This document provides information on emergency care and triage. It discusses the principles of emergency care which include providing care without delay and using triage to prioritize patients. Triage involves sorting patients into categories of emergent, urgent, and non-urgent based on the seriousness of their conditions. The document then describes the triage process in more detail, including the different color codes used to categorize patients and the criteria for each category. It also discusses the roles of triage team members and how to set up an effective triage system.

1. Prepare by:
RN Arpana Bhusal
BNS

2. EMERGENCY CARE
Emergency care is that care must be
rendered without delay.
3.2 PRINCIPLE OF EM CARE:
One of the first principle of emergency care
is triage

3. Cont…….
Emergent :
 Patients have the highest priority
their conditions are life
threatening and they must been
immediately.
Urgent :
 Patients have serious health
problem but not immediately life
threatening ones , they must be
seen within 1 hour.

4. Cont…..
 Non urgent :
 Patients have episodic illness that can be
addressed within 24 hours without increased
morbidity.

5. TRAIGE

6. PURPOSES OF TRIAGE
• Triage is necessary for the following
purposes:
To separate out the minor injuries to reduced
burden on the management of critical cases.
To provide the equitable and rational
distribution of resources.
A “color code” will be given to establish the
priority of access. To treatment on the basis
of the seriousness of the cases.

7. Cont….
In an advanced triage process injured
people are sorted into categories:
RED:
• very critical , danger of death , immediate
treatment , life threatening condition.
Typical problems are:
 Respiration / airway
 Pulse

8. Cont…..
 Mental status
 Severe burn which compromise airway.
YELLOW:
 Fairly critical , high level of risk , potential
danger of death , treatment can not be delay,
Typical problems are:
 Burn patient without airway problem
 Major bone and joint injuries.

9. Cont……
 Back and spine injuries,
GREEN:
 Not very critical , no risk of condition
worsening , treatment can be delayed
Typical problems are:
 Minor cuts
 Minor painful and swollen
 Minor soft tissue injuries.

10. Cont….
BLACK:
 Victim is extremely critical and dying.
 They are used for the decreased and for
those whose injuries are so extensive.
 They are will not be able to survive given
the care that is available.

12. PRINCIPLE OF TRIAGE SYSTEM
Should be simple.
Does not require advanced assessment skill.
Does not specific diagnosis.
Should be easy to perform.
Should provide for rapid and simple life
saving intervention.
Should be easy to teach and learn.

13. BENEFITS OF TRIAGE
Identify patients who requires rapid
medical care to save life.
Provides rational distribution of casaulties.
 By separating out the minor injuries ,
reduced urgent burden on each hospital.

14. GENERAL TRIAGE GUIDELINES
 Greet client and family in a
warm manner.
 Perform brief visual
assessment.
 Documents the
assessment.
 Triages clients into priority
group using appropriate
guideline.

15. Cont….
Transport client to treatment
area when necessary.
Keeps patient / families aware
of delays.
Reassesses waiting client to
is necessary.
Instruct client to notify triage
nurse of any change in
condition.

16. TRIAGE TEAM MEMBERS
1. Physician
2. Nurses - junior and senior
3. Student nurse
4. Lab technician
5. Sweeper
6. Clearner
7. Compounder
8. Security guard
9. Driver

17. TRIAGE SET- UP
Ventilator
Pulse oxymetery
Defibrillator
X – ray , scanning
Oxygen , suction
equipment
Infusion pumps
Emergency trolley with
medication

18. Cont…
Tracheostomy and
intubation set
Solution and instruments
Ambulance

19. ROLE OF TRIAGE NURSES
Greet patients and identify
your self.
Maintain privacy and
confidentiality.
Visualize all incoming patients
even while interviewing other.
Maintain good communication
between triage and treatment
team.

20. Cont….
Use all resources to maintain
high standard of care.
Teaching ….. Use of
thermometer , first aid??
Avoiding lecturing.
Crowd control.
Telephone
Communicate with team
leader and seek feedback on
decision.

21. D-I-S-A-S-T-E-R
Triage
For any hospital
while responding to
a mass casualty
event; the goal is to
save as many lives
as possible with the
available resources

22. D-I-S-A-S-T-E-R
Triage
● This could mean
application of the
principles of field
triage in casualty
● The purpose of
which is to
determine who
gets what kind
of care

23. D-I-S-A-S-T-E-R
Triage
● The term comes
from the French
verb trier
● Meaning to
separate, sort, sift
or select

24. D-I-S-A-S-T-E-R
Triage
A process of prioritizing patients
based on the severity of their
condition, in order to treat as
many as possible when
resources are insufficient

25. D-I-S-A-S-T-E-R
Triage
All to be treated
immediately is
impossible, so one
has to select the
suitable patients
for immediate
care based on
certain criteria ❏ Right Patient
❏ Right Place
❏ Right Time

26. Colour Category Time span
Red Emergent Within 15 minutes
Yellow Urgent Within 30 minutes
Green Delayed Within 60 minutes
Black Deceased Post mortem
D-I-S-A-S-T-E-R
Triage

27. Delayed
Yes
Open airway & Look for
movements/ Respiration
Able to walk
No
Look for Breathing
No
No
Dead
Immediate
Yes
Yes
Normal Breathing ?
No
Yes
Normal Capillary refill?
No
No
No
Yes
Normal Capillary refill?
Yes
Follow commands?
Yes
Urgent
Triag
e
Siev
e

29. D-I-S-A-S-T-E-R
Triage - Badge
● It is selected by
the Triage Nurse /
officer and worn
on each patient
involved.
● It helps for any
other staff to
immediately
identify
seriousness of the
case

30. D-I-S-A-S-T-E-R
Triage - Tape
Instead of the
triage badge,
one may use
triage tape to be
worn around the
wrist

31. D-I-S-A-S-T-E-R
Triage - Tag

32. D-I-S-A-S-T-E-R
Triage - Nurse
❏ The triage nurse
should be in view of
the waiting area of
the casualty at all
times
❏ Prioritize the waiting
patients periodically

33. D-I-S-A-S-T-E-R
Triage - Nurse
● Greeting patients and families
in a warm, empathetic manner
● Performing brief visual
assessments
● Documenting the
assessments triaging patients
into priority groups using
appropriate guidelines

34. THANK YOU