Nursing School Chapter 21: Emergency Severity Index (ESI) Triage

ESI Triage

• Categorize emergency department clients according to the Emergency Severity Index (ESI)
  • ESI incorporates illness severity and resource use to determine who to treat first
  • Triage system: most critically ill are treated first
• ESI levels:
  • ESI-1: Unstable ABCs, obvious life/organ threat, risk of dying, high resource intensity
    • Examples: cardiac arrest, intubated trauma patient, overdose with bradypnea, severe respiratory distress
  • ESI-2: Threatened ABCs, high-risk patient, high resource intensity
    • Examples: chest pain from ischemia, multiple trauma unless responsive
  • ESI-3: Stable ABCs, medium to high resource intensity
    • Examples: abdominal pain, gynecological disorders unless in severe distress, hip fracture in older patient
  • ESI-4: Stable ABCs, low resource intensity
    • Examples: closed extremity trauma, simple laceration, cystitis
  • ESI-5: Stable ABCs, need exam only
    • Examples: cold symptoms, minor burn, prescription refill

Primary Survey

• ABCDEFG assessment:
  • A: Alertness and Airway
    • Stabilize cervical spine and assess airway
    • Airway management: least to most invasive method
  • B: Breathing
    • Assess for airflow, fractured ribs, pulmonary emboli, pneumothorax, asthma attacks
    • Give high-flow oxygen with non-rebreather mask
  • C: Circulation and control of hemorrhage
    • Assess for hemorrhagic shock, check femoral or carotid pulse
    • Treat with 2 large bore IV catheters, aggressive IV fluid resuscitation, and packed red blood cells
  • D: Disability
    • Conduct neuro assessment with Glasgow Coma Scale
    • Assess pupils for size, shape, equality, and reactivity
  • E: Exposure and Environmental Control
    • Cut off clothing, prevent hypothermia, and preserve forensic evidence
  • F: Full set of vitals and family presence
    • Obtain full set of vitals, including BP in both arms if necessary
    • Have a healthcare provider explain the situation to family and friends
  • G: Get monitoring devices and give comfort
    • Attach monitoring devices, give lab tests, and provide comfort measures

Secondary Survey

• Brief survey to address all injuries
  • History and Head-to-Toe assessment:
    • Listen to caregivers, assess mechanism of injury, signs, and symptoms
    • Use MIST (Mechanism of injury, Injuries sustained, Signs and symptoms, Treatment before arrival)
    • Use SAMPLE (Symptoms, Allergies, Medications, Past medical history, Last meal, Events)
  • Full body assessment for abnormalities
    • Head, neck, and face: check for extraocular movements, Battle sign, Racoon eyes
    • Chest: inspect for respiratory distress
    • Abdomen and Flanks: inspect for blunt trauma or intra-abdominal hemorrhage, perform FAST assessment
    • Pelvis and Peritoneum: palpate the pelvis, assess for bladder distention, hematuria, dysuria, and rectal exam
    • Extremities: assess for point tenderness, crepitus, and tenderness
    • Posterior surfaces: logroll trauma patients, inspect for hidden injuries

Pulmonary

• Respiratory System Review:
  • Obstructive Pulmonary Disease: primary focus on asthma
  • Acute Respiratory Failure (ARF) and Acute Respiratory Distress Syndrome (ARDS)
  • Selecting indications for mechanical ventilation:
    • ARF, apnea, inability to breathe or protect the airway, acute respiratory distress
    • Severe hypoxemia and/or hypercapnia, respiratory muscle fatigue
  • Invasive vs. non-invasive ventilation:
    • Invasive: ET tube, tracheostomy
    • Non-invasive: mask, typical for COPD and heart failure
  • Nursing interventions for intubated patients:
    • Monitor LOC, hemodynamic stability, patient-ventilator interaction, and patient tolerance
    • Auscultate breath sounds, assess for decreased ventilation or adventitious sounds
    • Monitor ventilator settings and alarms, tube placement, and cuff pressure

Mechanical Ventilation

• Complications associated with mechanical ventilation:
  • Aspiration: treat by raising HOB 30 degrees, using Yankauer suction catheter or sterile use single catheter
  • Alterations in gastric mobility: start bowel regimen
  • Ventilator disconnection and malfunction: teach patient not to touch tube or remove tube, check secure tubes, and use alarms
  • Infection: complication, normal defenses of the upper and lower respiratory systems are bypassed
  • Sodium and water imbalance: treat based on deficiencies
  • Alveolar hypotension: air leaking, not good settings on ET tube, sedation effects
  • Barotrauma: too high air pressure ruptures alveoli
  • Volutrauma: too large of volume causes rupture
  • Vent-associated pneumonia: (due to no hand washing, contaminated equipment, adverse environment, or patient can't cough or clear secretions)
  • How to avoid vent-associated pneumonia: minimizing sedation, early mobilization, using ET tubes with subglottic secretion drainage ports, elevating the head of the bed, and oral care with chlorhexidine

Artificial Airway

• Pathophysiology, clinical manifestations, complications, interprofessional care, and nursing management of patients with an artificial or critical airway
• Differences between acute asthma exacerbation and status asthmaticus:
  • Acute asthma: alert and oriented, focused on breathing, frightened, agitated if hypoxemic
  • Status asthmaticus: extreme acute asthma attack, characterized by hypoxia, hypercapnia, and acute respiratory failure, life-threatening

Asthma

• Clinical manifestations associated with severe asthma:
  • Trigger- infection, allergen, exercise, irritant- leads to inflammatory mediators- massive vasodilation and cellular infiltration
  • Symbicort drug of choice for everyday use (LABA/ICS inhaler)
  • SABA and corticosteroid for rescue
  • Supplemental oxygen, need continuous pulse ox, normal PaO2— > or equal to 80%

Acute Respiratory Failure and Acute Respiratory Distress Syndrome

• Etiology, pathophysiology, and clinical manifestations of acute respiratory failure (ARF):
  • One or both of the gas exchange functions of the lungs are compromised
  • Not a disease but a symptom that reflects lung function
  • Life-threatening disorder with a high mortality rate
  • Causes: shunts, diffusion limitation, alveolar hypoventilation
  • Pathophysiology: mismatch between ventilation (V) and perfusion (Q)
  • Clinical manifestations: mental status change, late sign cyanosis, PaO2 less than or equal to 45 mm Hg

Respiratory Failure

• Nursing and interprofessional management of hypoxemic or hypercapnic respiratory failure:
  • Hypoxemic respiratory failure: defined as a PaO2 less than or equal to 60 mm Hg with normal or slightly suboptimal PaCO2 levels
  • Hypercapnic respiratory failure: defined as a PaCO2 greater than 50 mm Hg, which may or may not be accompanied by hypoxemia and/or acidemia
  • Treatment: treat underlying cause, assess ability to breathe immediately, oxygen therapy, may need intubation and mechanical ventilation
  • Medications: bronchodilators, corticosteroids, diuretics, iv antibiotics
  • Nursing management: maintain patent airway, suctioning, absence of dyspnea, ensure they can effectively cough and clear secretions, chest physiotherapy, keep ABGs the same, may need non-invasive positive pressure ventilation, hydration### Acute Respiratory Distress Syndrome (ARDS)
• ARDS is a life-threatening condition that occurs when the lungs are injured, causing inflammation and flooding of the airspaces
• Causes of ARDS:
  • Direct injury: pathogen in lungs, aspiration, virus, bacteria, drowning
  • Indirect injury: sepsis, massive trauma, blood transfusion, pancreatitis
• Pathophysiology:
  • Injury or exudative phase
  • Reparative or proliferative phase
  • Fibrotic or fibroproliferative phase
• Diagnostic criteria:
  • Development within 1 week of a known clinical insult or new or worsening respiratory symptoms
  • Chest x-ray with new bilateral opacities
  • Low PaO2/FIO2 (P/F) ratio:
    • Mild ARDS: P/F ratio < 300 with PEEP or CPAP > 5 cm H2O
    • Moderate ARDS: P/F ratio < 200 with PEEP or CPAP > 5 cm H2O
    • Severe ARDS: P/F ratio < 100 with PEEP or CPAP > 5 cm H2O
• Symptoms:
  • Initial presentation: mild dyspnea, tachypnea, cough, restlessness, fine scatter crackles
  • As ARDS worsens: changes in mental status, tachycardia, hypotension, and severe changes in oxygen, ventilation, and acid-base balance

Nursing and Interprofessional Management of ARDS

• Mechanical ventilation
• Antibiotics if caused by sepsis or organism
• Corticosteroids to calm inflammation response
• Select measures to prevent and manage complications of ARF and ARDS:
  • Infection control
  • Managing secretions
  • Keeping the patient well oxygenated

Organ Transplantation

• Transplant process:
  • Organ donation from deceased or living donors
  • ABO and HLA matching
  • Crossmatching
  • Immunosuppression therapy
• Types of rejection:
  • Hyperacute: occurs within 24 hours, no treatment
  • Acute: occurs within 6 months, reversible with immunosuppressive drugs
  • Chronic: occurs over months or years, irreversible
• Immunosuppressive therapy:
  • Calcineurin inhibitors
  • Corticosteroids
  • Purine synthesis antagonists
  • Sirolimus
• Side effects of immunosuppressive therapy:
  • Bone marrow suppression
  • Increased risk of infection

Graft-Versus-Host Disease (GVHD)

• Occurs when an immunodeficient patient receives immunocompetent cells
• Target organs: skin, liver, and GI tract
• Symptoms:
  • Skin: maculopapular rash, which may be itchy or painful
  • Liver: jaundice, high liver enzymes
  • GI: diarrhea, abdominal pain, GI bleeding, and malabsorption
• Treatment:
  • Corticosteroids
  • Immunosuppressive agents
  • Radiating blood products
  • Ibrutinib

Burns

• Classification:
  • Partial-thickness burns: erythema, blanching on pressure, pain, and mild swelling
  • Full-thickness burns: dry, waxy, white, or leathery skin, visible thrombosed vessels, and insensitivity to pain
• Severity factors:
  • Inhalation injury
  • Patient age
  • Past medical history
  • Concomitant injury
  • Anatomical location of injury
• Rule of Nines:
  • Head and neck: 9%
  • Upper extremities: 9% each
  • Lower extremities: 18% each
  • Front trunk: 18%
  • Back trunk: 18%
  • Perineal area: 1%
• 3 burn phases:
  • Emergent: resolves immediate problems, up to 72 hours
  • Acute: begins with mobilization of interstitial fluid, continues until wounds are nearly healed
  • Rehabilitation: begins when wounds have nearly healed, focus on self-care and minimizing skin and joint contractures### Fluid and Electrolyte Management in Burns
• Hypernatremia may occur after successful fluid resuscitation, improper tube feedings, or inappropriate fluid administration
• Restrict sodium in IVs, enteral or oral feedings
• Hyperkalemia may occur in patients with renal failure, adrenocortical insufficiency, or massive deep muscle injury
• Assess for manifestations of hyperkalemia
• Hypokalemia occurs with vomiting, diarrhea, prolonged GI suction, or IV therapy without potassium supplementation
• Assess for manifestations of hypokalemia

Nutritional Needs of the Burn Patient

• Antioxidant protocol includes selenium, vitamin E, acetylcysteine, ascorbic acid, zinc, and a multivitamin
• Meeting daily caloric requirements is crucial and should start within the first 1-2 days post-burn
• Dietitian calculates daily caloric requirements and makes adjustments as the patient's condition changes
• Encourage high-protein, high-carbohydrate foods to meet caloric goals
• Weigh the patient weekly to evaluate progress

Prioritizing Nursing Interventions

• First, don't give anything cool to the patient
• Use pulse ox to check oxygen level if patient is becoming agitated and restless from hypoxemia
• Prioritize nursing interventions in order: coping, fluids and electrolytes, infection, nutrition, pain, perfusion, and tissue integrity

Calculating IV Fluid Replacement

• Use the Parkland formula: 2mL/kg per %TBSA
• Calculate the initial volume of fluid to infuse within the first 8 hours of resuscitation

Assessment of the Nervous System

• Normal mental status: alert and oriented, orderly thought processes, appropriate mood and affect
• Normal cranial nerves: smell intact, visual fields full, extraocular movements intact, facial sensation and movements intact
• Normal motor system: normal gait and station, symmetric muscle bulk and tone
• Normal sensory system: intact sensation to light touch, position sense, and pain
• Normal reflexes: biceps, triceps, brachioradialis, patellar, and Achilles tendon reflexes 2/5 bilaterally

Abnormal Findings

• Dysphagia, ophthalmoplegia, anisocoria, diplopia, homonymous hemianopsia, papilledema, anosognosia, apraxia, ataxia, dyskinesia, hemiplegia, nystagmus, analgesia, astereognosis, aphasia, and dysarthria

Diagnostic Studies

• Imaging studies: MRI, CT scans, PET scans, and X-rays
• Electrophysiological tests: EEG, EMG, and nerve conduction studies
• Cerebrospinal fluid (CSF) analysis: lumbar puncture
• Neuropsychological testing: assess cognitive function and behavioral changes

Acute Intracranial Problems

• Increased intracranial pressure (ICP): 5-15 mm Hg
• Cerebral perfusion pressure (CPP): 60-100 mm Hg
• Clinical manifestations: LOC, vital signs, ocular signs, decreased motor function, headache, vomiting
• Management: increase head of bed (HOB), intubate and vent, ICP monitor, optimize cerebral metabolism

Head Trauma

• Types of head injuries: scalp lacerations, skull fractures, and brain injuries
• Scalp lacerations: external head trauma, bleeding, and infection
• Skull fractures: linear, depressed, or comminuted
• Clinical manifestations: LOC, vomiting, headache, and decreased motor function

Brain Injuries

• Diffuse injuries: concussion, diffuse axonal injury
• Focal injuries: contusions, lacerations, hematomas, and cranial nerve injuries
• Management: medical and surgical interventions to prevent secondary injury

Interprofessional and Nursing Management

• Test for fluid leaking: dextrostix, Tes-Tape strip, and CSF leak test
• Management: emergency management, ICP monitoring, and surgical management
• Nursing management: prevention of increased ICP, frequent neurologic status, and close monitoring of fluid and electrolyte levels

This quiz covers the Emergency Severity Index (ESI) used in triage systems to categorize emergency department clients according to illness severity and resource use. Learn how to prioritize patients based on their condition.