What is Triage?

• ROSEN's Emergency Medicine: "Triage, or sorting by acuity, is by definition an abbreviated decision-making process that can never be completely safe because of the limited information available, the lack of time invested, and the variety of presentations of illness and injury."
• Tintinalli's Emergency Medicine: "To accomplish the most good for the most number of patients, the triage team should evaluate all patients arriving at the ED and classify their condition with regard to severity of injury and need for treatment."

Where is Triage Used?

1. Emergency Departments (EDs) - every day, for routine patient flow
2. Mass Casualty Incidents (MCIs) - disasters, large accidents, warfare, pandemics
3. Prehospital/EMS - paramedics at the scene before hospital transfer
4. Military/Battlefield - the original context in which triage was developed (traced to French military surgeon Baron Dominique-Jean Larrey under Napoleon)

Triage Categories (Color-Coded System)

Emergency Severity Index (ESI)

Key Triage Systems

• START (Simple Triage and Rapid Treatment) - the standard mass casualty triage tool; assesses ability to walk, breathing, pulse/perfusion, and mental status
• SALT (Sort, Assess, Lifesaving Interventions, Treatment/Transport) - used by some US agencies
• 5-Level Australasian Triage Scale - used in Australia, with categories from Resuscitation (immediate) to Non-Urgent (seen within 2 hours)

Undertriage vs. Overtriage

• Undertriage (assigning too low a priority) - directly dangerous to the individual patient; increases risk of adverse outcomes
• Overtriage (assigning too high a priority) - wastes resources and may compromise care for other patients

Triage at Disasters

• Manually opening airways
• Controlling external hemorrhage

Hematuria - Blood in the Urine

Types of Hematuria

1. Gross Hematuria

• Blood is visible to the naked eye - urine appears pink, red, or brown ("tea-colored")
• Always alarming to the patient
• The most common cause of gross hematuria in patients over 50 years is bladder cancer

2. Microscopic Hematuria

• Blood is not visible but detected on lab testing
• Defined as ≥3 RBCs per high-powered field (HPF) on urine microscopy in adults
• In children, >5 RBCs/HPF on at least two weekly samples is considered abnormal
• Affects an estimated 2-31% of people; often an incidental finding on routine urinalysis

Pseudohematuria (Important to Distinguish!)

• Certain foods: beets, berries, rhubarb
• Medications: rifampin, phenazopyridine
• Myoglobinuria (muscle breakdown/rhabdomyolysis) - urine dipstick positive for "blood" but no RBCs on microscopy
• Hemoglobinuria (intravascular hemolysis)

A urine dipstick alone is NOT sufficient. Microscopic analysis of a clean midstream urine sample is required to confirm true hematuria - Campbell Walsh Wein Urology.

Causes of Hematuria

• In 61% of patients with hematuria, no significant pathology is found after full evaluation
• However, the malignancy detection rate is ~2.6% in screening studies, making workup essential - Textbook of Family Medicine

Localizing the Source

• Vermiform (worm-shaped) clots = upper urinary tract (kidney/ureter)
• Cuboid clots = bladder origin

Diagnosis and Evaluation

1. Urine dipstick - screening (can give false positives with myoglobin or hemoglobin)
2. Urine microscopy - confirmatory; looks for RBCs, casts, dysmorphic cells
3. Urine culture - to rule out infection
4. Imaging - CT urogram (gold standard), ultrasound, or MRI to evaluate kidneys and urinary tract
5. Cystoscopy - direct visualization of the bladder; essential to exclude bladder cancer in adults
6. Urine cytology - looks for malignant cells
7. Renal biopsy - if glomerulonephritis is suspected (especially with RBC casts, proteinuria, hypertension)

• Age >35-40
• Smoking history
• Industrial chemical exposure (aromatic amines, benzene)
• Alkylating chemotherapy history
• Chronic foreign body in urinary tract
• Analgesic abuse

Treatment

Key Clinical Points

• Hematuria is painless in most cases, but pain can occur when clots obstruct the upper urinary tract or cause urinary retention
• Never ignore hematuria, even a single episode - it may be the only symptom of bladder or kidney cancer
• Gross hematuria in a person over 50 is bladder cancer until proven otherwise
• Microscopic hematuria with RBC casts points to a glomerular (nephritic) source
• Re-evaluation is required if hematuria persists after treating an initial benign cause (e.g., UTI)

• Vascular Access Port (in oncology/IV therapy)
• Visual Acuity Preservation (in ophthalmology)

Shockable Rhythm

• The heart quivers chaotically with no organized electrical activity
• No effective cardiac output
• Treated with immediate defibrillation + CPR

Non-Shockable Rhythm

• No electrical activity at all in the heart
• Defibrillation has no effect (there is nothing to "reset")
• Treated with CPR + adrenaline (epinephrine) only

Quick Memory Aid

The logic: defibrillation works by stopping chaotic electrical activity so the heart's natural pacemaker can restart. In asystole, there is no activity to stop - shocking it does nothing.

Pressure Ulcer (Decubitus Ulcer / Bedsore / Pressure Injury)

Pathophysiology

1. Pressure - the primary cause; compresses blood and lymphatic vessels
2. Shearing forces - layers of tissue slide over each other (e.g., patient sliding down in bed)
3. Friction - skin rubs against a surface
4. Moisture - incontinence, sweat weaken skin integrity

1. Pressure on tissues overlying a bony prominence
2. Ischemia from occlusion of blood and lymphatic vessels
3. Endothelial cell swelling and vessel leak
4. Plasma leakage into the interstitium
5. Increased distance between skin cells and blood supply
6. Hemorrhage
7. Non-blanchable erythema
8. Accumulation of edema, inflammatory cells, toxic wastes, bacteria
9. Death of muscle, subcutaneous tissue, and skin

Common Sites (Bony Prominences)

• Sacrum (most common)
• Heels and ankles
• Hips / greater trochanter
• Ischial tuberosity
• Elbows
• Shoulder blades
• Back of head (occiput)
• Medial/lateral malleoli

Staging (National Pressure Injury Advisory Panel - NPIAP)

Risk Factors

• Immobility (spinal cord injury, post-op, coma)
• Dementia, Parkinson disease
• Congestive heart failure
• Incontinence - increases risk by a factor of 5 (moisture effect)
• Nutritional deficiencies: hypoalbuminemia, low protein, vitamin deficiency, cachexia
• Anemia
• Diabetes mellitus
• Advanced age

A formal risk assessment using the Braden Scale should be done for all at-risk patients (assesses sensory perception, moisture, activity, mobility, nutrition, friction/shear).

Complications

• Sepsis - most serious complication
• Cellulitis
• Osteomyelitis (especially Stage 3/4)
• Peritonitis (if ulcer penetrates into abdominal cavity)
• Nosocomial reservoir for antibiotic-resistant bacteria (e.g., MRSA, Pseudomonas, Proteus, B. fragilis)
• Mortality: in-hospital death rates of 23-36% in patients with pressure ulcers (usually due to severe underlying disease)

Prevention

1. Frequent repositioning - every 2 hours for high-risk patients; 2-4 times/day for lower risk
2. 30-degree lateral positioning - avoids direct pressure on bony prominences
3. Pressure-reducing devices - alternating air mattresses, gel mattresses, water mattresses (regular foam pads are insufficient)
4. Skin care - keep skin clean and dry; manage incontinence
5. Nutrition - adequate protein, calories, vitamin C, zinc
6. Education - multidisciplinary team approach significantly reduces incidence

Treatment

Key Nursing Interventions

• Assess skin every shift, especially over bony prominences
• Document wound size, depth, color, drainage, odor
• Use pressure-offloading devices
• Encourage mobility and activity when possible
• Ensure adequate nutrition and hydration
• Involve wound care specialist for Stage 3/4 ulcers

CAUTI - Catheter-Associated Urinary Tract Infection

Definition

1. A positive urine culture for bacteria
2. An indwelling urinary catheter (Foley) in place for >2 consecutive days - still present or removed the day prior
3. At least one symptom of UTI

"CAUTIs are the most common nosocomial (hospital-acquired) infection." - Sabiston Textbook of Surgery

Why Catheters Cause Infection

• Providing a direct path for pathogens (rectal flora, skin bacteria, environment) to reach the bladder
• Bypassing the urethral sphincters, which are a natural defense
• Eliminating the protective turbulence of natural voiding that flushes bacteria out
• Causing trauma to the urothelium, making it susceptible to bacterial colonization

Common Causative Organisms

• Escherichia coli (most common)
• Klebsiella, Proteus, other Enterobacteriaceae
• Pseudomonas aeruginosa
• Enterococcus
• Staphylococcus aureus (including MRSA)
• Yeasts (usually colonizers; rarely true infection, except in immunocompromised)

Symptoms

Note: Dysuria and frequency are NOT reliable symptoms in patients with an indwelling catheter, as the catheter itself can cause these symptoms.

Diagnosis

1. Urinalysis - presence of pyuria (WBCs in urine) supports infection; but pyuria alone does NOT distinguish CAUTI from asymptomatic bacteriuria
2. Urine culture - sent ONLY when the patient has symptoms (do NOT culture routinely)
3. Absence of pyuria makes CAUTI highly unlikely
4. Urine culture stewardship is key - inappropriate culturing leads to overtreatment and antibiotic resistance

Prevention (Tiered Approach - University of Michigan / CDC)

• Intermittent catheterization (preferred in spinal cord injury patients)
• External condom catheters (males)
• Female external catheters

Treatment

1. Remove or replace the catheter before starting antibiotics
2. Antibiotics based on culture and sensitivity:
   • First-line: Ciprofloxacin, levofloxacin, or TMP-SMX
   • If MDR organisms suspected: piperacillin-tazobactam, cefepime, or carbapenem
   • Nitrofurantoin: good option if no systemic illness and CrCl ≥30 mL/min
3. Duration:
   • 7 days - prompt responders
   • 10-14 days - delayed responders
   • 3 days - women <65 years with appropriate response

Why CAUTI Matters

• Most common healthcare-associated infection (HAI)
• Leads to unnecessary antibiotic use, contributing to antibiotic resistance
• Can progress to pyelonephritis, bacteremia, and sepsis
• Largely preventable - removal of unnecessary catheters is the single most effective intervention
• Hospitals are often not reimbursed for CAUTI-related costs under CMS (Centers for Medicare & Medicaid) rules in the US, making prevention a quality and financial priority

Oxygen Delivery Devices & Flow Rates

Low-Flow Devices

Rule of thumb for nasal cannula: each 1 L/min increase adds ~4% FiO2

• 1 L/min = 24%, 2 L/min = 28%, 3 L/min = 32%, 4 L/min = 36%, 5 L/min = 40%, 6 L/min = 44%

High-Flow Devices

Specialized/Advanced Devices

Key Clinical Points

Memory Aid

In COPD patients, use a Venturi mask to avoid giving too much oxygen, which can suppress their hypoxic drive and cause CO2 retention.

Vital Signs - Normal Ranges

Adults (≥18 years)

Pediatric Vital Signs (Age-Based)

Temperature - Definitions

Blood Pressure - Classifications (JNC / AHA)

Heart Rate - Definitions

Respiratory Rate - Definitions

Oxygen Saturation (SpO2)

Memory Aid - Adult Normals at a Glance

"60-100-12-20-120/80-37-95"

• HR: 60-100 | RR: 12-20 | BP: 120/80 | Temp: 37°C | SpO2: ≥95%