dark blue, dark purple 1 to 4 days
Green, yellow-green 5 to 7 days
Yellow, brown 7 to 10 days
Normal tint, disappearance of bruise 1 to 3 wk
GRBQ052-2149G-C24[51-52].qxd 7/28/05 12:32 AM Page 51 quark07 27B:GRBQ052:Chapters:Chapter-24:
Cough
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity • Pain Scale • Vital Signs
• Oxygen Saturation • Medications • Associated Symptoms
51
GRBQ052-2149G-C24[51-52].qxd 7/28/05 12:32 AM Page 52 quark07 27B:GRBQ052:Chapters:Chapter-24:
52 Cough
RELATED PROTOCOLS:
Asthma • Breathing Problems • Cold Symptoms
GRBQ052-2149G-C25[53-54].qxd 7/28/05 12:32 AM Page 53 quark07 27B:GRBQ052:Chapters:Chapter-25:
Crying Baby
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History (Including Birth History) • Severity • Pain Scale
• Vital Signs • Oxygen Saturation
53
GRBQ052-2149G-C25[53-54].qxd 7/28/05 12:32 AM Page 54 quark07 27B:GRBQ052:Chapters:Chapter-25:
54 Crying Baby
Notes
GRBQ052-2149G-C26[55-56].qxd 7/28/05 12:33 AM Page 55 quark07 27B:GRBQ052:Chapters:Chapter-26:
Depression
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity • Pain Scale • Vital Signs
• Medications
55
GRBQ052-2149G-C26[55-56].qxd 7/28/05 12:33 AM Page 56 quark07 27B:GRBQ052:Chapters:Chapter-26:
56 Depression
RELATED PROTOCOLS:
Anxiety
Notes
GRBQ052-2149G-C27[57-58].qxd 7/28/05 12:33 AM Page 57 quark07 27B:GRBQ052:Chapters:Chapter-27:
Diabetic Problems
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity • Pain Scale • Vital Signs
• Oxygen Saturation • Serum Glucose Level • Medications
57
GRBQ052-2149G-C27[57-58].qxd 7/28/05 12:33 AM Page 58 quark07 27B:GRBQ052:Chapters:Chapter-27:
58 Diabetic Problems
RELATED PROTOCOLS:
Altered Mental Status • Fever • Wound Infection
Notes
GRBQ052-2149G-C28[59-60].qxd 7/28/05 12:33 AM Page 59 quark07 27B:GRBQ052:Chapters:Chapter-28:
Diarrhea, Adult
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity of Symptoms • Pain Scale
• Vital Signs • Medications • Diet • Travel • Family Members • Laxatives • Chronic Diarrhea
• Abdominal Surgery • Recent Antibiotic Therapy • Drinking from Wells or Streams
59
GRBQ052-2149G-C28[59-60].qxd 7/28/05 12:33 AM Page 60 quark07 27B:GRBQ052:Chapters:Chapter-28:
60 Diarrhea, Adult
RELATED PROTOCOLS:
Abdominal Pain, Adult • Poisoning, Exposure or Ingestion • Vomiting
Notes
GRBQ052-2149G-C29[61-62].qxd 7/28/05 12:33 AM Page 61 quark07 27B:GRBQ052:Chapters:Chapter-29:
Diarrhea, Pediatric
?
KEY QUESTIONS:
Name • Age • Weight • Onset • Allergies • Prior History • Severity of Symptoms
• Diaper Count • Pain Scale • Vital Signs • Medications • Diet • Travel
• Health of Family Members • Laxatives • Chronic Diarrhea • Abdominal Surgery
• Recent Antibiotic Therapy • Drinking from Wells or Streams or travel outside the country
61
GRBQ052-2149G-C29[61-62].qxd 7/28/05 12:33 AM Page 62 quark07 27B:GRBQ052:Chapters:Chapter-29:
62 Diarrhea, Pediatric
RELATED PROTOCOLS:
Abdominal Pain, Pediatric • Poisoning, Exposure or Ingestion • Vomiting
Notes
GRBQ052-2149G-C30[63-64].qxd 7/28/05 12:33 AM Page 63 quark07 27B:GRBQ052:Chapters:Chapter-30:
Ear Problems
(for foreign body, see Foreign Body, Ear)
?
KEY QUESTIONS:
Name • Age • Onset • History • Temperature • Allergies • Medication • Pain Scale
• Vital Signs
63
GRBQ052-2149G-C30[63-64].qxd 7/28/05 12:33 AM Page 64 quark07 27B:GRBQ052:Chapters:Chapter-30:
64 Ear Problems
RELATED PROTOCOLS:
Foreign Body, Ear
Notes
GRBQ052-2149G-C31[65-66].qxd 7/28/05 12:40 AM Page 65 quark07 27B:GRBQ052:Chapters:Chapter-31:
?
KEY QUESTIONS:
Name • Age • Onset • Cause • Vital Signs • Pain Scale • Entrance and Exit Wounds
• Oxygen Saturation
65
GRBQ052-2149G-C31[65-66].qxd 7/28/05 12:40 AM Page 66 quark07 27B:GRBQ052:Chapters:Chapter-31:
RELATED PROTOCOLS:
Chest Pain • Extremity Injury
Notes
GRBQ052-2149G-C32[67-68].qxd 7/28/05 12:37 AM Page 67 quark07 27B:GRBQ052:Chapters:Chapter-32:
Extremity Injury
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity • Pain Scale • Cause • Vital Signs
• Oxygen Saturation • Neurovascular Status of Extremity
67
GRBQ052-2149G-C32[67-68].qxd 7/28/05 12:37 AM Page 68 quark07 27B:GRBQ052:Chapters:Chapter-32:
68 Extremity Injury
RELATED PROTOCOLS:
Electrical Shock • Laceration • Puncture Wound
GRBQ052-2149G-C33[69-70].qxd 7/28/05 12:37 AM Page 69 quark07 27B:GRBQ052:Chapters:Chapter-33:
?
KEY QUESTIONS:
Name • Age • Onset • Cause • Allergies • Corrective Glasses or Contact Use • Visual Acuity
• Vital Signs • Tetanus Immunization Status • Medications
69
GRBQ052-2149G-C33[69-70].qxd 7/28/05 12:37 AM Page 70 quark07 27B:GRBQ052:Chapters:Chapter-33:
Notes
GRBQ052-2149G-C34[71-72].qxd 7/28/05 12:37 AM Page 71 quark07 27B:GRBQ052:Chapters:Chapter-34:
?
KEY QUESTIONS:
Name • Age • Prior History • Onset • Type of Tube • Length of Time Tube in Place
• Pain Scale • Vital Signs
71
GRBQ052-2149G-C34[71-72].qxd 7/28/05 12:37 AM Page 72 quark07 27B:GRBQ052:Chapters:Chapter-34:
Notes
GRBQ052-2149G-C35[73-74].qxd 7/28/05 12:37 AM Page 73 quark07 27B:GRBQ052:Chapters:Chapter-35:
Fever
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Allergies • Prior History • Pain Scale
• Vital Signs • Weight • Oxygen Saturation
73
GRBQ052-2149G-C35[73-74].qxd 7/28/05 12:37 AM Page 74 quark07 27B:GRBQ052:Chapters:Chapter-35:
74 Fever
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity • Pain Scale • Vital Signs
• Medications
75
GRBQ052-2149G-C36[75-76].qxd 7/28/05 12:37 AM Page 76 quark07 27B:GRBQ052:Chapters:Chapter-36:
RELATED PROTOCOLS:
Extremity Injury
Notes
GRBQ052-2149G-C37[77-78].qxd 7/28/05 12:38 AM Page 77 quark07 27B:GRBQ052:Chapters:Chapter-37:
?
KEY QUESTIONS:
Name • Age • Onset • Identification of Foreign Body • Prior History • Medications
• Allergies • Pain Scale • Vital Signs
77
GRBQ052-2149G-C37[77-78].qxd 7/28/05 12:38 AM Page 78 quark07 27B:GRBQ052:Chapters:Chapter-37:
RELATED PROTOCOLS:
Ear Problems • Laceration
Notes
GRBQ052-2149G-C38[79-80].qxd 7/28/05 12:40 AM Page 79 quark07 27B:GRBQ052:Chapters:Chapter-38:
?
KEY QUESTIONS:
Name • Age • Onset • Severity of Symptoms • Consideration for Poisoning
• Foreign Object/Substance Ingested • Vital Signs • Medications
79
GRBQ052-2149G-C38[79-80].qxd 7/28/05 12:40 AM Page 80 quark07 27B:GRBQ052:Chapters:Chapter-38:
RELATED PROTOCOLS:
Abdominal Pain, Adult • Abdominal Pain, Child • Foreign Body, Inhaled
Notes
GRBQ052-2149G-C39[81-82].qxd 7/28/05 12:38 AM Page 81 quark07 27B:GRBQ052:Chapters:Chapter-39:
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity of Symptoms • Pain Scale
• Object Inhaled • Medications • Oxygen Saturation • Vital Signs
81
GRBQ052-2149G-C39[81-82].qxd 7/28/05 12:38 AM Page 82 quark07 27B:GRBQ052:Chapters:Chapter-39:
RELATED PROTOCOLS:
Asthma • Breathing Problems • Foreign Body, Ingested
Notes
GRBQ052-2149G-C40[83-84].qxd 7/28/05 12:40 AM Page 83 quark07 27B:GRBQ052:Chapters:Chapter-40:
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity of Symptoms • Pain Scale
• Vital Signs • Description of Object • Medications
83
GRBQ052-2149G-C40[83-84].qxd 7/28/05 12:40 AM Page 84 quark07 27B:GRBQ052:Chapters:Chapter-40:
RELATED PROTOCOLS:
Rectal Problems • Sexual Assault • Vaginal Bleeding, Abnormal
Notes
GRBQ052-2149G-C41[85-86].qxd 7/28/05 12:43 AM Page 85 quark07 27B:GRBQ052:Chapters:Chapter-41:
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity • Pain Scale
• Vital Signs • Tetanus Status
85
GRBQ052-2149G-C41[85-86].qxd 7/28/05 12:43 AM Page 86 quark07 27B:GRBQ052:Chapters:Chapter-41:
RELATED PROTOCOLS:
Laceration • Wound Infection
Notes
GRBQ052-2149G-C42[87-88].qxd 7/28/05 12:51 AM Page 87 quark07 27B:GRBQ052:Chapters:Chapter-42:
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity • Pain Scale • Vital Signs
• Medications
87
GRBQ052-2149G-C42[87-88].qxd 7/28/05 12:51 AM Page 88 quark07 27B:GRBQ052:Chapters:Chapter-42:
RELATED PROTOCOLS:
Urination Problems
Notes
GRBQ052-2149G-C43[89-90].qxd 7/28/05 1:00 AM Page 89 quark07 27B:GRBQ052:Chapters:Chapter-43:
Headache
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity of Symptoms
• Pain Scale • Vital Signs
89
GRBQ052-2149G-C43[89-90].qxd 7/28/05 1:00 AM Page 90 quark07 27B:GRBQ052:Chapters:Chapter-43:
90 Headache
RELATED PROTOCOLS:
Cold Symptoms • Fever • Head Injury
See Appendix I: Headache: Common Characteristics
Notes
GRBQ052-2149G-C44[91-92].qxd 7/28/05 12:51 AM Page 91 quark07 27B:GRBQ052:Chapters:Chapter-44:
Head Injury
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity of Symptoms • Pain Scale
• Vital Signs • Oxygen Saturation • Medications • Glascow Coma Scale Score
91
GRBQ052-2149G-C44[91-92].qxd 7/28/05 12:51 AM Page 92 quark07 27B:GRBQ052:Chapters:Chapter-44:
92 Head Injury
RELATED PROTOCOLS:
Headache • Motor Vehicle Accident
See Appendices J through N: MVA Triage Questions and Mechanisms of Injury
Notes
GRBQ371R-C45[93-94].qxd 10/19/2007 19:10pm Page 93 Aptara Inc.
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity of Symptoms
• Pain Scale • Vital Signs • Oxygen Saturation • Cardiac History (stent, CABG, valve, MI, pacers)
93
GRBQ052-2149G-C45[93-94].qxd 7/28/05 12:51 AM Page 94 quark07 27B:GRBQ052:Chapters:Chapter-45:
RELATED PROTOCOLS:
Anxiety • Breathing Problems • Chest Pain • Diarrhea, Adult • Diarrhea, Pediatric
• Lightheadedness/Fainting • Vomiting
Notes
GRBQ052-2149G-C46[95-96].qxd 7/28/05 12:52 AM Page 95 quark07 27B:GRBQ052:Chapters:Chapter-46:
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity of Symptoms
• Pain Scale • Vital Signs • Oxygen Saturation • Cardiac History (stent, CABG, pacer, MI)
95
GRBQ052-2149G-C46[95-96].qxd 7/28/05 12:52 AM Page 96 quark07 27B:GRBQ052:Chapters:Chapter-46:
RELATED PROTOCOLS:
Breathing Problems • Chest Pain • Lightheadedness/Fainting
Notes
GRBQ052-2149G-C47[97-98].qxd 7/28/05 12:59 AM Page 97 quark07 27B:GRBQ052:Chapters:Chapter-47:
Heat Exposure
?
KEY QUESTIONS:
Name • Age • Onset • Temperature • Cardiac History • Hypertension • Diabetes • Vital Signs
• Oxygen Saturation • Medications • Prior History
97
GRBQ052-2149G-C47[97-98].qxd 7/28/05 12:59 AM Page 98 quark07 27B:GRBQ052:Chapters:Chapter-47:
98 Heat Exposure
Notes
GRBQ052-2149G-C48[99-100].qxd 7/28/05 12:52 AM Page 99 quark07 27B:GRBQ052:Chapters:Chapter-48:
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Mechanism of Injury
• Severity of Symptoms • Pain Scale
99
GRBQ052-2149G-C48[99-100].qxd 7/28/05 12:52 AM Page 100 quark07 27B:GRBQ052:Chapters:Chapter-48:
RELATED PROTOCOLS:
Extremity Injury
Notes
GRBQ052-2149G-C49[101-102].qxd 7/28/05 12:52 AM Page 101 quark07 27B:GRBQ052:Chapters:Chapter-49:
Hives
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity of Symptoms • Pain Scale
• Suspected Cause • Medications • Vital Signs • Recent Changes in Food or Medication
101
GRBQ052-2149G-C49[101-102].qxd 7/28/05 12:52 AM Page 102 quark07 27B:GRBQ052:Chapters:Chapter-49:
102 Hives
RELATED PROTOCOLS:
Allergic Reaction • Bee Sting • Breathing Problems • Rash, Adult and Pediatric
Notes
GRBQ052-2149G-C50[103-104].qxd 7/28/05 12:52 AM Page 103 quark07 27B:GRBQ052:Chapters:Chapter-50:
Hypertension
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Medications • Severity • Pain Scale
• Associated Symptoms • Vital Signs • Oxygen Saturation • Last Elevated Reading
103
GRBQ052-2149G-C50[103-104].qxd 7/28/05 12:52 AM Page 104 quark07 27B:GRBQ052:Chapters:Chapter-50:
104 Hypertension
RELATED PROTOCOLS:
Breathing Problems • Chest Pain
Notes
GRBQ052-2149G-C51[105-106].qxd 7/28/05 1:02 AM Page 105 quark07 27B:GRBQ052:Chapters:Chapter-51:
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity of Symptoms
• Pain Scale • Vital Signs
105
GRBQ052-2149G-C51[105-106].qxd 7/28/05 1:02 AM Page 106 quark07 27B:GRBQ052:Chapters:Chapter-51:
RELATED PROTOCOLS:
Rectal Problems
Notes
GRBQ052-2149G-C52[107-108].qxd 7/28/05 1:02 AM Page 107 quark07 27B:GRBQ052:Chapters:Chapter-52:
Jaundice
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Medications • Pain Scale • Vital Signs
107
GRBQ052-2149G-C52[107-108].qxd 7/28/05 1:02 AM Page 108 quark07 27B:GRBQ052:Chapters:Chapter-52:
108 Jaundice
RELATED PROTOCOLS:
Abdominal Pain, Adult • Fever • Itching Without a Rash
Notes
GRBQ052-2149G-C53[109-110].qxd 7/28/05 1:02 AM Page 109 quark07 27B:GRBQ052:Chapters:Chapter-53:
Jaundice, Newborn
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Medications • Vital Signs
109
GRBQ052-2149G-C53[109-110].qxd 7/28/05 1:02 AM Page 110 quark07 27B:GRBQ052:Chapters:Chapter-53:
RELATED PROTOCOLS:
Abdominal Pain, Pediatric • Fever • Rash
Notes
GRBQ052-2149G-C54[111-112].qxd 7/28/05 1:03 AM Page 111 quark07 27B:GRBQ052:Chapters:Chapter-54:
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Pain Scale • Vital Signs
111
GRBQ052-2149G-C54[111-112].qxd 7/28/05 1:03 AM Page 112 quark07 27B:GRBQ052:Chapters:Chapter-54:
RELATED PROTOCOLS:
Extremity Injury
Notes
GRBQ052-2149G-C55[113-114].qxd 7/28/05 1:03 AM Page 113 quark07 27B:GRBQ052:Chapters:Chapter-55:
Laceration
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Mechanism of Injury
• Severity • Pain Scale • Vital Signs • Last Tetanus Immunization
113
GRBQ052-2149G-C55[113-114].qxd 7/28/05 1:03 AM Page 114 quark07 27B:GRBQ052:Chapters:Chapter-55:
114 Laceration
RELATED PROTOCOLS:
Wound Infection
Notes
GRBQ052-2149G-C56[115-116].qxd 7/28/05 1:03 AM Page 115 quark07 27B:GRBQ052:Chapters:Chapter-56:
Lightheadedness/Fainting
?
KEY QUESTIONS:
Name • Age • Onset • Prior History • Fluid Intake • Medication • Pain Scale • Vital Signs
• Oxygen Saturation
115
GRBQ052-2149G-C56[115-116].qxd 7/28/05 1:03 AM Page 116 quark07 27B:GRBQ052:Chapters:Chapter-56:
116 Lightheadedness/Fainting
RELATED PROTOCOLS:
Altered Mental Status • Abdominal Pain, Adult • Abdominal Pain, Pediatric • Chest Pain
• Diarrhea, Adult • Diarrhea, Pediatric • Headache • Vaginal Bleeding, Abnormal • Vomiting
Notes
GRBQ052-2149G-C57[117-118].qxd 7/28/05 1:03 AM Page 117 quark07 27B:GRBQ052:Chapters:Chapter-57:
Menstrual Problems
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity • Pain Scale
• Vital Signs • Number of Saturated Pads or Tampons Per Hour • Birth Control
• Possibility of Pregnancy
117
GRBQ052-2149G-C57[117-118].qxd 7/28/05 1:03 AM Page 118 quark07 27B:GRBQ052:Chapters:Chapter-57:
RELATED PROTOCOLS:
Abdominal Pain, Adult • Vaginal Bleeding, Abnormal
Notes
GRBQ052-2149G-C58[119-120].qxd 7/28/05 1:03 AM Page 119 quark07 27B:GRBQ052:Chapters:Chapter-58:
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity • Pain Scale • Vital Signs
• Oxygen Saturation • Extent of Injuries
119
GRBQ052-2149G-C58[119-120].qxd 7/28/05 1:03 AM Page 120 quark07 27B:GRBQ052:Chapters:Chapter-58:
RELATED PROTOCOLS:
Ankle Pain and Swelling • Back Pain • Cold Exposure, Hypothermia/Frostbite • Extremity Injury
• Head Injury • Knee Pain and Swelling • Neck Pain • Puncture Wound • Shoulder Pain
See Appendix J: MVA Triage Questions; Appendix K: Mechanisms of Injury from Trauma: Adult; Appendix L:
Mechanisms of Injury: School Age and Adolescent; Appendix M: Mechanisms of Injury: Toddler and
Preschooler; Appendix N: Mechanisms of Injury: Infant
Notes
GRBQ052-2149G-C59[121-122].qxd 7/28/05 1:03 AM Page 121 quark07 27B:GRBQ052:Chapters:Chapter-59:
Mouth Problems
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity • Pain Scale
• Vital Signs • Oxygen Saturation
121
GRBQ052-2149G-C59[121-122].qxd 7/28/05 1:03 AM Page 122 quark07 27B:GRBQ052:Chapters:Chapter-59:
RELATED PROTOCOLS:
Breathing Problems • Sore Throat • Toothache/Tooth Injury
Notes
GRBQ052-2149G-C60[123-124].qxd 7/28/05 1:04 AM Page 123 quark07 27B:GRBQ052:Chapters:Chapter-60:
Neck Pain
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Mechanism of Injury
• Pain Scale • Vital Signs • Oxygen Saturation
123
GRBQ052-2149G-C60[123-124].qxd 7/28/05 1:04 AM Page 124 quark07 27B:GRBQ052:Chapters:Chapter-60:
RELATED PROTOCOLS:
Chest Pain • Ear Problems • Fever • Head Injury • Sore Throat • Toothache/Tooth Injury
Notes
GRBQ052-2149G-C61[125-126].qxd 7/28/05 1:25 AM Page 125 quark07 27B:GRBQ052:Chapters:Chapter-61:
Nosebleed
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Medications • Pain Scale • Vital Signs
• Oxygen Saturation
125
GRBQ052-2149G-C61[125-126].qxd 7/28/05 1:25 AM Page 126 quark07 27B:GRBQ052:Chapters:Chapter-61:
126 Nosebleed
RELATED PROTOCOLS:
Cold Symptoms • Foreign Body, Inhaled
Notes
GRBQ052-2149G-C62[127-128].qxd 7/28/05 1:25 AM Page 127 quark07 27B:GRBQ052:Chapters:Chapter-62:
?
KEY QUESTIONS:
Name • Age • Weight • Onset • Amount • Emesis After Ingestion • Allergies • Prior History
• Medications • Pain Scale • Vital Signs • Oxygen Saturation • Name of Agent (if Known)
127
GRBQ052-2149G-C62[127-128].qxd 7/28/05 1:25 AM Page 128 quark07 27B:GRBQ052:Chapters:Chapter-62:
RELATED PROTOCOLS:
Alcohol and Drug Use, Abuse, and Dependence • Bites, Insect and Tick • Bites, Marine Animal • Bites,
Snake • Suicidal Behavior
See Appendix Q, Biological Agents/Chemical Agents; Appendix O, Drugs of Abuse; Appendix P: Poisonings
GRBQ052-2149G-C63[129-130].qxd 7/28/05 1:25 AM Page 129 quark07 27B:GRBQ052:Chapters:Chapter-63:
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity • Pain Scale • Vital Signs
• Oxygen Saturation • Gestational Age • Recent Ultrasound • Number of Pregnancies
129
GRBQ052-2149G-C63[129-130].qxd 7/28/05 1:25 AM Page 130 quark07 27B:GRBQ052:Chapters:Chapter-63:
RELATED PROTOCOLS:
Pregnancy, Back Pain • Pregnancy, Vaginal Bleeding • Pregnancy, Vaginal Discharge
Notes
GRBQ052-2149G-C64[131-132].qxd 7/28/05 1:25 AM Page 131 quark07 27B:GRBQ052:Chapters:Chapter-64:
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity • Pain Scale • Vital Signs
• Oxygen Saturation • Gestational Age • Recent Ultrasound • Number of Pregnancies
131
GRBQ052-2149G-C64[131-132].qxd 7/28/05 1:25 AM Page 132 quark07 27B:GRBQ052:Chapters:Chapter-64:
RELATED PROTOCOLS:
Pregnancy, Abdominal Pain • Pregnancy, Vaginal Bleeding • Pregnancy, Vaginal Discharge
Notes
GRBQ052-2149G-C65[133-134].qxd 7/28/05 1:26 AM Page 133 quark07 27B:GRBQ052:Chapters:Chapter-65:
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity • Pain Scale • Vital Signs
• Last Menstrual Period • Number of Regular-Size Saturated Pads • Medications
133
GRBQ052-2149G-C65[133-134].qxd 7/28/05 1:26 AM Page 134 quark07 27B:GRBQ052:Chapters:Chapter-65:
RELATED PROTOCOLS:
Pregnancy, Abdominal Pain • Pregnancy, Back Pain • Pregnancy, Vaginal Discharge
Notes
GRBQ052-2149G-C66[135-136].qxd 7/28/05 1:26 AM Page 135 quark07 27B:GRBQ052:Chapters:Chapter-66:
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity • Pain Scale • Vital Signs
• Last Menstrual Period • Medications
135
GRBQ052-2149G-C66[135-136].qxd 7/28/05 1:26 AM Page 136 quark07 27B:GRBQ052:Chapters:Chapter-66:
RELATED PROTOCOLS:
Pregnancy, Vaginal Bleeding • Vaginal Bleeding, Abnormal
Notes
GRBQ052-2149G-C67[137-138].qxd 7/28/05 1:26 AM Page 137 quark07 27B:GRBQ052:Chapters:Chapter-67:
Pregnancy, Vomiting
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity • Pain Scale
• Vital Signs • Gestational Age • Number of Pregnancies • Medications
137
GRBQ052-2149G-C67[137-138].qxd 7/28/05 1:26 AM Page 138 quark07 27B:GRBQ052:Chapters:Chapter-67:
RELATED PROTOCOLS:
Pregnancy, Abdominal Pain • Vomiting
Notes
GRBQ052-2149G-C68[139-140].qxd 7/28/05 1:26 AM Page 139 quark07 27B:GRBQ052:Chapters:Chapter-68:
Puncture Wound
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Pain Scale • Vital Signs
• Tetanus Immunization Status • Mechanism of Injury (Appendices K–N)
139
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RELATED PROTOCOLS:
Bites, Animal and Human • Bites, Marine Animal • Bites, Snake • Foreign Body, Skin • Laceration
• Motor Vehicle Accidents • Suicidal Behavior • Wound Infection
Notes
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?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Pain Scale • Vital Signs
• Oxygen Saturation • Number of Wet Diapers in an Infant
141
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RELATED PROTOCOLS:
Allergic Reaction • Bites, Animal and Human • Bites, Insect and Tick • Bites, Marine Animal
• Bites, Snake • Poisoning, Exposure or Ingestion
Notes
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?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity • Pain Scale
• Vital Signs
143
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RELATED PROTOCOLS:
Abdominal Pain, Adult • Abdominal Pain, Pediatric • Foreign Body, Rectum/Vagina • Sexual Assault
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Seizure
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity • Pain Scale
• Vital Signs • Oxygen Saturation • Drug and Alcohol Use
145
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146 Seizure
RELATED PROTOCOLS:
Altered Mental Status • Alcohol and Drug Use, Abuse, and Dependence • Bites, Animal and Human
• Bites, Insect and Tick • Bites, Marine Animal • Bites, Snake • Confusion • Diabetic Problems
• Fever • Head Injury • Poisoning, Exposure or Ingestion
Notes
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?
KEY QUESTIONS:
Name • Age • Weight • Onset • Allergies • Prior History • Medications • Pain Scale
• Vital Signs • Oxygen Saturation
147
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RELATED PROTOCOLS:
Altered Mental Status • Confusion • Diabetic Problems • Fever • Head Injury
• Poisoning, Exposure or Ingestion
Notes
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Sexual Assault
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Pain Scale • Vital Signs • Oxygen Saturation
• Mechanism of Injury • Last Menstrual Period • Last Consensual Intercourse
149
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RELATED PROTOCOLS:
Foreign Body, Rectum or Vagina • Rectal Problems • Vaginal Bleeding, Abnormal
Notes
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Shoulder Pain
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Pain Scale • Vital Signs
• Oxygen Saturation • Cause
151
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RELATED PROTOCOLS:
Chest Pain • Extremity Injury • Motor Vehicle Accident
Notes
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?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity • Pain Scale
• Vital Signs • Oxygen Saturation
153
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RELATED PROTOCOLS:
Cold Symptoms • Fever • Sore Throat
Notes
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Sore Throat
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Associated Symptoms • Pain Scale
• Vital Signs • Oxygen Saturation • Medications
155
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RELATED PROTOCOLS:
Breathing Problems • Cold Symptoms • Cough • Ear Problems • Fever
Notes
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Suicidal Behavior
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Pain Scale • Vital Signs • Oxygen Saturation
• Prior Suicide Attempts and Method
157
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RELATED PROTOCOLS:
Anxiety • Depression • Poisoning, Exposure or Ingestion
Notes
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Sunburn
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity • Pain Scale
• Vital Signs • Tetanus Immunization Status
159
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160 Sunburn
RELATED PROTOCOLS:
Burns • Heat Exposure • Lightheadedness/Fainting
Notes
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Toothache/Tooth Injury
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity • Pain Scale
• Vital Signs
161
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RELATED PROTOCOLS:
Mouth Problems
Notes
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?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity • Pain Scale
• Vital Signs • Date Catheter Inserted
163
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RELATED PROTOCOLS:
Abdominal Pain, Adult • Abdominal Pain, Pediatric • Fever • Urination Problems
Notes
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Urination Problems
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity • Pain Scale
• Vital Signs
165
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RELATED PROTOCOLS:
Abdominal Pain, Adult • Abdominal Pain, Pediatric • Back Pain • Fever • Urinary Catheter Problems
Notes
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?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity • Pain Scale
• Vital Signs • Birth Control Measures • Last Menstrual Period • Number of Pregnancies
167
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RELATED PROTOCOLS:
Foreign Body, Rectum or Vagina • Pregnancy, Vaginal Discharge
Notes
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Vomiting
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity • Pain Scale
• Vital Signs • Health of Other Household Members • Recent Trauma
169
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170 Vomiting
RELATED PROTOCOLS:
Abdominal Pain, Adult • Abdominal Pain, Pediatric • Diarrhea, Adult • Diarrhea, Pediatric • Fever
• Head Injury • Poisoning, Exposure or Ingestion • Pregnancy, Vomiting
Notes
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Weakness
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity • Vital Signs
• Oxygen Saturation • Pain Scale (for chest pain, see Chest Pain; for difficulty breathing, see
Breathing Problems; for altered mental status, see Altered Mental Status)
171
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172 Weakness
RELATED PROTOCOLS:
Altered Mental Status • Breathing Problems • Chest Pain • Fever • Headache
GRBQ052-2149G-C85[173-174].qxd 7/28/05 1:35 AM Page 173 quark07 27B:GRBQ052:Chapters:Chapter-85:
Wound Infection
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity • Pain Scale
• Vital Signs
173
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RELATED PROTOCOLS:
Abdominal Pain, Adult • Abdominal Pain, Pediatric • Diabetic Problems
Notes
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?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity • Pain Scale
• Vital Signs • Mechanism of Injury
175
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RELATED PROTOCOLS:
Extremity Injury • Motor Vehicle Accident • Shoulder Pain
Notes
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Bibliography
Anscombe Wood, D. (2004, June 7). On the level(s). Muller, A. A. (2003). Small amounts of some drugs can be
NurseWeek. Available at: http://www.nurseweek.com toxic to young children: One pill or one swallow can
news/features/04-06/triage.asp. Accessed April 26, 2005. require aggressive treatment. Journal of Emergency
Beckstrand, R. L., & Sanders, E. K. (2003). A 39-year-old man Nursing, 29(3), 290–293.
with left shoulder pain: Comparing 3- and 5-point triage Rosen, P., Barkin, R., Hayden, R., Schaider, J., & Wolfe, R.
scales. Journal of Emergency Nursing, 29(4), 387–389. (1999). The 5-minute emergency medicine consult.
Bowman, M., & Baxt, W. (2003). Office emergencies. Philadelphia: Lippincott Williams & Wilkins.
Philadelphia: Saunders. RnCeus.com (2002). Biochemical terrorism: An ER
Briggs, J. (2002). Telephone triage protocols for nurses (2nd resource. Available at: http://www.rnceus.com. Accessed
ed.). Philadelphia: Lippincott Williams & Wilkins. April 26, 2005.
Dart, R. (2000). The 5-minute toxicology consult. Philadelphia: Tipsord-Klinkhammer, B. (Ed.) (1998). Triage: Meeting the
Lippincott Williams & Wilkins. challenge (2nd ed.). Des Plaines, IL: Emergency Nurses
Davis, M. A., Greenough, G., & Votey, S. (Eds.) (1999). Signs Association.
& symptoms in emergency medicine. St. Louis: Mosby. Travers, D., Waller, A., Bowling, M., Flowers, D., &
Emde, K. (2003). MDMA (Ecstasy) in the emergency Tintinalli, J. (2002). Five-level triage system more effec-
department. Journal of Emergency Nursing, 29(5), tive than three-level in tertiary emergency department.
440–443. Journal of Emergency Nursing 28(5), 395–400.
Ferri, F. (2003). Ferri’s clinical advisor: Instant diagnosis and Zimmermann, P. G. (2003). Orienting ED nurses to triage:
treatment. St. Louis: Mosby. Using scenario-based test-style questions to promote
Grossman, V. G. A. (2003). Quick reference to triage (2nd critical thinking. Journal of Emergency Nursing, 29(3),
ed.). Philadelphia: Lippincott Williams & Wilkins. 256–258.
Molczan, K. (2001). Triaging orthopedic injuries. Journal of Zimmermann, P. G. (2003). Tricks for the ED trade. Journal
Emergency Nursing, 27(3), 297–300. of Emergency Nursing, 29(5), 453–458.
177
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<axn>
Appendix A
Q = Quality of pain
● What does it feel like?
● Does the patient use descriptive words, such as burning, stabbing, crushing, or tearing?
R = Region/Radiation
● Where is the pain?
● Is it in one spot?
● Does it start in one spot and travel to another?
● Ask the patient to point to where it hurts using one finger.
S = Severity of pain
● If the patient were to describe the pain with a number from 0 to 10, with 0 being the least severe and
10 being the worst pain imaginable, what number would the patient give this pain?
T = Time
● When did this start?
● How long have the symptoms persisted?
● How long did it last?
● Has it ever happened before?
T = Treatment
● Has the patient taken any medication to treat this?
● What time was the last dose?
● Has the patient done anything to treat him- or herself?
● What has or has not worked for the patient?
179
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Appendix B
R E M E M B E R :
• The patient’s normal range should always be taken into consideration.
• Heart rate, blood pressure, and respiratory rate are expected to increase during times of
fever or stress.
• Respiratory rate on infants should be counted for a full 60 seconds.
• In a clinically decompensating child, the blood pressure will be the last to change. Just
because your pediatric patient’s blood pressure is normal, don’t assume that your
patient is stable.
• Bradycardia in children is an ominous sign, usually a result of hypoxia. Act quickly, as
this child is extremely critical.
180
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<axn>
Appendix C
Dosage
181
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Appendix D
182
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<axn>
Appendix E
43.0 109.4
42.0 107.6
41.0 105.8
40.5 104.9
40.0 104.0
39.5 103.1
39.0 102.2
38.5 101.3
38.0 100.4
37.5 99.5
37.0 98.6
36.5 97.7
36.0 96.8
35.0 95.0
34.0 93.2
33.0 91.4
32.0 89.6
31.0 87.8
30.0 86.0
29.0 84.2
28.0 82.4
27.0 80.6
26.0 78.8
25.0 77.0
24.0 75.2
23.0 73.4
(continued)
183
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184 Appendix E
Celsius Fahrenheit
22.0 71.6
21.0 69.8
20.0 68.0
19.0 66.2
18.0 64.4
<axn>
Appendix F
1 0.45
2 0.90
3 1.35
4 1.80
5 2.25
6 2.70
8 3.60
10 4.50
11 5
22 10
33 15
44 20
55 25
66 30
77 35
88 40
99 45
110 50
121 55
132 60
143 65
154 70
165 75
176 80
187 85
198 90
209 95
(continued )
185
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186 Appendix F
Pound Kilogram
220 100
231 105
242 110
253 115
264 120
275 125
286 130
297 135
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<axn>
Appendix G
(continued)
187
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188 Appendix G
(continued )
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Appendix H
(continued)
190
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(continued)
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192 Appendix H
<axn>
Appendix I
194 Appendix I
Migraines Pain:
Periodic with gradual onset
Throbbing, severe
Frequently unilateral, may progress to bilateral
Often above the eye(s)
Associated signs and symptoms:
Photophobia
Sensitivity to sound
Nausea
Vomiting
Sinus Headache Pain:
Over the sinus areas (above the eyes, beside the nose, or over the
cheekbone)
Associated signs and symptoms:
Fever
Nasal drainage or congestion
Ear pain
Tenderness, swelling, or erythema of the sinus area
Subarachnoid Hemorrhage Pain:
“Worst headache of my life”
Associated signs and symptoms:
With or without transient impairment of consciousness
Tension Pain:
Diffuse yet steady dull pain or pressure
“Band-like” (back of head and neck, across forehead, and/or
temporal areas)
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Appendix J
196 Appendix J
What is the last thing the patient remembers before the accident?
What is the first thing the patient remembers after the accident?
<axn>
Appendix K
Pedestrian struck by car Fractures of the femur, tibia, and fibula on side of
• Adult point of impact is usually knee/hip impact
Fractured pelvis
Contralateral ligament damage to knee
Pedestrian struck by car Contralateral skull fracture
• Short adult/child point of impact involves Chest injury with rib and/or sternal fracture
chest and/or head May be thrown, resulting in head/back injury
Shoulder dislocation and/or scapular fracture
Patellar and lower femur fracture
Pedestrian dragged under a vehicle Pelvic fracture
MVA: Unrestrained front seat passenger Posterior dislocation of acetabulum
• Front impact Fractures of femurs and/or patellas
MVA: Unrestrained driver Head injury, c-spine injury, pelvic fracture
• Front impact Flail chest, fractured sternum
Aortic or tracheal tears
Pulmonary/cardiac contusion
Ruptured or lacerated liver or spleen
Femur and/or patellar fracture, hip dislocation
MVA: Unrestrained driver or passenger Chest: flail, fractured sternum, pulmonary/cardiac
• Side impact contusion
Fractures of clavicle, acetabulum, pelvis
Lateral neck strain or injury
Driver: ruptured spleen
Passenger: ruptured liver
MVA: Passenger without headrest restraint Hyperextension of neck resulting in high c-spine or
• Rear impact vertebral fracture or ruptured disk(s), causing
intradural hemorrhage, edema, spinal cord
compression
(continued)
197
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198 Appendix K
MVA: Rotational force from spinning car Combination of frontal and side impact–induced
injuries
MVA: Rollover of vehicle Multitude of external and internal injuries
MVA: Ejection from vehicle Injuries at point of impact
MVA: Restrained driver or passenger Compression of soft tissue organs, c-spine injuries, rib
and sternal fractures, cardiac contusions, ruptured
diaphragm
Lap belt only: head, neck, facial, and chest injuries
Shoulder strap only: severe neck injury, decapitation
Air bag deployed: facial injuries, abrasions/burns of
arms
Fall
• Landing on feet Compression fractures of lumbosacral spine
Fractures of calcaneus
• Landing on buttocks Compression fracture of lumbar vertebrae
Pelvic fracture
Coccyx fracture
Diving Forceful cervical spine compression resulting in
• Head first fracture, dislocation, and/or displacement of
vertebral bone fragments into spinal canal
Blunt head trauma Coup/contra-coup injury
• Person’s moving head strikes a stationary Depressed skull fracture
object Cerebral hematoma, contusions, or laceration
Blunt chest trauma Pulmonary contusion
• Moving object strikes a person’s chest Hemothorax
Rib fractures
Crush injury to chest Traumatic asphyxia
• Crushing trauma to chest forces blood from heart
via the superior vena cava to veins of the head, neck,
and upper chest, causing subconjunctival and/or
retinal hemorrhage, conjunctival edema, and
characteristic deep violet skin color
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<axn>
Appendix L
(continued)
199
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200 Appendix L
<axn>
Appendix M
(continued)
201
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202 Appendix M
<axn>
Appendix N
(continued)
203
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204 Appendix N
Abdomen Pliable pelvic girdle does not protect Laceration, fracture, rupture of solid
internal organs organs (liver, spleen, kidney): MVAs,
abuse, falls
Portion of bowel adheres to spine Hematoma, perforation of hollow organs
Organs easily crushed between bony (esophagus, stomach, intestines): MVAs,
structure and injury object physical abuse
Chest Tongue large in relation to oral cavity Respiratory arrest: airway compromise,
Narrow airway foreign body ingestion, obstruction
Obligate nose breather Pneumothorax: MVAs, falls, abuse
Short trachea Pulmonary/cardiac contusion: MVAs, falls
Pliable rib cage
Mobile mediastinal structures
Absence of valves in superior and
inferior vena cava
Head Head large in proportion to body Skull fractures: abuse, falls
Poor head control as a result of weak Subdural hematoma: abuse
neck muscles Retinal hemorrhages: abuse, traumatic
Pliable body structures and vessels asphyxia
predispose infant to diffuse head Diffuse cerebral swelling: MVAs, abuse, falls
injury High cervical fracture: MVAs
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<axn>
Appendix O
Drugs of Abuse
Drug Name/ Street Method Physical Mental
Type Name Used Effects Effects
Alcohol (a CNS Booze, Swallowed Blurs vision; slurs speech, Scrambles thought
depressant) hooch, in liquid alters coordination; process, impairs
juice, form causes heart and liver judgment, causes
brew damage, addiction, memory loss, alters
gastric and esophageal perception, causes
ulcers, brain damage, delirium, apathy
blackouts,
hypoglycemia, anemia,
Wernicke-Korsakoff
syndrome, oral cancer,
fetal alcohol syndrome;
death from overdose
Cocaine (a CNS Coke, c-dust, Smoked/ Rapidly metabolized, Euphoria, illusion
stimulant) snow, toot, free based, producing a brief high of mental or
white lady, inhaled/ of 30 minutes; chronic physical power,
blow, rock(s), snorted, use can result in cocaine extreme mood
crack, flake, injected, psychosis, a condition swings, restlessness,
big “C,” swallowed similar to paranoid hallucinations,
happy dust, in powder, schizophrenia, intense paranoia, psychosis,
Bernice, pill, or psychological dependence, severe depression,
fluff, rock form dilated pupils, profuse anxiety, formication
caine, sweating, runny nose,
coconut, dry mouth, tachycardia,
icing, hypertension, insomnia,
mojo, zip anorexia, indifference to
pain, destruction of nasal
septum, heart and lung
damage; death from
overdose
(continued)
205
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206 Appendix O
(continued)
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chlordiazepox-
ide (Librium),
lorazepam
(Ativan),
oxazepam
(Serax),
alprazolam
(Xanax)
Hallucinogens Angel dust, Swallowed in Drooling, nystagmus, Disorientation, amnesia,
(drugs that killer, pill form, restlessness, incoordi- anxiety, depression,
alter percep- black sprayed on nation, rigid muscles, confusion, agitation,
tions of whack, a cigarette tachycardia, hypertension, violent behavior,
reality) supergrass, and superhuman strength, hostility, suicidal urges,
PCP peace pill, smoked dulled sensations to extreme personality
sherms, touch and pain, changes
superweed, impaired speech; death
DOA, CJ, is common, but from
goon dust, accidents, not from
dust joint, overdose; extremely
live one, dangerous drug, as it is
mad dog, a narcotic, stimulant,
T-buzz, depressant, and hallu-
wobble cinogen; a “trip” is a
weed, cycle of stimulation,
zombie depression, hallucination,
and then repeats itself,
lasting 2 to 14 hours
LSD Acid, blue Swallowed in Nausea, tachycardia, Altered perception of
heaven, liquid form, tachypnea, hyperthermia, reality, psychotic
instant zen, dropped on hypertension, dilated disturbances, paranoia,
purple sugar cube, pupils, diaphoresis, synesthesia, hallucina-
hearts, pure sprayed on palpitations, incoordi- tions, mood swings,
love, sugar paper tablet nation; trips last 4 to terrifying flashbacks
cubes, tail 14 hours; heightens all
lights five senses
Mescaline, Mesc, moon, Swallowed in Same as LSD Same as LSD
psilocybin peyote, natural
mushrooms buttons form
Inhalants: Inhaled or Incoordination, impaired Memory and thought
Gasoline, sniffed vision, neuropathy, impairment, depression,
airplane using a muscle weakness, aggression, hostility,
glue, paper or anemia, vertigo, paranoia, abusive
(continued)
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208 Appendix O
(continued)
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(continued)
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210 Appendix O
<axn>
Appendix P
Poisonings
Substance and
Common/Street Name Clinical Signs and Symptoms
(continued)
211
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212 Appendix P
Substance and
Common/Street Name Clinical Signs and Symptoms
(continued)
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Poisonings 213
Substance and
Common/Street Name Clinical Signs and Symptoms
Other: nausea, vomiting, diarrhea, abdominal pain
Ethylene glycol CNS: ataxia, slurred speech, irritability, cerebral edema, convulsions, coma
Cardiopulmonary: tachycardia, bradycardia, hypotension, hypertension,
pulmonary edema
Other: nausea, vomiting, abdominal pain, hematemesis, acute renal failure,
myalgia, hypocalcemia
Hallucinogens CNS: restlessness, anxiety, incipient dread, distortions of reality, helplessness,
coma, hyperreflexia
Cardiopulmonary: tachycardia, hypertension, dysrhythmias, tachypnea,
respiratory arrest
Other: nausea, vomiting, hyperpyrexia, coagulopathies
Hydrocarbons CNS: intoxication, headache, euphoria, slurred speech, lethargy, coma
Cardiopulmonary: respiratory distress, cyanosis, aspiration, tachycardia,
dysrhythmia
Other: mucosal irritation, gastritis, diarrhea, acute renal failure
Hypoglycemic agents CNS: headache, blurred vision, anxiety, irritability, confusion, stupor, coma,
seizures
Cardiopulmonary: respiratory distress, apnea, palpitations, tachycardia,
hypertension, premature ventricular contractions
Other: nausea, facial flushing, hypoglycemia, facial flushing, pallor
Iron CNS: lethargy, seizures, coma
Cardiopulmonary: tachycardia, tachypnea, hypotension
Other: vomiting, abdominal pain, GI bleeding, diarrhea, renal failure,
hepatic necrosis
Isoniazid CNS: ataxia, hyperreflexia, agitation, hallucinations, psychosis, coma, seizures
Cardiopulmonary: hypotension, tachycardia, shock, respiratory depression,
Kussmaul respirations
Other: hyperthermia, nausea, vomiting, severe anion gap, rhabdomyolysis
Lead (adult) CNS: headache, confusion, altered mental status, seizures, nerve entrapment,
motor neuropathy
Cardiopulmonary/reproductive: hypertension, alterations in sperm count
and quality
Other: anorexia, dyspepsia, constipation, renal failure
Lead (pediatric) CNS: cognitive dysfunction, decreased IQ, encephalopathy, irritability,
headache, coma
Hematologic: anemia, basophilic stippling
Other: nausea, vomiting, abdominal pain, mild hearing loss
Lithium CNS: lethargy, confusion, tremor, ataxia, slurred speech, hyperreflexia,
clonus, dystonia
Cardiopulmonary: EKG changes, respiratory failure
Other: nausea, vomiting, diarrhea, diabetes insipidus, leukocytosis
(continued)
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214 Appendix P
Substance and
Common/Street Name Clinical Signs and Symptoms
Methanol CNS: inebriation, ataxia, seizures, coma, blurred vision, dilated pupils,
headache, confusion
Cardiopulmonary: hyperpnea, hypotension
Other: metabolic acidosis, nausea, vomiting, abdominal pain
Nonsteroidal CNS: drowsiness, dizziness, lethargy, seizures
anti-inflammatories Cardiopulmonary: hypotension, tachycardia, hyperventilation, apnea
Other: nausea, vomiting, abdominal pain, acute renal failure, metabolic
acidosis
Organophosphates CNS: headache, dizziness, tremors, anxiety, weakness, incoordination,
convulsions, coma
Cardiopulmonary: hypotension, bradycardia, atrioventricular block, asystole,
bronchospasm, pulmonary edema
Other: miosis, anorexia, abdominal cramps, salivation, lacrimation
Phencyclidines CNS: impaired judgment, agitation, violent behavior, psychosis, paranoia,
coma, seizures, dyskinesia
Cardiopulmonary: hypertension, tachycardia, apnea
Other: hyperthermia, acute renal failure, hypoglycemia
Phenothiazines CNS: agitation, seizures, coma, extrapyramidal signs, tardive dyskinesia
Cardiopulmonary: respiratory depression, pulmonary edema, tachycardia,
EKG changes, V tach
Other: hyperthermia, priapism, acute renal failure, constipation, ileus,
agranulocytosis, anemia
Phenytoins CNS: ataxia, nystagmus, cortical depression, confusion, slurred speech, coma,
seizures
Cardiopulmonary: hypotension, bradycardia, myocardial depression with
rapid IV infusion
Other: nausea, vomiting
Salicylates CNS: tinnitus, deafness, delirium, seizures, coma, agitation, lethargy,
confusion, cerebral edema
Cardiopulmonary: hypotension, shock, tachypnea, noncardiac pulmonary
edema, hyperventilation
Other: nausea, vomiting, hepatic injury, acute renal insufficiency, hematemesis
Sympathomimetics CNS: anxiety, headache, agitation, altered mentation, diaphoresis, stroke,
seizures
Cardiopulmonary: palpitations, chest pain, myocardial ischemia,
tachydysrhythmias, hypertension
Other: dilated pupils, dry mucous membranes, urinary retention, hyperthermia
Theophylline CNS: tremor, agitation, nervousness, seizures
Cardiopulmonary: hypotension, tachycardia, tachypnea, hypertension,
dysrhythmias
Other: nausea, vomiting, abdominal pain, hypokalemia, hyperglycemia,
leukocytosis
(continued)
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Poisonings 215
Substance and
Common/Street Name Clinical Signs and Symptoms
Appendix Q
216 (continued)
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Biological Agents
Agent and Signs, Symptoms, Contagious
Incubation Sequelae, and Vaccine Between
Period Mode of Acquisition Source Available Humans Treatment Comments
(continued)
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218 Appendix Q
Biological Agents
Agent and Signs, Symptoms, Contagious
Incubation Sequelae, and Vaccine Between
Period Mode of Acquisition Source Available Humans Treatment Comments
(continued)
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Biological Agents
Agent and Signs, Symptoms, Contagious
Incubation Sequelae, and Vaccine Between
Period Mode of Acquisition Source Available Humans Treatment Comments
(continued)
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220 Appendix Q
Biological Agents
Agent and Signs, Symptoms, Contagious
Incubation Sequelae, and Vaccine Between
Period Mode of Acquisition Source Available Humans Treatment Comments
(continued)
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Biological Agents
Agent and Signs, Symptoms, Contagious
Incubation Sequelae, and Vaccine Between
Period Mode of Acquisition Source Available Humans Treatment Comments
(continued)
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222 Appendix Q
Biological Agents
Agent and Signs, Symptoms, Contagious
Incubation Sequelae, and Vaccine Between
Period Mode of Acquisition Source Available Humans Treatment Comments
(continued)
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Biological Agents
Agent and Signs, Symptoms, Contagious
Incubation Sequelae, and Vaccine Between
Period Mode of Acquisition Source Available Humans Treatment Comments
Viral hem- VHF is a term used to Most Available Humans There Mortality
orrhagic describe a severe VHFs only for may are no rate
fevers multisystem are yellow trans- treatments varies
(VHF) syndrome in which insect or fever mit for most with each
the overall vascular animal and some of of the VHF;
system is damaged borne Argentine these VHFs most are
Initially, fever, fatigue, The hemor- VHFs Supportive between
dizziness, muscle vectors rhagic to other care is 50% and
aches, weakness, for Ebola fever at humans given 90%
and extreme fatigue and this time mortality
are seen Marburg No vaccines rate
Severe infections will viruses exist for
produce are un- the other
bleeding under the known VHFs
skin (petechiae), Humans
internal bleeding, become
or bleeding from infected
body orifices; these through
patients will contact
progress to shock, with
nervous system rodent’s
malfunction, coma, bodily
delirium, seizures, fluids or
and/or renal failure when
VHF refers to a group bitten
of illnesses caused by an
by several families arthro-
of viruses: pod
Arenaviruses
(Argentine,
Bolivian, Lassa);
Bunyaviruses (Rift
Valley, Hantavirus);
Filoviruses (Ebola,
Marburg);
Flaviviruses (tick-
borne, Kyasanur
Forest)
(continued)
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224 Appendix Q
Biological Agents
Agent and Signs, Symptoms, Contagious
Incubation Sequelae, and Vaccine Between
Period Mode of Acquisition Source Available Humans Treatment Comments
Q fever: Sudden onset of high Infected Yes, although Rare Q fever: Q fever:
Coxiella fevers (104°F to milk, not com- doxycy- 2%
burnetii ; 105°F), severe urine, mercially cline; most mortality
incubation headache, malaise, feces, available efficient rate
is 2 to 3 myalgia, confusion, amniotic in the when Chronic Q
weeks sore throat, fluid of United started fever:
post- chills, sweats, animals States within first 65%
exposure nonproductive Humans 3 days of mortality
cough, nausea, are illness rate
vomiting, diarrhea, infected Chronic Q
abdominal pain, by fever:
chest pain inhaling doxycycline
Fever lasts for 1 to 2 dried, with
weeks contam- quinolones
Thirty percent to 50% inated for at least
of patients develop particles 4 years or
pneumonia Ingestion doxycycline
This agent is highly of conta- with
infectious and minated hydrochlor-
resistant to heat, milk may oquine for
drying, and most produce 1.5 to 3
disinfectants; it illness years
easily becomes
airborne and is
inhaled by humans
and therefore is at
risk of abuse by
bioterrorists
Chronic Q fever
occurs when
infection persists
for 6 months;
these patients are
prone to
endocarditis
Sources: Arnon, 2001; CDC, 2001; Inglesby, 2000; CDC, 1997; Henderson, 1999; Dennis, 2001. Reprinted with permission from
www.rnceus.com.
(continued)
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Chemical Agents
Onset of Signs and
Agents and Symptoms Symptoms, Routes
Descriptions Post-Exposure of Exposure Action, Risks Decontamination and Treatment
Nerve agents
Sarin; Pure Immediately Runny nose, Chemicals Skin: Remove contaminated
liquid is if inhaled; watery eyes, that attack clothing (double bag in plastic
clear, may be drooling, the nervous bags and seal) and wash skin
colorless, several blurred vision, system by with large amount of soap and
tasteless; hours if it headache, binding w/ water or 5% bleach. Rinse well
becomes touches the excessive acetyl- with water.
brown with skin sweating, chest cholinesterase, Eyes: Immediately flush eyes
aging tightness, allowing with water for 10 to 15
difficulty acetylcholine minutes; do NOT cover eyes
breathing, to overstimu- with patches afterward.
nausea, vomit- late the Ingestion: Do NOT induce
ing, loss of glands and vomiting. If patient alert and
bowel/bladder voluntary able to swallow, immediately
control, muscle muscles until administer activated charcoal.
cramps, they fail. Vapor: Remove outer clothing
twitching, Lethal; 1 drop and place in sealed double bag.
confusion, on the skin Care for exposed skin as above.
convulsions, can cause Emergency treatment and
paralysis, and death in antidotes: Maintain airway,
coma less than cardiac monitor, IVs, monitor
Can enter the 15 minutes vital signs. Follow ACLS
body by protocols. Administer atropine
inhalation, (2 mg for adults, 0.05 to 0.1
ingestion, mg/kg for children) every 5 to
through the 10 minutes until respiratory
eyes and skin status stabilizes; antidote
(2-PAM CL); diazepam for
seizures (barbiturates and
phenytoin are not effective)
VX; amber Onset of Runny nose, Kills by Skin: Remove contaminated
colored, symptoms watery eyes, binding clothes and wash skin with
tasteless, varies drooling, acetyl- large amounts of soap and
and based on excessive cholinesterase; water, 10% sodium carbonate,
odorless route of sweating, chest this causes or 5% liquid household
oily liquid exposure tightness, dys- constant bleach. Rinse well with water.
VX absorbs pnea, pinpoint stimulation Administer antidote only if
very pupils, nausea, of glands and local sweating and muscular
rapidly vomiting, voluntary twitching are present.
(continued)
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226 Appendix Q
Chemical Agents
Onset of Signs and
Agents and Symptoms Symptoms, Routes
Descriptions Post-Exposure of Exposure Action, Risks Decontamination and Treatment
VX (cont’d ) through abdominal muscles until Eyes: Immediately flush eyes with
the eyes cramps, in- ultimate water for 10 to 15 minutes, then
At least 100 continence of fatigue and a place respiratory
times more bowel or cessation of protective mask. Use antidote
toxic than bladder, breathing only if more symptoms than
Sarin when twitching, ability just miosis occur. VX absorbs
entering headache, Extremely lethal 100 times faster through the
through confusion, and persis- eyes than Sarin does.
the skin coma, or tent; can last Ingestion: Do NOT induce vom-
and twice seizures for months in iting.
as toxic by Can enter the cold weather; Inhalation: Use positive-
inhalation body by evaporates pressure, full-face breathing
inhalation, 1,500 times mask. Do NOT perform
ingestion, slower than mouth-to-mouth on a patient
through the water with VX exposure!
eyes and skin Immediately administer nerve
Death can occur agent antidote.
within 15 min- Emergency treatment and
utes of absorp- antidotes: Maintain airway,
tion of fatal cardiac monitor, IVs, monitor
dosage. vital signs. Follow ACLS
protocols. Administer atropine
(2 mg for adults, 0.05 to 0.1
mg/kg for children) every 5 to
10 minutes until respiratory
status stabilizes; antidote
(2-PAM CL); diazepam for
seizures (barbiturates and
phenytoin are not effective)
GF (cyclohexyl Depending Runny nose, Organophos- Skin: Remove contaminated
sarin); on the dose, miosis, phorus clothes and wash skin with
colorless onset of headache, compound, a large amounts of soap and
and symptoms dyspnea, chest lethal water, 10% sodium carbonate,
odorless within tightness, cholinesterase or 5% liquid household
liquid in minutes or cough, drool- inhibitor bleach. Rinse well with water.
pure form hours ing, excessive similar in Administer antidote only if
Rapid absorp- sweating, action to local sweating and muscular
tion copious sinus sarin twitching is present.
through secretions, Eyes: Immediately flush eyes
the eyes nausea, with water for 10 to 15 minutes,
(continued)
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Chemical Agents
Onset of Signs and
Agents and Symptoms Symptoms, Routes
Descriptions Post-Exposure of Exposure Action, Risks Decontamination and Treatment
(continued)
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228 Appendix Q
Chemical Agents
Onset of Signs and
Agents and Symptoms Symptoms, Routes
Descriptions Post-Exposure of Exposure Action, Risks Decontamination and Treatment
(continued)
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Chemical Agents
Onset of Signs and
Agents and Symptoms Symptoms, Routes
Descriptions Post-Exposure of Exposure Action, Risks Decontamination and Treatment
compressed Contact with vision, sore Long-term Eyes: Flush eyes with water for
liquefied skin can throat, cough, exposure may 10 to 15 minutes (be sure to
gas with cause dyspnea, lung result in lung remove contact lenses), then
characteris immediate edema, death fibrosis refer for medical attention.
tic odor frostbite Enters the body Inhalation: Apply oxygen, place
by inhalation in sitting position. May need
artificial ventilation. Seek
medical evaluation.
Titanium tetra- Symptoms Red painful eyes Corrosive to Skin: Remove contaminated
chloride; may be with burns, skin, eyes, clothing, rinse with plenty of
colorless to delayed skin blisters, respiratory, water, then wash with soap
light yellow cough, dysp- and GI tract; and water
liquid with nea, chest can cause Eyes: Flush eyes with water for
pungent tightness, permanent 10 to 15 minutes (be sure to
odor abdominal eye damage remove contact lenses), then
pain, shock, Long-term refer for medical attention.
coma exposure may Ingestion: Rinse mouth. Do
Enters the body result in lung NOT induce vomiting. Seek
by inhalation impairment medical attention immediately
or ingestion Inhalation: Apply oxygen, place
in sitting position. May need
artificial ventilation. Seek
medical evaluation.
Blister agents
Lewisite; Immediate Eyelid swelling, Causes blind- Skin: Immediately wash skin and
amber to symptoms severe eye ness within clothes with 5% sodium
dark brown with eye pain, iritis, 1 minute of hypochlorite or household
liquid with exposure, copious sinus exposure bleach within 1 minute of
a strong, inhalation, drainage, Nonfatal exposure, then cut and remove
penetrating or violent sneez- hemolysis contaminated cloth. Rewash
geranium ingestion ing, cough, results in skin again with 5% liquid
odor; the Skin contact frothing anemia household bleach. Then wash
pure produces mucus, lung Metabolites contaminated skin a third time
compound symptoms edema, large excreted by with soap and water.
is a within 30 skin blisters liver cause Eyes: Immediately flush eyes
colorless, minutes and burns, focal necrosis with water for 10 to 15 minutes.
odorless, diarrhea, of liver, bil- Ingestion: Rinse mouth. Do
oily liquid hypothermia, iary passages, NOT induce vomiting. Give
hypotension and intestine patient milk to drink.
(continued)
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230 Appendix Q
Chemical Agents
Onset of Signs and
Agents and Symptoms Symptoms, Routes
Descriptions Post-Exposure of Exposure Action, Risks Decontamination and Treatment
(continued)
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Chemical Agents
Onset of Signs and
Agents and Symptoms Symptoms, Routes
Descriptions Post-Exposure of Exposure Action, Risks Decontamination and Treatment
Blood agents
Arsine; Immediate to Causes immedi- Chronic Skin: Remove contaminated
colorless delayed ate frostbite exposure is clothing, then rinse with
compressed symptoms, when contact carcinogenic plenty of water. Do NOT
liquefied depending made with eyes to humans remove clean clothing. Seek
gas with a on or skin medical help for frostbite.
characteris- exposure Headache, Eyes: Flush eyes with water for
tic odor confusion, 10 to 15 minutes, follow with
dizziness, an immediate eye exam.
nausea, vomit- Inhalation: Apply oxygen, place
ing, abdominal in sitting position. May need
pain, dyspnea, artificial ventilation.
lung edema,
kidney failure,
damage to
blood cells,
death
Enters the body
by inhalation
Cyanogen Effects of Causes Overexposure Skin: Remove contaminated
chloride; exposure immediate results in clothing, then rinse with
colorless may be frostbite when death plenty of water. Do NOT
compressed delayed contact made remove clean clothing. Seek
liquefied with eyes or medical help for frostbite.
gas with a skin Eyes: Flush eyes with water for
pungent Sore throat, 10 to 15 minutes, follow with
odor severe tearing, an immediate eye exam.
confusion, Inhalation: Apply oxygen, place
drowsiness, in sitting position. May need
unconscious- artificial ventilation.
ness, nausea,
vomiting, lung
edema
Enters the body
by inhalation
or absorbed
through the
skin
(continued)
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232 Appendix Q
Chemical Agents
Onset of Signs and
Agents and Symptoms Symptoms, Routes
Descriptions Post-Exposure of Exposure Action, Risks Decontamination and Treatment
234 Appendix Q
Pre-Hospital Antidote Management When Military Mark I Kits Are Not Available
Mild Symptoms (Localized
Sweating, Difficulty Breathing, Severe Symptoms (Apnea,
Nausea, Vomiting, Diarrhea, Seizures, Flaccid Paralysis,
Patient Age Muscle Fasciculations, Weakness) Unconsciousness)
A L E R T S
• 2-PAM Cl solution needs to be reconstituted from the vial containing 1 g of desiccated
2-PAM Cl with 3 mL of saline, 5% distilled water, or sterile water; shake well. Resulting
solution is 3.3 mL of 300 mg/mL.
• Assisted ventilation should be started after the administration of the antidote for severe
cases of exposure.
• Repeat the atropine every 5 to 10 minutes until secretions have diminished and breathing
has returned to baseline.
(continued )
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Infant: 2 years old Atropine: 0.05 mg/kg IM or 0.02 Atropine: 0.1 mg/kg IM or 0.02
mg/kg IV mg/kg IV
2-PAM Cl: 15 mg/kg IV slowly 2-PAM Cl: 15 mg/kg IV slowly
Child: 2–10 years old Atropine: 1 mg IM Atropine: 2 mg IM
2-PAM Cl: 15 mg/kg IV slowly 2-PAM Cl: 15 mg/kg IV slowly
Adolescent: 10 years old Atropine: 2 mg IM Atropine: 4 mg IM
2-PAM Cl: 15 mg/kg IV slowly 2-PAM Cl: 15 mg/kg IV slowly
Adult Atropine: 2 to 4 mg IM Atropine: 6 mg IM
2-PAM Cl: 15 mg/kg (1 g) IV 2-PAM Cl: 15 mg/kg (1 g) IV
slowly slowly
Frail elderly Atropine: 1 mg IM Atropine: 2 mg IM
2-PAM Cl: 5 to 10 mg/kg IV 2-PAM Cl: 5 to 10 mg/kg IV
slowly slowly
Sources: CDC, 2001; ATSDR, 2001.
A L E R T S
• 2-Pam Cl solution may need to be reconstituted from the vial containing 1 gram of des-
iccated 2-PAM Cl with 3 mL of saline, 5% distilled water, or sterile water; shake well.
Resulting solution is 3.3 mL of 300 mg/mL.
• Use phentolamine for hypertension induced by 2-PAM (5 mg IV for adults, 1 mg IV for
children).
• Use diazepam for seizure control (0.2 to 0.5 mg IV for children 5 years old; 1 mg IV
for children 5 years old; 5 mg IV for adults).
• Repeat atropine every 5 to 10 minutes until secretions have diminished & dyspnea
relieved (for infants, use 2 mg IM or 1 mg IV)
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Appendix R
(continued)
236
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Communicable Diseases, Colds Versus Flu, and Sexually Transmitted Diseases 237
Communicable Diseases
Incubation Period Contagious Period
Disease Mode of Transmission (Days) (Days)
(continued)
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238 Appendix R
Communicable Diseases
Incubation Period Contagious Period
Disease Mode of Transmission (Days) (Days)
Herpes (varicella) Soiled dressings or Can be 2 to 3 weeks One to 5 days before the
zoster/shingles articles onset of the rash until
all sores have crusted
over—usually 10 to
21 days
Impetigo
Staph Hand-to-skin contact 4 to 10 days Until draining lesions heal
Strep Respiratory droplet, 1 to 3 days Untreated: weeks or
direct contact months; treated: 24
hours on antibiotics
Influenza Airborne, direct contact 1 to 3 days Children: 7 days; adults:
3 to 5 days
Kawasaki Unknown, seasonal Unknown Unknown
variation
Legionnaire Airborne 2 to 10 days Person-to-person: none
pneumonia
Lice
Head/body Direct contact, indirect 7 to 13 days Continuous if alive, until
contact with objects first treatment; live off
host for 7 to 21 days
Pubic (crabs) Sexual contact Egg-to-egg cycle lasts Live off host for 2 days
3 weeks
Lyme disease Tickborne 3 to 32 days Person-to-person: none
Measles (rubeola) Airborne, direct contact 7 to 18 days Before the onset of symp-
w/nasal secretions toms to 4 days after the
appearance of the rash
Meningitis
Bacterial: Direct contact, respira- 2 to 10 days Usually after 24 hours on
Meningococcal tory, droplet from antibiotic therapy
nose and mouth
Bacterial: Droplet from nose and 2 to 4 days Noncommunicable
Haemophilus mouth within 24 to 48 hours
on antibiotic therapy
Viral Varies with specific Variable; often approxi-
infectious agent mately 7 days
Mononucleosis Saliva 4 to 6 weeks Prolonged, possibly a year
Pertussis Direct contact, airborne 6 to 20 days Gradually decreases over
droplet 3 weeks
Pinworms Direct transfer (anus to 2 to 6 weeks As long as females are
mouth), indirect con- alive, eggs survive for
tact (infested bed, etc.) about 2 weeks
(continued)
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Communicable Diseases, Colds Versus Flu, and Sexually Transmitted Diseases 239
Communicable Diseases
Incubation Period Contagious Period
Disease Mode of Transmission (Days) (Days)
(continued)
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240 Appendix R
Communicable Diseases
Incubation Period Contagious Period
Disease Mode of Transmission (Days) (Days)
Communicable Diseases, Colds Versus Flu, and Sexually Transmitted Diseases 241
AIDS/HIV May remain asymptomatic for many Disease progression (from HIV to
years AIDS) is variable from a few
Developing signs and symptoms months to 12 years. Early interven-
include fatigue, fever, poor appetite, tion is essential in preserving and
unexplained weight loss, general- maintaining optimal health status.
ized lymphadenopathy, persistent
diarrhea, night sweats
Chancroid Painful genital ulceration(s) with ten- Chancroid has been associated with
der inguinal adenopathy increased risk of acquiring HIV
Ulcers may be necrotic or erosive infection. Patients should be tested
for other infections that cause
ulcers (i.e., syphilis).
Chlamydial Yellow mucopurulent cervical exudate Untreated, may develop endometritis,
Cervicitis May or may not be symptomatic salpingitis, ectopic pregnancy, and/or
Male sexual partner will likely have subsequent infertility. High preva-
nongonococcal urethritis lence of coinfection with gonococcal
infection. Infection during preg-
nancy may lead to premature rup-
ture of membranes, pneumonia, or
conjunctivitis in the infant.
Enteric Infections Sexually transmissible enteric infec- Occurs frequently with oral-genital
tions, particularly among homosex- and oral-anal contact. Infections
ual males can be life threatening if they
Abdominal pain, fever, diarrhea, vom- become systemic. Organisms may
iting be shigella, hepatitis A, giardia.
Epididymitis May or may not be transmitted sexu- Usually caused by gonorrhea or
ally chlamydia. May be caused by
Can be asymptomatic Escherichia coli after anal inter-
Non-sexually transmitted, is associ- course. Must rule out a testicular
ated with a urinary tract infection torsion before making the diagnosis
Unilateral testicular pain, swelling of epididymitis.
Genital Warts Soft, fleshy, painless growth(s) around Caused by the human papillomavirus.
the anus, penis, vulvovaginal area, Must rule out other causes of
cervix, urethra, or perineum lesion(s) such as syphilis, etc.
Lesions may cause tissue destruc-
tion. Cervical warts are associated
with neoplasia.
Gonorrhea Males may have dysuria, urinary fre- Untreated, risk of arthritis, dermatitis,
quency, thin clear or yellow urethral bacteremia, meningitis, endocardi-
discharge tis. At risk: Males: epididymitis,
(continued)
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242 Appendix R
Gonorrhea (cont’d ) Females may have mucopurulent vagi- infertility, urethral stricture, and
nal discharge, abnormal menses, sterility. Females: pelvic inflamma-
dysuria, or no symptoms tory disease. Newborns: ophthalmia
neonatorum, pneumonia
Hepatitis B Anorexia, malaise, nausea, vomiting, Chronic hepatitis, cirrhosis, liver can-
abdominal pain, jaundice, skin rash, cer, liver failure, death. Chronic car-
arthralgias, arthritis rier occurs in 6% to 10% of cases.
Infants born with hepatitis B are at
high risk for developing chronic
liver disease.
Herpes genitalis Clustered vesicles that rupture, leaving Other causes of genital ulcers
(Herpes simplex painful, shallow genital ulcer(s) that (syphilis, chancroid, etc.) must be
type 2) eventually crust ruled out.
Initial outbreak last for 14 to 21 days;
subsequent outbreaks are less severe
and last 8 to 12 days
Nongonococcal Dysuria, urinary frequency, mucoid to Can be caused by chlamydia,
Urethritis purulent urethral discharge mycoplasma, trichomonas, or her-
Some men may be asymptomatic pes simplex. Can cause urethral
Female sexual partners may have cer- strictures, prostatitis, epididymitis.
vicitis or PID
Pelvic Inflammatory Lower abdominal pain, fever, cervical Must rule out appendicitis or ectopic
Disease motion tenderness, dyspareunia, pregnancy. Risk for pelvic abscess,
purulent vaginal discharge, dysuria, future ectopic pregnancy, infertility,
increased abdominal pain while pelvic adhesions.
walking.
Proctitis Sexually transmitted gastrointestinal May be caused by chlamydia, gonor-
illnesses rhea, herpes simplex, and syphilis.
Proctitis occurs with anal intercourse, Among patients coinfected with
resulting in inflammation of the HIV, herpes proctitis may be severe.
rectum with anorectal pain, tenes-
mus, and rectal discharge
Proctocolitis Sexually transmitted gastrointestinal May be caused by campylobacter,
illnesses shigella, or chlamydia. Other oppor-
Proctocolitis occurs with either anal tunistic infections may be involved
intercourse or with oral-fecal con- among immunosuppressed HIV
tact, resulting in symptoms of proc- patients.
titis as well as diarrhea, abdominal
cramps, and inflammation of the
colonic mucosa
(continued)
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Communicable Diseases, Colds Versus Flu, and Sexually Transmitted Diseases 243
Pubic Lice Slight discomfort to intense itching Sexual partners within the last month
May have pruritic, erythematous mac- should be treated. May develop lym-
ules, papules, or secondary excoria- phadenitis or a secondary bacterial
tion in the genital area infection of the skin or hair follicle.
If lice are found on the eyelashes, they
are usually pubic lice
Scabies The mite burrows under the skin of Sexual partners, household members,
the fingers, penis, and wrists and close contacts within the past
Scabies among adults may be sexually month should be examined and
transmitted, while usually not sexu- treated. May develop a secondary
ally transmitted among children infection, often with nephrotogenic
Itching (worse at night), papular erup- streptococci.
tions, and excoriation of the skin
Syphilis
Primary syphilis Painless, indurated ulcer (chancre) at All genital ulcers should be suspected
site of infection approximately to be syphilitic. Patients should be
10 days to 3 months after exposure tested for HIV and retested in
Secondary Rash, mucocutaneous lesions, lym- 3 months. At-risk sex partners are
syphilis phadenopathy, condylomata lata those within the past 3 months plus
Symptoms occur 4 to 6 weeks after duration of symptoms for primary
exposure and resolve spontaneously syphilis, and 6 months plus dura-
within weeks to 12 months tion of symptoms for secondary
syphilis.
Latent syphilis Seroreactive yet asymptomatic Should be clinically evaluated for ter-
Can be clinically latent for a period of tiary disease (i.e., aortitis, neu-
weeks to years rosyphilis, etc). At-risk sex partners
Latency sometimes lasts a lifetime are those within the past year for
early latent syphilis.
Tertiary/late May have cardiac, neurologic, oph-
syphilis thalmic, auditory, or gummatous
lesions
Neurosyphilis May see a variety of neurologic signs Diagnosis made based on a variety of
and symptoms, including ataxia, tests including: reactive serologic
bladder problems, confusion, test results, cerebrospinal fluid
meningitis, uveitis (CSF) protein or cell count abnor-
May be asymptomatic malities, positive VDRL on CSF.
Congenital Needs to be ruled out for infants born Syphilis frequently causes abortion,
syphilis to mothers with untreated syphilis, stillbirth, and complications of pre-
mothers who received incomplete maturity of infant. Treated infants
treatment, or insufficient follow-up must be followed very closely and
of reported treated syphilis retested every 2 to 3 months. Most
(continued)
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244 Appendix R
Serologic tests for mother and infant infants are nonreactive by 6 months.
can be negative at delivery if mother Infants with positive CSF should be
was infected late in pregnancy retested every 6 months and be
retreated if still abnormal at 2 years.
Trichomoniasis Profuse, thin, foamy, greenish- yellow Trichomoniasis often coexists with
(Vaginitis) discharge with foul odor gonorrhea. Perform a complete
May be asymptomatic STD assessment if trichomoniasis is
Male partners may have urethritis diagnosed.
Source: Grossman, V. A. (2003). Quick Reference to Triage (2nd ed.). Philadelphia: Lippincott Williams & Wilkins.
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<axn>
Appendix S
GREETING
●Greets patient courteously
●Utilizes proper opening script
(identifies self)
●Gathers appropriate
demographic data
●Comments:
ASSESSMENT
●Identifies emergency signs and
symptoms
●Measures vital signs
●Gathers appropriate patient his-
tory
●Upgrades patient to higher level
of urgency as needed (child,
confused adult, foreign-language
speaker)
●Makes assignment for care and
acuity within appropriate time
frame
●Identifies and documents patient
medications and allergies
●Orders appropriate medication
or diagnostic studies, per facility
protocol
●Offers and documents interim
care measures if not emergent
(splint, ice pack, emesis basin)
(continued)
245
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246 Appendix S
Time: Time:
● Documents appropriately,
including assessment, nursing
interventions, acuity, and dispo-
sition
● Comments:
COMMUNICATION SKILLS
●Conveys a positive image of
organization
●Maintains a courteous, calm,
professional demeanor
●Exhibits ability to adapt to differ-
ent personalities and emotions
●Assumes control of the inter-
view: listens attentively, inter-
jects appropriately, and elicits
necessary information
●Takes time with the patient when
appropriate; efficient without
compromising quality
●Uses simple, direct language that
the patient understands
●Does not interrupt
●Speaks at a moderate rate with
expressive modulation of tone
●Comments:
CLOSING
● Ends interview efficiently
● Informs patient of next step and
expected wait
● If patient has to wait, instructs
patient /family member to
inform triage nurse of any
changes or worsening of the
problem while waiting
● Comments:
<axn>
Appendix T
Training Exercises
248 Appendix T
7. Protocol: ___________________________
10. Protocol: ___________________________
Page Number _______
Page Number _______
Intervention(s):
Intervention(s):
_______________________________________
_______________________________________
Expected Outcome:
Expected Outcome:
_______________________________________
_______________________________________
Name of Facility Guideline:
Name of Facility Guideline:
_______________________________________
_______________________________________
8. Protocol: ___________________________
Page Number _______
Intervention(s):
_______________________________________
Name ________________ Date Completed________
Expected Outcome:
_______________________________________ Reviewed by___________ Date Reviewed_________
Name of Facility Guideline:
_______________________________________
IDENTIFYING HOW AGE AND CHRONIC ILLNESS IMPACT THE ASSIGNMENT OF AN ACUITY LEVEL
AND RISK FOR WAITING TO BE SEEN
• Select 10 different protocols that impact the acuity history of blood clotting problems; history of
level based on age, medical condition, or chronic diabetes; congestive heart failure or blood clotting
illness. problems
• Indicate, in the space provided, the name of the Acuity Level: Level 2
protocol, page number, condition that impacted Risk for Waiting: High risk
the acuity level, acuity level, risk for waiting, nurs- Nursing Considerations: Emergent, Refer for
ing considerations for referral to treatment. treatment within minutes
• Consider facility guidelines for appropriate waiting
1. Protocol: ___________________________
times for each category.
Page Number _______
Condition Impacting Acuity:
Example: _______________________________________
Protocol: Chest Pain
Acuity Level: ________________________
Page Number _______
Risk for Waiting:_____________________
Condition Impacting Acuity: Age 35 yr and heart
Nursing Consideration:
palpitations; recent trauma, childbirth, surgery, or
_______________________________________
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6. Protocol: ___________________________
Page Number _______
Condition Impacting Acuity:
Name ________________ Date Completed________
_______________________________________
Acuity Level: ________________________ Reviewed by___________ Date Reviewed_________
Risk for Waiting:_____________________
Nursing Consideration:
_______________________________________
(continued)
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250 Appendix T
SCENARIO PRACTICE
The purpose of this exercise is to help the nurse tender nodes or exudate in the back of the throat.
orient to the triage protocols and teach new nurses He is able to swallow and handle his secretions
to recognize an emergent situation, appropriate well and speak in full sentences. He describes his
disposition, and what to anticipate in terms of pain as a 5/10 on the pain scale. His vital signs are
utilization of resources. In addition, it can assist the BP 114/76, P 70, R 18, T 98.6°F.
nurse in identifying when it is appropriate to initiate Acuity Level: _________ Triage Category: ______
diagnostic studies and interventions based on facility
Time Frame to Be Seen: ____________________
guidelines.
For each scenario described below, identify in the Nursing Considerations: ___________________
space provided: Protocol Referenced: _______ Page Number ____
• The acuity level and triage category based on the 5-
tier triage system 3. A 19-year-old male has a chief complaint of
• Time frame to be seen by the physician (consider nausea since this morning. He states he “threw
facility policy for semi-urgent and non-urgent up” once this morning. He denies diarrhea or
patients) abdominal pain. He has been able to tolerate
• Anticipated nursing considerations, interventions, fluids. His vital signs are BP 120/76, P 80, R 18,
medical diagnostics, procedures, and consultations T 98.4°F.
• The protocol used and associated page number Acuity Level: _________ Triage Category: ______
EXAMPLE: A 58-year-old male has a chief complaint Time Frame to Be Seen: ____________________
of midsternal chest pain, nausea, and diaphoresis Nursing Considerations: ___________________
for the past 2 hours. He describes his pain as 8/10
Protocol Referenced:_______ Page Number ____
on the pain scale. His vital signs are BP 140/90,
P 96, R 22.
4. A 42-year-old female has a chief complaint of a
Acuity Level: 2 High Risk Triage Category: Emergent severe headache, described as the “worst
Time Frame to Be Seen: Should not wait to be seen headache of my life,” that started 1 hour prior to
Nursing Considerations: Anticipate IV, labs, EKG, arrival. She describes her pain as 10/10 on the
monitor, medications, O2 pain scale. She is awake and alert but obviously
Protocol Referenced: Chest pain Page Number ______ uncomfortable. She denies a head injury or
history of headaches. Her vital signs are BP
150/80, P 90, R 20, T 98.2°F.
1. A 26-year-old female has a chief complaint of
urinary frequency and burning when she Acuity Level: _________ Triage Category: ______
urinates. She denies flank pain or vaginal Time Frame to Be Seen: ____________________
discharge. Her last menstrual period was 2 weeks Nursing Considerations: ___________________
ago. She is taking birth-control pills. Her vital
Protocol Referenced: _______ Page Number ____
signs are BP 118/72, P 70, R 18, T 97.6°F.
Acuity Level: _________ Triage Category: ______ 5. A 68-year-old male reportedly collapsed at the
Time Frame to Be Seen: ____________________ mall and has been brought in by the paramedics.
Nursing Considerations: ___________________ His wife states that he had been complaining
Protocol Referenced: _______ Page Number ____ about chest discomfort before collapsing. He was
defibrillated 3 times and CPR has been in
2. A 17-year-old male has a chief complaint of a progress for the past 20 minutes. His pupils
sore throat since yesterday. He denies swollen or remain reactive to light.
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Acuity Level: _________ Triage Category: ______ 9. A 19-year-old male has a chief complaint that he
Time Frame to Be Seen: ____________________ was stabbed in the chest twice by his girlfriend
about 30 minutes ago. He states he is having
Nursing Considerations: ___________________
some difficulty catching his breath. He is pale
Protocol Referenced: _______ Page Number ____ and his vital signs are BP 70/40, P 128, R 26,
T 98.1°F.
6. A 24-year-old male injured his ankle while Acuity Level: _________ Triage Category: ______
playing basketball 2 hours ago. He reportedly
Time Frame to Be Seen: ____________________
came down on his ankle and felt a pop. The ankle
is now painful, swollen, and ecchymotic. He states Nursing Considerations: ___________________
that he is unable to bear weight on that extremity Protocol Referenced: _______ Page Number ____
due to the discomfort. He describes the pain as
6/10 on the pain scale. His vital signs are BP 10. A 67-year-old male has a chief complaint of
110/60, P 80, R 20, T 98.2°F. sudden weakness on his left side. He has a
Acuity Level: _________ Triage Category: ______ noticeable facial droop and is unsteady on his
Time Frame to Be Seen: ____________________ feet. He states that the symptoms started about 1
hour prior to arrival. His vital signs are BP
Nursing Considerations: ___________________ 160/94, P 98, R 20, T 100.1°F.
Protocol Referenced: _______ Page Number ____ Acuity Level: _________ Triage Category: ______
Time Frame to Be Seen: ____________________
7. A 24-year-old female has a chief complaint of Nursing Considerations: ___________________
dizziness and states her mind “feels fuzzy, she
can’t think straight.” She states she has a history Protocol Referenced:_______ Page Number ____
of diabetes and took her insulin this morning but
can’t remember whether or not she ate breakfast. 11. A 17-year-old male has a chief complaint of left
Her vital signs are BP 118/70, P 70, R 16, T 98.2°F. ear pain since last night. He states this happens
Acuity Level: _________ Triage Category: ______ every time he goes swimming, but this time he
can’t seem to shake it. His vital signs are BP
Time Frame to Be Seen: ____________________ 116/72, P 74, R 16, T 98.2°F.
Nursing Considerations: ___________________ Acuity Level: _________ Triage Category: ______
Protocol Referenced: _______ Page Number ____ Time Frame to Be Seen: ____________________
Nursing Considerations: ___________________
8. An 82-year-old female has a chief complaint of Protocol Referenced: _______ Page Number ____
“weakness, a little confused and has no appetite.”
Her daughter states that she has generally been
healthy and active up until the past few days. She 12. A 33-year-old male has a chief complaint of
also states that her mother had been complaining nausea, vomiting, and diarrhea for 3 days. He
of “some burning with urination.” Her vital signs states that he has been ill since returning from a
are BP 118/70, P 80, R 18, T 100.6°F. camping trip a few days ago. He has been unable
to keep anything down and nothing has worked
Acuity Level: _________ Triage Category: ______ to stop the vomiting or diarrhea. His vital signs
Time Frame to Be Seen: ____________________ are BP 106/62, P 88, R 18, T 98.4°F.
Nursing Considerations: ___________________ Acuity Level: _________ Triage Category: ______
Protocol Referenced: _______ Page Number ____ Time Frame to Be Seen: ____________________
(continued)
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252 Appendix T
Nursing Considerations: ___________________ and breathing without difficulty. Her vital signs
Protocol Referenced: _______ Page Number ____ are BP 126/70, P 68, R 18, T 98.4°F. Pain scale
6/10.
13. A 72-year-old male has a chief complaint of Acuity Level: _________ Triage Category: ______
abdominal pain. He states it is “pretty bad” and Time Frame to Be Seen: ____________________
radiates into his back. His wife states that the pain Nursing Considerations: ___________________
started about 2 hours ago and he nearly fainted
Protocol Referenced: _______ Page Number ____
several times prior to arrival in the Emergency
Department. His vital signs are BP 174/92, P 88,
R 20, T 98.2°F, Pain Scale 7/10. 17. A 28-year-old female has a chief complaint of a
headache, rated 7/10 on the pain scale. She has
Acuity Level: _________ Triage Category: ______
nausea and photophobia and states this episode is
Time Frame to Be Seen: ____________________ similar to other migraines she has experienced in
Nursing Considerations: ___________________ the past but this one has not responded to her
Protocol Referenced: _______ Page Number ____ usual homecare measures and pain medications.
Her vital signs are BP 118/68, P 88, R 22, T 98.2°F.
14. A 42-year-old male is concerned he may have an Acuity Level: _________ Triage Category: ______
allergic reaction to something he ate. He recently Time Frame to Be Seen: ____________________
ingested some peanut oil by accident and states Nursing Considerations: ___________________
he has had a severe allergy to peanuts in the past.
Protocol Referenced: _______ Page Number ____
His vital signs are BP 144/88, P 108, R 24, T 98.2°F.
He suddenly collapses after you take his vital
signs. 18. A 34-year-old female has a chief complaint of
facial injuries, including ecchymosis to both eyes,
Acuity Level: _________ Triage Category: ______
a swollen lip, and dried blood around the nose.
Time Frame to Be Seen: ____________________ She states a book fell off the shelf and hit her in
Nursing Considerations: ___________________ the face. Her vital signs are BP 138/78, P 88, R 22,
Protocol Referenced: _______ Page Number ____ T 98.2°F. Pain scale 5/10.
Acuity Level: _________ Triage Category: ______
15. A 48-year-old male has a chief complaint of Time Frame to Be Seen: ____________________
vomiting blood and abdominal pain. He is pale Nursing Considerations: ___________________
and diaphoretic. His vital signs are BP 80/50,
Protocol Referenced: _______ Page Number ____
P 118, R 24, T 98.2°F. Pain scale 6/10.
Acuity Level: _________ Triage Category: ______
19. A 77-year-old female has a chief complaint of a
Time Frame to Be Seen: ____________________ shoulder injury. She states she tripped and fell
Nursing Considerations: ___________________ about 3 hours ago on her right shoulder. She is
Protocol Referenced: _______ Page Number ____ able to ambulate and has pain and swelling to the
right upper arm. She has limited range of motion
in the right arm. Her circulation, sensation, and
16. A 17-year-old female has a chief complaint of movement are intact. Her vital signs are BP
dental pain. She has a history of right upper 138/78, P 88, R 20, T 98.2°F. Pain scale 7/10.
molar pain and swelling for the past 10 days. She
states she has been unable to get in to see a Acuity Level: _________ Triage Category: ______
dentist for the past 2 weeks. She is alert, oriented, Time Frame to Be Seen: ____________________
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Nursing Considerations: ___________________ the pain scale. His vital signs are BP 128/78, P 88,
Protocol Referenced: _______ Page Number ____ R 20, T 98.2°F.
Acuity Level: _________ Triage Category: ______
20. A 28-year-old male has a chief complaint of
splashing cleaning fluid in both eyes 20 minutes Time Frame to Be Seen: ____________________
ago. He tried to splash cold water into his eyes Nursing Considerations: ___________________
immediately afterward. His eyes are reddened,
swollen, and painful. He rates his pain a 7/10 on Protocol Referenced: _______ Page Number ____
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Index
255
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256 Index
Index 257
258 Index