Vitals and triage

• Triage is derived from the French word meaning "to sort".
• Mass casualty situations arise when the number of patients exceeds the available resources.
• Resources in mass casualty includes space, personnel, tools, equipment like ventilators, blood, PPE, tourniquets, and IV fluids, as well as transport.
• Emergency departments operate in a state of mass casualty that varies in severity.

Pre-Hospital Triage: START Triage

• START triage utilizes the SALT methodology, which involves:
  • Sorting
  • Assessing
  • Life-saving interventions
  • Treating and Transporting
• The primary goal of the START triage algorithm is to identify patients who require and can benefit from life-saving interventions.
• Respiratory rate serves as a quick and reliable proxy for assessing a patient's level of acuity.
• Perfusion assessment involves checking both radial pulse and capillary refill.
• Pediatric triage has notable differences, including using 5 rescue breaths, and AVPU(Alert, Voice, Pain, Unresponsive)

MARCH Triage

• MARCH triage was developed by the military, acknowledging that managing the airway is ineffective if the patient is actively bleeding.
• The goal of military (combat) triage is to keep fingers on triggers and prioritize those who need more intervention, differing from civilian triage that prioritizes those who would benefit from life-saving interventions.
• In mass-casualty situations with penetrating injuries, MARCH is a reasonable approach.
• Examples of mass casualty were:
  • Boston Marathon (2013), resulting in 3 fatalities and about 265 injuries with penetrating injuries.
  • Pulse Nightclub (2016), resulting in 50 fatalities and 58 injuries from gunfire.
  • Las Vegas (2017), resulting in 61 fatalities and about 860 injuries from gunfire or shrapnel.

Triage in the ED

• Assess if the patient is sick or not sick, considering their physiological reserve and acuity.
• Use ABCDE or 12345 approach to triage
• Determine the resources needed for the patient which includes:
  • Actively trying to die
  • Needing a lot of resources
  • Maybe a CT scan or an LP
  • Maybe an x-ray
  • Med refill, etc.
• A patient initially triaged as a lower priority (D) might be upgraded to a higher priority (C or B) based on vital signs like a heart rate of 120.
• Unique triage might be needed during a pandemic situation.

Trauma Designations at UNMH

• Trauma patients are categorized into levels with specific admission criteria.
• Level 1 trauma criteria might include:
  • Penetrating trauma to the "box" area
  • Injuries above the elbow or knee
  • Altered mental status in the setting of trauma
  • Ejection from a vehicle
  • Prolonged extrication at the scene
  • Tourniquet in place.

Heart Rate

• Cardiac output is the product of heart rate and stroke volume.
• Conditions that can lower heart rate include:
  • Intrinsic factors of Aging, ischemic heart disease, and surgery/trauma.
  • Extrinsic factors such as medications/drugs/toxins, electrolyte disorders like hyperkalemia, dysfunctional implanted pacemakers, infection, endocrinopathy, and increased ICP.
• Conditions that can elevate heart rate(related to CVPR dysrhythmias) is when:
  • The heart attempts to compensate for decreased stroke volume which can include, hypovolemia, PE, or MI.
  • Increased metabolic need that can be related to Sepsis, trauma, stress/anxiety/anger, and licit/illicit drugs.

Temperature

• Fever isn't a binary concept, with many providers considering >38 degrees Celsius (100.3F) as a fever.
• The patient should be treated, not just the temperature reading.
• "Degree" of temperature elevation doesn't correlate with disease severity.
• The most accurate temperature is that of the liver/spleen.
• Measuring temperature rectally is pretty good, while orally is just ok.
• Temporal and tympanic measurements can vary by more than a degree Celsius.
• Temporal infrared is more specific
• Axillary temperature measurement is not to be used
• Accurate temperature matters in:
  • Data collection
  • Neonates
  • Neutropenic patients
• Factors that can elevate temperature are:
  • Infection
  • Exogenous or malignant hyperthermia
• Factors that can lower temperature are:
  • Elderly age
  • Infection
  • Exogenous hypothermia

Respiratory Rate

• Ensure the documented respiratory rate is correct by counting or observing the patient's breathing.
• Respiratory drive is stimulated more by CO2 levels than oxygenation.
• Ventilation is the primary method for rapid pH change.
• Holding breath lowers the pH.
• Hyperventilation elevates the pH rises.
• Depth of breathing matters:
  • Deep, fast breathing (Kussmaul) suggests acidosis.
  • Shallow, fast breathing compensates for poor alveolar recruitment due to rib fractures, asthma, COPD, pneumonia/COVID, or anxiety.
  • Shallow, slow breathing might indicate the person is dying.
• An acidotic patient can have a normal respiratory rate.

Blood Pressure

• How blood pressure is measured in research should influence decision-making in evidence-based medicine.

• A whole lecture on shock and perfusion is expected

• Blood pressure is not the same as perfusion.

• A person with a 'normal' blood pressure may be poorly perfusing.

• A person with an 'abnormal' blood pressure may be perfusing well.

• A single high blood pressure reading in a patient with acute stress or injury is not hypertension.

• Other indicators related to blood pressure:

  • Shock index(HR/SBP)Normal 0.5-0.7, higher numbers suggesting 'occult shock'.
  • Pulse pressure(SBP-DBP): Normal at approx. 25% of SBP.
    • Low (narrow) pulse pressure = low stroke volume, cardiogenic shock, CHF.
    • High (wide) can mean an increase in stroke volume, normal exercise, anemia, atherosclerosis, distributive shock, increased ICP, pregnancy, or aortic dissection.
  • Mean arterial pressure (MAP)= DP+(1/3)(SBP-DBP): Normal 65-110.

• Blood pressure can be elevated due to:

  • Atherosclerosis
  • Stress/anxiety/injury
  • Drugs

• Blood pressure can be lowered by:

  • Hypovolemia
  • Vasodilation
  • Poor cardiac output
  • Vagal response
  • Drugs

Orthostatics

• Orthostatics single-site study:
  • From Australia, orthostatics were performed on consecutive ED patients after measuring HR and BP.
  • Orthostatic Hypotension (OH) was defined as a decrease in systolic and/or diastolic by at least 20 and 10 mmHg.
  • 22.1% of all comers has orthostatic hypotension, not just those with syncope.
• The diagnostic utility for patients with syncope if >1/5 of everyone who comes to the ED has OH is undetermined. Limited by single-center study with 312 patients.

Oxygen Saturation

• Pulse oximetry works:
  • By passing two wavelengths of light through capillary beds.
  • Shorter red wavelengths are absorbed by oxyhemoglobin, and longer IR wavelengths are absorbed by hemoglobin. The percentage of oxyhemoglobin is then calculated.
• At this altitude, an O2 saturation above 90% is considered acceptable. 93% is the classic "normal" at sea level.
• Low oxygen saturation is caused by:
  • Poor alveolar gas exchange
  • Airway compromise
  • Poorly functioning hemoglobin
  • Anemia
• Falsely normal/high readings via oximetry can be caused by carbon monoxide (CO) poisoning.
• Darker skin tone is known to falsely elevate measurements.

Perfusion Index

• The perfusion index (PI) is the ratio between pulsatile and non-pulsatile blood, reflecting pulse strength at the probe location and peripheral perfusion.
• The PI is designated by “PI,” “Perf,” or “Perf I” on the monitor.
• Hypotension results in low MAP but can result in:
  • Distributive shock that may result in a nice high perfusion index, that potentially needs pressors.
  • Hypovolemic shock that will cause tight peripheral vasculature and tiny little weak perfusion index, in the case of needing fluids and or blood
• Normal PI depends on the monitor, varying from numbers to bar graphs.
• Follow the trend.
• Use depends on if being measured on finger.

End-Tidal CO2

• As carbon-based lifeforms, tissues create CO2 which we breathe out
• The rate at which CO2 leaves the lungs depends on cardiac output, lung perfusion, alveolar recruitment and function, and dead space.
• In a healthy person, end-tidal CO2 approximates blood PaCO2.

What we can use it for?

• Monitoring during sedation: monitors ventilatory status better than oxygenation.
• ET tube placement: the stomach doesn't ventilate well; colorimetric devices can be used.
• CPR: To assess adequate chest compressions.
• If end-tidal drops while doing compressions, switch compressors.
• During an off-schedule pulse-check when end-tidal suddenly jumps, consider the presence of ROSC.
• If EtCO2 doesn’t come up above 10 after a few minutes of compressions, that the patient will do well is not high.

What can make it high?

• Sepsis
• Poorly compensated acidosis
• Intermittent apnea.

What can make it low?

• Well compensated acidosis
• Apnea