Emergency Department Triage Manual, E-F

Emergency Department Triage Manual, E-F

ED Triage Manual, E-F

Edema

1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
  • Oropharyngeal edema
  • Tense abdomen
  • Limb edema with impaired distal neurovascular status
  • Facial, neck edema with exposure to suspected allergen
  • Edema with anuria
  • Pitting edema
  • Localized edema
  • History of edema, resolved

Environmental Emergencies

1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
  • CO exposure with cardiopulmonary compromise or mental status change
  • Heat exposure with:
    • Dizziness
    • Vomiting
    • Temperature > 39.0°C
  • Frostbite
  • Rectal temperature
    < 36.0°C (96.8°F)
  • Radiation exposure
  • Hx: struck by lightning
  • CO exposure without symptoms
  • Near-drowning with respiratory distress or Hx of resuscitative efforts
  • Heat exposure with:
    • Headache
    • Hyperventilation
    • Muscle cramps
    • Sweating
    • Nausea
  • Hx: near-drowning without respiratory distress or Hx of resuscitative efforts

Epistaxis

1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
  • Hemodynamic instability
  • Active epistaxis with known coagulopathy
  • Tachycardia
  • Hypertension
  • Resolved epistaxis with known coagulopathy
  • Active epistaxis
  • Resolved epistaxis

Eye Emergencies

1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
 
  • Blunt trauma to eye with:
    • Diplopia
    • Hyphema
    • Limited EOM
    • Point tenderness
    • Step-off orbital rim
    • Inability to assess eyeball
      secondary to edema
    • Refusal to open eye
    • Penetrating injury
  • < 1 mo age with purulent exudate
  • Hx: chemical in eyes with:
    • Pain
    • Tearing
    • Refusal to open eye
  • Irregular or nonreactive pupil
  • 360° subconjunctival edema
  • 360° conjunctival edema
  • Appearance blue, black, brown material on surface of sclera
  • Concerns for orbital cellulitis
  • Sudden onset loss of vision
  • Unilateral erythema, edema with fever, Hx: fever
  • Eyelid laceration
  • Hx: FB in eyes with:
    • Pain
    • Tearing
    • Refusal to open eye
  • Chemical in eyes with first aid at home, now asymptomatic
  • Subconjunctival hemorrhage
  • Exudate
  • Itching
  • Mild unilateral erythema, edema without fever
  • Scleral edema

Fainting/Syncope

1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
  • Hypertension
    Hx: IDDM
  • Cardiac disease
  • Alert, awake without clear precipitating event
  • Hx consistent with vasovagal event
  • Near syncopal episode

Fever

1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
  • Fever, hx: fever ≥ 38°C (100.4°F) with:
    • Age ≤ 8 wks
    • Oncologic disorder
    • Central line in place
    • Special immunology
    • Organ transplantation
    • Neutropenia
  • Fever, hx: fever ≥ 38.4°C (101.1°F) with sickle cell disease
  • ≥ 38°C with age 9-12 wks
  • Females ≥ 39°C and
    < 12 mos
  • Uncircumcised males
    ≥ 39°C and < 12 mos
  • Fever > 3 days
  • Do not do rectal temperature in oncology patients
  • Protective isolation needed for the following populations
    • BMT/stem cell transplant within 90 days
    • Aplastic anemia
    • SCID

Foreign Bodies

1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
  • Drooling and/or Stridor
  • Hemodynamic Instability
  • Suspected disc (button) battery in any orifice including ear
  • Significant respiratory distress
  • Dysphagia
  • Wheezing
  • Tachypnea
  • Retractions
  • Nasal flaring
  • Unequal breath sounds
  • Decreased breath sounds
  • Tachycardia
  • Chest pain
  • Suspected magnet ingestion
  • Ear Foreign Body with severe pain or obvious blood/drainage from ear canal 
  • Hx: significant choking with cyanosis
  • Possible swallowed foreign body
  • Vomiting
  • Rectal or vaginal foreign bodies without suspicion of abuse
  • Ear foreign body with:
    • Pain
    • Expandable Object
    • Hx of unsuccessful attempts
  • Ear, nose foreign body without symptoms
  • Hx: significant choking episode with symptoms now at baseline

Always evaluate for button battery ingestion in patient with possible/history of unknown foreign body or coin ingestion.

If suspicion for presence of Button Battery Ingestion (nasal or ingestion):

  1. Order STAT AP single view chest X-ray using Triage RN Standing Order (if clinically indicated, contact PEM to order sinus X-ray)
  2. Secure Chat Team 7 or Team 1 PEM when X-ray order is placed
  3. Escort immediately to ED Radiology

Note: If ingestion is suspected to be intentional with the goal of self-harm (e.g., child had suicidal ideation before swallowing object), activate the ED Behavioral Health Pathway. Initiate consults with Social Work and Psychiatry.