(Julie K. Briggs, Valerie G.A. Grossman BSN CEN Emergency Nursing 5 Tier Triage Protocol

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EMERGENCY NURSING
5-Tier
Triage Protocols
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EMERGENCY NURSING
5-Tier
Triage Protocols
Julie K. Briggs, RN, BSN, MHA

Manager Emergency Services
Providence St. Vincent Medical Center
Portland, Oregon
Valerie G. A. Grossman, RN, BSN, CEN

Senior Nurse Counselor
Via Health: Call Center
Rochester, New York
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Copyright © 2006 by Lippincott Williams & Wilkins.
All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted, in any
form or by any means—electronic, mechanical, photocopy, recording, or otherwise—without prior written permission of the publisher,
except for brief quotations embodied in critical articles and reviews and testing and evaluation materials provided by publisher to instruc-
tors whose schools have adopted its accompanying textbook. Printed in the United States of America. For information write Lippincott
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Materials appearing in this book prepared by individuals as part of their official duties as U.S. Government employees are not covered by
the above-mentioned copyright.
9 8 7 6 5
Library of Congress Cataloging-in-Publication Data
Briggs, Julie K.
Emergency nursing : 5-tier triage protocols / Julie K. Briggs, Valerie G. A. Grossman.
p. ; cm.
Includes bibliographical references and index.
ISBN 13: 978-1-58255-371-9
ISBN 1-58255-371-8 (alk. paper)
1. Emergency nursing--Handbooks, manuals, etc. 2. Triage (Medicine)--Handbooks, manuals, etc. I. Grossman, Valerie G. A.
II. Title.
[DNLM: 1. Triage—methods—Handbooks. 2. Emergencies—nursing—Handbooks. 3. Emergency Service, Hospital—

Handbooks.
WY 49 B854e 2006]
RT120.E4B745 2006
610.73'6—dc22
2005015208
Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However,
the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information
in this book and make no warranty, express or implied, with respect to the content of the publication.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in
accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in
government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the
package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly impor-
tant when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use
in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned
for use in his or her clinical practice.
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Contributor and Reviewers
Contributor
Theresa Tavernero, RN, BSN, CEN, MHA
Nurse Consultant
Tacoma, Washington
Reviewers
Marge Bentler, RN, BSN, CEN Bret Lambert, MD, FACEP
Emergency Department Emergency Medicine
Good Samaritan Hospital Good Samaritan Hospital
Puyallup, Washington Puyallup, Washington
Clinical Assistant Professor of Medicine
Michael Brook, MD, FACEP University of Washington Medical Center
Emergency Medicine Seattle, Washington
Good Samaritan Hospital
Puyallup, Washington Theresa Tavernero, RN, BSN, CEN, MHA
Clinical Assistant Professor of Medicine Nurse Consultant
University of Washington Medical Center Tacoma, Washington
Seattle, Washington
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Preface
The Need for 5-Level Triage Protocols This protocol manual can help to achieve the fol-
Today, most emergency departments in the United lowing goals:
States, Canada, United Kingdom, Australia, and New
Zealand use some type of triage acuity system to ●
Provide consistency in triage decisions among dif-
determine how quickly a patient needs to be seen ferent nurses
and who can safely wait until rooms or resources are ●
Utilize healthcare resources in the most appropri-
available to provide the necessary care. While the ate manner
most common system has been the 3-tier system that ●
Set minimum expectations for triage decisions
rates patients as Emergent, Urgent, or Non-Urgent, ●
Guide the nurse in asking the right questions
the 5-tier triage system is rapidly gaining momen- ●
Assist the nurse in determining how soon the
tum as the system of choice. Studies have shown that patient needs to be seen
hospitals using a 5-tier system have reported greater ●
Remind the nurse of interventions to consider
consistency and accuracy in triage decisions. In 2002, ●
Serve as a reference for experienced nurses
the Emergency Nurses Association adopted a resolu- ●
Aid the less-experienced nurse in conducting the
tion promoting 5-level triage in the United States. triage assessment
In today’s rapidly changing health care environ- ●
Serve as a training tool in orientation
ment, an efficient emergency department is critical
to providing appropriate care at the appropriate time Protocol Components
in the appropriate setting. A 5-level triage system Each protocol has been developed to ensure accuracy
helps to ensure that patients are not over-triaged, and consistency among the different protocols. Each
which depletes scarce resources that may be needed protocol includes the following:
for a patient requiring immediate intervention, or
under-triaged, which puts the patient at risk for dete- Title: Protocols are arranged alphabetically and are
rioration while waiting to be seen. symptom-based. There are a few diagnosis-based
Emergency Nursing: 5-Level Triage Protocols will protocols, such as diabetic problems or asthma,
assist the triage nurse to function in a more consis- which are based on a known diagnosis or past his-
tent, reliable, and safe manner. The five levels are tory.
Resuscitation, Emergent, Urgent, Semi-Urgent, and Key Questions: These questions prompt the nurse
Non-Urgent, and they are based on patient acuity, to routinely ask for baseline and background infor-
severity of symptoms, the degree of risk for deterio- mation. To assist the nurse in meeting JCAHO and
ration while waiting, and the need for additional regulatory agency requirements, a prompt to ask
resources. In the protocols, ascending levels of about the pain scale and measure vital signs is
urgency are indicated by bolder headings and darker included in the Key Questions of all the protocols.
red icons and shading. The pain scale used is to be determined by each
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viii Preface
facility. Other key questions are protocol-specific waiting. Generally, this category of patient could be
and prompt the nurse to measure oxygen saturation seen in a lower acuity treatment area, and can safely
or ask about the mechanism of injury or tetanus wait. Each facility should determine acceptable wait-
immunization status. ing times if a room is not immediately available. In
Acuity Level/Assessment and Nursing Considerations: assigning this acuity, the nurse should consider that
The assessment is categorized from Level 1 through the patient may need only a simple exam. To improve
Level 5, with the most severe and life-threatening customer service, the nurse should reassess the wait-
symptoms listed first in Level 1. ing patient, per facility protocol, and offer comfort
Level 1—Resuscitation: This category is critical measures.
and the patient’s condition is life-threatening if not Nursing Considerations: In addition to assigning
managed immediately. In assigning this acuity, the acuity based on symptoms and resources needed, the
nurse should consider that the patient’s condition nurse is prompted when appropriate to initiate cer-
could quickly deteriorate and will require multiple tain nursing interventions. Nurses should initiate
staff at the bedside, mobilization of the resuscitation only those nursing interventions that have been
team, and many resources. approved by their facilities.
Level 2—Emergent: This category is high risk for Relevant Protocols: This section lists additional pro-
a patient waiting for treatment. The patient’s condi- tocols to consider that may assist in determining a
tion could deteriorate rapidly if treatment is delayed. more appropriate patient disposition.
In assigning this acuity, the nurse should consider
that the patient will require multiple diagnostic stud-
ies or procedures, frequent consultation with the Appendices
physician, and continuous monitoring. This section provides additional information to sup-
Level 3—Urgent: This category is moderate risk port the protocols, broaden the nurse’s scope of
for a patient waiting to be seen. The patient’s condi- knowledge, and prompt the nurse to look further in
tion is stable, but treatment should be provided as identifying potentially lethal conditions.
soon as possible to relieve distress and pain. Each Appendix A: The PQRSTT mnemonic assessment
facility should determine acceptable waiting times if a guide assists the nurse in asking the questions that will
room is not immediately available. In assigning this result in a comprehensive and high-quality interview.
acuity, the nurse should consider that the patient may Appendices B, C, D, E, F: Provide quick reference
need multiple diagnostic studies or procedures and charts to determine the appropriate dosages for
should be monitored for changes in condition while acetaminophen and ibuprofen, as well as weight and
waiting. temperature conversions.
Level 4—Semi-Urgent: This category is low risk
Appendices G, H, I: Provide additional information
for deterioration while the patient is waiting.
about three symptoms that are potentially life-threat-
Symptoms are less severe and the patient can safely
ening: abdominal pain, chest pain, and headaches.
wait for treatment. Each facility should determine
While nurses do not diagnose, it is important that
acceptable waiting times if a room is not immedi-
they understand the conditions and symptoms that
ately available. In assigning this acuity, the nurse
may be lethal.
should consider that the patient may need a simple
diagnostic study or procedure. Patients should be Appendices J, K, L, M, N: Address mechanism of
reassessed while waiting, per facility protocol. To injury (MOI) by age group. This handy guide
enhance customer service, the nurse should offer describes the types of injuries the nurse could antici-
comfort measures. pate based on age and MOI. This information will
Level 5—Non-Urgent: This category is a lower help to alert the nurse to potentially lethal conditions
risk for further deterioration while the patient is that initially could go undetected.
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Preface ix
Appendix O: A comprehensive reference tool on the impact the severity of symptoms, the appropriate
most commonly used, abused, and recreational triage disposition, and the triage experience:
drugs, their common names, and their effects. ●
Ages 65 and 1 month
Appendix P: A good reference on the signs and ●
Comorbidities, smoking, obesity, chronic disease,
symptoms of the most common types of poisoning. alcohol or drug use/abuse, immunosuppression,
Appendix Q: A handy reference on the biological hypertension, sedentary life style
and chemical agents most commonly anticipated to ●
Mechanism of injury (see appendices for age-
be used in a terrorist attack. The triage nurse may be specific guidelines)
the first to recognize the symptoms or a pattern and ●
Continued assessment while waiting
should report findings to the appropriate authority, ●
Potential EMTALA violations (all patients have a
per facility policy. right to a medical screening— review the facility’s
EMTALA policies)
Appendix R: A comprehensive chart describing the
most common communicable diseases, cold vs. flu In addition, the triage nurse should:
symptoms, and STDs. Includes modes of transmis-
sion, incubation periods, and contagious periods.
●
Develop and use standing orders to facilitate treat-
ment/diagnostic interventions at triage to improve
Appendix S: A triage assessment form to use as a patient satisfaction and throughput.
model in evaluating nurses’ interactions with ●
Keep patients informed while waiting—use this
patients. opportunity to continually reassess and improve
Appendix T: A set of training exercises to aid nurses customer satisfaction.
in identifying appropriate interventions at triage and ●
Monitor consistency in applying triage criteria and
identifying risk factors that might have an impact on assigning acuity.
assignment of acuity level. ●
Train staff in use of protocols with the 5-tier triage
system.
Additional Triage Guidelines ●
Create scenarios to rate consistency in the applica-
While every effort was made to design each protocol tion of triage protocols.
in the most comprehensive manner possible to be
age-specific and reflective of high-risk patients, the Julie K. Briggs, RN, BSN, MHA
triage nurse should be aware of the many factors that Valerie G. A. Grossman, BSN, CEN
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Acknowledgments
This has been a great experience and opportunity to work together from across the country in the creation of
this worthwhile project. We would like to express our gratitude and appreciation to Marge Bentler, RN, BSN,
CEN, Dr. Bret Lambert and Dr. Michael Brook for their thorough review and suggestions. We would also like to
extend a special thank you to Theresa Tavernero, RN, BSN, CEN, MHA, for her interest, contributions and
insightful suggestions for developing a quality product.
Julie Briggs and Valerie Grossman
Additionally, I would like to thank Valerie Grossman, my husband Worth, and my parents and friends for their
continued support and encouragement throughout this project, as I struggled to balance deadlines and life’s
unforeseeable challenges.
Julie
I am honored to have worked on this book with Julie, who has been a friend and mentor for many years. My
sincere appreciation goes to my daughters (Sarah and Nicole), my sister (Christina), and my parents (John and
Marie), who support my every project . . . and to Senior Chief Petty Officer Scott D. Grossman, US Navy, for
wherever he is in the world, he is always a role model for our family to emulate.
Valerie
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Contents
Protocols • Diabetic Problems, 57

• Abdominal Pain, Adult, 1 • Diarrhea, Adult, 59
• Abdominal Pain, Child, 3 • Diarrhea, Pediatric, 61
• Alcohol and Drug Use, Abuse, and • Ear Problems, 63
Dependence, 5 • Electric Shock/Lightning Injury, 65
• Allergic Reaction, 7 • Extremity Injury, 67
• Altered Mental Status, 9 • Eye Injury or Problems, 69
• Ankle Pain and Swelling, 11 • Feeding Tube Problems, 71
• Anxiety, 13 • Fever, 73
• Asthma, 15 • Finger and Toe Problems, 75
• Back Pain, 17 • Foreign Body, Ear, 77
• Bee Sting, 19 • Foreign Body, Ingested, 79
• Bites, Animal and Human, 21 • Foreign Body, Inhaled, 81
• Bites, Insect and Tick, 23 • Foreign Body, Rectum or Vagina, 83
• Bites, Marine Animal, 25 • Foreign Body, Skin, 85
• Bites, Snake, 27 • Genital Problems, Male, 87
• Body Art Complications, 29 • Headache, 89
• Breast Problems, 35 • Head Injury, 91
• Breathing Problems, 37 • Heart Rate, Rapid, 93
• Burns, 39 • Heart Rate, Slow, 95
• Chest Pain, 41 • Heat Exposure, 97
• Cold Exposure, Hypothermia/Frostbite, 43 • Hip Pain and Swelling, 99
• Cold Symptoms, 45 • Hives, 101
• Confusion, 47 • Hypertension, 103
• Contusion, 49 • Itching Without a Rash, 105
• Cough, 51 • Jaundice, 107
• Crying Baby, 53 • Jaundice, Newborn, 109
• Depression, 55 • Knee Pain and Swelling, 111
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xiv Contents
• Laceration, 113 Bibliography, 177

• Lightheadedness/Fainting, 115
Appendices
• Menstrual Problems, 117
• Motor Vehicle Accident, 119 A: The PQRSTT Mnemonic Assessment
• Mouth Problems, 121 Guide, 179
• Neck Pain, 123 B: Pediatric Vital Signs: Normal Ranges,
• Nosebleed, 125 180
• Poisoning, Exposure or Ingestion, 127 C: Ibuprofen Dosage Chart, 181
• Pregnancy, Abdominal Pain, 129 D: Acetaminophen Dosage Chart, 182
• Pregnancy, Back Pain, 131 E: Temperature Conversion Chart, 183
• Pregnancy, Vaginal Bleeding, 133 F: Weight Conversion Chart, 185
• Pregnancy, Vaginal Discharge, 135 G: Differential Diagnosis of Abdominal
• Pregnancy, Vomiting, 137 Pain, 187
• Puncture Wound, 139 H: Differential Diagnosis of Chest Pain, 190
• Rash, Adult and Pediatric, 141 I: Headache: Common Characteristics,
• Rectal Problems, 143 193
• Seizure, 145 J: MVA Triage Questions, 195
• Seizure, Pediatric Febrile, 147 K: Mechanisms of Injury From Trauma:
• Sexual Assault, 149 Adult, 197
• Shoulder Pain, 151 L: Mechanisms of Injury: School Age and
• Sinus Pain and Congestion, 153 Adolescent, 199
• Sore Throat, 155 M: Mechanisms of Injury: Toddler and
• Suicidal Behavior, 157 Preschooler, 201
• Sunburn, 159 N: Mechanisms of Injury: Infant, 203
• Toothache/Tooth Injury, 161 O: Drugs of Abuse, 205
• Urinary Catheter Problems, 163 P: Poisonings, 211
• Urination Problems, 165 Q: Biological Agents/Chemical Agents, 216
• Vaginal Bleeding, Abnormal, 167 R: Communicable Diseases, Colds versus
• Vomiting, 169 Flu, and Sexually Transmitted Diseases,
• Weakness, 171 236
• Wound Infection, 173 S: Triage Skills Assessment, 245
• Wrist Pain and Swelling, 175 T: Training Exercises, 247
Index, 255
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Abdominal Pain, Adult
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Associated Symptoms • Pain Scale
• Description and Location of the Pain • Vital Signs • Medications
Acuity Level/Assessment Nursing Considerations

••• Level 1: Critical Resuscitation
Pale, diaphoretic, and confused or weak Immediate treatment
Unresponsive Many resources needed
Apnea or severe respiratory distress Staff at bedside
Pulseless Mobilization of resuscitation team
••• Level 2: High Risk Emergent

Penetrating wound to abdomen Do not delay treatment
New-onset, rapidly increasing pain in Notify physician
abdomen radiating to back or legs and age Nothing by mouth until examined
50 yr Do not remove protruding object if present
Vomiting large amount of blood Multiple diagnostic studies or procedures
Lightheadedness Frequent consultation
Sudden-onset severe pain and abnormal vital Constant monitoring
signs
Signs and symptoms of dehydration
Age 50 yr and systolic BP 100
Bloody stools (unrelated to hemorrhoids or
rectal fissure)
Vaginal bleeding saturating more than three
regular-size pads per hour
History of fainting episodes
Altered mental status
••• Level 3: Moderate Risk Urgent

Severe pain Refer for treatment as soon as possible
Heavy vaginal bleeding and possibility of Nothing by mouth until examined
pregnancy Monitor for change in condition
Sudden onset May need multiple diagnostic studies or
Constipation and fever 101°F (38.3°C) procedures
1
2 Abdominal Pain, Adult

Vomiting dark, coffee-ground–like emesis If vital signs abnormal, consider Level 2
Vomiting and abdominal distention
Pregnancy
Rapidly increasing pain
Right lower quadrant pain with poor appetite,
nausea or vomiting, or fever
Ingestion of plant, drug, or chemical
Age 65 yr
••• Level 4: Low Risk Semi-Urgent

Black tarry stools with foul odor Reassess while waiting, per facility protocol
History of recent abdominal surgery or Nothing by mouth until examined
chronic pain Offer comfort measures
Nausea and vomiting May need simple diagnostic study or procedure
Fever 101°F (38.3°C)
Continuous pain 1 hour
Painful or difficult urination
Blood in urine
Unexplained progressive abdominal swelling
••• Level 5: Lower Risk Non-Urgent

No other symptoms, but parent/patient Reassess while waiting, per facility protocol
concerned Offer comfort measures
Intermittent pain May need examination only
Overconsumption of foods or fluids
Flatulence
Sensation of bladder fullness
RELATED PROTOCOLS:
Diarrhea, Adult • Foreign Body, Ingestion • Menstrual Problems • Poisoning, Exposure or Ingestion
• Pregnancy, Abdominal Pain • Urination Problems • Vaginal Bleeding, Abnormal • Vomiting
See Appendix G: Differential Diagnosis of Abdominal Pain
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Abdominal Pain, Child
?
KEY QUESTIONS:
• Description and Location of the Pain • Vital Signs • Medications

Pale, diaphoretic, and confused, weak, or limp Immediate treatment
Apnea or severe respiratory distress Many resources needed
Unresponsive Staff at bedside

Altered mental status Do not delay treatment
New-onset, rapidly increasing severe pain Notify physician
Grasping abdomen, walking bent over, Do not remove protruding object if present
screaming, or lying with knees drawn Multiple diagnostic studies or procedures
toward chest Frequent consultation
Ingestion of unknown chemical substance, Continuous monitoring
plant, medication, or object Nothing by mouth until examined
Signs and symptoms of dehydration
Penetrating wound to abdomen
Severe pain 1 hr

Possibility of pregnancy Refer for treatment as soon as possible
Sudden onset May need multiple diagnostic studies or
Fever 101°F (38.3°C) procedures
Age 2 yr and intermittent pain Monitor for change in condition
Recent abdominal trauma Nothing by mouth until examined
Right lower quadrant pain with poor appetite, If vital signs abnormal, consider Level 2
nausea, vomiting, or fever
Severe nausea or vomiting
Bloody or jelly-like stools
Black stools
History of recent abdominal surgery
3
4 Abdominal Pain, Child

Unable to comfort
Suspected abuse

Mild nausea and vomiting Reassess while waiting, per facility protocol
Painful or difficult urination Offer comfort measures
Blood in urine Nothing by mouth until examined
May need simple diagnostic study or procedure

Intermittent pain associated with eating, Reassess while waiting, per facility protocol
empty stomach, or use of pain, antibiotic, May need examination only
or anti-inflammatory medications Offer comfort measures
Unexplained progressive abdominal swelling
RELATED PROTOCOLS:
Constipation • Diarrhea • Foreign Body, Ingestion • Menstrual Problems • Poisoning, Exposure or
Ingestion • Pregnancy, abdominal pain • Urination Problems • Vaginal Bleeding • Vomiting
See Appendix G: Differential Diagnosis of Abdominal Pain
Notes
Alcohol and Drug Use, Abuse,

and Dependence
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Medications • Pain Scale • Vital Signs
• Drug or Drinking Habits • Amount and Frequency • Hours or Days Since Last Use or Drink

Apnea or severe difficulty breathing Immediate treatment
Pale, diaphoretic, and lightheaded or Many resources needed
weak Staff at bedside
Unresponsive Mobilization of resuscitation team
Pulseless

Under the influence and rapid heart rate, chest Do not delay treatment
pain, difficulty breathing, shakiness, Notify physician
dizziness Multiple diagnostic studies or procedures
Threat to hurt self or others Frequent consultation
Suicidal behavior Continuous monitoring
Overdose Keep suicidal patient under observation

Palpitations Refer for treatment as soon as possible
Signs of withdrawal; rapid heartbeat, Contact crisis worker, per facility policy
diaphoresis, fever, auditory or visual Monitor for change in condition
hallucinations or delusions May need multiple diagnostic studies or
Extremely anxious, sense of terror, agitation procedures
Severe pain If abnormal vital signs, consider Level 2
New onset of hallucinations or paranoia Keep suicidal patient under observation
Suicidal thoughts but no action
5
6 Alcohol and Drug Use, Abuse, and Dependence

Hyperventilation Provide bag and hyperventilation instructions
Profuse sweating as necessary
Acute anxiety Reassess while waiting, per facility protocol
Distorted perceptions Offer comfort measures
Difficulty functioning May need a simple diagnostic study or
procedure
Maintain visual contact of patient

No physical symptoms Reassess while waiting, per facility protocol
History of intermittent use and parent wants Offer comfort measures
patient tested May need an examination only
Request for help with addiction May need social worker consult
RELATED PROTOCOLS:
Altered Mental Status • Anxiety • Chest Pain
See Appendix O: Drugs of Abuse
Notes
Allergic Reaction
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity • Pain Scale • Suspected Cause
• Vital Signs • Oxygen Saturation • Medications

Severe difficulty breathing Immediate treatment
Pale, diaphoretic, lightheaded, or weak Mobilization of resuscitation team
Unable to speak Many resources needed
Severe swelling of tongue or throat
Hypotension
O2 saturation 90% with oxygen

Moderate oral swelling Do not delay treatment
Audible stridor or wheezing Notify physician
Hoarse voice Multiple diagnostic studies or procedures
Moderate respiratory distress Frequent consultation
Speaking in short words Continuous monitoring
Prior anaphylaxis requiring epinephrine
Difficulty swallowing
Chest pain
Rapid progression of symptoms
Urticaria and hives throughout body
O2 saturation 90% on room air

Symptoms persist after administration of Refer for treatment as soon as possible
Benadryl or epinephrine Monitor for change in condition
Minimal oral swelling May need a breathing treatment while waiting
Mild respiratory distress May need multiple diagnostic studies or
Speaking in partial sentences procedures
7
8 Allergic Reaction

Persistent nausea, vomiting, or diarrhea If vital signs abnormal, consider Level 2
Urticaria 50% of body
Fever or severe pain

Dermal contact with allergen Reassess while waiting, per facility protocol
Speaking in full sentences Offer comfort measures
Urticaria in large, localized area May need a simple diagnostic study or
Moderate pain procedure

Persistent rash Reassess while waiting, per facility protocol
No respiratory problems Offer comfort measures
Suspect medication reaction May need an examination only
Urticaria in small localized area
Minimal swelling in face or extremities
RELATED PROTOCOLS:
Asthma • Bee Sting • Breathing Problems • Hives
Notes
Altered Mental Status
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity • Pain Scale
• Vital Signs • Oxygen Saturation

Apnea or severe respiratory distress Refer for immediate treatment
Pale, diaphoretic, and lightheaded or weak Mobilization of resuscitation team
Status epilepticus Many resources needed
Pulseless

Drug or alcohol overdose Notify physician
Danger to self or others Multiple diagnostic studies or procedures
Severe headache Frequent consultation
Chest pain Continuous monitoring
Rapid heartbeat with syncope/diaphoresis
Abnormal vital signs (HR50 or 100, R8)
Diabetic
Pregnancy and heavy vaginal bleeding or
abdominal pain
Severe abdominal pain
Loss of movement in arms or legs, confusion,
difficulty speaking, numbness, tingling or
blurred vision, and onset 2 hr ago
Extreme agitation or restlessness
Headache and projectile vomiting
Headache, fever, and stiff or painful neck
Hallucinations, delusions, or mania
9
10 Altered Mental Status

Person is arousable, oriented, and any of the Refer for treatment as soon as possible
following: May need multiple diagnostic studies or
Headache, fever without stiff or painful neck procedures
Recent head injury or trauma (rule out head Monitor for change in condition
bleed) If vital signs abnormal, consider Level 2
New seizure and prolonged postictal state
Persistent high fever
Severe abdominal pain and normal vital signs
Temporary slurred speech or weakened grips
Tonic or clonic seizure
Recently ingested pain, cold, or sleeping
medication

Brief period of loss of consciousness Offer comfort measures
Alcohol intoxication Reassess while waiting, per facility protocol
Recreational drug use May need simple diagnostic study or procedure

Exhaustion Offer comfort measures
Sleep deprivation Reassess while waiting, per facility protocol
May need examination only
RELATED PROTOCOLS:
Alcohol and Drug Use, Abuse, and Dependence • Breathing Problems • Chest Pain • Fever • Headache
• Head Injury
Ankle Pain and Swelling (nontraumatic;

for injury, see Extremity Injury)
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity • Pain Scale • Vital Signs

Ankle swelling and severe difficulty breathing Immediate treatment
Staff at bedside
Mobilization of resuscitation team
Many resources needed

Chest pain Do not delay treatment
Coughing blood Notify physician
New onset and unable to walk Multiple diagnostic studies or procedures
No pedal pulse in affected extremity Frequent consultation
Foot pale, cold, or blue compared to other foot Continuous monitoring
Severe pain

Swelling and pain in ankle, thigh, or calf Refer for treatment as soon as possible
Pain or swelling and fever Monitor for change in condition
Area over ankle, calf, or thigh hotwarm to May need multiple diagnostic studies or
touch or red procedures
Sudden swelling and tenderness in single leg or If vital signs abnormal, consider Level 2
ankle
Foot numb compared to other foot
Difficulty walking
Pregnancy and sudden weight gain
11
12 Ankle Pain and Swelling

Pain in the joint or base of the big toe Reassess while waiting, per facility protocol
Red and shiny skin over the joint Offer comfort measures
May need a simple diagnostic study or
procedure

Pregnancy and gradual weight gain Reassess while waiting, per facility protocol
Offer comfort measures
May need an examination only
RELATED PROTOCOLS:
Extremity Injury
Notes
Anxiety
(if chest pain is present, see Chest Pain)
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Medications • Severity • Pain Scale
• Vital Signs

Pale, diaphoretic and lightheaded or weak Many resources needed
Staff at bedside

New onset of hallucinations or paranoia Do not delay treatment
Confusion Notify physician
Suicidal behavior Multiple diagnostic studies or procedures
Overdose Frequent consultation
Altered mental status Continuous monitoring

Palpitations Refer for treatment as soon as possible
Difficulty functioning Contact crisis worker, per facility policy
Extremely anxious Monitor for change in condition
Severe pain May need multiple diagnostic studies or
procedures
If abnormal vital signs, consider Level 2

Hyperventilation Provide bag and hyperventilation instructions
Profuse sweating as necessary
Persistent upset stomach Reassess while waiting, per facility protocol
Emotional or situational stress Offer comfort measures
Increased caffeine consumption May need a simple diagnostic study or procedure
13
14 Anxiety

No physical symptoms Reassess while waiting, per facility protocol
History of anxiety episodes and now Offer comfort measures
asymptomatic May need an examination only
RELATED PROTOCOLS:
Breathing Problems • Chest Pain
Notes
Asthma
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior Asthma History • Severity • Duration • Prior Treatment
• Medications • Pain Scale • Vital Signs • Oxygen Saturation • Peak Flow Meter Measurement

Apnea or severe respiratory distress Immediate treatment
Unable to speak Staff at bedside
Central cyanosis Mobilization of resuscitation team
Pale, diaphoretic, lightheaded, or weak

Speaking in short words Do not delay treatment
Use of accessory muscles and fatigue Notify physician
Sudden onset of wheezing after medication, Multiple diagnostic studies or procedures
food, bee sting, or exposure to known Frequent consultation
allergen Continuous monitoring
Peak flow rate 50% of baseline
Chest pain
Heightened anxiety, fear, or restlessness

Speaking in partial sentences Refer for treatment as soon as possible
Severe cough Monitor for change in condition
Prior hospitalization for same symptoms May need a breathing treatment while waiting
Persistent, audible wheezing 20 min after May need multiple diagnostic studies or
treatment procedures
Fever 103°F (39.4°C) If abnormal vital signs, consider Level 2
15
16 Asthma

Speaking in full sentences Reassess while waiting, per facility protocol
Persistent cough after use of inhaler or Offer comfort measures
nebulizer May need a simple diagnostic study or
Fever 103°F (39.4°C) procedure
Age 60 yr and fever 101°F (38.3°C)
Peak flow rate 80% of baseline

Fever and green or yellow nasal discharge Reassess while waiting, per facility protocol
Resolution of wheezing after use of inhaler or Offer comfort measures
nebulizer May need an examination only
Peak flow back to baseline
RELATED PROTOCOLS:
Allergic Reaction • Breathing Problems • Cough
Notes
Back Pain
?
KEY QUESTIONS:
• Medications

Pale, diaphoretic, and lightheaded or weak Many resources needed
Recent trauma and unable to move toes or
severe weakness in one or both lower
extremities

Altered mental status Refer for treatment within minutes
New-onset, rapidly increasing pain and age Notify physician
60 yr Multiple diagnostic studies or procedures
New-onset loss of sensation to lower Frequent consultation
extremities Continuous monitoring
Progressive weakness in legs Do not remove penetrating object
Loss of bladder or bowel control
Penetrating trauma to back or flank

Severe back or abdominal pain Refer for treatment as soon as possible
New-onset numbness and tingling in legs Monitor for change in condition
Hematuria and severe abdominal or flank pain May need multiple diagnostic studies or
Hematuria and blunt trauma to the back or procedures
flank If abnormal vital signs, consider Level 2
Pain with urination and fever 100.5°F
(38.1°C) or chills
New-onset, rapidly increasing pain and age
60 yr
17
18 Back Pain

History of diabetes, immunosuppression, or
intravenous drug abuse
Unable to urinate 8 hr
Male with fever and nausea or vomiting
History of disk injury or back surgery

Trauma within past week and worsening pain, Reassess while waiting, per facility protocol
numbness, tingling, or weakness in Offer comfort measures
extremity May need simple diagnostic study or procedure
Pain restricting ability to walk
Age 65 yr
Pain increasing with activity
Pain radiating to buttocks or hips

Chronic low back pain Reassess while waiting, per facility protocol
Minor discomfort Offer comfort measures
Rash over the painful area May need an examination only
RELATED PROTOCOLS:
Motor Vehicle Accident • Neck Pain • Urination Problems
Bee Sting
?
KEY QUESTIONS:
• Oxygen Saturation • Previous Bee Sting Reaction and Treatment

Hypotension Many resources needed
Unable to speak

Moderate oral swelling Do not delay treatment
Audible stridor or wheezing Notify physician
Hoarse voice Multiple diagnostic studies or procedures
Moderate respiratory distress Frequent consultation
Speaking in short words Continuous monitoring
Chest pain
Rapid progression of symptoms
Bee sting in the mouth

Speaking in partial sentences Refer for treatment as soon as possible
Nausea, vomiting, or weakness Monitor for changes in condition
10 stings May need multiple diagnostic studies or
Generalized hives after Benadryl or epinephrine procedures
19
20 Bee Sting

Mild wheezing If abnormal vital signs, consider Level 2
Minimal reaction to bee sting and:
Bee sting in the mouth

Able to speak in full sentences Reassess while waiting, per facility protocol
Urticaria or rash locations other than sting site Offer comfort measures
Signs of infection: drainage, fever, red streaks, May need a simple diagnostic study or
or pus 24–48 hrs after the sting procedure

Localized swelling, pain, or urticaria around Reassess while waiting, per facility protocol
sting site Offer comfort measures
RELATED PROTOCOLS:
Allergic Reaction • Bites, Insect and Tick • Breathing Problems • Hives
Notes
Bites, Animal and Human
?
KEY QUESTIONS:
Name • Age • Onset • Location • Allergies • Prior History • Severity • Pain Scale
• Vital Signs • Tetanus Immunization Status

Pulseless Many resources needed

Pulsatile bleeding Notify physician
Multiple gaping wounds Multiple diagnostic studies or procedures
Difficulty breathing or swallowing Frequent consultation
Constant monitoring

Gaping wounds May need multiple diagnostic studies or
procedures
Monitor for changes in condition
If vital signs abnormal, consider Level 2

Moderate pain Reassess while waiting, per facility protocol
Stable wounds Offer comfort measures
Abrasive wounds May need a simple diagnostic study or
Signs of infection: drainage, fever, red streaks, procedure
or pus 24 hr after the bite
History of chronic illness
Controlled bleeding
Risk for rabies exposure
21
22 Bites, Animal and Human

No break in skin Reassess while waiting, per facility protocol
Tetanus status unknown or booster 5 yr Offer comfort measures
RELATED PROTOCOLS:
Laceration • Puncture Wound • Wound Infection
Notes
Bites, Insect and Tick
?
KEY QUESTIONS:
• Vital Signs • Type of Insect

Hypotension Mobilization of resuscitation team
Unable to speak
Unable to swallow, drooling

Speaking in short words Notify physician
Difficulty breathing or chest pain Multiple diagnostic studies or procedures
Swelling of tongue or mouth with difficulty Frequent consultation
swallowing Constant monitoring

Speaking in partial sentences May need multiple diagnostic studies or
Prior anaphylaxis to insect bite requiring procedures
epinephrine Monitor for changes in condition
Widespread hives If vital signs abnormal, consider Level 2
Numerous bites, stings, or ticks
Flu-like symptoms with a history of tick bite 2
to 4 wk previous
Brown recluse spider bite
Black widow spider and no other symptoms
23
24 Bites, Insect and Tick

Signs of infection: fever, red streaks, pus, or Offer comfort measures
drainage 24 hr after bite May need a simple diagnostic study or
Unable to remove tick or tick head remains procedure
under skin
Peeling skin around the site

Sporadic hives Reassess while waiting, per facility protocol
RELATED PROTOCOLS:
Allergic Reaction • Laceration • Wound Infection
Notes
Bites, Marine Animal
?
KEY QUESTIONS:
• Tetanus Immunization Status • Marine Animal Identification

Unable to speak

Limb amputation Multiple diagnostic studies or procedures
Chest pain or difficulty breathing Frequent consultation
Swelling of throat, tongue, lips Continuous monitoring
Loss of pulses distal to injury

Diaphoretic Monitor for changes in condition
Pallor May need multiple diagnostic studies or
Hives procedures
Extremity swelling If abnormal vital signs, consider Level 2
Vision changes

Stung by Portuguese man-of-war jellyfish Offer comfort measures
Decreased range of motion For catfish, lionfish, scorpion fish, sea urchin,
Stinger present stingrays, starfish, stone fish, and
25
26 Bites, Marine Animal

surgeonfish spine punctures: consider
soaking injured part in hot saltwater for 30
to 90 min for pain relief while waiting
procedure

History of non-poisonous bite with no signs Reassess while waiting, per facility protocol
or symptoms Offer comfort measures
Tetanus status unknown or booster 5 yr May need an examination only
RELATED PROTOCOLS:
Allergic Reaction • Laceration • Puncture Wound • Wound Infection
Notes
Bites, Snake
?
KEY QUESTIONS:
• Vital Signs • Tetanus Immunization Status • Type of Snake

Apnea or severe difficulty breathing Refer for immediate treatment
Pale, diaphoretic, and lightheaded or weak Staff at bedside
Unable to speak

Bite from a poisonous snake, such as rattlesnake, Notify physician
copperhead, water moccasin, or coral snake Multiple diagnostic studies or procedures
Chest pain Frequent consultation
Difficulty swallowing or breathing Constant monitoring

Puncture wound(s) from unidentified snake May need multiple diagnostic studies or
Purple rash, fever, pallor, or facial numbness or procedures
tingling Monitor for change in condition
Prior anaphylaxis to snake bite requiring If vital signs abnormal, consider Level 2
epinephrine

Multiple bites from nonpoisonous snake Offer comfort measures
Signs of local infection: drainage, fever, red May need a simple diagnostic study or
streaks, or pus 24 hr after bite procedure
Swelling around the wound
27
28 Bites, Snake

Need for updated tetanus immunization Reassess while waiting, per facility protocol
RELATED PROTOCOLS:
Allergic Reaction • Laceration • Wound Infection
Notes
Body Art Complications
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History (Including Infectious Diseases) • Severity
• Pain Scale • Vital Signs • Oximetry • Location of Body Art • Performed by Whom (Professional
Versus Amateur) • When Performed • Immunizations (dT, Hep B)

Pulseless Staff at bedside
Remove piercings that interfere with c-spine
stabilization, medical antishock trousers,
intubation, Sager splint, Foley catheter, or
defibrillator
Avoid using wire cutters to remove piercings

Fever, hypotension, tachycardia, weakness Notify physician
Chest pain Multiple diagnostic studies or procedures
Piercing torn from site and unable to stop Frequent consultation
bleeding with pressure Continuous monitoring
Remove piercings that interfere with c-spine
stabilization, medical antishock trousers,
intubation, Sager splint, foley catheter or
defibrillation
Avoid using wire cutters to remove piercings

Skin reddened, peeling off in sheets May need multiple diagnostic studies or
Skin red and warm to touch and fever procedures
Fever, chills, general malaise, or headache Monitor for change in condition
Vomiting, abdominal pain, jaundice Leave piercing in place if possible
29
30 Body Art Complications

Piercing torn from site, bleeding controlled If vital signs abnormal, consider Level 2
Swallowed oral jewelry
Swollen lymph nodes and fever

Skin red and warm to touch, swelling, or red Offer comfort measures
streaks (no fever) May need simple diagnostic study or procedure
Jewelry slipped inside of piercing site, no Leave piercing in place if possible
visible jewelry
Swollen lymph node
Darkened hard and painful area around the
piercing or tattoo

Body art remorse (patient or parent requests Reassess while waiting, per facility protocol
reversal of procedure) Offer comfort measures
No other symptoms, but new piercing or May need examination only
tattoo and patient or parent concerned
RELATED PROTOCOLS:
Laceration • Wound Infection
Common Complications: Body Piercing

Location Jewelry Used Healing Time Common Complications
Ampallang Barbell stud 6 to 12 mo • Keloid formation
• May interrupt the flow of urine
(may need to sit to void)
• Formation of abscesses, cysts, or
boils
• Ripping and tearing of skin if
jewelry gets caught on clothing
Cheek Labret stud 6 to 8 wk • Swelling, infection, gum injury,
increased salivation
• Chipped or broken teeth
• Speech impairment
Body Art Complications 31
Common Complications: Body Piercing (continued)

Cheek Labret stud 6 to 8 wk • Aspiration or ingestion of
(continued) loosened jewelry
• Difficulty chewing and
swallowing
• Massive systemic infection,
septic shock
boils
Clitoris Captive bead 4 to 10 wk • Keloid formation
ring, barbell stud • Formation of abscesses,
cysts, or boils
Clitoris hood Captive bead 4 to 10 wk • Keloid formation
ring, captive • Formation of abscesses, cysts, or
stone ring, boils
circular barbell • Ripping and tearing of skin if
Earlobe Captive bead 4 to 6 wk • Keloid formation
ring, circular • Formation of abscesses, cysts, or
barbell, captive boils
stone ring • Ripping and tearing of skin if
Ear cartilage Same pieces as 4 to 12 mo • Keloid formation
an earlobe; larger • Formation of abscesses, cysts, or
gauge is used boils
• Prone to pseudomonal infections
Ear plug Increasing sizes Gradual • Keloid formation
of an object enlargement • Overstretching of skin
of lobe
Eyebrow Captive bead 6 to 8 wk • Keloid formation
ring, captive • Ripping and tearing of skin if
stone ring, jewelry gets caught on clothing
barbell studs • Formation of abscesses, cysts, or
boils
• Excess hair growth over piercing
area
• Development of cysts
• Periorbital cellulitis

Foreskin Captive bead 6 to 8 wk • Formation of abscesses, cysts, or
ring, captive boils
stone ring, • Ripping and tearing of skin if
circular barbell jewelry gets caught on clothing
Frenum Barbell stud 6 to 8 wk • Keloid formation
boils
Hand web Captive bead 6 to 12 mo • Difficult healing, due to high rate
ring, captive of infection
stone ring, • Formation of abscesses, cysts, or
barbell studs boils
Implants Captive bead 2 to 4 mo • Pressure on nerves, blood
ring, captive vessels, and muscles
stone ring, • Radiating pain that continues
barbell studs, after healing complete
circular barbell, • Shifting (when the object moves
assorted other from its intended place)
items (beads, • Rejection by the body’s immune
spikes, coral, system
etc.) • Excess hair growth over
implantation area
boils
Labia majora Captive bead 6 to 10 wk • Keloid formation
stone ring, boils
Labia minora Captive bead 6 to 10 wk • Keloid formation
stone ring, boils
Lip Captive bead 2 to 3 mo • Swelling, infection, gingival
ring, captive injury, increased salivation
stone ring, • Keloid formation
barbell studs • Excess hair growth over pierced
area
Body Art Complications 33

Lip Captive bead 2 to 3 mo • Chipped or broken teeth
(continued) ring, captive • Speech impairment
stone ring, • Aspiration or ingestion of
barbell studs loosened jewelry
septic shock
boils
Nasal septum Captive bead 2 to 8 mo • Formation of abscesses, cysts, or
ring, circular boils
barbell, septum • Ripping and tearing of skin if
retainer jewelry gets caught on clothing
Navel Captive bead 4 to 12 mo • Very slow to heal: redness of
ring, captive area can last for months
stone ring, • Keloid formation
circular barbell • Excess hair growth over pierced
area
• Very high rate of infection
(compared to other piercings)
because of:
• constant friction, rubbing, and
movement, and
• a bacteria-friendly environment
(warm, dark, and moist)
boils
Nipples (female) Captive bead 3 to 6 mo • May damage some of the milk-
ring, captive producing ducts, causing mastitis
stone ring, or problems with future breast-
circular barbell feeding
boils
Nipples (male) Captive bead 3 to 6 mo • Formation of abscesses, cysts, or
ring, captive boils
stone ring, • Ripping and tearing of skin if
circular barbell jewelry gets caught on clothing

Nostril Captive bead 2 to 4 mo • Keloid formation
stone ring boils
Scrotum Captive bead 6 to 8 wk • Ripping and tearing of skin if
ring, captive jewelry gets caught on clothing
stone ring,
circular barbell
Tongue Barbell stud 4 to 6 wk • Swelling, infection, gingival
injury, increased salivation
• Keloid formation
• Chipped or broken teeth
• Speech impairment
• Aspiration or ingestion of
loosened jewelry
• Difficulty breathing, chewing,
and swallowing
• Prolonged bleeding
septic shock
• Damage to veins and nerves,
including neuroma development
Tragus Captive bead 6 to 12 mo • Formation of abscesses, cysts, or
ring, circular boils
barbell, captive
stone ring
Uvula Captive bead 6 to 8 wk • Swelling, infection, injury,
ring, circular increased salivation
barbell, barbell • Speech impairment
stud • Aspiration or ingestion of
loosened jewelry
• Difficulty breathing and
swallowing
boils
Breast Problems
?
KEY QUESTIONS:


Difficulty breathing or chest pain Notify physician
Multiple diagnostic studies or procedures
Frequent consultation
Constant monitoring

Gaping lacerations May need multiple diagnostic studies or
procedures
Monitor for changes in condition

Skin ulceration Offer comfort measures
Bloody discharge May need a simple diagnostic study or
Foul-smelling discharge from nipples procedure
Red, swollen, hot breasts
Trauma to breast
Signs of infection: drainage, fever, red streaks,
or pus
35
36 Breast Problems

Nipple discharge in non-pregnant woman Reassess while waiting, per facility protocol
Lump in breast unrelated to menstrual cycle Offer comfort measures
Dimpling of breast tissue May need examination only
Lump in a male breast
Unable to remove piercing
RELATED PROTOCOLS:
Body Art Complications • Lacerations • Wound Infection
Notes
Breathing Problems
?
KEY QUESTIONS:
Name • Age • Weight • Onset • Allergies • Prior History • Severity • Pain Scale

Central cyanosis
Severe retractions or acute cyanosis (Pediatric)

Feeling of suffocation Notify physician
History of pulmonary embolus, blood clots, or Multiple diagnostic studies or procedures
lung collapse Frequent consultation
Speaking in short words Accurate O2 saturation dependent upon good
Pale skin or cyanotic fingernails circulation and warm extremities
Moderate retractions (Pediatric) Carbon monoxide poisoning will show
Drooling adequate O2 saturation in spite of poor
O2 saturation 94% with oxygen oxygenation
Audible wheezes or severe stridor
Diaphoresis
Moderate use of accessory muscles
Difficulty breathing and exposure to allergen
that caused a significant reaction in the past
Trauma and chest deformity
37
38 Breathing Problems

Pain increasing with movement or breathing Refer for treatment as soon as possible
Speaking in partial sentences Monitor for changes in condition
Mild, audible wheezes at rest May need a breathing treatment while waiting
Tight cough May need multiple diagnostic studies or
Frothy pink or copious white sputum procedures
History of asthma not relieved with inhaler If abnormal vital signs, consider Level 2
Sudden or progressive shortness of breath and:
Wheezing within past 2 hr;
Recent trauma, surgery, or childbirth;
Inhalation of a foreign body;
Pallor; or
High anxiety

Speaking in full sentences Reassess while waiting, per facility protocol
Fever 103°F (39.4°C) Offer comfort measures
Productive cough with gray, green, or yellow May need a simple diagnostic study or
sputum procedure
Age 60 yr and fever 101°F (38.3°C)

O2 saturation 95% on room air Reassess while waiting, per facility protocol
Occasional nonproductive cough Offer comfort measures
Hyperventilation and numbness or tingling in May need an examination only
fingers or face
New stressful event or situation
Exposure to environment irritant
Recent cold or flu symptoms
RELATED PROTOCOLS:
Allergic Reaction • Asthma • Chest Pain • Foreign Body, Inhaled
Burns
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Mechanism of Injury
• Severity • Pain Scale • Vital Signs • Last Tetanus Immunization • Size and Location of Burn


Extensive white and painless burn Notify physician
Extensive red and blistered burn and severe Multiple diagnostic studies or procedures
pain Frequent consultation
Difficulty breathing Continuous monitoring
Chest pain or rapid irregular heartbeat
Electrical or radiation burn
Smoke inhalation with singed facial hair
Burn circles neck extremity (and distal pulse)

Burned area charred (small area) Reassess, per facility protocol
Blistered or white painless burn size of a May need multiple diagnostic studies or
hand procedures
Burn over a joint Monitor for changes in condition
Blisters on face or neck If vital signs abnormal, consider Level 2
Burn 1 inch and on face, eyes, ears, neck,
hands, feet, or genital area
39
40 Burns

History of chronic illness Reassess while waiting, per facility protocol
Moderate pain Offer comfort measures
Signs of infection May need simple diagnostic study or procedure
Tetanus immunization 10 yr previous

Minimal pain Reassess while waiting, per facility protocol
Multiple open blisters Offer comfort measures
RELATED PROTOCOLS:
Breathing Problems • Laceration • Poisoning, Exposure or Ingestion • Wound Infection
Notes
Chest Pain
?
KEY QUESTIONS:
• Associated Symptoms • Vital Signs • Oxygen Saturation

Central cyanosis Many resources needed
Hypotension

Lightheadedness or weakness Notify physician
Cool, moist skin Administer O2 per facility protocol
Nausea or vomiting EKG per facility protocol
Pain radiates to neck, shoulders, jaw, back, or IV per facility protocol
arms Administer aspirin per facility protocol
Age 35 yr and heart palpitations Administer nitroglycerin per facility protocol
Difficulty breathing Many diagnostic studies or procedures
Skin pale Frequent consultation
Bilateral rales or rhonchi Continuous monitoring
Persistent pain after 3 doses of nitroglycerin If chest pain severe and worsens with
5 min apart breathing, movement, palpitation, or
Known cardiac disease coughing, consider Level 3
Severe chest pain at rest or awakens person
Coughing up blood
History of recent trauma, childbirth, or
surgery
Recreational street drug or prescription drug
abuse within past 24 hr
History of heart disease, diabetes, congestive
heart failure, or blood clotting problems
Severe pain
41
42 Chest Pain

Moderate pain Refer for treatment as soon as possible
Stable vital signs and rhythm Monitor for changes in condition
Age 35 yr and heart palpitations May need multiple diagnostic studies or
No difficulty breathing procedures
Heavy smoker If abnormal vital signs, consider Level 2
Pain, swelling, warmth, or redness of leg
Pain with exertion
Strong family history of heart disease, heart
attack, stroke, or diabetes

Recent injury and pain increases with Reassess while waiting, per facility protocol
movement and inspiration Offer comfort measures
Fever, cough, congestion May need simple diagnostic study or
procedure

Pain worsens when pressure applied to the area Reassess while waiting, per facility protocol
Intermittent pain increases with deep Offer comfort measures
breathing and coughing May need examination only
Chronic pain
RELATED PROTOCOLS:
Breathing Problems • Cold Symptoms
See Appendix H: Differential Diagnosis of Chest Pain
Cold Exposure, Hypothermia/Frostbite
?
KEY QUESTIONS:
Name • Age • Onset • Length and Time of Exposure • Body Temperature • Vital Signs
• Pain Scale • Medications • Tetanus Status


Altered mental status lethargy Do not delay treatment
Depressed level of consciousness Notify physician
Muscle rigidity Multiple diagnostic studies or procedures
Skin hard, cold, white, blue, yellow, or waxy Frequent consultation
(3rd-degree frostbite) Continuous monitoring
Purple fingers, toes, or nail beds Re-warm as soon as possible
Unable to raise body temperature
Poor coordination or lightheadedness
Infant, elderly, disabled, or immunosuppressed

Blistering or peeling skin (2nd-degree frostbite) Monitor for changes in condition
Persistent shivering after warming May need multiple diagnostic studies or
procedures

Signs of infection (redness, swelling, pain, red Reassess while waiting, per facility protocol
streaks, warmth) Offer comfort measures
Cold, mild shivering May need a simple diagnostic study or
Redness followed by blister formation in 24 to procedure
36 hr and skin is soft
43
44 Cold Exposure, Hypothermia/Frostbite

Cold but no skin blistering Reassess while waiting, per facility protocol
Able to talk and drink warm fluids Offer comfort measures
Asymptomatic May need an examination only
Notes
Cold Symptoms
?
KEY QUESTIONS:

O2 saturation 90% with oxygen Staff at bedside

Difficulty breathing (unrelated to nasal Notify physician
congestion) Multiple diagnostic studies or procedures
Chest pain (unrelated to chest wall movement) Frequent consultation
Petechiae, fever, headache, pain with neck Constant monitoring
flexion
Infant 12 wk old with a temperature
100.4°F (38.0°C)

Fever 103°F (39.4°C) May need multiple diagnostic studies or
Child 12 wk old and fever 105°F (41.5°C) procedures
Signs of dehydration Monitor for changes in condition
Neck pain or rigidity If vital signs abnormal, consider Level 2
History of immunosuppression, 60 yr or
diabetes, and fever 100.5°F (38.1°C)
Chest pain with deep inspiration or coughing
45
46 Cold Symptoms

Intermittent wheezing unrelated to diagnosed Offer comfort measures
asthma May need a simple diagnostic study or
History of chronic illness procedure
Sinus pain, sore throat, or fever persists
3 days
Green or brown sputum 72 hr

Earache Reassess while waiting, per facility protocol
Sore throat Offer comfort measures
Runny nose May need examination only
Intermittent cough
RELATED PROTOCOLS:
Breathing Problems • Fever • Sore Throat
Notes
Confusion
?
KEY QUESTIONS:

Pale, diaphoretic, lightheaded, or weak Staff at bedside
Status epilepticus Mobilization of resuscitation team
Unresponsive

Recent head injury or trauma with loss of Do not delay treatment
consciousness Notify physician
Drug or alcohol overdose Multiple diagnostic studies or procedures
Exposure to chemicals or ingestion of drug(s) Frequent consultation
Disoriented to name, date, or place Continuous monitoring
Temperature 102°F (38.9°C)
Sudden weakness on one side of the body
Difficulty speaking

History of psychosis Refer for treatment as soon as possible
History of diabetes, stroke, high blood Monitor for changes in condition
pressure, or cardiac disease May need multiple diagnostic studies or
Fever 101°F (38.3°C) in the elderly or procedures
immunosuppressed If abnormal vital signs, consider Level 2
History of drug or alcohol abuse
47
48 Confusion

Taking medications known to cause confusion Reassess while waiting, per facility protocol
Recently taking a new medication Offer comfort measures
History of seizure disorder May need a simple diagnostic study or
Persistent confusion after fever clears procedure
History of dementia or chronic brain
syndrome and change in status
Low-grade fever

History of dementia or chronic brain Reassess while waiting, per facility protocol
syndrome and no change in status Offer comfort measures
Afebrile May need an examination only
RELATED PROTOCOLS:
Altered Mental Status • Fever
Notes
Contusion
?
KEY QUESTIONS:
• Oxygen Saturation • Specifics of Injury • Medications


Chest pain Notify physician
Blunt chest or abdominal trauma Multiple diagnostic studies or procedures
Chest, flank, or abdominal wall bruising Frequent consultation
Possibility of deep trauma (solid organ Continuous monitoring
laceration, hollow organ rupture) Refer to Bruise Assessment chart to determine
Risk of domestic violence (separate patient age of contusion (page 50)
from visitor for safety)
History inconsistent with injuries
Battle sign or raccoon eyes
Circumferential ecchymoses of neck
Fever, weakness, tachycardia, hypotension

Trauma and possibility of a fracture or muscle May need multiple diagnostic studies or
hematoma procedures
Bite marks Monitor for changes in condition
Bruising over multiple areas Monitor circulation, movement, and sensation
Difficulty walking of affected extremity
49
50 Contusion

History of bleeding problems or use of blood Refer to Bruise Assessment chart below to
thinners determine age of contusion
Increased pain, swelling, redness, fever, or red If vital signs abnormal, consider Level 2
streaks

Small bruises on extremities Offer comfort measure
May need simple diagnostic study or
procedure
Refer to Bruise Assessment chart below to
determine age of contusion

Contusion healing but patient or parent Reassess while waiting, per facility protocol
No other symptoms May need examination only
Refer to Bruise Assessment chart below to
determine age of contusion
RELATED PROTOCOLS:
Extremity Injury
Bruise Assessment
Color of Bruise Age of Bruise
Red, reddish blue Less than 24 hr since time of injury
Dark blue, dark purple 1 to 4 days
Green, yellow-green 5 to 7 days
Yellow, brown 7 to 10 days
Normal tint, disappearance of bruise 1 to 3 wk
Cough
?
KEY QUESTIONS:
• Oxygen Saturation • Medications • Associated Symptoms

Unable to speak Mobilization of resuscitation team
Oxygen saturation 90% with oxygen Many resources needed
Central cyanosis

Drooling Notify physician
Severe difficulty breathing Multiple diagnostic studies or procedures
Intercostal and substernal retractions Frequent consultation
Severe stridor Continuous monitoring
Speaking in short words
Blue lips or tongue
Feeling of suffocation
Frothy pink sputum
Child 12 mo with rapid breathing and
persistent cough

Speaking in partial sentences Monitor for changes in condition
Mild stridor May need multiple diagnostic studies or
Wheezing heard across the room procedures
History of asthma and non-responsive to If abnormal vital signs, consider Level 2
home care
Fever 103°F (39.4°C)
Fever 100.5°F (38.1°C) and age 60 yr or
immunosuppressed
51
52 Cough

Coughing up blood
Cough unrelated to cold symptoms and
history of recent trauma, surgery,
childbirth, heart attacks, blood clots, or
long sedentary period

Speaking in full sentences Offer comfort measures
No stridor May need a simple diagnostic study or
Occus wheezing, rales, or rhonchi with procedure
auscultation
History of asthma and has not taken
medication or a breathing treatment
Persistent fever 72 hr and no response to
fever-reducing measures
Coughing interferes with sleep
Intermittent barking cough unrelieved by
exposure to cool air, humidifier, or steam
Green or brown sputum 72 hr

History of croup Reassess while waiting, per facility protocol
Cough caused by exercise Offer comfort measures
Intermittent chest discomfort with deep, May need an examination only
productive coughing
No other signs or symptoms but parent or
patient concerned
Cough and weight loss
Earache
Sore throat
RELATED PROTOCOLS:
Asthma • Breathing Problems • Cold Symptoms
Crying Baby
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History (Including Birth History) • Severity • Pain Scale

Central cyanosis Staff at bedside

Temperature 100.4°F (38°C) in infants Notify physician
12 wk Multiple diagnostic studies or procedures
Blue lips or tongue Frequent consultation
Petechiae Continuous monitoring
Extreme lethargy

Inability to console infant Refer for treatment as soon as possible
Recent trauma Monitor for change in condition
Risk of abuse May need multiple diagnostic studies or
Unexplained bruising procedures
Intermittent lethargy or irritability If abnormal vital signs, consider Level 2
Persistent crying 2 hr If suspected abuse, keep infant under
Projectile vomiting observation

Recent use of “cold” medication Reassess while waiting, per facility protocol
Fever, vomiting, cold symptoms Offer comfort measures
Raised, red, or itchy rash May need a simple diagnostic study or
Fever, vomiting, or pulling ears procedure
53
54 Crying Baby

2 hr since last feeding Reassess while waiting, per facility protocol
3 hr since last nap Offer comfort measures
Recent immunizations and fever May need an examination only
Notes
Depression
?
KEY QUESTIONS:
• Medications

Severe respiratory distress Immediate treatment
Hypotension Staff at bedside

Suicidal or homicidal gesture Notify physician
Overdose or other potentially serious attempt Multiple diagnostic studies or procedures
at self-harm Frequent consultation
Psychosis Continuous monitoring

Suicidal/homicidal ideation with a plan and Monitor for changes in condition
the means to carry out the plan May need multiple diagnostic studies or
Past inpatient psychiatric admission for procedures
depression If abnormal vital signs, consider Level 2
Adolescent acting out, provocative or risk- Keep suicidal patient under observation while
taking behavior waiting to be seen
Recent childbirth, family loss, trauma, or Contact crisis or social worker, per facility
emotional trauma protocol
Change in behavior, crying, or withdrawal
Anxiety interferes with daily activity

Suicidal thoughts without a plan or the means Offer comfort measures
to carry out the plan
55
56 Depression

Difficulty concentrating, sleeping, or May need a simple diagnostic study or
maintaining interpersonal relationships procedure
Inability to experience pleasure
Ethyl alcohol ingestion
Situational depression
Change in medication or dose
Out of medication

Reported history of depression with no Reassess while waiting, per facility protocol
current signs or symptoms Offer comfort measures
RELATED PROTOCOLS:
Anxiety
Notes
Diabetic Problems
?
KEY QUESTIONS:
• Oxygen Saturation • Serum Glucose Level • Medications

Seizure

Intractable vomiting Notify physician
Blood sugar 60 Multiple diagnostic studies or procedures
Hypoglycemic infant Frequent consultation
Insulin overdose Constant monitoring
Measure serum glucose level

Blood sugar 400 or 80 May need multiple diagnostic studies or
Rapid respiratory rate procedures
Fruity breath odor Monitor for changes in condition
Lightheaded If vital signs abnormal, consider Level 2
Profuse diaphoresis Measure serum glucose level
Wound with signs of infection: drainage, fever,
red streaks, or pus
Persistent vomiting and inability to keep down
medication

Slow healing wound Offer comfort measures
57
58 Diabetic Problems

Upper respiratory infection with fever and May need a simple diagnostic study or
cough procedure
Headache or nausea and prolonged period
since last meal

Request for prescription refill Reassess while waiting, per facility protocol
New-onset insulin-dependent diabetes Offer comfort measures
mellitus and requests additional education May need examination only
for self-administration of insulin
RELATED PROTOCOLS:
Altered Mental Status • Fever • Wound Infection
Notes
Diarrhea, Adult
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity of Symptoms • Pain Scale
• Vital Signs • Medications • Diet • Travel • Family Members • Laxatives • Chronic Diarrhea
• Abdominal Surgery • Recent Antibiotic Therapy • Drinking from Wells or Streams

Unresponsive Immediate treatment
Staff at bedside

Confusion, lethargy, disorientation Do not delay treatment
Altered mental status Notify physician
Severe weakness or lightheadedness Multiple diagnostic studies or procedures
Pallor, diaphoresis Frequent consultation
Large amounts frank bloody stool Continuous monitoring

Severe abdominal pain 2 hr Refer for treatment as soon as possible
Signs of dehydration: decreased urination, Monitor for changes in condition
sunken eyes, loose dry skin, excessive thirst, May need multiple diagnostic studies or
dry mouth procedures
Lightheadedness upon standing Collect/save stool specimen, per facility
Fever 101°F (38.3°C) and unresponsive to protocol
fever-reducing measures If vital signs abnormal, consider Level 2
Diarrhea every 30 to 60 min for 6 hr If tolerating oral fluids, give small amounts
Diarrhea 5 days frequently
Loss of bowel control
Persistent vomiting 3 days
59
60 Diarrhea, Adult

Yellow, green, or frothy stool Reassess while waiting, per facility protocol
Moderate abdominal pain Offer comfort measures
Diarrhea 6 times/24 hr May need simple diagnostic study or procedure
Diarrhea 2 days
Low-grade fever
Nausea

Diarrhea 6 times/24 hr Reassess while waiting, per facility protocol
Loose stools Offer comfort measures
RELATED PROTOCOLS:
Abdominal Pain, Adult • Poisoning, Exposure or Ingestion • Vomiting
Notes
Diarrhea, Pediatric
?
KEY QUESTIONS:
Name • Age • Weight • Onset • Allergies • Prior History • Severity of Symptoms
• Diaper Count • Pain Scale • Vital Signs • Medications • Diet • Travel
• Health of Family Members • Laxatives • Chronic Diarrhea • Abdominal Surgery
• Recent Antibiotic Therapy • Drinking from Wells or Streams or travel outside the country

Hypotensive Mobilization of resuscitation team

Severe weakness or lightheadedness Multiple diagnostic studies or procedures
Cold, gray skin Frequent consultation
Large amounts frank bloody stool Constant monitoring
Infant 12 wks and fever 100.4°F (38.0°C)
Capillary refill 2 seconds

Signs of dehydration: age 1 yr and no urine Refer for treatment as soon as possible
8 hr, age 1 yr and no urine 12 hr, Reassess, per facility protocol
sunken eyes or fontanels, crying without Monitor for changes in condition
tears, excessive thirst, dry mouth May need multiple diagnostic studies or
Severe abdominal pain (drawing knees to chest procedures
with cramping) Collect/save stool specimen, per facility
Lightheadedness upon standing protocol
Fever 105°F (40.6°C) and unresponsive to If vital signs abnormal, consider Level 2
fever-reducing measures 3 months old If tolerating oral fluids, give small amounts
Age 1 mo and diarrhea 3 times frequently
Age 1 yr and diarrhea 8 times/8 hr
61
62 Diarrhea, Pediatric

Abdominal pain 2 hr and no improvement
with each episode of diarrhea
Vomiting clear fluids and watery diarrhea 3
times

Diarrhea 3 days Reassess while waiting, per facility protocol
Fever unresponsive to fever-reducing measures Offer comfort measures
Temperature 103°F (39.4°C) May need simple diagnostic study or
Temperature 101°F (38.3°C) 24 hr procedure
Bloody stools
Receiving antibiotic therapy

Chronic diarrhea Reassess while waiting, per facility protocol
Recent diet change Offer comfort measures
Bloody stools and history of anal fissure May need examination only
RELATED PROTOCOLS:
Abdominal Pain, Pediatric • Poisoning, Exposure or Ingestion • Vomiting
Notes
Ear Problems
(for foreign body, see Foreign Body, Ear)
?
KEY QUESTIONS:
Name • Age • Onset • History • Temperature • Allergies • Medication • Pain Scale
• Vital Signs


Injury and fluid leaking from ear Multiple diagnostic studies or procedures
Battle sign (bruising behind ear) with head Frequent consultation
trauma Continuous monitoring
Check for CSF with head trauma

Pain, swelling, and bloody and/or purulent Monitor for changes in condition
discharge from ear May need multiple diagnostic studies or
Redness or facial drooping on affected side of procedures
face associated with blow to head If abnormal vital signs, consider Level 2
Sudden hearing loss with pain
Pain unresponsive to analgesics
History of diabetes/immunosuppression
and earpain
63
64 Ear Problems

Mild tenderness on bone behind ear Reassess while waiting, per facility protocol
Slight swelling, pain, warmth, drainage, low- Offer comfort measures
grade fever May need a simple diagnostic study or
Unable to remove wax plug with medication procedure
Decreased hearing, along with pain with Do not instill liquid drops if eardrum rupture
cracking or popping noise suspected
Mild/intermittent ringing in ears
Antibiotics for ear infection 3 days and
earache persists

Sunburn Reassess while waiting, per facility protocol
Itching Offer comfort measures
Pain after exposure to cold May need an examination only
Pain after swimming or exposure to water
RELATED PROTOCOLS:
Foreign Body, Ear
Notes
Electric Shock/Lightning Injury
?
KEY QUESTIONS:
Name • Age • Onset • Cause • Vital Signs • Pain Scale • Entrance and Exit Wounds
• Oxygen Saturation

Hypotension

Severe pain Notify physician
Altered mental status Multiple diagnostic studies or procedures
Weakness, chest pain, irregular pulse, Frequent consultation
palpitations Continuous monitoring
Evidence of burn marks (entrance and/or exit Monitor for internal injury, even if no external
wounds) signs of burn are present
Seizure Perform frequent extremity vascular checks
Age 18 mo Obtain 12-lead EKG as soon as possible
History of unconsciousness Observe for entrance/exit burn wounds
Pallor, diaphoresis Start IV if patient burned or monitoring shows
Oxygen saturation 92% abnormalities

History of cardiac disease Refer for treatment as soon as possible
Exposure to 220-W voltage or greater Monitor for changes in condition
Burn to face Monitor for internal injury, even with no
Bloody/cloudy urine external signs of burn
Perform frequent extremity vascular checks
May need multiple diagnostic studies or
procedures
65
66 Electric Shock/Lightning Injury

Muscle pain Obtain 12-lead EKG as soon as possible
Headache Apply dry dressing to burn wounds
Fatigue If abnormal vital signs, consider Level 2

Asymptomatic but parent or patient Reassess while waiting, per facility protocol
May need simple diagnostic study or
procedure

Reassess while waiting, per facility protocol
RELATED PROTOCOLS:
Chest Pain • Extremity Injury
Notes
Extremity Injury
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Severity • Pain Scale • Cause • Vital Signs
• Oxygen Saturation • Neurovascular Status of Extremity

Apnea or severe difficulty breathing Refer for immediate treatment
Pulsatile bleeding Apply pressure dressing to stop bleeding

Severe pain in hip or thigh after traumatic Notify physician
injury and unable to ambulate Multiple diagnostic studies or procedures
Bone protrudes through the skin Frequent consultation
Partial or complete amputation Continuous monitoring
Penetrating wound and object still present Do not remove penetrating object
Unable to stop bleeding with pressure Apply pressure dressing to stop bleeding
Fingers or toes of affected limb are cold, pale,
mottled or numb
No pulse in affected extremity and
cyanosis/pallor
Prolonged capillary refill 2–3 seconds
High-pressure injection injury

Deformed limb Refer for treatment as soon as possible
Severe pain with movement or weight bearing May need multiple diagnostic studies or
Unable to move part of arm, hand, or foot procedures
distal to deep laceration Monitor for changes in condition
Unable to remove ring and distal digit is If vital signs abnormal, consider Level 2
turning pale, white, or blue Remove ring from swollen digit
Severe swelling, pain, and loss of sensation Apply splint, per facility protocol
67
68 Extremity Injury

Increasing swelling or bruising around wound Elevate and apply ice pack for pain or swelling
of person taking anticoagulants Assess ankle injury using Ottawa criteria
Puncture wound into a joint Order radiographs, per facility protocol
Numbness and tingling
Open fracture
Fever, drainage, red streaks

Pain with movement or weight bearing Offer comfort measures
Difficulty moving the joint nearest the injury Reassess while waiting, per facility protocol
Puncture wound through sole of shoe May need simple diagnostic study or
Reported pop or snap at time of injury procedure
Suspicious history of injury (suspect abuse) Remove ring from swollen digit
Visible debris in wound after scrubbing Apply splint, per facility protocol
History of diabetes Elevate and apply ice pack for pain or swelling
No improvement in pain 3 days post injury Assess ankle injury using Ottawa criteria
Numbness or tingling Order radiographs, per facility protocol

Pain, swelling, or discoloration Offer comfort measures
Chronic discomfort with old injury Reassess while waiting, per facility protocol
History of arthritis or tendonitis May need examination only
No improvement in swelling 2 wk post
injury
RELATED PROTOCOLS:
Electrical Shock • Laceration • Puncture Wound
Eye Injury or Problems
?
KEY QUESTIONS:
Name • Age • Onset • Cause • Allergies • Corrective Glasses or Contact Use • Visual Acuity
• Vital Signs • Tetanus Immunization Status • Medications


Laceration or penetrating injury to eye Notify physician
Blow or trauma to eye with marked loss of Multiple diagnostic studies or procedures
vision Frequent consultation
Flashing light in visual field Continuous monitoring
Blood in iris (colored part of eye) Immediate irrigation for chemical burns
Clear, jelly-like discharge from injured eye Instill optic anesthetic, per facility protocol
Corneal burn (exposure of eye to alkali or Consider c-spine injury with traumatic injury
acid)
Unilateral painless loss of vision

Burn to eye (thermal or light) Monitor for changes in condition
Persistent blurred/double vision May need multiple diagnostic studies or
Swelling, pain, tearing of eye procedures
Eye pain associated with facial/orbital trauma Offer cool compresses to reduce swelling
Ecchymosis surrounding eye Instill optic anesthetic, per facility protocol
Increasing pain with eye movement If vital signs abnormal, consider Level 2
Laceration to eyelid
Foreign body in eye
Swollen eyelids red, warm to touch, and fever
101.4
69
70 Eye Injury or Problems

Discomfort or irritation persists 24 hr after Reassess while waiting, per facility protocol
injury or removal of foreign body Offer comfort measures
Signs of infection develop after injury: mild May need a simple diagnostic study or
pain, swelling, redness, drainage, or fever procedure
Small blood vessel rupture in sclera
Fever 101.4 and swollen red eyelids or
tear duct
Persistent itching, redness, burning, and
discharge
History of improper contact lens usage;
inability to remove contacts

Dry eyes and itching Reassess while waiting, per facility protocol
Mild eye crusting Offer comfort measures
Asymptomatic May need an examination only
Notes
Feeding Tube Problems
?
KEY QUESTIONS:
Name • Age • Prior History • Onset • Type of Tube • Length of Time Tube in Place
• Pain Scale • Vital Signs


Severe bleeding through or at site of tube Notify physician
Continuous monitoring

Swelling, bleeding, or foul-smelling purulent Monitor for change in condition
discharge at insertion site May need multiple diagnostic studies or
procedures

Signs of infection at insertion site: mild Offer comfort measures
redness, swelling, pain, red streaks, or May need a simple diagnostic study or
drainage procedure
Feeding tube dislodged or fallen out
71
72 Feeding Tube Problems

Tube frequently clogs after feeding or Reassess while waiting, per facility protocol
medication administration Offer comfort measures
Unable to unclog after trying home care May need an examination only
measures
Possible tube displacement
Unable to pass solution into feeding tube
Asymptomatic
Notes
Fever
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Allergies • Prior History • Pain Scale
• Vital Signs • Weight • Oxygen Saturation


Confusion or disorientation Do not delay treatment
Excessive drooling or difficulty swallowing Multiple diagnostic studies or procedures
Age 12 wk and temperature 100.4°F Frequent consultation
(38.0°C) Continuous monitoring
Lethargy
Petechiae
Severe signs of dehydration in elderly, pediatric,
immunosuppressed, or compromised patient
Anuria or decreased urine output 24 hr
Sunken eyes or fontanel, poor skin turgor, or
excessive thirst in infant
Severe headache, neck stiffness, neck pain, and
photophobia

Temperature 104°F (40°C) and unresponsive Monitor for change in condition
to fever-reducing measures May need multiple diagnostic studies or
Temperature 102°F (39°C) and: procedures
Flank or back pain and painful/bloody If vital signs abnormal, consider Level 2
urination
73
74 Fever

Shortness of breath, pleuritic pain, Administer acetaminophen or ibuprofen, per
wheezing and/or productive cough facility protocol
History of diabetes, cancer,
HIV/AIDS, kidney/liver disease, pregnancy,
or recent surgery
Nausea/vomiting
Pediatric:
Persistent irritability, inconsolable
Infant age 3 to 6 mo and rectal temperature
102°F (39°C) with diarrhea, vomiting,
and dehydration

Low-grade fever persists 72 hr and no Reassess while waiting, per facility protocol
known cause Offer comfort measures
Earache, sore throat, mildly swollen glands May need a simple diagnostic study or
Rash procedure
Frequent and/or mild burning with urination
Vaginal discharge

Temp 101°F (38.2°C) with no other Reassess while waiting, per facility protocol
symptoms Offer comfort measures
Recent immunization May need an examination only
Finger and Toe Problems
?
KEY QUESTIONS:
• Medications


Open fracture Notify physician
Amputation Multiple diagnostic studies or procedures
Digits are cold, pale, blue, or mottled and Frequent consultation
numb Continuous monitoring

Prolonged capillary refill May need multiple diagnostic studies or
Obvious deformity with compromised circulation procedures
Crush trauma Monitor for change in condition
Unable to stop bleeding with pressure Check capillary refill
Puncture wound into a joint Monitor circulation, movement, and sensation
Inability to remove rings, and digit is turning of affected extremity
blue, pale, or white If vital signs abnormal, consider Level 2
Fever, drainage, warm to touch, red streaks
Exposed or injured nail bed

Swelling Offer comfort measures
Decreased range of motion
75
76 Finger and Toe Problems

Bruising of the digit May need simple diagnostic study or
Subungual hematoma procedure
Pain and swelling at second
metatarsophalangeal joint
Numbness or tingling

Pain or swelling without injury Reassess while waiting, per facility protocol
Minor bleeding under the nail Offer comfort measures
Digit pain and history of arthritis or old injury May need examination only
RELATED PROTOCOLS:
Extremity Injury
Notes
Foreign Body, Ear
?
KEY QUESTIONS:
Name • Age • Onset • Identification of Foreign Body • Prior History • Medications
• Allergies • Pain Scale • Vital Signs


Foreign body movement in ear causing Notify physician
hysteria (insect) Multiple diagnostic studies or procedures
Object impaled in ear Frequent consultation
CSF leaking from ear Continuous monitoring

Unable to remove foreign body Monitor for change in condition
Facial drooping on side of injury May need multiple diagnostic studies or
Loss of coordination procedures

Foreign body in ear requiring simple removal Reassess while waiting, per facility protocol
Persistent discomfort Offer comfort measures
Hearing loss May need a simple diagnostic study or procedure
Persistent bleeding 30 min
Lacerated earlobe
Severe swelling of earlobe
External ear red and swollen
77
78 Foreign Body, Ear

Foreign body removed but parent or patient Reassess while waiting, per facility protocol
RELATED PROTOCOLS:
Ear Problems • Laceration
Notes
Foreign Body, Ingested
?
KEY QUESTIONS:
Name • Age • Onset • Severity of Symptoms • Consideration for Poisoning
• Foreign Object/Substance Ingested • Vital Signs • Medications


Excessive salivation, drooling, or gagging Notify physician
Coughing, choking, or dyspnea Access poison control center as necessary
Evidence of burn to lips and/or tongue (1-800-222-1222)
Vomiting associated with possible corrosive Multiple diagnostic studies or procedures
substance Frequent consultation
Suicidal behavior Continual monitoring
Difficulty breathing Observe suicidal patient until placed in a room
Hematemesis
Drooling
Chest pain
Poisonous substance

Nausea and vomiting Engage family/emergency medical staff in
Object ingested larger than a nickel in children identifying foreign object, if unknown
Difficulty swallowing Instruct parent/patient to check stool for
Sharp object object
Abdominal distention May need multiple diagnostic studies or
Object ingested larger than quarter in adult procedures
Monitor for change in condition
79
80 Foreign Body, Ingested

Suspicious history or foreign body sensation Reassess while waiting, per facility protocol

Small wood or plastic object or dull glass Offer comfort measures
Object ingested smaller than a penny May need examination only
Asymptomatic but parent/patient is concerned Reassess while waiting, per facility protocol
RELATED PROTOCOLS:
Abdominal Pain, Adult • Abdominal Pain, Child • Foreign Body, Inhaled
Notes
Foreign Body, Inhaled
?
KEY QUESTIONS:
• Object Inhaled • Medications • Oxygen Saturation • Vital Signs

Cyanosis Immediate treatment
Unable to speak Mobilization of resuscitation team
O2 saturation 90% with oxygen Many resources needed
Pulseless
Choking

Difficulty breathing Notify physician
Inspiratory stridor Multiple diagnostic studies or procedures
Bilateral wheezing Frequent consultation
Significant coughing Continuous monitoring
Drooling
Retractions
Speaking in short words
Pallor and diaphoresis
Unequal breath sounds

Fever Refer for treatment as soon as possible
Severe pain Monitor for change in condition
Lightheadedness May need multiple diagnostic studies or
Unilateral wheezing procedures
Expiratory wheezing If abnormal vital signs, consider Level 2
Nasal flaring
Speaking in partial sentences
81
82 Foreign Body, Inhaled

Sensation of foreign body with no respiratory Reassess while waiting, per facility protocol
signs and symptoms Offer comfort measures
Speaking in full sentences May need a simple diagnostic study or procedure

No symptoms but parent or patient concerned Reassess while waiting, per facility protocol
O2 saturation 95% on room air Offer comfort measures
RELATED PROTOCOLS:
Asthma • Breathing Problems • Foreign Body, Ingested
Notes
Foreign Body, Rectum or Vagina
?
KEY QUESTIONS:
• Vital Signs • Description of Object • Medications

Pale, diaphoretic, and confused or weak Many resources needed
Violent assault with weapon (e.g., knife, blunt Staff at bedside
object) Mobilization of resuscitation team
Severe respiratory distress

Heavy rectal/vaginal bleeding Do not delay treatment
Fever and systolic BP 100 Notify physician
Multiple injuries from assault Multiple diagnostic studies or procedures
Severe abdominal pain Frequent consultation
Altered mental status Constant monitoring
Traumatic injury to rectum or vagina with
foreign object

Urinary retention or hematuria Refer for treatment as soon as possible
Moderate rectal/vaginal bleeding Monitor for change in condition
Unable to remove foreign body May need multiple diagnostic studies or
High fever, chills, nausea, or vomiting procedures
Abdominal pain with movement If vital signs abnormal, consider Level 2
Suspect sexual abuse If sexual abuse suspected and perpetrator
Insertion of a sharp object present, move up to Level 2

Sensation of rectal or vaginal fullness Reassess while waiting, per facility protocol
Rectal/vaginal pain Offer comfort measures
Peri-rectal abscess May need simple diagnostic study or procedure
83
84 Foreign Body, Rectum or Vagina

Retained tampon or condom
Scant rectal or vaginal bleeding
Unable to pass stool

Report of possible foreign body and no signs Reassess while waiting, per facility protocol
or symptoms Offer comfort measures
RELATED PROTOCOLS:
Rectal Problems • Sexual Assault • Vaginal Bleeding, Abnormal
Notes
Foreign Body, Skin
?
KEY QUESTIONS:
• Vital Signs • Tetanus Status

Unresponsive Refer for immediate treatment
Pale, diaphoretic, and confused or weak Mobilization of resuscitation team

Febrile and abnormal vital signs (BP 100) Do not delay treatment
Fish hook imbedded in the eye Notify physician
Heavy bleeding from injury site Multiple diagnostic studies or procedures
Altered mental status Frequent consultation
Object impaled and difficulty breathing Continuous monitoring

Object impaled in the face and no respiratory Refer for treatment as soon as possible
impairment May need multiple diagnostic studies or
Severe pain procedures
Object imbedded in a joint space Monitor for change in condition
Object deeply imbedded Obtain radiograph(s) for metal foreign body,
Obvious injury to tendons, nerves, or vessels per facility protocol
High level of anxiety Do not soak area of foreign body
Substance adhered to facial area (e.g., eyelids) If abnormal vital signs, consider Level 2

Non-removable fish hook Offer comfort measures
Object imbedded with minimal bleeding or no Reassess while waiting, per facility protocol
loss of sensation or function May need simple diagnostic study or procedure
Moderate pain
85
86 Foreign Body, Skin

Foreign substance adhered to skin (e.g., tar,
super glue)
Signs of infection: redness, fever, pain, red
streaks, warmth, pus

Minimal pain Offer comfort measures
Pierced earring inside of an earlobe or other Reassess while waiting, per facility protocol
non-vital structure May need examination only
No symptoms but parent or person concerned
RELATED PROTOCOLS:
Laceration • Wound Infection
Notes
Genital Problems, Male
?
KEY QUESTIONS:
• Medications

Severe respiratory distress Refer for immediate treatment

Trauma with heavy, pulsatile bleeding Notify physician
Sudden-onset unilateral testicular pain in Multiple diagnostic studies or procedures
patient 20 yr Frequent consultation
Priapism Continuous monitoring
Foreign body in penis Do not remove penetrating object

Blood at meatus Refer for treatment as soon as possible
Fever and pain with urination May need multiple diagnostic studies or
Penis caught in zipper procedures
Severe swelling If abnormal vital signs, consider Level 2
Urinary retention

Penile discharge with fever and pain Reassess while waiting, per facility protocol
Open sore or wound on penis May need simple diagnostic study or procedure
Suspected sexually transmitted disease exposure
Penile discharge
Burning with urination
87
88 Genital Problems, Male

Erectile dysfunction Reassess while waiting, per facility protocol
Pain during or after intercourse Offer comfort measures
Loss of sexual interest May need an examination only
RELATED PROTOCOLS:
Urination Problems
Notes
Headache
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity of Symptoms


“Worst headache of my life” Do not delay treatment
Fever and stiff or painful neck Notify physician
Sudden onset of unilateral weakness Multiple diagnostic studies or procedures
Altered mental status Frequent consultation
Difficulty speaking or swallowing Continuous monitoring
Nuchal rigidity
Hyperreflexia
Petechia

Acute onset of severe headache Refer for treatment as soon as possible
Vomiting/nausea Monitor for change in condition
Vision changes May need multiple diagnostic studies or
Exposure to chemicals or smoke procedures
Recent head injury/trauma If vital signs abnormal, consider Level 2
Known exposure to meningitis (bacterial)

Low-grade fever Reassess while waiting, per facility protocol
History of migraines and photosensitivity Offer comfort measures
Body aches May need a simple diagnostic study or
Acute stress procedure
Fever
89
90 Headache

Sinus symptoms Reassess while waiting, per facility protocol
Cold symptoms Offer comfort measures
Caffeine withdrawal May need an examination only
Pain occurs with reading
No other symptoms but parent or patient
concerned
RELATED PROTOCOLS:
Cold Symptoms • Fever • Head Injury
See Appendix I: Headache: Common Characteristics
Notes
Head Injury
?
KEY QUESTIONS:
• Vital Signs • Oxygen Saturation • Medications • Glascow Coma Scale Score

Seizure Staff at bedside
Apnea or severe respiratory distress Mobilization of resuscitation team
Pulseless

Severe neck pain Notify physician
Uncontrolled bleeding Multiple diagnostic studies or procedures
High-risk mechanism of injury Frequent consultation
Clear drainage from nose or ears Continuous monitoring
Change in speech Protect C-spine
New-onset weakness or numbness Refer to MVA Triage Questions (Appendix J)
Battle sign or raccoon eyes
Obvious dent to head

History of loss of consciousness, fine now Refer for treatment as soon as possible
Visual changes Monitor for changes in condition
Vomiting 3 times or projectile vomiting May need multiple diagnostic studies or
Deceleration injury procedures
Infant fall 2 ft If vital signs abnormal, consider Level 2
Suspect child abuse or neglect Refer to Mechanisms of Injury
Loss of memory, fine now (Appendices K–N)
Change in balance or equilibrium Ice pack to help reduce swelling
Facial lacerations
91
92 Head Injury

Nausea Reassess while waiting, per facility protocol
Infant fall 2 ft Offer comfort measures
Injury and no loss of consciousness May need a simple diagnostic study or
Headache 1 wk post injury procedure

No symptoms but parent or patient concerned Reassess while waiting, per facility protocol
RELATED PROTOCOLS:
Headache • Motor Vehicle Accident
See Appendices J through N: MVA Triage Questions and Mechanisms of Injury
Notes
GRBQ371R-C45[93-94].qxd 10/19/2007 19:10pm Page 93 Aptara Inc.
Heart Rate, Rapid
?
KEY QUESTIONS:
• Pain Scale • Vital Signs • Oxygen Saturation • Cardiac History (stent, CABG, valve, MI, pacers)


Chest, jaw, or arm pain Notify physician
Adult HR 150 Multiple diagnostic studies or procedures
Child HR 180 Frequent consultation
Facial cyanosis or pallor
Possible overdose
Lightheadedness or dizziness
Unsteady walking
Diaphoresis

History of heart disease, paroxysmal Refer for treatment as soon as possible
supraventricular tachycardia, or thyroid May need multiple diagnostic studies or
disease procedures
Intermittent episodes of fast heart rate Monitor for change in condition
History of antihistamine or diet pill use If vital signs abnormal, consider Level 2
Signs of dehydration
Possible drug ingestion or exposure
Anxiety attack
93
94 Heart Rate, Rapid

Diarrhea Reassess while waiting, per facility protocol
Vomiting Offer comfort measures
New medication May need a simple diagnostic study or
Increased caffeine consumption procedure
Increased stress or emotional anxiety
HR 140 and regular

History of palpitations Reassess while waiting, per facility protocol
No symptoms Offer comfort measures
Mild fever May need examination only
Associated pain or anxiety
RELATED PROTOCOLS:
Anxiety • Breathing Problems • Chest Pain • Diarrhea, Adult • Diarrhea, Pediatric
• Lightheadedness/Fainting • Vomiting
Notes
Heart Rate, Slow
?
KEY QUESTIONS:
• Pain Scale • Vital Signs • Oxygen Saturation • Cardiac History (stent, CABG, pacer, MI)


Chest, neck, arm, or jaw pain Notify physician
Difficulty breathing Multiple diagnostic studies or procedures
Facial cyanosis or pallor Frequent consultation
Possible overdose of beta blockers, thyroid Constant monitoring
medications, digoxin, or tricyclic
antidepressants
Systolic BP 90
Dizziness or lightheadedness
Unsteady ambulation
Diaphoresis

New medication Refer for treatment as soon as possible
Unexplained weight gain, fatigue, chronically May need multiple diagnostic studies or
feeling “cold” procedures
History of heart disease, heart block, or Monitor for change in condition
pacemaker malfunction If vital signs abnormal, consider Level 2
Nausea/vomiting
Irregular HR
95
96 Heart Rate, Slow

HR usually slow Reassess while waiting, per facility protocol
Athletic conditioning Offer comfort measures
procedure

Asymptomatic but parent or patient Reassess while waiting, per facility protocol
RELATED PROTOCOLS:
Breathing Problems • Chest Pain • Lightheadedness/Fainting
Notes
Heat Exposure
?
KEY QUESTIONS:
Name • Age • Onset • Temperature • Cardiac History • Hypertension • Diabetes • Vital Signs
• Oxygen Saturation • Medications • Prior History


Profuse sweating with rapid heart rate (heat Multiple diagnostic studies or procedures
exhaustion) Frequent consultation
Signs of cardiovascular collapse/shock (low BP, Continuous monitoring
increased HR, increased RR)
Skin hot and dry with no sweating
(heatstroke)
Seizures

Muscle cramps or loss of coordination Monitor for changes in condition
Vomiting May need multiple diagnostic studies or
Dark yellow or orange urine procedures
Dizziness, faintness, weakness If alert, encourage cold liquid intake
Age 10 yr or 70 yr Do not give acetaminophen or aspirin to lower
temperature
Place patient in cool, shady area
97
98 Heat Exposure

Headache Reassess while waiting, per facility protocol
Nausea Offer comfort measures
Flushing May need simple diagnostic study or procedure

Symptoms improved with intake of oral fluids Reassess while waiting, per facility protocol
Asymptomatic Offer comfort measures
Notes
Hip Pain and Swelling
?
KEY QUESTIONS:
• Severity of Symptoms • Pain Scale

Unresponsive Refer for immediate treatment

Blue or gray foot/toes on affected side Notify physician
External or internal rotation and decreased Multiple diagnostic studies or procedures
motion, sensation, or circulation distally Frequent consultation
Constant monitoring

History of injury or fall Refer for treatment as soon as possible
External rotation of foot May need multiple diagnostic studies or
Immobility or deformity procedures
Shortened limb If vital signs abnormal, consider Level 2
Injury and history of bleeding problems
Ecchymosis

Moderate pain with movement Reassess while waiting, per facility protocol
procedure
99
100 Hip Pain and Swelling

Chronic hip or joint pain Reassess while waiting, per facility protocol
Pain increases with activity Offer comfort measures
Pain relieved by OTC medications May need examination only
RELATED PROTOCOLS:
Extremity Injury
Notes
Hives
?
KEY QUESTIONS:
• Suspected Cause • Medications • Vital Signs • Recent Changes in Food or Medication

Pale, diaphoretic and lightheaded, or weak Mobilization of resuscitation team

Prior anaphalaxis requiring epinephrine Notify physician
Urticaria and hives throughout body Multiple diagnostic studies or procedures
Speaking in short words Frequent consultation
Hives and rapidly progressing: Continuous monitoring
Drooling
Difficulty breathing
Wheezing
Chest tightness
Swelling of tongue or throat

Nausea or vomiting Refer for treatment as soon as possible
Abdominal pain/diarrhea Monitor for change in condition
Severe pain or distress May need a breathing treatment while waiting,
Lightheadedness per facility protocol
Facial or lip swelling May need multiple diagnostic studies or
Inability to speak in full sentences procedures
Contact with known allergen If vital signs abnormal, consider Level 2
101
102 Hives

Swelling of extremities Reassess while waiting, per facility protocol
Diarrhea Offer comfort measures
Speaking in full sentences May need a simple diagnostic study or
Hives respond to antihistamines procedure
New onset with emotional stimulus
Moderate discomfort

History of a viral illness Reassess while waiting, per facility protocol
Hives have resolved Offer comfort measures
RELATED PROTOCOLS:
Allergic Reaction • Bee Sting • Breathing Problems • Rash, Adult and Pediatric
Notes
Hypertension
?
KEY QUESTIONS:
• Associated Symptoms • Vital Signs • Oxygen Saturation • Last Elevated Reading


Severe weakness Notify physician
History of thoracic or abdominal dissection Administer O2 per facility protocol
Persistent numbness and tingling in hands and Perform EKG per facility protocol
feet Administer IV per facility protocol
Coughing up blood or blood-tinged sputum Many diagnostic studies or procedures
Difficulty breathing Frequent consultation
Persistent nosebleed Continuous monitoring
Diastolic blood pressure 140 mm Hg
Severe headache, blurred vision, nausea, or
vomiting
Chest, neck, shoulders, jaw, or back pain

History of heart disease, diabetes, congestive Refer for treatment as soon as possible
heart failure, or blood-clotting problems Monitor for changes in condition
May need multiple diagnostic studies or
procedures
Consider EKG per facility protocol
103
104 Hypertension

Periods of dizziness after starting new blood Reassess while waiting, per facility protocol
pressure medication Offer comfort measures
Receiving treatment for hypertension and May need simple diagnostic study or procedure
persistent blood pressure 160/100 mm Hg
Intermittent nosebleed
Strong family history of heart disease, heart
attack, stroke, or diabetes

Persistent blood pressure readings 140/90 Reassess while waiting, per facility protocol
mm Hg Offer comfort measures
RELATED PROTOCOLS:
Breathing Problems • Chest Pain
Notes
Itching Without a Rash
?
KEY QUESTIONS:


Notify physician
Constant monitoring

Itching started after taking new medication Refer for treatment as soon as possible
Severe pain May need multiple diagnostic studies or
Onset occurred after exposure to a known procedures
allergen Monitor for change in condition
Recent drug withdrawal If vital signs abnormal, consider Level 2

Jaundiced skin Reassess while waiting, per facility protocol
Persistent itching Offer comfort measures
Open wounds from scratching May need a simple diagnostic study or
Vaginal itching procedure
105
106 Itching Without a Rash

Generalized itching Reassess while waiting, per facility protocol
Itching around genitals Offer comfort measures
Lice, crabs, or nits present May need examination only
Contact dermatitis
Exposure to poison ivy or oak
Rectal itching
RELATED PROTOCOLS:
Rectal Problems
Notes
Jaundice
?
KEY QUESTIONS:


Notify physician

Malnutrition and weight loss Refer for treatment as soon as possible
Signs of dehydration Monitor for changes in condition
Fever May need multiple diagnostic studies or
Immunosuppressed, diabetic, or pregnant procedures
Severe pain If abnormal vital signs, consider Level 2

Known or suspected exposure to blood Reassess while waiting, per facility protocol
borne pathogens Offer comfort measures
Dark urine May need a simple diagnostic study or
Clay-colored stools procedure
Vomiting
Abdominal pain
Loss of appetite
Age 10 yr or 70 yr
New onset but no other symptoms
107
108 Jaundice

Prior history of jaundice and no other Reassess while waiting, per facility protocol
symptoms Offer comfort measures
RELATED PROTOCOLS:
Abdominal Pain, Adult • Fever • Itching Without a Rash
Notes
Jaundice, Newborn
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Medications • Vital Signs

Pale and weak or not moving Staff at bedside

Jaundice below the waistline Notify physician

No wet diapers 8 hr Refer for treatment as soon as possible
Decreased oral intake Monitor for changes in condition
Decreased activity May need multiple diagnostic studies or
Signs of dehydration: poor skin turgor, sunken procedures
eyes or fontanel, crying without tears If abnormal vital signs, consider Level 2
Fever 100.4°F (38.0°C)
Temperature 96.8°F (36.0°C)

Worsening jaundice 7 days Reassess while waiting, per facility protocol
No stool 24 hr Offer comfort measures
Stools white, yellow, or gray May need a simple diagnostic study or
procedure
109
110 Jaundice, Newborn

No other symptoms but parents concerned Reassess while waiting, per facility protocol
Onset of jaundice after 7 days of age Offer comfort measures
RELATED PROTOCOLS:
Abdominal Pain, Pediatric • Fever • Rash
Notes
Knee Pain and Swelling
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Pain Scale • Vital Signs


Cyanosis of foot or leg on affected side Notify physician
Pale, paralyzed, or markedly weak leg Continuous monitoring

History of acute trauma May need multiple diagnostic studies or
Obvious deformity procedures
Leg numb Monitor for change in condition
Offer wheelchair and elevate extremity
Offer ice pack for known injury

Inability to bear weight Reassess while waiting, per facility protocol
Red, swollen, hot joint May need simple diagnostic study or procedure
Pain and swelling increasing with activity
111
112 Knee Pain and Swelling

Chronic or intermittent pain or swelling Offer comfort measures
Knee buckling or locking Reassess while waiting, per facility protocol
RELATED PROTOCOLS:
Extremity Injury
Notes
Laceration
?
KEY QUESTIONS:
• Severity • Pain Scale • Vital Signs • Last Tetanus Immunization


Exposure of deep structures (tissue, tendons, Multiple diagnostic studies or procedures
organs, bone, etc.) Frequent consultation
Laceration near a major artery Continuous monitoring
No pulse distal to laceration Apply compression dressing to control
Cyanotic distal to laceration bleeding
Impaled object Leave impaled object in place
Gaping, bleeding wound

Gaping wound with bleeding controlled Reassess, per facility protocol
History of bleeding disorder May need multiple diagnostic studies or
Laceration involves a joint procedures
Decreased range of motion of the limb Monitor for changes in condition
Facial laceration If vital signs abnormal, consider Level 2

Taking anticoagulant Offer comfort measures
Signs of infection May need simple diagnostic study or procedure
113
114 Laceration

Road abrasions
Stable laceration(s) with bleeding controlled,
awaiting cleaning and suturing

Minor laceration in need of cleaning and Reassess while waiting, per facility protocol
minimal repair Offer comfort measures
RELATED PROTOCOLS:
Wound Infection
Notes
Lightheadedness/Fainting
?
KEY QUESTIONS:
Name • Age • Onset • Prior History • Fluid Intake • Medication • Pain Scale • Vital Signs


Severe pain Do not delay treatment
Confusion, lethargy, disorientation Notify physician
Altered mental status Multiple diagnostic studies or procedures
Weakness or inability to move arms or legs Frequent consultation
Difficulty speaking, disturbed vision Continuous monitoring
Irregular HR or palpitations
Chest pain

Recent head trauma with nausea or vomiting Refer for treatment as soon as possible
Moderate to severe vomiting or diarrhea Monitor for changes in condition
Bleeding and tachycardia May need multiple diagnostic studies or
Postural vital signs procedures
Persistent headache or change in vision Measure serum glucose level
Diabetes If abnormal vital signs, consider Level 2

Symptoms interfere with activities Reassess while waiting, per facility protocol
Symptoms occur after taking new medication Offer comfort measures
Symptoms occur with head movement May need a simple diagnostic study or
Pregnancy or LMP 6 wk previous procedure
Exposure to sun or hot environment
Earache, tinnitus, loss of hearing
115
116 Lightheadedness/Fainting

History of dieting Reassess while waiting, per facility protocol
Increased stress, emotional event, or Offer comfort measures
hyperventilation May need an examination only
Symptoms occur with alcohol consumption
RELATED PROTOCOLS:
Altered Mental Status • Abdominal Pain, Adult • Abdominal Pain, Pediatric • Chest Pain
• Diarrhea, Adult • Diarrhea, Pediatric • Headache • Vaginal Bleeding, Abnormal • Vomiting
Notes
Menstrual Problems
?
KEY QUESTIONS:
• Vital Signs • Number of Saturated Pads or Tampons Per Hour • Birth Control
• Possibility of Pregnancy


Hypotensive Notify physician
Partial or complete expulsion of products of Multiple diagnostic studies or procedures
conception Frequent consultation
Persistent bleeding saturating 2 regular-size Continuous monitoring
pads or tampons per hour 2 hr
Severe pain and possibility of pregnancy
Sexually active and last period 6 wk prior and
abdominal or shoulder pain

Heavy vaginal bleeding with clots May need multiple diagnostic studies or
Saturating 1 regular-size pad per hour 6 hr procedures
Fainting or lightheadedness sitting or standing up Monitor for changes in condition
Use of tampons and sudden high fever, If vital signs abnormal, consider Level 2
sunburn-type rash, general ill feeling,
lightheadedness, vomiting, watery diarrhea,
tachycardia, or headache
117
118 Menstrual Problems

Cramping interferes with daily activity Offer comfort measures
Persistent vaginal discharge Reassess while waiting, per facility protocol
Persistent vaginal bleeding 10 days or 21 May need simple diagnostic study or procedure
days since last period
Possible pregnancy, bleeding, and no pain
No menses and taking birth control pills

Unusually heavy menstrual flow Offer comfort measures
Scant menstruation Reassess while waiting, per facility protocol
Period missed or delayed and age 40 y May need examination only
RELATED PROTOCOLS:
Abdominal Pain, Adult • Vaginal Bleeding, Abnormal
Notes
Motor Vehicle Accident
?
KEY QUESTIONS:
• Oxygen Saturation • Extent of Injuries

High risk: mechanism of injury C-spine immobilization

Uncontrolled bleeding Notify physician
High rate of speed Multiple diagnostic studies or procedures
Unrestrained in vehicle Frequent consultation
Bruising over vital organs Continuous monitoring
Multiple large lacerations C-spine immobilization
Point tenderness
High risk medical history (diabetes, cancer,
hemophilia, etc.)

Ambulatory at scene of a minor MVA May need multiple diagnostic studies or
Small lacerations with bleeding controlled procedures
Moderate risk Mechanism of injury Monitor for changes in condition
119
120 Motor Vehicle Accident

Minor bruising or aches Reassess while waiting, per facility protocol
Minor lacerations or abrasions with bleeding May need simple diagnostic study or procedure
controlled If other occupant of same vehicle was a fatality,
consider Level 3

No complaints of pain, bruising, or injury Offer comfort measures
from a low-speed, minor MVA Reassess while waiting, per facility protocol
24 hr since MVA (with no major complaints) May need examination only
RELATED PROTOCOLS:
Ankle Pain and Swelling • Back Pain • Cold Exposure, Hypothermia/Frostbite • Extremity Injury
• Head Injury • Knee Pain and Swelling • Neck Pain • Puncture Wound • Shoulder Pain
See Appendix J: MVA Triage Questions; Appendix K: Mechanisms of Injury from Trauma: Adult; Appendix L:
Mechanisms of Injury: School Age and Adolescent; Appendix M: Mechanisms of Injury: Toddler and
Preschooler; Appendix N: Mechanisms of Injury: Infant
Notes
Mouth Problems
?
KEY QUESTIONS:

Sudden swelling in back of throat or tongue Many resources needed
Injury impedes airway
Pale, diaphoretic, and lightheaded or weak

Inability to open/close mouth, jaw locked in Notify physician
place Multiple diagnostic studies or procedures
Penetrating injury to the back of the mouth Frequent consultation
Uncontrolled bleeding Continuous monitoring
Traumatic injury that may potentially impede Maintain airway
airway
“Kissing tonsils” (unable to swallow own saliva)
Drooling
Tongue amputation

Severe pain not relieved with OTC Refer for treatment as soon as possible
medications or ice pack May need multiple diagnostic studies or
Gaping lacerations procedures
Facial swelling with unobstructed airway Monitor for change in condition
“Kissing tonsils” (able to swallow own saliva) Control bleeding
Difficulty speaking If vital signs abnormal, consider Level 2
Pain with facial swelling
121
122 Mouth Problems

Foul taste is or odor from mouth Reassess while waiting, per facility protocol
Open sores, blisters, or white patches May need simple diagnostic study or procedure
Fever and mouth sores

Dental caries and pain Offer comfort measures
Red or tender gums Reassess while waiting, per facility protocol
Sore spot on tongue May need examination only
RELATED PROTOCOLS:
Breathing Problems • Sore Throat • Toothache/Tooth Injury
Notes
Neck Pain
?
KEY QUESTIONS:
• Pain Scale • Vital Signs • Oxygen Saturation

High risk mechanism of injury with Many resources needed
neurological deficits

High risk mechanism of injury with no Notify physician
neurological deficits Multiple diagnostic studies or procedures
Sudden onset of chest, jaw, or neck pain (no Frequent consultation
known injury) Continuous monitoring
Difficulty breathing
Severe headache and fever 101.3°F (38.5°C)
Petechiae
Sudden onset of numbness, tingling, weakness
in both arms or legs
Diaphoresis, palpitations, nausea, and/or
vomiting
Severe pain

Neck pain worsens with flexion Refer for treatment as soon as possible
Low risk mechanism of injury May need multiple diagnostic studies or
Photophobia procedures
Nausea and vomiting Monitor for changes in condition
Weakness or numbness in one arm If vital signs abnormal, consider Level 2
123
124 Neck Pain

Moderate neck pain worsens with extension Offer comfort measures
Swollen glands, sore throat, cold symptoms, Reassess while waiting, per facility protocol
earache May need simple diagnostic study or procedure
Swelling on one or both sides of neck
Pain interferes with daily activity

Neck pain without history of trauma or illness Offer comfort measures
Chronic neck pain Reassess while waiting, per facility protocol
Slept in awkward position May need examination only
RELATED PROTOCOLS:
Chest Pain • Ear Problems • Fever • Head Injury • Sore Throat • Toothache/Tooth Injury
Notes
Nosebleed
?
KEY QUESTIONS:

Pale, diaphoretic, dizzy, or weak Many resources needed

Abnormal vital signs Notify physician
Uncontrolled bleeding with clots Multiple diagnostic studies or procedures
Provide IV access per facility protocol
Lab draw, consider blood type and cross per
facility protocol

Moderate to heavy bleeding (anterior bleed) May need multiple diagnostic studies or
Bleeding from nasal or facial trauma procedures
Hemoptysis Monitor for change in condition
Bleeding uncontrolled after 30 min of direct If abnormal vital signs, consider Level 2
pressure Instruct patient to gently blow through the
History of bleeding disorder or other nose to clear nares
hematologic disease (leukemia, Administer nasal spray to help control
thrombocytopenia, etc.) and intermittant bleeding, per facility protocol
nosebleeds Clamp nose for 10 min
Headache
Normal vital signs and lightheadedness
125
126 Nosebleed

Intermittent nosebleed (3 in past 48 hours) Reassess while waiting, per facility protocol
Recent nasal surgery Offer comfort measures
Frequent use of cocaine May need a simple diagnostic study or
Moderate pain procedure

Seasonal allergies Reassess while waiting, per facility protocol
Frequent use of nasal sprays Offer comfort measures
History of frequent controlled nosebleeds May need an examination only
RELATED PROTOCOLS:
Cold Symptoms • Foreign Body, Inhaled
Notes
Poisoning, Exposure or Ingestion
?
KEY QUESTIONS:
Name • Age • Weight • Onset • Amount • Emesis After Ingestion • Allergies • Prior History
• Medications • Pain Scale • Vital Signs • Oxygen Saturation • Name of Agent (if Known)

Contact National Poison Control Center for
advice (1-800-222-1222)

Lethargy Notify physician
Recent seizure or postictal Frequent consultation
Wheezing, stridor, shortness of breath Continuous monitoring
Ingestion of an acid, alkali, or hydrocarbon Contact National Poison Control Center for
agent advice (1-800-222-1222)
Burns on lips or tongue Provide IV access, perform EKG, per facility
Cyanosis protocol
Unstable vital signs If suicide attempt, place in observed area until
Suicide attempt bed available
Constricted or dilated pupils If multiple patients with similar symptoms,
Known carbon monoxide exposure consider WMD exposure and initiate
Strong suspicion of exposure to WMD agent decontamination procedures per facility plan
and symptomatic
Excessive drooling or sweating or hyperactive
reflexes
Fever 104°F (40.0°C)
Child found with open medication bottle or
other potentially dangerous substances
127
128 Poisoning, Exposure or Ingestion

Nausea, vomiting, diarrhea May need multiple diagnostic studies or
Abdominal pain procedures
Headache Monitor for changes in condition
Ataxia If vital signs abnormal, consider Level 2
Dizziness or lightheadedness Contact National Poison Control Center for
Psychiatric history advice (1-800-222-1222)
Cognitive dysfunction
Irritability
Smell of chemical on breath or clothes

Poison oak or poison ivy exposure and Offer comfort measures
urticaria and rash May need simple diagnostic study or procedure
advice (1-800-222-1222)

Gave twice the recommended amount of OTC Reassess while waiting, per facility protocol
medication Offer comfort measures
Asymptomatic but parent or patient concerned May need examination only
advice (1-800-222-1222)
RELATED PROTOCOLS:
Alcohol and Drug Use, Abuse, and Dependence • Bites, Insect and Tick • Bites, Marine Animal • Bites,
Snake • Suicidal Behavior
See Appendix Q, Biological Agents/Chemical Agents; Appendix O, Drugs of Abuse; Appendix P: Poisonings
Pregnancy, Abdominal Pain
?
KEY QUESTIONS:
• Oxygen Saturation • Gestational Age • Recent Ultrasound • Number of Pregnancies

Imminent delivery, crowning noted Staff at bedside
Seizure Mobilization of resuscitation team
Ruptured membranes with prolapsed cord Many resources needed
Pale, diaphoretic, and lightheaded or weak Monitor fetal heart tones

No fetal movement with gestational age 24 wk Notify physician
Passing tissue with heavy vaginal bleeding Multiple diagnostic studies or procedures
Painful vaginal bleeding (abruptio placentae) Frequent consultation
and pregnancy 20 wk Continuous monitoring
Contractions every 2 to 3 min (precipitous If pregnancy 20 wk, transfer to labor and
birth) and pregnancy 20 wk delivery, per facility protocol
Monitor fetal heart tones

Painless vaginal bleeding (placenta previa) and Refer for treatment as soon as possible
pregnancy 20 wk May need multiple diagnostic studies or
First trimester of pregnancy (ectopic) procedures
Twenty to 37 wk gestation (preterm labor) Monitor for changes in condition
Nausea, vomiting, diarrhea If vital signs abnormal, consider Level 2
Bright red emesis, stools, or hematuria Postural vital signs
Sudden weight gain, edema, headache If pregnancy 20 wk, transfer to labor and
History of prior pregnancy complications delivery, per facility protocol
Fever 102.2°F (39.0°C) Monitor fetal heart tones
129
130 Pregnancy, Abdominal Pain

Frequent urination or burning Reassess while waiting, per facility protocol
Fever, cough, earache, sore throat May need simple diagnostic study or procedure
Vaginal discharge

Heartburn Offer comfort measures
“Morning sickness” Reassess while waiting, per facility protocol
RELATED PROTOCOLS:
Pregnancy, Back Pain • Pregnancy, Vaginal Bleeding • Pregnancy, Vaginal Discharge
Notes
Pregnancy, Back Pain
?
KEY QUESTIONS:
• Oxygen Saturation • Gestational Age • Recent Ultrasound • Number of Pregnancies

Imminent delivery, crowning noted Mobilization of resuscitation team
Seizure Many resources needed
Ruptured membranes with prolapsed cord Monitor fetal heart tones
Pale, diaphoretic, and lightheaded or weak Place in knee-chest or Trendelenburg position
Check cord for pulsation

Contractions and 37 wk gestation Notify physician
No fetal movement Multiple diagnostic studies or procedures
Strong, regular contractions Frequent consultation
Recent trauma Continuous monitoring
If pregnancy 20 wk, transfer to labor and
delivery, per facility protocol

Fever 102.2°F (39.0°C) Refer for treatment as soon as possible
Urinary frequency, burning, hematuria May need multiple diagnostic studies or
Difficulty starting a urine stream procedures
Flank pain Monitor for changes in condition
Rectal pain If vital signs abnormal, consider Level 2
Right upper quadrant pain or shoulder pain Orthostatic vital signs
Multigravida and history of prior pregnancy If pregnancy 20 wk, transfer to labor and
complications delivery, per facility protocol
131
132 Pregnancy, Back Pain

Musculoskeletal pain Reassess while waiting, per facility protocol

Mild pain associated with increase in activity Offer comfort measures
Reassess while waiting, per facility protocol
RELATED PROTOCOLS:
Pregnancy, Abdominal Pain • Pregnancy, Vaginal Bleeding • Pregnancy, Vaginal Discharge
Notes
Pregnancy, Vaginal Bleeding
?
KEY QUESTIONS:
• Last Menstrual Period • Number of Regular-Size Saturated Pads • Medications

Prolapsed cord Many resources needed
Pale, diaphoretic, and lightheaded Monitor fetal heart tones
Place in knee-chest or Trendelenburg position

Profuse, bright red blood and pregnancy Notify physician
20 wk Multiple diagnostic studies or procedures
Passing large clots or products of conception Frequent consultation
Painful vaginal bleeding (abruptio placentae) Continuous monitoring
Hypotension or tachycardia If pregnancy 20 wk, transfer to labor and
Severe abdominal pain delivery, per facility protocol
Lightheadedness Monitor fetal heart tones
No fetal movement and pregnancy 20 wk Position patient on left side
Known trauma

Painless vaginal bleeding and pregnancy 20 wk May need multiple diagnostic studies or procedures
Moderate flow, bright red blood (placenta Monitor for changes in condition
previa) If vital signs abnormal, consider Level 2
Strong, regular contractions Postural vital signs
Leaking clear fluid If pregnancy 20 wk, transfer to labor and
10 fetal movements in 1 hr delivery, per facility protocol
133
134 Pregnancy, Vaginal Bleeding

Minimal bleeding but patient concerned Reassess while waiting, per facility protocol

Spotting dark brown or pink blood after Offer comfort measures
intercourse Reassess while waiting, per facility protocol
RELATED PROTOCOLS:
Pregnancy, Abdominal Pain • Pregnancy, Back Pain • Pregnancy, Vaginal Discharge
Notes
Pregnancy, Vaginal Discharge
?
KEY QUESTIONS:
• Last Menstrual Period • Medications

Ruptured membranes with prolapsed cord Mobilization of resuscitation team
Place in knee-chest or Trendelenburg position

Severe abdominal pain Notify physician
No fetal movement and pregnancy 20 wk Multiple diagnostic studies or procedures
Imminent delivery with crowning or meconium Frequent consultation
If pregnancy 20 wk, transfer to labor and
delivery, per facility protocol

Fever 102.2°F (39.0°C) with purulent vaginal Refer for treatment as soon as possible
discharge May need multiple diagnostic studies or
Herpes outbreak with regular contractions or procedures
leaking of fluid Monitor for changes in condition
Green, brown, or red-stained fluid If vital signs abnormal, consider Level 2
135
136 Pregnancy, Vaginal Discharge

Irregular contractions Reassess while waiting, per facility protocol
History of STD exposure May need simple diagnostic study or procedure
Clumped, white, curd-like discharge

Lost mucous plug Offer comfort measures
Increase in vaginal mucus secretions Reassess while waiting, per facility protocol
RELATED PROTOCOLS:
Pregnancy, Vaginal Bleeding • Vaginal Bleeding, Abnormal
Notes
Pregnancy, Vomiting
?
KEY QUESTIONS:
• Vital Signs • Gestational Age • Number of Pregnancies • Medications

Pale, diaphoretic, and lightheaded Staff at bedside
Pale, diaphoretic, dizzy, weak Many resources needed

Vomiting bright red blood Notify physician
Recent head or abdominal trauma Continuous monitoring
Abnormal vital signs Monitor fetal heart tones

Signs of dehydration May need multiple diagnostic studies or
Coffee ground emesis procedures
Diabetes and hyperglycemia or hypoglycemia Monitor for changes in condition
Lightheadedness Postural vital signs
Orthostatic vital signs If vital signs abnormal, consider Level 2
Dark, amber urine Monitor fetal heart tones
Right upper or lower quadrant pain
Abdominal pain and nausea, vomiting, or
diarrhea
Fever 102.2°F (39.0°C)
137
138 Pregnancy, Vomiting

Nausea and vomiting associated with Reassess while waiting, per facility protocol
gastroenteritis May need simple diagnostic study or procedure
Vomiting 24 hr (no dehydration signs)

Heartburn Offer comfort measures
No other symptoms but patient concerned Reassess while waiting, per facility protocol
RELATED PROTOCOLS:
Pregnancy, Abdominal Pain • Vomiting
Notes
Puncture Wound
?
KEY QUESTIONS:
• Tetanus Immunization Status • Mechanism of Injury (Appendices K–N)

Involvement of vital organ Many resources needed

High risk mechanism of injury (mass, size, and Notify physician
velocity of wounding object and direction of Multiple diagnostic studies or procedures
impact) Frequent consultation
Large amount of bleeding and difficult to Continuous monitoring
control with pressure Leave impaled object in place
Pulsatile bleeding Apply compression dressing to control
Pulses absent distal to injury bleeding
Skin cyanotic distal to wound Refer to appropriate mechanism of injury
High-pressure injection injury resource in appendices K–N
Impaled object obvious to head or trunk

Paresthesia distal to injury Reassess, per facility protocol
Pulses weak distal to injury May need multiple diagnostic studies or
Decreased range of motion to the affected area procedures
Puncture wound in a joint Monitor for changes in condition
Fever and chills If vital signs abnormal, consider Level 2
History of bleeding disorder, cancer, etc. Do not soak if wood sliver
139
140 Puncture Wound

Tip of impaled object broken off and not
visible
Foreign body sensation persists
Impaled object obvious to an extremity

Puncture wound through a shoe Offer comfort measures
No prior tetanus prophylaxis May need simple diagnostic study or procedure
Fever, red streaks, purulent drainage Do not soak if wood sliver

Small object in distal extremity Reassess while waiting, per facility protocol
No other symptoms but parent or patient Offer comfort measures
concerned May need examination only
Tetanus prophylaxis status 5 yr Do not soak if wood sliver
RELATED PROTOCOLS:
Bites, Animal and Human • Bites, Marine Animal • Bites, Snake • Foreign Body, Skin • Laceration
• Motor Vehicle Accidents • Suicidal Behavior • Wound Infection
Notes
Rash, Adult and Pediatric
?
KEY QUESTIONS:
• Oxygen Saturation • Number of Wet Diapers in an Infant

Anaphylaxis Many resources needed
Pulseless

Fever and petechiae (nonblanching) or purpura Notify physician
(nonblanching) Multiple diagnostic studies or procedures
Fever and severe localized pain Frequent consultation
Red skin peeling off in sheets Continuous monitoring
Stiff neck, severe headache
Sudden onset of hives and difficulty breathing
Child with any of the following:
Unusual drowsiness, refusal to drink, and noisy
or fast breathing
Signs of dehydration: sunken eyes or fontanel,
no wet diapers
Drooling

Redness and swelling of the eyelid Reassess, per facility protocol
Facial swelling May need multiple diagnostic studies or
Fever, red rash, and using tampons or history procedures
of recent surgery Monitor for changes in condition
Severe itching, irritation, and open skin If vital signs abnormal, consider Level 2
141
142 Rash, Adult and Pediatric

Signs of infection: redness, swelling, pain, red Offer comfort measures
streaks, or drainage from wound May need simple diagnostic study or procedure
Fever, sore throat, or cold symptoms
Joint pain or swelling
Exposure to poison oak or poison ivy
Localized area of painful blisters
Non localized fluid filled blisters
Newborn with blisters
Blanching petechiae or purpura and no fever
Multiple lesions in mouth
Rash, blisters, pimples, or crusting under
diaper area

Dermatitis Reassess while waiting, per facility protocol
Herpes outbreak Offer comfort measures
Asymptomatic rash lasting 48 hr May need examination only
Recent exposure to chickenpox or measles May isolate patients with communicable disease
Red or weeping rash in groin or diaper area exposure and symptomatic from other
Extensive rash, cause unknown waiting patients
RELATED PROTOCOLS:
Allergic Reaction • Bites, Animal and Human • Bites, Insect and Tick • Bites, Marine Animal
• Bites, Snake • Poisoning, Exposure or Ingestion
Notes
Rectal Problems (see Foreign Body,

Rectum or Vagina, for foreign body problem)
?
KEY QUESTIONS:
• Vital Signs


Heavy rectal bleeding mixed in the stool or Notify physician
passing of blood clots Multiple diagnostic studies or procedures
Traumatic injury to rectum by a knife or blunt Frequent consultation
object Continuous monitoring
Black or bloody stools and lightheadedness
Frequent black, tarry stools

Severe rectal pain Refer for treatment as soon as possible
Sexual assault May need multiple diagnostic studies or
Urinary retention procedures
Moderate rectal bleeding and no history of Monitor for change in condition
hemorrhoids; or bleeding with constipation If vital signs abnormal, consider Level 2
Acute abdominal pain, bloating, nausea, or
vomiting
Rectal pain and fever 102.2°F (39.0°C)
Foreign body in rectum
Constipation and vomiting brown, yellow, or
green bitter-tasting emesis
143
144 Rectal Problems

Black or bloody stools and use of blood
thinners, steroids, nonsteroidal anti-
inflammatory medications, or large doses
of aspirin

Moderate rectal pain or itching that interferes Reassess while waiting, per facility protocol
with activities of daily living Offer comfort measures
Minimal rectal bleeding and history of May need simple diagnostic study or procedure
hemorrhoids or bleeding with constipation
Low-grade fever or signs of infection:
spreading redness, open sores, drainage
Exposure to an STD
Painful blisters around rectal area
Last bowel movement 5 days previous
Infant with no stool 6–10 days
Fever, constipation and history of recent
surgery, injury, childbirth, or diverticulitis

Worms visible in the stool Reassess while waiting, per facility protocol
Rectal itching Offer comfort measures
Chronic constipation May need examination only
Intermittent rectal pain with bowel
movements
RELATED PROTOCOLS:
Abdominal Pain, Adult • Abdominal Pain, Pediatric • Foreign Body, Rectum/Vagina • Sexual Assault
Seizure
?
KEY QUESTIONS:
• Vital Signs • Oxygen Saturation • Drug and Alcohol Use


History of head injury Notify physician
Pregnancy: eclampsia Multiple diagnostic studies or procedures
Overdose or poisoning Frequent consultation
Sudden onset of weakness, inability to move Continuous monitoring
one side of the body, difficulty speaking If multiple patients with similar symptoms or
Strong suspicion of exposure to WMD agent suspected exposure to WMD agent, initiate
and symptomatic decontamination procedures, per facility plan
Severe headache See appendix Q, Biological Agents/Chemical
First-time seizure Agents
Persistent, unusual lethargy

Fever 101.4°F May need multiple diagnostic studies or
Sudden cessation of alcohol or drug procedures
consumption in the chronic user Monitor for changes in condition
Frequent seizures while taking anticonvulsant If vital signs abnormal, consider Level 2
medications
145
146 Seizure

Headache
Nuchal rigidity
History of seizures and inconsistent use of
medications or excessive alcohol use

History of cancer, diabetes, or Offer comfort measures
immunosuppression May need simple diagnostic study or procedure
History of seizures and out of medication

History of psychosomatic seizures Reassess while waiting, per facility protocol
History of seizures and alert and oriented after Offer comfort measures
waking up from the seizure May need examination only
RELATED PROTOCOLS:
Altered Mental Status • Alcohol and Drug Use, Abuse, and Dependence • Bites, Animal and Human
• Bites, Insect and Tick • Bites, Marine Animal • Bites, Snake • Confusion • Diabetic Problems
• Fever • Head Injury • Poisoning, Exposure or Ingestion
Notes
Seizure, Pediatric Febrile
?
KEY QUESTIONS:
Name • Age • Weight • Onset • Allergies • Prior History • Medications • Pain Scale


Severe headache Notify physician
Stiff or painful neck Multiple diagnostic studies or procedures
Vomiting Frequent consultation
First-time seizure Continuous monitoring
Child 6 mo or 5 yr
Fever 105°C

Earache or respiratory infection unresponsive Refer for treatment as soon as possible
to antibiotics May need multiple diagnostic studies or
History of febrile seizures or high fever spikes procedures
Signs of dehydration: sunken eyes or fontanel, Monitor for changes in condition
dry diaper If vital signs abnormal, consider Level 2
Persistent fever 102°F (38.0°C), Apply cooling measures
unresponsive to fever-reducing measures

Feeding poorly Reassess while waiting, per facility protocol
Decreased fluid intake Offer comfort measures
147
148 Seizure, Pediatric Febrile

Alert and oriented after a seizure Reassess while waiting, per facility protocol
Afebrile with history of febrile seizures Offer comfort measures
Child wants to sleep after seizure, but easily May need examination only
aroused without irritability
RELATED PROTOCOLS:
Altered Mental Status • Confusion • Diabetic Problems • Fever • Head Injury
• Poisoning, Exposure or Ingestion
Notes
Sexual Assault
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Pain Scale • Vital Signs • Oxygen Saturation
• Mechanism of Injury • Last Menstrual Period • Last Consensual Intercourse


Profuse bleeding Notify physician
Genital trauma Multiple diagnostic studies or procedures
Multiple traumas from assault Frequent consultation
Head injury Continuous monitoring
Difficulty breathing, chest pain, or abdominal
pain
Suspected fractures or dislocations
Victim is a minor

Sexual assault 72 hr previous May need multiple diagnostic studies or
Severe anxiety procedures
Use of objects Monitor for changes in condition
Possible exposure to date-rape drug If vital signs abnormal, consider Level 2
Abrasions, lacerations, bruising, discoloration, Sexual assault kit and sexual assault counselor,
or swelling per facility protocol
Victim requests examination and collection of
evidence
149
150 Sexual Assault

Sexual assault 72 hr previous Offer comfort measures
Contact sexual assault counselor, per facility
protocol

Alleged assault without penetration Reassess while waiting, per facility protocol
RELATED PROTOCOLS:
Foreign Body, Rectum or Vagina • Rectal Problems • Vaginal Bleeding, Abnormal
Notes
Shoulder Pain
?
KEY QUESTIONS:
• Oxygen Saturation • Cause


Pain radiates to chest, jaw, or neck Notify physician
Sudden onset, no known injury, and several Multiple diagnostic studies or procedures
cardiac risk factors present Frequent consultation
Decreased circulation in affected arm
Open fracture

Menstrual period 2–4 wk late and abdominal May need multiple diagnostic studies or procedures
pain present Monitor for changes in condition
Fever and swollen, red, and tender joint Check capillary refill
Inability to raise arm above head Monitor circulation, movement, and sensation of
Blunt trauma affected extremity
Decreased sensation in the affected arm If vital signs abnormal, consider Level 2

Continued pain with decreased ROM Offer comfort measures
Recent injury and no improvement in pain May need simple diagnostic study or procedure
after 3 days of ice, heat, and rest
Discomfort in distal joints
151
152 Shoulder Pain

Chronic pain Reassess while waiting, per facility protocol
Discomfort increasing with activity Offer comfort measures
Progressive joint pain and stiffness May need examination only
RELATED PROTOCOLS:
Chest Pain • Extremity Injury • Motor Vehicle Accident
Notes
Sinus Pain and Congestion
?
KEY QUESTIONS:


Stiff neck and fever Notify physician
Wheezing with retractions Multiple diagnostic studies or procedures
Abnormal vital signs Frequent consultation
Provide IV access, per facility protocol
Lab draw, per facility protocol

Severe headache or earache May need multiple diagnostic studies or
Fever 104°F (40.0°C) and unresponsive to procedures
fever-reducing measures Monitor for changes in condition
Mild wheezing If vital signs abnormal, consider Level 2
Facial pain, swelling, redness, warmth,
drainage, or fever
Immunocompromised patient
Fever 102°F (39.0°C) and productive
cough or shortness or breath

Sore throat and persistent low-grade fever Offer comfort measures
153
154 Sinus Pain and Congestion

Headache worsening with movement May need simple diagnostic study or procedure
Fever 101°F (38.3°C)
Green, brown, or yellow nasal discharge

Sinus congestion Reassess while waiting, per facility protocol
Allergies Offer comfort measures
Afebrile May need examination only
RELATED PROTOCOLS:
Cold Symptoms • Fever • Sore Throat
Notes
Sore Throat
?
KEY QUESTIONS:


Difficulty breathing (unrelated to nasal Notify physician
congestion) Multiple diagnostic studies or procedures
Excessive drooling in a child Frequent consultation
Stridor or inability to swallow own saliva Constant monitoring
“Kissing tonsils” and drooling

Severe pain and difficulty swallowing Refer for treatment as soon as possible
Inability to open mouth completely May need multiple diagnostic studies or
Signs of dehydration procedures
Sore throat and lip or mouth swelling Monitor for changes in condition
Neck pain or rigidity If vital signs abnormal, consider Level 2
History of immunosuppression, 60 yr or Rapid strep test, per facility protocol
diabetes, and fever 100.5°F (38.1°C)
History of rheumatic fever, mitral valve
prolapse, or other heart problems
“Kissing tonsils” and able to swallow on saliva
155
156 Sore Throat

Skin rash Reassess while waiting, per facility protocol
Exposure to strep throat 2 wk previous Offer comfort measures
Moderate pain May need a simple diagnostic study or
Hoarseness procedure
Yellow pus or white mucus at back of throat Rapid strep test, per facility protocol
and fever
Sore throat persists 3 days
Earache
Red or enlarged tonsils

Mild discomfort 2 days Reassess while waiting, per facility protocol
Afebrile Offer comfort measures
Chronic nasal congestion May need examination only
Coughing or sneezing with allergies
RELATED PROTOCOLS:
Breathing Problems • Cold Symptoms • Cough • Ear Problems • Fever
Notes
Suicidal Behavior
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Prior History • Pain Scale • Vital Signs • Oxygen Saturation
• Prior Suicide Attempts and Method


Pulsatile bleeding from wounds Notify physician
Threat to self or others Multiple diagnostic studies or procedures
Overdose or poisoning Frequent consultation
Psychosis and potential harm to self or others Continuous monitoring
Head trauma Apply compression dressing to control bleeding
Hanging attempt and facial cyanosis, scleral Remove and check all clothing for weapons or
hemorrhage, tongue swelling, petechiae means to commit suicide
Has means to carry out suicidal plan

Refusal to talk, withdrawn, or no eye contact May need multiple diagnostic studies or
History of prior attempts procedures
Depression Maintain constant supervision of patient
Intoxication Monitor for changes in condition
Has suicidal plan with means to carry it out If vital signs abnormal, consider Level 2
Contact crisis personnel or social worker, per
facility protocol

Suicidal thoughts with no plans Offer comfort measures
157
158 Suicidal Behavior

Stopped taking medication May need simple diagnostic study or procedure
Observe while waiting
Contact crisis personnel or social worker, per
facility protocol

History of depression controlled with Reassess while waiting, per facility protocol
medication Offer comfort measures
RELATED PROTOCOLS:
Anxiety • Depression • Poisoning, Exposure or Ingestion
Notes
Sunburn
?
KEY QUESTIONS:
• Vital Signs • Tetanus Immunization Status

Hypotension, tachycardia Mobilization of resuscitation team

Temperature 104.9°F (40.5°C) and Notify physician
unresponsive to cooling measures Multiple diagnostic studies or procedures
Dry, hot skin and lightheadedness Frequent consultation
Diaphoresis, cool skin, and lightheadedness Continuous monitoring
Perform cooling measures
Provide IV access, per facility protocol

Visual changes and/or severe eye pain May need multiple diagnostic studies or
Signs of dehydration procedures
Vomiting Monitor for changes in condition
Circumferential burns around extremities, If vital signs abnormal, consider Level 2
digits, or genitals
Large area of blistered skin

Small areas of blisters Offer comfort measures
Open blisters May need simple diagnostic study or procedure
Red streaks extending from blistered area
Tetanus immunization 10 yr previous
159
160 Sunburn

Mild sunburn Reassess while waiting, per facility protocol
Sunburn responsive to OTC analgesics May need examination only
RELATED PROTOCOLS:
Burns • Heat Exposure • Lightheadedness/Fainting
Notes
Toothache/Tooth Injury
?
KEY QUESTIONS:
• Vital Signs


Traumatic dental injuries with risk of airway Notify physician
compromise or neck injury Multiple diagnostic studies or procedures
Gnawing pain in lower teeth and chest, neck, Frequent consultation
shoulder, or arm Continuous monitoring
Similar pain in the past and related to a heart Tooth needs to be placed in socket ASAP;
problem minutes count
Tooth knocked out
Bleeding uncontrolled with constant pressure

Facial pain, swelling, redness, warmth, May need multiple diagnostic studies or
drainage, or fever procedures
Fever 104°F (40.0°C) and unresponsive to Monitor for changes in condition
fever-reducing measures If vital signs abnormal, consider Level 2
History of cardiac valve replacement
Fever and neck pain
Severe swelling of oral tissue

Swollen painful gums Offer comfort measures
161
162 Toothache/Tooth Injury

Purulent drainage May need simple diagnostic study or procedure
Foul taste or odor in mouth
Recent dental work in painful area
Chipped or fractured tooth

Sores in mouth Reassess while waiting, per facility protocol
Loose or decayed tooth May need examination only
Sensitive to heat, cold, or pressure Offer comfort measures
Tooth discolored
RELATED PROTOCOLS:
Mouth Problems
Notes
Urinary Catheter Problems
?
KEY QUESTIONS:
• Vital Signs • Date Catheter Inserted


Severe flank, abdominal, or back pain and fever Notify physician
102°F (39.0°C) Multiple diagnostic studies or procedures
Profuse bright red blood from catheter Frequent consultation

Gross hematuria May need multiple diagnostic studies or
Passing clots through catheter procedures
Painful, distended bladder Monitor for changes in condition
No urine output 8 hr If vital signs abnormal, consider Level 2
Surgically placed catheter or tube displaced

Recent urological surgery Offer comfort measures
Taking a blood-thinning agent and urine pink May need simple diagnostic study or procedure
or red
Skin irritation near meatus
Cloudy, foul-smelling urine
Fever 100.4°F (38.0°C)
163
164 Urinary Catheter Problems

Catheter leak Reassess while waiting, per facility protocol
Mild discomfort Offer comfort measures
RELATED PROTOCOLS:
Abdominal Pain, Adult • Abdominal Pain, Pediatric • Fever • Urination Problems
Notes
Urination Problems
?
KEY QUESTIONS:
• Vital Signs


Severe abdominal pain with fever 102°F Notify physician
(39.0°C) Multiple diagnostic studies or procedures
Hematuria and flank trauma, history of renal Frequent consultation
transplant, or severe abdominal or flank pain Continuous monitoring
Severe abdominal pain and unable to void
8 hr or catheter bag empty 8 hr
Traumatic injury to urethra and unable to stop
bleeding with pressure

Fever 102°F (39.0°C) May need multiple diagnostic studies or
Persistent flank, back, or abdominal pain procedures
Hematuria and colicky flank pain or use of Monitor for changes in condition
anticoagulants If vital signs abnormal, consider Level 2
Pain with urination, back or flank pain, and Urine sample and dip, per facility protocol
fever 100.5°F (38.1°C)
Pain or bleeding and history of diabetes or
immunosuppression
New onset of incontinence
History of renal or prostate disease
Recent trauma (back, abdominal, genital area)
165
166 Urination Problems

Unable to urinate 4–8 hr
Recent urinary or abdominal surgery and
dysuria

Fever 100.4°F (38.0°C) Offer comfort measures
Nausea or vomiting May need simple diagnostic study or procedure
Genital herpes or STD Urine sample and dip, per facility protocol
Difficulty urinating after sexual intercourse
Urinary frequency, urgency, and/or hematuria
Full bladder and unable to urinate 4 hr

Burning sensation after exposure to bubble Reassess while waiting, per facility protocol
baths, nylon underwear, soaps, or other Offer comfort measures
products applied to the perineal area May need examination only
Urinary frequency or fullness
Nocturia
RELATED PROTOCOLS:
Abdominal Pain, Adult • Abdominal Pain, Pediatric • Back Pain • Fever • Urinary Catheter Problems
Notes
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Vaginal Bleeding, Abnormal
?
KEY QUESTIONS:
• Vital Signs • Birth Control Measures • Last Menstrual Period • Number of Pregnancies


Sexual assault and profuse bleeding or injury Notify physician
with an object Multiple diagnostic studies or procedures
Profuse bleeding 3 full-size pad/hr Frequent consultation
Passing products of conception Continuous monitoring
Diaphoretic
History of blood disorders
Pregnancy 20 wk
Hypotension
Vaginal bleeding, abdominal or shoulder pain,
last period 2–4 wk late and possibility of
pregnancy
Retained foreign object

Nausea, vomiting, or lightheadedness May need multiple diagnostic studies or
Increased thirst or signs of dehydration procedures
Increased abdominal pain with movement Monitor for changes in condition
Orthostatic changes If vital signs abnormal, consider Level 2
Recent abortion or miscarriage with fever, Measure orthostatic vital signs
pain, and increasing bleeding
167
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168 Vaginal Bleeding, Abnormal

Cramping Offer comfort measures
Heavier-than-normal period May need simple diagnostic study or procedure
Bleeding increased with increase in activity or
change in birth control pills
Bleeding 10 days

Spotty bleeding after sexual intercourse Reassess while waiting, per facility protocol
Recently started taking oral contraceptives Offer comfort measures
Normal menses May need examination only
Patient concerned about menopause or
pregnancy
RELATED PROTOCOLS:
Foreign Body, Rectum or Vagina • Pregnancy, Vaginal Discharge
Notes
Vomiting
?
KEY QUESTIONS:
• Vital Signs • Health of Other Household Members • Recent Trauma


Head injury Notify physician
Persistent vomiting of frank blood or coffee Multiple diagnostic studies or procedures
grounds–like emesis Frequent consultation
Chest, jaw, or arm pain Continuous monitoring
Abdominal trauma
Diabetic and glucose 400 mg/dL

Severe abdominal pain or headache 2 hr Refer for treatment as soon as possible
Signs of dehydration May need multiple diagnostic studies or
Possible ingestion of, or exposure to poisonous procedures
substance Monitor for changes in condition
History of diabetes, cancer, other chronic If abnormal vital signs, consider Level 2
illness, or immunosuppression
Age 60 yr and vomited more than once
Fever 104°F (40°C)
Orthostatic vital signs
169
170 Vomiting

Recent ingestion of an antibiotic, pain Offer comfort measures
medication, or new medication May need a simple diagnostic study or
Vomiting 48 hr procedure

Vomiting 24 hr Reassess while waiting, per facility protocol
Recent surgery, hospitalization, or diagnostic Offer comfort measures
procedure May need an examination only
Other household members are ill
Excessive ingestion of food, alcohol, or fluids
Possible pregnancy
RELATED PROTOCOLS:
Abdominal Pain, Adult • Abdominal Pain, Pediatric • Diarrhea, Adult • Diarrhea, Pediatric • Fever
• Head Injury • Poisoning, Exposure or Ingestion • Pregnancy, Vomiting
Notes
Weakness
?
KEY QUESTIONS:
Name • Age • Onset • Allergies • Medications • Prior History • Severity • Vital Signs
• Oxygen Saturation • Pain Scale (for chest pain, see Chest Pain; for difficulty breathing, see
Breathing Problems; for altered mental status, see Altered Mental Status)


Sudden onset or persistent altered mental status Do not delay treatment
Drug or alcohol overdose Notify physician
Inability to stand, walk, or bear weight Multiple diagnostic studies or procedures
Severe headache Frequent consultation
Rapid heartbeat with syncope/diaphoresis Finger-stick glucose
Sudden onset of weakness to one side of the
body
Weakness in face, arm, or leg
Visual disturbances
Speech and language problems
Irregular pulse
Severe abdominal pain
Loss of movement in arms or legs, confusion,
difficulty speaking, numbness, tingling or
blurred vision, and onset 2 hr
Hand or foot cold or blue
Orthostatic vital signs
171
172 Weakness

Recent head injury or trauma (rule out head Refer for treatment as soon as possible
bleed) May need multiple diagnostic studies or
Persistent high fever procedures
Severe abdominal pain and normal vital signs Monitor for changes in condition
Temporary slurred speech or weakened grips If vital signs abnormal, consider Level 2
Pain, swelling, warmth, or redness in affected
limb
Severe pain interfering with normal activity

History of dieting or use of diuretics Offer comfort measures
Gradual onset of numbness, tingling, or Reassess while waiting, per facility protocol
burning sensation in extremities May need a simple diagnostic study or
Pain radiates to arm or leg procedure
Fever; cough; green, yellow, or brown sputum;
body aches for 24 hr; and unresponsive to
home care measures
History of taking cholesterol-lowering
medication
Recent history of frequent falls

Exhaustion Offer comfort measures
Occasional weakness Reassess while waiting, per facility protocol
History of neuromuscular problems that are May need examination only
unresponsive to medication
Increased exercise, activity level, or stress
History of muscular pain
RELATED PROTOCOLS:
Altered Mental Status • Breathing Problems • Chest Pain • Fever • Headache
Wound Infection
?
KEY QUESTIONS:
• Vital Signs


Sutured or stapled wound 50% open Notify physician

Surgical wound dehiscence May need multiple diagnostic studies or
Purulent drainage procedures
Fever Monitor for changes in condition
Swollen lymph nodes If abnormal vital signs, consider Level 2
Red streaking away from the wound
Headache or general illness

High-risk history (e.g., diabetes, Offer comfort measures
immunosuppression, chronic illness, May need a simple diagnostic study or
chemotherapy, use of steroids) and wound procedure
not healing well
173
174 Wound Infection

Wound itching Reassess while waiting, per facility protocol
Tetanus immunization 5–10 yr previous Offer comfort measures
RELATED PROTOCOLS:
Abdominal Pain, Adult • Abdominal Pain, Pediatric • Diabetic Problems
Notes
Wrist Pain and Swelling
?
KEY QUESTIONS:
• Vital Signs • Mechanism of Injury


No radial pulse Multiple diagnostic studies or procedures
Cyanosis of the hand Frequent consultation
Open fracture Continuous monitoring
Suicidal behavior Continuous observation of suicidal patient

Unsplinted angulated deformity May need multiple diagnostic studies or
Wrist swollen to twice its normal size procedures
Fever, drainage, red streaks Monitor for changes in condition

Splinted deformity Offer comfort measures
High-risk mechanism of injury May need a simple diagnostic study or
Decreased mobility procedure
Inability to make a fist
175
176 Wrist Pain and Swelling

Pain, swelling, or discoloration Reassess while waiting, per facility protocol
Chronic discomfort (old injury) Offer comfort measures
History of arthritis or tendonitis May need an examination only
Pain increasing with repetitive activities
RELATED PROTOCOLS:
Extremity Injury • Motor Vehicle Accident • Shoulder Pain
Notes
Bibliography
Anscombe Wood, D. (2004, June 7). On the level(s). Muller, A. A. (2003). Small amounts of some drugs can be
NurseWeek. Available at: http://www.nurseweek.com toxic to young children: One pill or one swallow can
news/features/04-06/triage.asp. Accessed April 26, 2005. require aggressive treatment. Journal of Emergency
Beckstrand, R. L., & Sanders, E. K. (2003). A 39-year-old man Nursing, 29(3), 290–293.
with left shoulder pain: Comparing 3- and 5-point triage Rosen, P., Barkin, R., Hayden, R., Schaider, J., & Wolfe, R.
scales. Journal of Emergency Nursing, 29(4), 387–389. (1999). The 5-minute emergency medicine consult.
Bowman, M., & Baxt, W. (2003). Office emergencies. Philadelphia: Lippincott Williams & Wilkins.
Philadelphia: Saunders. RnCeus.com (2002). Biochemical terrorism: An ER
Briggs, J. (2002). Telephone triage protocols for nurses (2nd resource. Available at: http://www.rnceus.com. Accessed
ed.). Philadelphia: Lippincott Williams & Wilkins. April 26, 2005.
Dart, R. (2000). The 5-minute toxicology consult. Philadelphia: Tipsord-Klinkhammer, B. (Ed.) (1998). Triage: Meeting the
Lippincott Williams & Wilkins. challenge (2nd ed.). Des Plaines, IL: Emergency Nurses
Davis, M. A., Greenough, G., & Votey, S. (Eds.) (1999). Signs Association.
& symptoms in emergency medicine. St. Louis: Mosby. Travers, D., Waller, A., Bowling, M., Flowers, D., &
Emde, K. (2003). MDMA (Ecstasy) in the emergency Tintinalli, J. (2002). Five-level triage system more effec-
department. Journal of Emergency Nursing, 29(5), tive than three-level in tertiary emergency department.
440–443. Journal of Emergency Nursing 28(5), 395–400.
Ferri, F. (2003). Ferri’s clinical advisor: Instant diagnosis and Zimmermann, P. G. (2003). Orienting ED nurses to triage:
treatment. St. Louis: Mosby. Using scenario-based test-style questions to promote
Grossman, V. G. A. (2003). Quick reference to triage (2nd critical thinking. Journal of Emergency Nursing, 29(3),
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177
<axn>
Appendix A
The PQRSTT Mnemonic Assessment Guide

P = Provoking factors
● What makes it (pain, breathing, etc.) worse?
● What makes it better?
● Any known trauma or injury?
Q = Quality of pain
● What does it feel like?
● Does the patient use descriptive words, such as burning, stabbing, crushing, or tearing?
R = Region/Radiation
● Where is the pain?
● Is it in one spot?
● Does it start in one spot and travel to another?
● Ask the patient to point to where it hurts using one finger.
S = Severity of pain
● If the patient were to describe the pain with a number from 0 to 10, with 0 being the least severe and
10 being the worst pain imaginable, what number would the patient give this pain?
T = Time
● When did this start?
● How long have the symptoms persisted?
● How long did it last?
● Has it ever happened before?
T = Treatment
● Has the patient taken any medication to treat this?
● What time was the last dose?
● Has the patient done anything to treat him- or herself?
● What has or has not worked for the patient?
179
Appendix B
Pediatric Vital Signs: Normal Ranges

Weight
Systolic Blood
Age Group Respiratory Rate Heart Rate Pressure Kilogram Pounds
Newborn 30–50 120–160 50–70 2–3 4.5–7

Infant (1–12 mo) 20–30 80–140 70–100 4–10 9–22
Toddler (1–3 yr) 20–30 80–130 80–110 10–14 22–31
Preschooler (3–5 yr) 20–30 80–120 80–110 14–18 31–40
School Age (6–12 yr) 18–25 70–110 85–120 20–42 41–92
Adolescent (13 yr) 12–20 55–110 100–120 50 110
R E M E M B E R :
• The patient’s normal range should always be taken into consideration.
• Heart rate, blood pressure, and respiratory rate are expected to increase during times of
fever or stress.
• Respiratory rate on infants should be counted for a full 60 seconds.
• In a clinically decompensating child, the blood pressure will be the last to change. Just
because your pediatric patient’s blood pressure is normal, don’t assume that your
patient is stable.
• Bradycardia in children is an ominous sign, usually a result of hypoxia. Act quickly, as
this child is extremely critical.
180
<axn>
Appendix C
Ibuprofen Dosage Chart*
Dosage
Approximate Approximate Drops Syrup Junior Adult

Weight Range Weight Range Dose (50 mg/ (100 mg/ Chewable Tablets Tablets
(kg) (lb) (mg) 1.25 mL) 5 mL) (50 mg) (100 mg) (200 mg)
2.5 5.5 25 0.625 mL — — — —

2.6–5 5.7–11 50 1.25 mL 2.5 mL 1 tab — —
5–7.5 11–16.5 75 1.875 mL 3.75 mL 1.5 tabs — —
7.6–10 16.7–22 100 2.5 mL 5.0 mL 2 tabs 1 tab —
11–12 24–26 125 3 mL 6.25 mL 2.5 tabs — —
13–15 28–33 150 3.75 mL 7.5 mL 3 tabs 1.5 tabs —
16–17 35–37 175 — 8.75 mL 3.5 tabs — —
18–20 39–44 200 — 10 mL 4 tabs 2 tabs 1 tab
21–25 46–55 250 — 12.5 mL 5 tabs 2.5 tabs —
26–30 57–66 300 — 15 mL 6 tabs 3 tabs 1.5 tabs
31–35 68–77 350 — 17.5 mL 7 tabs 3.5 tabs —
36–40 79–88 400 — 20 mL 8 tabs 4 tabs 2 tabs
41–45 90–99 450 — — — 4.5 tabs —
46–50 101–110 500 — — — 5 tabs 2.5 tabs
51–55 112–121 550 — — — 5.5 tabs —
56–60 123–132 600 — — — 6 tabs 3 tabs
*Do not use Ibuprofen in children less than 6 months of age or those with chickenpox.
181
Appendix D
Acetaminophen Dosage Chart

Dosage
Approximate Approximate Drops Syrup Adult

Weight Range Weight Range Dose (80 mg/ (160 mg/ Chewable Chewable Tablets
(kg) (lb) (mg) 0.8 mL) mL) (80 mg) (160 mg) (325 mg)
5.9 13 40 1/2 dropper 1.25 mL — — —

(0.4 mL)
5.9–9 13–20 80 1 dropper 2.5 mL — — —
(0.8 mL)
9–11 21–26 120 1 1/2 dropper 3.75 mL — — —
(1.2 mL)
12–15 27–35 160 2 droppers 5 mL 2 tabs — —
(1.6 mL)
16–19 36–43 240 3 droppers 7.5 mL 3 tabs 1.5 tabs —
(2.4 mL)
20–28 44–62 320 — 10 mL 4 tabs 2 tabs 1 tab
28–35 63–79 400 — 12.5 mL 5 tabs 2.5 tabs —
36–40 80–89 480 — 15 mL 6 tabs 3 tabs —
41–45 90–99 560 — 17.5 mL 7 tabs 3.5 tabs —
46–50 101–110 650 — 20 mL — 4 tabs 2 tabs
51–55 112–121 825 — 25 mL — 5 tabs —
56–60 123–132 900 — 28 mL — 5.5 tabs —
61–65 133–143 975 — 30 mL — 6 tabs 3 tabs
65 143
182
<axn>
Appendix E
Temperature Conversion Chart

Celsius Fahrenheit
43.0 109.4
42.0 107.6
41.0 105.8
40.5 104.9
40.0 104.0
39.5 103.1
39.0 102.2
38.5 101.3
38.0 100.4
37.5 99.5
37.0 98.6
36.5 97.7
36.0 96.8
35.0 95.0
34.0 93.2
33.0 91.4
32.0 89.6
31.0 87.8
30.0 86.0
29.0 84.2
28.0 82.4
27.0 80.6
26.0 78.8
25.0 77.0
24.0 75.2
23.0 73.4
(continued)
183
184 Appendix E
Celsius Fahrenheit
22.0 71.6
21.0 69.8
20.0 68.0
19.0 66.2
18.0 64.4
Formula for Fahrenheit to Celsius: (1.8 Celsius reading) 32

Formula for Celsius to Fahrenheit: 0.55 (Fahrenheit reading 32)
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<axn>
Appendix F
Weight Conversion Chart

Pound Kilogram
1 0.45
2 0.90
3 1.35
4 1.80
5 2.25
6 2.70
8 3.60
10 4.50
11 5
22 10
33 15
44 20
55 25
66 30
77 35
88 40
99 45
110 50
121 55
132 60
143 65
154 70
165 75
176 80
187 85
198 90
209 95
(continued )
185
186 Appendix F
Pound Kilogram
220 100
231 105
242 110
253 115
264 120
275 125
286 130
297 135
<axn>
Appendix G
Differential Diagnosis of Abdominal Pain
Possible Diagnosis Signs and Symptoms
Abdominal Aortic Aneurysm Asymptomatic until leakage or rupture occurs

Abrupt onset of severe back, flank, or abdominal pain
Pulsatile abdominal mass, mottling of lower extremities, signs of
shock
Appendicitis Diffuse pain in epigastric or periumbilical area for 1–2 days
Localization of pain over the right lower quadrant between the
umbilicus and right iliac crest
Anorexia, nausea/vomiting, fever, tachycardia, pallor, peritoneal
signs
Increased pain with stairs, walking, etc.
Bowel Obstruction Severe, crampy, colicky abdominal pain
Vomiting, constipation, hypotension, tachycardia, abdominal
distention, hyperactive bowel sounds, fever
Cholecystitis (Inflammation Colicky discomfort in the right upper quadrant mid-epigastric
of Gallbladder) area
Pain radiating to the shoulders and back
Nausea/vomiting, fever, tachycardia, tachypnea, abdominal
guarding, jaundice, malaise
Cholelithiasis (Presence of Severe, steady, or colicky pain in the upper abdominal quadrant,
Gallbladder Stones) often right-sided
Pain usually begins 3–6 hours after a large meal
Pain radiation to scapula, back, or right shoulder
Nausea, vomiting, dyspepsia, mild to moderate jaundice
Constipation/Fecal Impaction Clinically defined as defecation 3 times per week
Each patient may interpret the symptoms differently
Fatigue, abdominal discomfort, headache, low back pain, anorexia,
restlessness
Duodenal or Ileojejunal Caused by a blow to the abdomen
Hematoma Immediate bruising over upper quadrant of abdomen
Epididymitis Infection or inflammation of the epididymis
(continued)
187
188 Appendix G
Swelling and enlargement of the epididymis, sudden swelling of

the spermatic cord, fever, dysuria, urethral discharge
Intussusception Paroxysms of acute abdominal pain, intermittent with pain-free
episodes
Currant jelly, mucus-type stools or rectal bleeding
Fever, lethargy, vomiting (food, mucus, fecal matter), dehydration
Orchitis Inflammation or infection of the testicle
Intense pain and swelling of the scrotum, dysuria, urethral
discharge, fever, discomfort in the groin/lower abdomen, acute
illness
Pancreatitis Severe, constant, upper quadrant midepigastric pain that radiates
to the midback
Pain worsens when lying flat on back, relieved when lying on side
with knees drawn up
Nausea, vomiting, fever, pallor, hypotension, tachycardia,
tachypnea, restlessness, malaise, fatty or foul-smelling stools,
abdominal distention, pulmonary crackles
Peritonitis Severe pain that gradually increases in intensity and worsens with
movement
Riding in car, climbing stairs, or jumping on one foot greatly
worsens pain
Radiation of pain to shoulder, back, or chest
Nausea, vomiting, fever, abdominal distention, rigidity, and
tenderness
Renal Calculi Location of stone depicts associated pain: flank, lower abdominal
quadrant, low back, groin, testicular, labial, or urethral meatus
Pain radiation varies on stone location
Nausea, vomiting, pallor, diaphoresis, marked restlessness,
dehydration
Ruptured Ovarian Cyst Sudden, severe, unilateral lower quadrant abdominal pain
associated with exercise or intercourse
Delayed or prolonged menstruation, vomiting, ascites, signs of
peritonitis
Tubal Pregnancy Intermittent diffuse abdominal pain
Radiation of pain to shoulder
Vaginal spotting/bleeding, syncope, dizziness, signs of peritonitis
or shock
Urinary Tract Infection Lower quadrant abdominal or pelvic pain
Urinary burning, frequency, urgency, hematuria, foul smelling
urine, fever, bladder spasms
Cystitis Dysuria, urinary frequency and urgency, fever, hematuria
Pyelonephritis Flank or back pain
Urinary frequency, dysuria, fever, malaise, nausea, vomiting, chills
(continued )
Differential Diagnosis of Abdominal Pain 189
Prostatitis Perineal aching, low back pain

Urinary frequency, dysuria, fever, malaise, urethral discharge,
prostate swelling
Testicular Torsion Sudden onset of severe, unilateral testicular pain and tenderness
Nausea, vomiting, fever, scrotal mass
Ulcer (Gastric, Duodenal, Colicky, burning, squeezing pain in the epigastric or midback area
Esophageal) Pain intensity is variable, often begins 1–3 hr after meals, worsens
at night
Nausea, vomiting, hematemesis, abdominal guarding, decreased or
absent bowel sounds
Appendix H
Differential Diagnosis of Chest Pain

System Cause Characteristics
Cardiovascular Acute Pain may be described as aching, pressing, squeezing, burning,

Myocardial tight
Infarction Intensity: vague to severe
Location of pain may be substernal, epigastric, or between the
shoulder blades
Pain may radiate to the neck, jaw, arm, back
Women may describe symptoms more of nausea, fatigue,
shortness of breath
Diabetic neuropathy patients may have only vague pain
Aneurysm Pain may be described as searing, continuous, severe
Pain may radiate to the back, neck, or shoulder(s)
Associated signs and symptoms: hypotension, diaphoresis,
syncope
Angina Pain may be described as squeezing, pressing, tight, relieved
with rest or nitroglycerin
Pain may be persistent and intermittent
Occurs with activity, anxiety, sex, heavy meals, smoking, or
at rest
Associated signs and symptoms: dyspnea, nausea, vomiting,
diaphoresis, indigestion
Cardiac Contusion Cardiac compression between the sternum and vertebral
column (falls, MVAs, blunt chest trauma, etc.)
May have EKG changes such as right bundle branch block,
ST-T wave abnormalities, Q waves, atrial fibrillation,
premature ventricular contractions, and A-V conduction
disturbances
Heart Transplant REJECTION may present with low-grade fever, fatigue,
dyspnea, peripheral edema, pulmonary crackles, malaise,
pericardial friction rub, arrhythmias, decreased EKG voltage,
hypotension, increased jugular distention
(continued)
190
Differential Diagnosis of Chest Pain 191
INFECTION may be masked by use of immunosuppressive

therapy; look for low-grade fever, cough, and malaise
CORONARY HEART DISEASE is common in patients with
heart transplants
Pericarditis Pain may be described as severe, continuous, worse when lying
on left side
Radiation of pain to shoulder or neck
History may include recent cardiac surgery, viral illness, or
myocardial infarction
Diffuse ST elevation in multiple leads
PQ segment depression
Tachydysrhythmias Pain may be described as severe, crushing, or generalized over
chest
Associated signs and symptoms: anxiety, tachycardia,
dizziness, impending doom
Gastrointestinal Hiatal Hernia Pain may be described as sharp, over the epigastrium
Occurs with heavy meals, bending over, lying down
Gastroesophageal Pain may be described as burning, heartburn, pressing
Reflux Disease Nonradiating pain, not influenced by activity
(GERD)
Musculo- Costochondritis Pain may be described as sharp or severe
skeletal Localized to affected area with tenderness on palpation
Associated signs and symptoms: cough, “cold”
Muscle Strain Pain may be described as aching
Occurs with increased use or exercise of upper-body muscles
Pain is severe, with localization over area of trauma
Pain worsens with palpations, movement, or cough
May have dyspnea
Pulmonary Noxious Fumes/ Pain may be described as searing; sense of suffocation
Smoke Inhalation History includes exposure to fire, pesticide, carbon monoxide,
paint, chemicals
Associated signs and symptoms: dyspnea, hypoxia, cough,
pallor, ashen skin, cyanosis, singed nasal hairs, soot in
oropharynx, gray or black sputum, hoarseness, drooling
Those with carbon monoxide poisoning may additionally
show nausea, headache, confusion, dizziness, irritability,
decreased judgment, ataxia, collapse
Pleural Effusion Pain may be described as sharp, localized, gradual onset, yet
continuous
Dyspnea on exertion or at rest
Pain worsens with breathing, coughing, movement
Common in smokers
(continued)
192 Appendix H
Pulmonary Pneumonia Pain may be described as continuous, dull discomfort to severe

pain
Associated signs and symptoms: fever, shortness of breath,
tachycardia, malaise, cough, tachypnea
Children may complain of abdominal pain instead of chest pain
Pneumothorax Pain may be described as sudden onset, sharp, severe
Associated signs and symptoms: shortness of breath
Pulmonary Acute shortness of breath
Embolism Risk factors include recent long bone fractures, surgery,
smoking, use of oral contraceptives, sitting for long periods of
time (e.g., long air travel)
Other Anxiety Pain may be described as aching, stabbing
Associated with stressful event, anxiety
Associated signs and symptoms: hyperventilation, carpal
spasms, palpitations, weakness, fear, sense of impending doom
Source: Grossman, V. A. (2003). Quick Reference to Triage (2nd ed.). Philadelphia: Lippincott Williams & Wilkins.
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<axn>
Appendix I
Headache: Common Characteristics

Headache Type Characteristics
Cerebellar Hemorrhage Pain:

Moderate to severe
Associated signs and symptoms:
Confusion
Vomiting
Altered gait
Cluster Headaches Pain:
Very painful
Knifelike
Unilateral
Over the eye
Excessive tearing
Facial swelling
Redness of the eye
Diaphoresis
Increased Intracranial Pressure Pain:
Usually not excruciating
Associated symptoms:
Nausea or vomiting
Lethargy
Diplopia
Transient visual difficulty
Meningitis Pain:
Mild to severe
Neck pain or stiffness
Fever
Malaise
Decreased appetite
Irritability
(continued)
193
194 Appendix I
Headache Type Characteristics
Migraines Pain:
Periodic with gradual onset
Throbbing, severe
Frequently unilateral, may progress to bilateral
Often above the eye(s)
Photophobia
Sensitivity to sound
Nausea
Vomiting
Sinus Headache Pain:
Over the sinus areas (above the eyes, beside the nose, or over the
cheekbone)
Fever
Nasal drainage or congestion
Ear pain
Tenderness, swelling, or erythema of the sinus area
Subarachnoid Hemorrhage Pain:
“Worst headache of my life”
With or without transient impairment of consciousness
Tension Pain:
Diffuse yet steady dull pain or pressure
“Band-like” (back of head and neck, across forehead, and/or
temporal areas)
Appendix J
MVA Triage Questions

When did the accident occur?
●Day
●Time
Where did it occur?

●Highway
●Country road
●City street
●Off road
●Speedway
Was the patient wearing a seat belt?

●What type? (lap, shoulder, etc.)
●Effectiveness during the accident?
What speed was the patient’s car traveling?

●Approximate speed of other vehicles involved in accident
●Approximate speed of patient’s vehicle
Where was the patient sitting in the car?

●Driver
●Front seat passenger
●Back seat passenger
●Box of the truck
What kind of vehicle was the patient in?

●Sport utility vehicle
●Compact car
●Other motorized vehicle
●Motorcycle
What damage was done to the vehicle?

(continued)
195
196 Appendix J
Did the airbag deploy?
Did the patient lose consciousness?

● For how long?
What is the last thing the patient remembers before the accident?
What is the first thing the patient remembers after the accident?
How was the patient injured in the car?

● Flying objects within the car
● Car crushed by other vehicle, tree, pole, etc.
Was the patient thrown from the car?

●Was something in the car thrown against the patient?
Was the patient ambulatory at the scene?

●Did the patient need to be extricated from the vehicle?
●How long did it take?
Were there any other people in the car?

●Were they injured?
●What are their injuries?
Was the pediatric patient in a car seat?

●Where was the car seat located within the vehicle?
●Was it struck by a deployed air bag?
●Was the car seat strapped tightly with the seatbelt?
Were there law enforcement personnel at the scene?

●If so, which agency?
Does the patient wear:

● Contact lenses?
● Glasses?
● Hearing aid?
● Were they worn at the scene?
● Dentures?
● Female patients: Is a tampon in place?
● Insulin pump or other medical device? Pacemaker? Internal cardiac defibrillator?
Where is the patient experiencing pain?
Is the patient taking any medication, especially aspirin or other anticoagulants?
Is there anyone the patient wishes to have notified?

<axn>
Appendix K
Mechanisms of Injury from Trauma: Adult

Trauma Associated Injuries
Pedestrian struck by car Fractures of the femur, tibia, and fibula on side of
• Adult point of impact is usually knee/hip impact
Fractured pelvis
Contralateral ligament damage to knee
Pedestrian struck by car Contralateral skull fracture
• Short adult/child point of impact involves Chest injury with rib and/or sternal fracture
chest and/or head May be thrown, resulting in head/back injury
Shoulder dislocation and/or scapular fracture
Patellar and lower femur fracture
Pedestrian dragged under a vehicle Pelvic fracture
MVA: Unrestrained front seat passenger Posterior dislocation of acetabulum
• Front impact Fractures of femurs and/or patellas
MVA: Unrestrained driver Head injury, c-spine injury, pelvic fracture
• Front impact Flail chest, fractured sternum
Aortic or tracheal tears
Pulmonary/cardiac contusion
Ruptured or lacerated liver or spleen
Femur and/or patellar fracture, hip dislocation
MVA: Unrestrained driver or passenger Chest: flail, fractured sternum, pulmonary/cardiac
• Side impact contusion
Fractures of clavicle, acetabulum, pelvis
Lateral neck strain or injury
Driver: ruptured spleen
Passenger: ruptured liver
MVA: Passenger without headrest restraint Hyperextension of neck resulting in high c-spine or
• Rear impact vertebral fracture or ruptured disk(s), causing
intradural hemorrhage, edema, spinal cord
compression
(continued)
197
198 Appendix K
MVA: Rotational force from spinning car Combination of frontal and side impact–induced
injuries
MVA: Rollover of vehicle Multitude of external and internal injuries
MVA: Ejection from vehicle Injuries at point of impact
MVA: Restrained driver or passenger Compression of soft tissue organs, c-spine injuries, rib
and sternal fractures, cardiac contusions, ruptured
diaphragm
Lap belt only: head, neck, facial, and chest injuries
Shoulder strap only: severe neck injury, decapitation
Air bag deployed: facial injuries, abrasions/burns of
arms
Fall
• Landing on feet Compression fractures of lumbosacral spine
Fractures of calcaneus
• Landing on buttocks Compression fracture of lumbar vertebrae
Pelvic fracture
Coccyx fracture
Diving Forceful cervical spine compression resulting in
• Head first fracture, dislocation, and/or displacement of
vertebral bone fragments into spinal canal
Blunt head trauma Coup/contra-coup injury
• Person’s moving head strikes a stationary Depressed skull fracture
object Cerebral hematoma, contusions, or laceration
Blunt chest trauma Pulmonary contusion
• Moving object strikes a person’s chest Hemothorax
Rib fractures
Crush injury to chest Traumatic asphyxia
• Crushing trauma to chest forces blood from heart
via the superior vena cava to veins of the head, neck,
and upper chest, causing subconjunctival and/or
retinal hemorrhage, conjunctival edema, and
characteristic deep violet skin color
<axn>
Appendix L
Mechanisms of Injury: School Age

and Adolescent (7 to 17 Years)
Common Mechanisms of Injury
Motor vehicle-related injuries
Occupant
Pedestrian
Bicycle-related injuries
Burns
Flames
Explosions
Suicide
Ingestion
Gunshot wounds
Hanging
Minor trauma
Superficial lacerations
Drowning
Falls
Sports-related injuries
Farm injuries
Penetrating trauma
Stabbing
Gunshot wounds
(continued)
199
200 Appendix L
Assaults Head/chest/abdomen: closed or open injuries, fractures, c-spine

injury
Bicycle-related injuries Head: closed or open injuries
Chest: pulmonary/cardiac contusion, pneumothorax, rib fractures
Burns (flames, explosions) Surface trauma; risk of multiple trauma exists
Drowning Respiratory: acute respiratory distress syndrome (ARDS)
Falls Head: cerebral swelling, epidural/subdural hematoma, skull
fracture, c-spine injury
Chest: pulmonary/cardiac contusion, hemo/pneumothorax
Abdomen and misc: same as for MVAs
Farm injuries Crush injuries
Minor trauma (superficial Surface trauma: lacerations, contusions
lacerations)
Motor vehicle accident Head: cerebral swelling, epidural/subdural hematoma, skull
(occupant, pedestrian) fractures, c-spine injuries
Chest: pulmonary/cardiac contusion, hemothorax or
pneumothorax rib fractures
Abdomen: liver: fracture, laceration; spleen: hematoma, laceration,
rupture; kidney: hematoma, contusion, hematuria; pancreas:
contusion
Misc: surface trauma, bony fractures
Penetrating trauma (stabbing, Head/chest/abdomen: variety of injuries to internal organs
gunshot wounds)
Sports-related injuries Head: c-spine injuries
Chest: rib fractures, pulmonary/cardiac contusions
Abdomen: same as MVA possibilities
Suicide (ingestion, gunshot Head: c-spine injury from hanging
wounds, hanging) Chest/abdomen: variety of injuries from penetrating trauma, falls,
MVAs
<axn>
Appendix M
Mechanisms of Injury: Toddler and Preschooler

(1 to 6 Years)
Motor vehicle-related injuries
Occupant
Pedestrian
Bicycle
Burns
Scald and flame
Drownings
Ingestions
Minor surface trauma
Child abuse
Firearms (preschoolers)
Falls
Sledding
Choking
Animal bites
(continued)
201
202 Appendix M
Injury Pattern Risk Factors Associated Injuries
Abdomen Pliable pelvic girdle fails to protect Laceration, fracture, hematoma

internal organs to solid organs (liver, spleen,
Proportionately larger abdominal kidney): MVAs, falls, abuse
organs Hematoma to hollow organs:
Ribs do not protect upper abdominal (esophagus, stomach,
contents intestines): MVAs
Organs are in close proximity to each
other
Portion of bowel adheres to spine
Chest Short trachea Pulmonary/cardiac contusions:
Compliant chest wall MVAs, falls, sledding
Mobile mediastinal structures Pneumothorax: MVAs, falls, abuse
Major vessels lack valves and predispose Traumatic asphyxia: MVAs
traumatic asphyxia
Head Thin, pliable bony structures predispose Diffuse cerebral swelling: MVAs, falls
diffuse cerebral injuries Subdural hematoma: abuse, falls
Skull fractures: MVAs, falls, abuse,
sledding
Long bones Salter Harris Fractures (prior to puberty) Long bone fractures: falls, MVAs,
Periosteum is stronger and allows bone abuse, sports
to bend, leading to greenstick fractures
<axn>
Appendix N
Mechanisms of Injury: Infant (Birth to 1 Year)

Airway compromise
Choking
Strangulation
Suffocation
Foreign body ingestion
Child abuse
Shaken baby syndrome
Falls
Burns (scalds or flame)
Drownings
Poisonings
Baby walkers
Motor vehicle–related injuries
With or without the proper use/placement of
car seats
(continued)
203
204 Appendix N
Injury Pattern Risk Factors Associated Injuries
Abdomen Pliable pelvic girdle does not protect Laceration, fracture, rupture of solid
internal organs organs (liver, spleen, kidney): MVAs,
abuse, falls
Portion of bowel adheres to spine Hematoma, perforation of hollow organs
Organs easily crushed between bony (esophagus, stomach, intestines): MVAs,
structure and injury object physical abuse
Chest Tongue large in relation to oral cavity Respiratory arrest: airway compromise,
Narrow airway foreign body ingestion, obstruction
Obligate nose breather Pneumothorax: MVAs, falls, abuse
Short trachea Pulmonary/cardiac contusion: MVAs, falls
Pliable rib cage
Mobile mediastinal structures
Absence of valves in superior and
inferior vena cava
Head Head large in proportion to body Skull fractures: abuse, falls
Poor head control as a result of weak Subdural hematoma: abuse
neck muscles Retinal hemorrhages: abuse, traumatic
Pliable body structures and vessels asphyxia
predispose infant to diffuse head Diffuse cerebral swelling: MVAs, abuse, falls
injury High cervical fracture: MVAs
<axn>
Appendix O
Drugs of Abuse
Drug Name/ Street Method Physical Mental
Type Name Used Effects Effects
Alcohol (a CNS Booze, Swallowed Blurs vision; slurs speech, Scrambles thought
depressant) hooch, in liquid alters coordination; process, impairs
juice, form causes heart and liver judgment, causes
brew damage, addiction, memory loss, alters
gastric and esophageal perception, causes
ulcers, brain damage, delirium, apathy
blackouts,
hypoglycemia, anemia,
Wernicke-Korsakoff
syndrome, oral cancer,
fetal alcohol syndrome;
death from overdose
Cocaine (a CNS Coke, c-dust, Smoked/ Rapidly metabolized, Euphoria, illusion
stimulant) snow, toot, free based, producing a brief high of mental or
white lady, inhaled/ of 30 minutes; chronic physical power,
blow, rock(s), snorted, use can result in cocaine extreme mood
crack, flake, injected, psychosis, a condition swings, restlessness,
big “C,” swallowed similar to paranoid hallucinations,
happy dust, in powder, schizophrenia, intense paranoia, psychosis,
Bernice, pill, or psychological dependence, severe depression,
fluff, rock form dilated pupils, profuse anxiety, formication
caine, sweating, runny nose,
coconut, dry mouth, tachycardia,
icing, hypertension, insomnia,
mojo, zip anorexia, indifference to
pain, destruction of nasal
septum, heart and lung
damage; death from
overdose
(continued)
205
206 Appendix O

CNS Reds, barbs, IV injection, Drowsiness, slurred speech, Confusion, impaired

depressants— yellow suppos- skeletal muscle relaxation, judgment, impaired
Barbiturates: jackets, itory, poor muscle control, performance, anxiety
phenobarbital red devils, swallowed incoordination, nausea, and tension followed
(Luminal), blue devils, in pill slowed reaction time, by a sense of calm,
amobarbital yellow form involuntary eye movements, mood swings,
(Amytal), submarine, hypotension, bradycardia, forgetfulness
secobarbital blues and bradypnea, constricted
(Seconal), reds, idiot pupils, clammy skin,
pentobarbital pills, sleepers, loss of appetite,
(Nembutal), stumblers, penetrates the placental
sodium downers wall (addiction is passed
pentothal to the baby); withdrawal is
prolonged and severe:
symptoms range from
temporary psychosis to
cardiac arrest; cellulitis at
injection site, chronic use
results in extreme
psychological and physical
addiction; death from
overdose
CNS Downers, Swallowed Same as barbiturates; Same as barbiturates
depressants— ludes, in pill physically and
Nonbarbiturates: soapers, form psychologically
methaqualone, wallbangers, addictive; withdrawal
quaalude, lemons, is very difficult; severe
soper lovers, interaction with alcohol;
quack, 714s, death from overdose
300s
CNS Downers Injection, Decreased reflex action, Alteration in spatial
depressants— swallowed vision changes, muscle judgment and sense of
Tranquilizers, in pill form relaxation, hypotension, time, sense of calm,
benzodi- bradycardia, slurred impaired judgment,
azepines speech, drowsiness, confusion, depression,
(reduce blurred vision; prolonged hallucinations
tension and use causes severe physical
anxiety and psychological
without addiction
sedating):
diazepam
(Valium),
(continued)
Drugs of Abuse 207

chlordiazepox-
ide (Librium),
lorazepam
(Ativan),
oxazepam
(Serax),
alprazolam
(Xanax)
Hallucinogens Angel dust, Swallowed in Drooling, nystagmus, Disorientation, amnesia,
(drugs that killer, pill form, restlessness, incoordi- anxiety, depression,
alter percep- black sprayed on nation, rigid muscles, confusion, agitation,
tions of whack, a cigarette tachycardia, hypertension, violent behavior,
reality) supergrass, and superhuman strength, hostility, suicidal urges,
PCP peace pill, smoked dulled sensations to extreme personality
sherms, touch and pain, changes
superweed, impaired speech; death
DOA, CJ, is common, but from
goon dust, accidents, not from
dust joint, overdose; extremely
live one, dangerous drug, as it is
mad dog, a narcotic, stimulant,
T-buzz, depressant, and hallu-
wobble cinogen; a “trip” is a
weed, cycle of stimulation,
zombie depression, hallucination,
and then repeats itself,
lasting 2 to 14 hours
LSD Acid, blue Swallowed in Nausea, tachycardia, Altered perception of
heaven, liquid form, tachypnea, hyperthermia, reality, psychotic
instant zen, dropped on hypertension, dilated disturbances, paranoia,
purple sugar cube, pupils, diaphoresis, synesthesia, hallucina-
hearts, pure sprayed on palpitations, incoordi- tions, mood swings,
love, sugar paper tablet nation; trips last 4 to terrifying flashbacks
cubes, tail 14 hours; heightens all
lights five senses
Mescaline, Mesc, moon, Swallowed in Same as LSD Same as LSD
psilocybin peyote, natural
mushrooms buttons form
Inhalants: Inhaled or Incoordination, impaired Memory and thought
Gasoline, sniffed vision, neuropathy, impairment, depression,
airplane using a muscle weakness, aggression, hostility,
glue, paper or anemia, vertigo, paranoia, abusive
(continued)
208 Appendix O

paint plastic bag headache, weight behavior, mood swings,

thinner, or rag loss, nausea, vomiting, withdrawal from family
dry sneezing, coughing, and friends, violent
cleaner nosebleeds, slurred behavior
fluid speech, tachycardia,
fatigue, dilated pupils,
chemical smell on breath;
brain, liver, and bone
marrow damage; death
by anoxia
Nitrous oxide Laughing gas, Inhaled or
whippets, sniffed by
buzz bomb, mask or
nitro balloons
Amyl nitrite, Poppers Inhaled or
butyl nitrite snappers, sniffed
pearls, aimies, from gauze
bolt, climax, or ampules
thrust
Marijuana/ Joint, grass, Smoked, Interference with psycho- Sensory distortion,
hashish hash, pot, swallowed logical maturation, decrease in motivation,
(a CNS “J,” Maryjane, in solid psychological dependence forgetfulness, confusion,
depressant) reefer, form anxiety, paranoia
Colombian
locoweed,
love weed
Narcotics
(natural or
synthetic
drugs that
contain or
resemble
opium;
CNS
depressants)
Dilaudid Dillys, Swallowed in Drowsiness, lethargy, Forgetfulness, sedation,
cowboys pill or hypotension, bradycardia, sense of peace
Percodan Perks, pink liquid form, muscle weakness; death
spoons injected from overdose
Demerol Peth
Methadone Dollies,
amidone,
fizzies
(continued)
Drugs of Abuse 209

Codeine Schoolboy Swallowed in

cody, threes, pill or liquid
fours form
Morphine Mojo, morphy, Smoked, IV Tolerance occurs quickly; Produces an intense
mud, injection addiction occurs in as orgasmic rush followed
dreamer, little as 1 to 3 weeks; by euphoria, peace, and
Miss Emma withdrawal is painful a comforting warmth;
with intense cramps, cold confusion, forgetfulness,
sweats, delirium, pain, stupor
fever, headaches, and
seizures lasting about
4 days
Heroin Horse, junk,
dope, blanco,
black pearl,
Bonita,
smack
Stimulants Hi speed Pill form, Body enters a state of stress, Extreme exhilaration and
(cause CNS Lip poppers injected, anorexia, tachycardia, stimulation, inflated
stimulation) Speckled birds snorted palpitations hypertension, confidence, irritability,
Amphetamines: inability to sleep, nasal and volatile and aggressive
Benzadrine, bronchial passages enlarge, behavior, nervousness,
Biphetamine restricted cerebral blood mood swings,
Dextroamphe- Dexies, flow, dilated pupils, hallucinations, paranoia,
tamines: brownies, sweating, restlessness, formication, psychosis,
Dexedrine, brown and muscle tremors, rapid and hypomania
Synatan, clears garbled speech, excessive
Appetral activity, brain damage,
seizures, CVA, coma; death
Methamphe- Speed, meth, from overdose; drug effects
tamines: crystal, last 4 to 14 hours;
Methedrine, crank, “speeding” occurs with
Desoxyn, crypto, ice, injection, causing user to
Ambar yellow bam go about 5 days without
sleep; causes birth defects,
extreme physical and
psychological addiction
Herbal Ultimate Pill, Same as above; often Extreme exhilaration and
stimulants Xphoria, powder, marketed as safe and legal stimulation, inflated
(ephedra) herbal liquid alternatives to street drugs; confidence, reduced
ecstasy, legal increased sexual sensation, inhibitions, euphoria,
weed, buzz higher energy level, happiness and
(continued)
210 Appendix O

tablets, cloud tachycardia, sweating, friendliness, empathy

9, black body tremors, dilated toward others,
lemonade, pupils, muscle spasms, irritability, volatile and
brainalizer, grinding of teeth, elevated aggressive behavior,
fungalore, blood pressure; easily nervousness, mood
herbal XTC, obtainable over the swings, hallucinations,
planet X, Internet, through paranoia, formication,
the drink, X magazines, and at stores psychosis, hypomania
tablets, brain such as convenient markets,
wash, buzz health food stores, and
tablets, “head shops”
fukola cola,
love potion
#69, naturally
high, rave
energy, love
drug, Adam,
XTC, X
Anesthetics: Liquid X, Oral Onset is 10 to 20 minutes, Mood swings, amnesia,
GHB and liquid duration is 2 to 3 hours; sleepiness, drunken
analogs ecstasy, slow slurred speech, loss appearance
water, “G,” of muscle coordination,
easy lay nausea, vomiting,
bradycardia or tachycardia,
hypotension, hypothermia;
overdose: cardiac and
respiratory arrest, seizures,
incontinences of stool and
urine, unconsciousness
Ketamine K, super K, Injected, Onset is immediate if Euphoria, paranoia,
special K, snorted, smoked or Injected; anxiety, disorientation,
God, jet, smoked, duration is 1 to 2 hours; violence, agitation,
honey oil, oral, about one-quarter the insomnia, delusions,
blast, gas rectal strength of PCP, depending pain relief, intoxication,
on the dose used; sweating, hallucinations, sleepy
slurred or slow speech, appearance, confusion
muscle rigidity, blank
stare, elevated body
temperature, tachycardia,
loss of muscle coordination,
hypertension, excess
strength
<axn>
Appendix P
Poisonings
Substance and
Common/Street Name Clinical Signs and Symptoms
Acetaminophen Nausea, vomiting, anorexia, malaise, oliguria, increased liver enzymes

(Tylenol) Diffuse abdominal pain that becomes right upper quadrant abdominal pain
Alcohol Sedation, relaxation, euphoria, memory loss, poor judgment, ataxia, slurred
speech, nausea, vomiting, obtundation, coma
In children, hypoglycemia occurs
Amphetamines CNS: agitation, delirium, hyperactivity, tremors, dizziness, mydriasis, CVA,
(prescription: Ritalin, headache, hyperreflexia, seizures, coma
Tenuate, Preludin, Psychiatric: euphoria, aggressive behavior, anxiety, hallucinations,
Dexadrine; street: compulsive repetitious actions
ice, crank, cat, jeff, Cardiopulmonary: palpitations, hypertensive crisis, tachycardia, reflex
ecstasy, mulka, bradycardia, dysrhythmias, myocardial infarction, aortic dissection,
crystal, speed) pulmonary edema, respiratory distress
Anticholinergics Classic toxidrome: “mad as a hatter” (altered mental status); “hot as a hare”
(antihistamines, (hyperthermia); “red as a beet” (flushed skin); “dry as a bone” (dry skin
antiparkinsonian, and mucous membranes); “blind as a bat” (blurred vision secondary to
cyclic antidepres- mydriasis) (Rosen et al, 1999)
sants, antipsy-
chotics, antispasmod-
ics, mushrooms,
Jimson weed)
Arsenic Acute ingestion: severe hemorrhagic gastroenteritis develops within hours,
bone marrow depression, encephalopathy, cardiomyopathy, pulmonary
edema, cardiac dysrhythmia, peripheral neuropathy
Chronic ingestion: weakness, anorexia, hyperkeratosis, hyperpigmentation,
hepatic injury, respiratory irritation, perforated nasal septum, tremor,
peripheral neuropathy
(continued)
211
212 Appendix P
Substance and
Barbiturates CNS: lethargy, slurred speech, incoordination, ataxia, coma, hyporeflexia,

(Pentothal, Nembutal, nystagmus, stupor
Seconal, Mysoline, Cardiopulmonary: hypotension, bradycardia, respiratory depression, apnea
Phenobarbital) Other: rhabdomyolysis, compartment syndrome, hypoglycemia
Benzodiazepines CNS: nystagmus, miosis, diplopia, impaired speech and coordination, amnesia,
(Xanax, Librium, ataxia, confusion, somnolence, depressed deep tendon reflexes, dyskinesia
Clonopin, Valium, Cardiopulmonary: hypotension, bradycardia, tachycardia (in response to the
Dalmane, Ativan, hypotension), respiratory depression, aspiration
Versed, Serax, Other: hypothermia, rhabdomyolysis, skin necrosis
Restoril, Halcion)
Beta-blockers CNS: seizures, coma, CNS depression
(Atenolol, Brevibloc, Cardiopulmonary: hypotension, bradycardia, cardiac conduction delays, heart
Inderal, Lopressor, block, heart failure, bronchospasm, pulmonary edema, respiratory depression
Tenormin, Timoptic)
Calcium-channel CNS: syncope, CNS depression, rare seizure, coma
blockers (Cardizem, Cardiopulmonary: severe bradycardia, atrioventricular block, intraventricular
Procardia, Calan SR) conduction delays, ventricular dysrhythmias, congestive heart failure,
respiratory depression, pulmonary edema
Other: hyperglycemia, nausea, vomiting, ileus, hypotension, metabolic acidosis
Carbamazepine (oral CNS: ataxia, dizziness, drowsiness, nystagmus, hallucinations, combativeness,
antiseizure coma, seizures
medications with a Cardiopulmonary: respiratory depression, aspiration pneumonia, hypotension,
similar structure to conduction disturbances, supraventricular tachycardia, bradycardia, EKG
tricyclic changes
antidepressants) Other: urinary retention, hyponatremia, myoclonus
Carbon monoxide CNS: headache, dizziness, ataxia, confusion, acute encephalopathy, syncope,
seizures, coma
Cardiopulmonary: chest pain, palpitations, dyspnea, myocardial infarction,
tachycardia, hypotension
Other: nausea, vomiting, decreased vision, retinal hemorrhage, lactic acidosis,
rhabdomyolysis
Choral hydrate CNS: headache, lightheadedness, ataxia, hyporeflexia, altered mental status
Cardiopulmonary: hypotension, ventricular and supraventricular
dysrhythmias, bradypnea
Other: nausea, vomiting, abdominal pain, rash, pear-like breath odor
Cyanide CNS: headache, confusion, syncope, seizures, coma, agitation, CNS stimulation
Cardiopulmonary: tachycardia and hypertension progressing into
bradycardia and hypotension
Digoxin CNS: colored visual halos, blurred vision, agitation, lethargy, seizures,
psychosis, hallucinations
Cardiopulmonary: hypotension, cardiovascular collapse, bradycardia,
Atria-ventrical block, paroxysmal atrial tachycardia, congestive heart failure
(continued)
Poisonings 213
Substance and
Other: nausea, vomiting, diarrhea, abdominal pain
Ethylene glycol CNS: ataxia, slurred speech, irritability, cerebral edema, convulsions, coma
Cardiopulmonary: tachycardia, bradycardia, hypotension, hypertension,
pulmonary edema
Other: nausea, vomiting, abdominal pain, hematemesis, acute renal failure,
myalgia, hypocalcemia
Hallucinogens CNS: restlessness, anxiety, incipient dread, distortions of reality, helplessness,
coma, hyperreflexia
Cardiopulmonary: tachycardia, hypertension, dysrhythmias, tachypnea,
respiratory arrest
Other: nausea, vomiting, hyperpyrexia, coagulopathies
Hydrocarbons CNS: intoxication, headache, euphoria, slurred speech, lethargy, coma
Cardiopulmonary: respiratory distress, cyanosis, aspiration, tachycardia,
dysrhythmia
Other: mucosal irritation, gastritis, diarrhea, acute renal failure
Hypoglycemic agents CNS: headache, blurred vision, anxiety, irritability, confusion, stupor, coma,
seizures
Cardiopulmonary: respiratory distress, apnea, palpitations, tachycardia,
hypertension, premature ventricular contractions
Other: nausea, facial flushing, hypoglycemia, facial flushing, pallor
Iron CNS: lethargy, seizures, coma
Cardiopulmonary: tachycardia, tachypnea, hypotension
Other: vomiting, abdominal pain, GI bleeding, diarrhea, renal failure,
hepatic necrosis
Isoniazid CNS: ataxia, hyperreflexia, agitation, hallucinations, psychosis, coma, seizures
Cardiopulmonary: hypotension, tachycardia, shock, respiratory depression,
Kussmaul respirations
Other: hyperthermia, nausea, vomiting, severe anion gap, rhabdomyolysis
Lead (adult) CNS: headache, confusion, altered mental status, seizures, nerve entrapment,
motor neuropathy
Cardiopulmonary/reproductive: hypertension, alterations in sperm count
and quality
Other: anorexia, dyspepsia, constipation, renal failure
Lead (pediatric) CNS: cognitive dysfunction, decreased IQ, encephalopathy, irritability,
headache, coma
Hematologic: anemia, basophilic stippling
Other: nausea, vomiting, abdominal pain, mild hearing loss
Lithium CNS: lethargy, confusion, tremor, ataxia, slurred speech, hyperreflexia,
clonus, dystonia
Cardiopulmonary: EKG changes, respiratory failure
Other: nausea, vomiting, diarrhea, diabetes insipidus, leukocytosis
(continued)
214 Appendix P
Substance and
Methanol CNS: inebriation, ataxia, seizures, coma, blurred vision, dilated pupils,
headache, confusion
Cardiopulmonary: hyperpnea, hypotension
Other: metabolic acidosis, nausea, vomiting, abdominal pain
Nonsteroidal CNS: drowsiness, dizziness, lethargy, seizures
anti-inflammatories Cardiopulmonary: hypotension, tachycardia, hyperventilation, apnea
Other: nausea, vomiting, abdominal pain, acute renal failure, metabolic
acidosis
Organophosphates CNS: headache, dizziness, tremors, anxiety, weakness, incoordination,
convulsions, coma
Cardiopulmonary: hypotension, bradycardia, atrioventricular block, asystole,
bronchospasm, pulmonary edema
Other: miosis, anorexia, abdominal cramps, salivation, lacrimation
Phencyclidines CNS: impaired judgment, agitation, violent behavior, psychosis, paranoia,
coma, seizures, dyskinesia
Cardiopulmonary: hypertension, tachycardia, apnea
Other: hyperthermia, acute renal failure, hypoglycemia
Phenothiazines CNS: agitation, seizures, coma, extrapyramidal signs, tardive dyskinesia
Cardiopulmonary: respiratory depression, pulmonary edema, tachycardia,
EKG changes, V tach
Other: hyperthermia, priapism, acute renal failure, constipation, ileus,
agranulocytosis, anemia
Phenytoins CNS: ataxia, nystagmus, cortical depression, confusion, slurred speech, coma,
seizures
Cardiopulmonary: hypotension, bradycardia, myocardial depression with
rapid IV infusion
Other: nausea, vomiting
Salicylates CNS: tinnitus, deafness, delirium, seizures, coma, agitation, lethargy,
confusion, cerebral edema
Cardiopulmonary: hypotension, shock, tachypnea, noncardiac pulmonary
edema, hyperventilation
Other: nausea, vomiting, hepatic injury, acute renal insufficiency, hematemesis
Sympathomimetics CNS: anxiety, headache, agitation, altered mentation, diaphoresis, stroke,
seizures
Cardiopulmonary: palpitations, chest pain, myocardial ischemia,
tachydysrhythmias, hypertension
Other: dilated pupils, dry mucous membranes, urinary retention, hyperthermia
Theophylline CNS: tremor, agitation, nervousness, seizures
Cardiopulmonary: hypotension, tachycardia, tachypnea, hypertension,
dysrhythmias
Other: nausea, vomiting, abdominal pain, hypokalemia, hyperglycemia,
leukocytosis
(continued)
Poisonings 215
Substance and
Toluene CNS: depression, euphoria, ataxia, seizures, insomnia, headache, coma

Cardiopulmonary: sudden cardiac death, dilated cardiomyopathy, myocardial
infarction
Other: renal failure, rhabdomyolysis, hematemesis, abdominal pain
Tricyclic CNS: agitation, tremors, seizures, drowsiness, lethargy, coma, ataxia, mania,
antidepressants dilated pupils
Cardiopulmonary: hypotension, tachycardia, bradycardia, EKG changes,
dysrhythmias
Other: urinary retention, priapism, leukopenia, nausea, vomiting
Sources: Rosen et al., 1999; Dart, 2000.
Appendix Q
Biological Agents/Chemical Agents

Biological Agents
Agent and Signs, Symptoms, Contagious
Incubation Sequelae, and Vaccine Between
Period Mode of Acquisition Source Available Humans Treatment Comments
Anthrax Resemble a common Infected Yes; Extremely Early 90% to

(inhaled): cold (fever, cough, animal approved unlikely treatment 100% of
Bacillus malaise) that tissue for ages is essential cases are
anthracis; progress to severe Spores 18 to 65 Penicillin fatal
7 days dyspnea, can live 3 injections Doxycycline
post- diaphoresis, stridor, in the given 2 Fluoroqui-
exposure cyanosis, and shock soil for weeks nolones
Chest radiograph years apart, (Cipro)
shows a mediastinal Biological followed Special
widening warfare by 3 more considera-
Gram-positive agent injections tions for
bacilli seen on at 6, 12, treatment
blood smear and and 18 of children,
culture months elderly, and
Hemorrhagic pregnant
mediastinitis, women
thoracic
lymphadenitis,
and/or meningitis
Inhalation of spores
from contaminated
animal products
Anthrax Spores enter the Infected Yes; Rare, but Early Death
(cuta- skin animal approved can treatment rare if
neous): Infection more likely tissue, for ages 18 occur is essential treated
Bacillus with a cut or hair, fur, to 65 Penicillin
anthracis; abrasion on the hides, Doxycycline
7 days skin leather
216 (continued)
Biological Agents/Chemical Agents 217
Biological Agents
post- Infections begins with Spores 3 injections Fluoroqui- 20% of

exposure a raised, itchy can live given 2 nolones untreated
bump that in the weeks (Cipro) cases are
resembles a bug bite soil for apart, Special fatal
Within 1 to 2 days, a years followed considera-
vesicle develops, Biological by 3 more tions for
followed by a warfare injections treatment
painless ulcer 1 to 3 agent at 6, 12, of children,
cm in diameter and 18 elderly, and
with a black months pregnant
necrotic center women
Lymph glands in the
adjacent area may
swell
Anthrax Early symptoms: Infected Yes; Extremely Early 25% to
(intesti- nausea, vomiting, animal approved unlikely treatment 75% of
nal): malaise, anorexia, tissue for ages is essential cases are
Bacillus fever, acute Spores 18 to 65 Penicillin fatal
anthracis; inflammation of can live 3 injections Doxycycline
7 days the GI tract in the given 2 Fluoroqui-
post- Advanced soil for weeks nolones
exposure symptoms: years apart, (Cipro)
abdominal pain, Biological followed Special
vomiting blood, warfare by 3 more considera-
severe diarrhea agent injections tions for
Illness progresses at 6, 12, treatment
rapidly and 18 of children,
Eating undercooked months elderly, and
contaminated food pregnant
women
Botulism Early symptoms: Contam- Botulinum No Antitoxin Presents
(food- abdominal cramps, inated toxoid is available public
borne): nausea, vomiting, food available, from CDC; health
Clostrid- diarrhea, and from but must be emer-
ium difficulty seeing, restau- supplies adminis- gency
botulinum; speaking, rants or are scarce tered early Mortality
incubation swallowing home and in course rate
depends canned mass of disease 8%
on amount sources outbreaks
(continued)
218 Appendix Q
Biological Agents
and rate Double or blurred Bacteria of disease Supportive

of toxin vision, drooping com- are rare care
absorp- eyelids, slurred monly
tion: speech, dry mouth found in
ranges Progresses to an the soil
from 2 acute, afebrile,
hours to 8 symmetric,
days descending flaccid
paralysis with
multiple cranial
nerve palsies, coma
The most poisonous
substance known; a
major bioweapon
threat due to its
extreme potency,
lethality, ease of
production, trans-
port, and misuse
Botulism Ptosis, diplopia, Man-made Botulinum No Supportive Same as
(inhaled): blurred vision, aerosol- toxoid is care for food-
Clostrid- dysarthria, dyspho- ized available, borne
ium nia, dysphagia form but botulism
botulinum; Progresses to an of the supplies
incubation acute, afebrile, infec- are scarce
depends symmetric, tion, and mass
on amount descending flaccid created outbreaks
and rate of paralysis with for use of disease
toxin multiple cranial in bioter- are rare
absorp- nerve palsies, coma rorism
tion, The most poisonous
ranges substance known; a
from 12 to major bioweapon
80 hours threat due to its
extreme potency,
lethality, ease of
production,
transport, and
misuse
(continued)
Biological Agents
Botulism Double or blurred Bacteria As for food- No Antitoxin Infectious

(wound): vision, drooping found in borne and available disease
Clostrid- eyelids, slurred soil inhaled from CDC; that
ium speech, dry mouth In recent botulism must be would
botulinum; Progresses to an years, adminis- NOT
incubation acute, afebrile, black tar tered early result
depends symmetric, heroin in course from
on amount descending flaccid from of disease bioter-
and rate paralysis with California Supportive rorism
of toxin multiple cranial is a care
absorption nerve palsies, coma prime
Will NOT penetrate source
intact skin
Botulism Lethargy, poor feed- Bacteria As for food- No Supportive Infectious
(intesti- ing, constipation, com- borne and care disease
nal): weakness, crying, monly inhaled Antitoxin that
Clostrid- and poor muscle found in botulism is not would
ium tone the soil routinely NOT
botulinum Occasionally, given for result
susceptible patients infant from
may harbor C. botulism bioter-
botulinum in their rorism
intestinal tract
(most often occurs
in infants)
Brucellosis Flulike symptoms, Ingestion None Extremely Doxycycline Mortality
(food- such as fever, of conta- available rare, al- and 2%
borne): sweats, headache, minated for though rifampin
Brucella back pain, and milk, humans may used in
species; physical dairy, or possibly combina-
incubation weakness. animal be tion for 6
is variable In severe cases, the products trans- weeks
patient may High risk mitted Recovery
develop hepatitis, in unpas- through takes a few
arthritis, spondylitis, teurized breast weeks to
anemia, leukopenia, milk, ice milk, several
thrombocytopenia, cream sexual months
meningitis, uveitis, and contact,
optic neuritis, cheeses or
(continued)
220 Appendix Q
Biological Agents
Brucellosis papilledema, and tissue

(food- endocarditis trans-
borne) Chronic symptoms planta-
(cont’d ) may include recur- tion
rent fevers, joint
pain, and fatigue
Brucellosis Same as for food- Inhalation None avail- See See previous See
(inhaled): borne brucellosis of able for previous previous
Brucella aerosol- humans
species ized
Brucella
Brucellosis Same as for food- Transmit- None avail- See See previous See
(wound): borne brucellosis ted via able for previous previous
Brucella skin humans
species abrasions
while
handling
infected
animals
Pneumonic Early signs are fever, Bacteria None at this Occurs Early treat- Death can
plague: headache, weakness, carried time; through ment is occur in
Yersinia dyspnea, and pro- by however, respira- important as little
pestis ; ductive cough rodents research is tory Streptomy- as 2 to 4
incubation (bloody or watery and their underway droplets cin days
is 1 to 6 sputum) fleas during Tetracycline
days post- May see nausea, Bioweapon face-to- Chloram-
exposure vomiting, abdomi- usage face phenicol
nal pain, or diarrhea would contact Doxycycline
Acutely swollen and occur Special
painful lymph after considera-
nodes appear on aerosoli- tions for
the second day of zation of treatment
infection, and the the of children,
overlying skin is bacteria elderly, and
erythematous pregnant
Pneumonia women
progresses over Respiratory
2 to 4 days followed isolation
(continued)
Biological Agents
by septic shock and precau-

death tions, pro-
phylactic
antibiotic
for close
contacts of
patient
Smallpox: Initial symptoms are Infected The United Occurs No proven Mortality
Variola high fever, fatigue, saliva States through treatment, rate
virus; headaches, and droplets has an respira- although 30%
incubation back aches emergency tory research
is 7 to 17 Two to 3 days supply droplets for
days post- later, a rash appears available during antivirals
exposure in the mouth and (has not face-to- continues
on the face, arms, been face Supportive
and legs, beginning routinely contact care should
as flat red lesions used since Can also include
that evolve at the 1972) be intra-
same rate; after a trans- venous
day or two the mitted fluids,
lesions become by antipyret-
pus-filled and conta- ics, and
begin to crust early minated antibiotics
in the second week; clothing for
scabs fall off after 3 or secondary
to 4 weeks bedding infections
Patients with Patients
smallpox are most admitted
infectious during to the
the first week of hospital
illness, although should be
they are placed in
contagious until all negative-
skin scabs are pressure
healed rooms; staff
In people exposed should use
to smallpox, the standard
vaccine can be precautions
(continued)
222 Appendix Q
Biological Agents
Smallpox given within 4 to protect

(cont’d ) days to lessen or against
prevent the illness spread of
the disease
Tularemia: Initial symptoms are Contami- Vaccine No Individual 2%
Francisella fever, pharyngitis, nated available; treatment mortality
tularensis ; headache, body arthro- not fully drugs of rate
incubation aches, and upper pods, approved choice:
is 1 to 14 respiratory illness, soil, for general strepto-
days post- rapidly progressing animals, use mycin,
exposure to bronchitis, water, gentamycin
pneumonia, and veg- Mass
pleuropneumonitis, etation casualty
bacteremia; may see Humans treatment
nausea, weight loss, become drugs of
malaise with infected choice:
continued illness by direct doxycy-
Inhalation would contact, cline,
have the greatest inges- ciprofloxin
adverse public tion, or Special
health inhaled considera-
consequences; infective tions for
release in a densely aerosols children,
populated area pregnant
would result in an women,
abrupt onset of a and those
sick population with
(but slower immuno-
progression than suppression
anthrax or plague)
This is a dangerous
bioweapon due to
its extreme
infectivity, ease of
dissemination, and
substantial capacity
to cause illness and
death
(continued)
Biological Agents
Viral hem- VHF is a term used to Most Available Humans There Mortality
orrhagic describe a severe VHFs only for may are no rate
fevers multisystem are yellow trans- treatments varies
(VHF) syndrome in which insect or fever mit for most with each
the overall vascular animal and some of of the VHF;
system is damaged borne Argentine these VHFs most are
Initially, fever, fatigue, The hemor- VHFs Supportive between
dizziness, muscle vectors rhagic to other care is 50% and
aches, weakness, for Ebola fever at humans given 90%
and extreme fatigue and this time mortality
are seen Marburg No vaccines rate
Severe infections will viruses exist for
produce are un- the other
bleeding under the known VHFs
skin (petechiae), Humans
internal bleeding, become
or bleeding from infected
body orifices; these through
patients will contact
progress to shock, with
nervous system rodent’s
malfunction, coma, bodily
delirium, seizures, fluids or
and/or renal failure when
VHF refers to a group bitten
of illnesses caused by an
by several families arthro-
of viruses: pod
Arenaviruses
(Argentine,
Bolivian, Lassa);
Bunyaviruses (Rift
Valley, Hantavirus);
Filoviruses (Ebola,
Marburg);
Flaviviruses (tick-
borne, Kyasanur
Forest)
(continued)
224 Appendix Q
Biological Agents
Q fever: Sudden onset of high Infected Yes, although Rare Q fever: Q fever:
Coxiella fevers (104°F to milk, not com- doxycy- 2%
burnetii ; 105°F), severe urine, mercially cline; most mortality
incubation headache, malaise, feces, available efficient rate
is 2 to 3 myalgia, confusion, amniotic in the when Chronic Q
weeks sore throat, fluid of United started fever:
post- chills, sweats, animals States within first 65%
exposure nonproductive Humans 3 days of mortality
cough, nausea, are illness rate
vomiting, diarrhea, infected Chronic Q
abdominal pain, by fever:
chest pain inhaling doxycycline
Fever lasts for 1 to 2 dried, with
weeks contam- quinolones
Thirty percent to 50% inated for at least
of patients develop particles 4 years or
pneumonia Ingestion doxycycline
This agent is highly of conta- with
infectious and minated hydrochlor-
resistant to heat, milk may oquine for
drying, and most produce 1.5 to 3
disinfectants; it illness years
easily becomes
airborne and is
inhaled by humans
and therefore is at
risk of abuse by
bioterrorists
Chronic Q fever
occurs when
infection persists
for 6 months;
these patients are
prone to
endocarditis
Sources: Arnon, 2001; CDC, 2001; Inglesby, 2000; CDC, 1997; Henderson, 1999; Dennis, 2001. Reprinted with permission from
www.rnceus.com.
(continued)
Chemical Agents
Onset of Signs and
Agents and Symptoms Symptoms, Routes
Descriptions Post-Exposure of Exposure Action, Risks Decontamination and Treatment
Nerve agents
Sarin; Pure Immediately Runny nose, Chemicals Skin: Remove contaminated
liquid is if inhaled; watery eyes, that attack clothing (double bag in plastic
clear, may be drooling, the nervous bags and seal) and wash skin
colorless, several blurred vision, system by with large amount of soap and
tasteless; hours if it headache, binding w/ water or 5% bleach. Rinse well
becomes touches the excessive acetyl- with water.
brown with skin sweating, chest cholinesterase, Eyes: Immediately flush eyes
aging tightness, allowing with water for 10 to 15
difficulty acetylcholine minutes; do NOT cover eyes
breathing, to overstimu- with patches afterward.
nausea, vomit- late the Ingestion: Do NOT induce
ing, loss of glands and vomiting. If patient alert and
bowel/bladder voluntary able to swallow, immediately
control, muscle muscles until administer activated charcoal.
cramps, they fail. Vapor: Remove outer clothing
twitching, Lethal; 1 drop and place in sealed double bag.
confusion, on the skin Care for exposed skin as above.
convulsions, can cause Emergency treatment and
paralysis, and death in antidotes: Maintain airway,
coma less than cardiac monitor, IVs, monitor
Can enter the 15 minutes vital signs. Follow ACLS
body by protocols. Administer atropine
inhalation, (2 mg for adults, 0.05 to 0.1
ingestion, mg/kg for children) every 5 to
through the 10 minutes until respiratory
eyes and skin status stabilizes; antidote
(2-PAM CL); diazepam for
seizures (barbiturates and
phenytoin are not effective)
VX; amber Onset of Runny nose, Kills by Skin: Remove contaminated
colored, symptoms watery eyes, binding clothes and wash skin with
tasteless, varies drooling, acetyl- large amounts of soap and
and based on excessive cholinesterase; water, 10% sodium carbonate,
odorless route of sweating, chest this causes or 5% liquid household
oily liquid exposure tightness, dys- constant bleach. Rinse well with water.
VX absorbs pnea, pinpoint stimulation Administer antidote only if
very pupils, nausea, of glands and local sweating and muscular
rapidly vomiting, voluntary twitching are present.
(continued)
226 Appendix Q
Chemical Agents
Onset of Signs and
VX (cont’d ) through abdominal muscles until Eyes: Immediately flush eyes with
the eyes cramps, in- ultimate water for 10 to 15 minutes, then
At least 100 continence of fatigue and a place respiratory
times more bowel or cessation of protective mask. Use antidote
toxic than bladder, breathing only if more symptoms than
Sarin when twitching, ability just miosis occur. VX absorbs
entering headache, Extremely lethal 100 times faster through the
through confusion, and persis- eyes than Sarin does.
the skin coma, or tent; can last Ingestion: Do NOT induce vom-
and twice seizures for months in iting.
as toxic by Can enter the cold weather; Inhalation: Use positive-
inhalation body by evaporates pressure, full-face breathing
inhalation, 1,500 times mask. Do NOT perform
ingestion, slower than mouth-to-mouth on a patient
through the water with VX exposure!
eyes and skin Immediately administer nerve
Death can occur agent antidote.
within 15 min- Emergency treatment and
utes of absorp- antidotes: Maintain airway,
tion of fatal cardiac monitor, IVs, monitor
dosage. vital signs. Follow ACLS
protocols. Administer atropine
(2 mg for adults, 0.05 to 0.1
mg/kg for children) every 5 to
10 minutes until respiratory
status stabilizes; antidote
GF (cyclohexyl Depending Runny nose, Organophos- Skin: Remove contaminated
sarin); on the dose, miosis, phorus clothes and wash skin with
colorless onset of headache, compound, a large amounts of soap and
and symptoms dyspnea, chest lethal water, 10% sodium carbonate,
odorless within tightness, cholinesterase or 5% liquid household
liquid in minutes or cough, drool- inhibitor bleach. Rinse well with water.
pure form hours ing, excessive similar in Administer antidote only if
Rapid absorp- sweating, action to local sweating and muscular
tion copious sinus sarin twitching is present.
through secretions, Eyes: Immediately flush eyes
the eyes nausea, with water for 10 to 15 minutes,
(continued)
Chemical Agents
Onset of Signs and
vomiting, then place respiratory

abdominal protective mask. Use antidote
cramps, only if more symptoms than
diarrhea, just miosis occur.
incontinence Ingestion: Do NOT induce vom-
of bowel and iting. Immediately administer
bladder, mus- nerve agent antidote.
cle twitching Inhalation: Use
and weakness, positive-pressure, full face,
confusion, self-contained breathing
apnea, coma, apparatus. For severe signs,
death immediately administer nerve
Can enter the agent antidote and oxygen.
body by Do NOT perform mouth-to-
inhalation, mouth resuscitation if face is
ingestion, contaminated with GF.
through the Emergency treatment and
eyes and skin antidotes: Maintain airway,
cardiac monitor, IVs, monitor
vital signs. Follow ACLS
protocols. Administer atropine
(2 mg for adults, 0.05 to 0.1
mg/kg for children) every 5 to
10 minutes until respiratory
status stabilizes; antidote
Pulmonary agents
Nitrogen The Cough, Causes lung Skin: Rinse with plenty of water
oxide; substance wheezing, sore edema then remove contaminated
red/brown and vapor throat, dizzi- Exposure of clothing and rinse again. Refer
gas or a irritate the ness, headache, high amounts for medical attention.
yellow eyes, skin, sweating, can cause Eyes: Flush eyes with water for
liquid with and dyspnea, death 10 to 15 minutes (be sure to
pungent respiratory vomiting, or remove contact lenses), then
odor tract. redness at point refer for medical attention.
Effects may of contact Ingestion: Rinse mouth with
be delayed (eyes, skin) copious amounts of water.
(continued)
228 Appendix Q
Chemical Agents
Onset of Signs and
Nitrogen Can enter the Inhalation: Apply oxygen, place

oxide body by in sitting position. Seek
(cont’d ) inhalation or medical evaluation.
ingestion
Chlorine; Effects may Very corrosive Corrosive Skin: Remove contaminated
green/ be delayed effects effects to clothing, then rinse skin with
yellow gas Tearing of the lungs, skin, plenty of water or a shower.
with eyes, headache, and eyes Seek medical help for burns.
pungent sore throat, Chronic Eyes: Flush eyes with water for
odor cough, exposure 10 to 15 minutes (be sure to
dyspnea, burn- results in remove contact lenses), then
ing sensation, erosion of the refer for medical attention.
lung edema, teeth, chronic Inhalation: Apply oxygen, place
frostbite, burns bronchitis in sitting position. May need
to the skin, Overexposure artificial ventilation. Seek
nausea, eye can cause medical evaluation.
pain, blurred death
vision
Enters the body
by inhalation
Sulfur Inhalation Frostbite to the Strong Skin: Remove contaminated
dioxide; symptoms skin, eye pain irritant to the clothing, then rinse with
colorless may be with redness eyes and plenty of water. Do NOT
gas or delayed and severe respiratory remove clean clothing. Seek
compressed Contact with burns, sore tract medical help for frostbite.
liquefied skin can throat, cough, Repeated or Eyes: Flush eyes with water for
gas with cause dyspnea, lung prolonged 10 to 15 minutes (be sure to
pungent immediate edema, reflex exposure can remove contact lenses), then
odor frostbite spasm of the cause asthma refer for medical attention.
larynx, Inhalation: Apply oxygen, place
respiratory in sitting position. May need
arrest, death artificial ventilation. Seek
Enters the body medical evaluation.
by inhalation
Phosgene; Inhalation Frostbite to the Corrosive Skin: Remove contaminated
colorless symptoms skin, eye pain to skin, clothing, then rinse with
gas, may be with redness respiratory plenty of water. Do NOT
colorless to delayed and severe tract, and remove clean clothing. Seek
yellow burns, blurred eyes medical help for frostbite.
(continued)
Chemical Agents
Onset of Signs and
compressed Contact with vision, sore Long-term Eyes: Flush eyes with water for
liquefied skin can throat, cough, exposure may 10 to 15 minutes (be sure to
gas with cause dyspnea, lung result in lung remove contact lenses), then
characteris immediate edema, death fibrosis refer for medical attention.
tic odor frostbite Enters the body Inhalation: Apply oxygen, place
by inhalation in sitting position. May need
artificial ventilation. Seek
medical evaluation.
Titanium tetra- Symptoms Red painful eyes Corrosive to Skin: Remove contaminated
chloride; may be with burns, skin, eyes, clothing, rinse with plenty of
colorless to delayed skin blisters, respiratory, water, then wash with soap
light yellow cough, dysp- and GI tract; and water
liquid with nea, chest can cause Eyes: Flush eyes with water for
pungent tightness, permanent 10 to 15 minutes (be sure to
odor abdominal eye damage remove contact lenses), then
pain, shock, Long-term refer for medical attention.
coma exposure may Ingestion: Rinse mouth. Do
Enters the body result in lung NOT induce vomiting. Seek
by inhalation impairment medical attention immediately
or ingestion Inhalation: Apply oxygen, place
in sitting position. May need
artificial ventilation. Seek
medical evaluation.
Blister agents
Lewisite; Immediate Eyelid swelling, Causes blind- Skin: Immediately wash skin and
amber to symptoms severe eye ness within clothes with 5% sodium
dark brown with eye pain, iritis, 1 minute of hypochlorite or household
liquid with exposure, copious sinus exposure bleach within 1 minute of
a strong, inhalation, drainage, Nonfatal exposure, then cut and remove
penetrating or violent sneez- hemolysis contaminated cloth. Rewash
geranium ingestion ing, cough, results in skin again with 5% liquid
odor; the Skin contact frothing anemia household bleach. Then wash
pure produces mucus, lung Metabolites contaminated skin a third time
compound symptoms edema, large excreted by with soap and water.
is a within 30 skin blisters liver cause Eyes: Immediately flush eyes
colorless, minutes and burns, focal necrosis with water for 10 to 15 minutes.
odorless, diarrhea, of liver, bil- Ingestion: Rinse mouth. Do
oily liquid hypothermia, iary passages, NOT induce vomiting. Give
hypotension and intestine patient milk to drink.
(continued)
230 Appendix Q
Chemical Agents
Onset of Signs and
Lewisite Severe irritation Long-term Inhalation: Apply oxygen, place

(cont’d ) and lung exposure can in sitting position. May need
edema; can cause chronic artificial ventilation. Do NOT
cause systemic lung impair- perform mouth-to-mouth
poisoning, ment and resuscitation if facial contami-
hemoconcen- cancer nation has occurred.
tration, shock,
and death
Can enter the
body by
inhalation,
ingestion,
through the
eyes and skin
Mustard gas; Rapid pene- Severe tearing Causes delayed Skin: Immediately wash skin and
pure liquid tration of and pain of severe clothes with 5% sodium
is colorless moist eyes with damage to the hypochlorite or household
and mucous possible respiratory bleach within 1 minute of
odorless; membranes blindness, tract and exposure, then cut and remove
agent- and skin sneezing, cytotoxic contaminated cloth. Flush skin
grade Delayed coughing, action on again with 5% sodium
material is severe anorexia, hematopoietic hypochlorite solution, then
yellow, symptoms diarrhea, fever, tissues wash contaminated skin a
brown, or of the res- skin blisters Lethal doses are third time with soap and water.
black with piratory Can enter the carcinogens Eyes: Immediately flush eyes
a sweet- tract body by and with water for 10 to
type odor inhalation, teratogens 15 minutes. Do not cover
of garlic or ingestion, or Distilled with bandages. Use dark
horseradish through the mustard is goggles or glasses.
eyes and skin; nearly pure, Ingestion: Do NOT induce
tender skin, while vomiting. Give patient milk
mucous mem- mustard gas to drink.
branes, and is only 70% Inhalation: Apply oxygen,
perspiration- to 80% pure place in sitting position.
covered skin May need artificial ventilation.
are more Do NOT perform
vulnerable mouth-to-mouth resuscitation
if facial contamination has
occurred.
(continued)
Chemical Agents
Onset of Signs and
Blood agents
Arsine; Immediate to Causes immedi- Chronic Skin: Remove contaminated
colorless delayed ate frostbite exposure is clothing, then rinse with
compressed symptoms, when contact carcinogenic plenty of water. Do NOT
liquefied depending made with eyes to humans remove clean clothing. Seek
gas with a on or skin medical help for frostbite.
characteris- exposure Headache, Eyes: Flush eyes with water for
tic odor confusion, 10 to 15 minutes, follow with
dizziness, an immediate eye exam.
nausea, vomit- Inhalation: Apply oxygen, place
ing, abdominal in sitting position. May need
pain, dyspnea, artificial ventilation.
lung edema,
kidney failure,
damage to
blood cells,
death
Enters the body
by inhalation
Cyanogen Effects of Causes Overexposure Skin: Remove contaminated
chloride; exposure immediate results in clothing, then rinse with
colorless may be frostbite when death plenty of water. Do NOT
compressed delayed contact made remove clean clothing. Seek
liquefied with eyes or medical help for frostbite.
gas with a skin Eyes: Flush eyes with water for
pungent Sore throat, 10 to 15 minutes, follow with
odor severe tearing, an immediate eye exam.
confusion, Inhalation: Apply oxygen, place
drowsiness, in sitting position. May need
unconscious- artificial ventilation.
ness, nausea,
vomiting, lung
edema
Enters the body
by inhalation
or absorbed
through the
skin
(continued)
232 Appendix Q
Chemical Agents
Onset of Signs and
Hydrogen Highly Corrosive, deep, Long-term Skin: Remove contaminated

chloride; corrosive; severe burns to exposure may clothing, then rinse with
colorless symptoms eyes and skin cause erosion plenty of water. Seek treat-
compressed may begin Sore throat, to the teeth or ment for burns.
liquefied immedi- blurred vision, chronic Eyes: Flush eyes with water for
gas with a ately or be coughing, dys- bronchitis 10 to 15 minutes; follow with
pungent delayed pnea, lung an immediate eye exam.
odor edema, burn- Inhalation: Apply oxygen, place
ing sensation in sitting position. May need
Enters the body artificial ventilation.
through
inhalation
Hydrogen Highly Headache, May injure Skin: Flush skin with plenty of
cyanide; irritating; confusion, CNS, water or take a shower. Wear
colorless symptoms drowsiness, respiratory gloves when administering
gas or may be dyspnea, loss of and first aid.
liquid immediate consciousness, circulatory Eyes: Immediately flush eyes
with a or delayed nausea, skin systems with water for 10 to 15 min-
characteris- and eye redness Exposure may utes then seek eye exam.
tic odor and pain, cause death Ingestion: Rinse mouth immedi-
burning ately. Do NOT induce vomit-
sensation ing.
Enters the body Inhalation: Apply oxygen, place
through in sitting position. May need
inhalation, artificial ventilation. Avoid
ingestion, eye mouth-to-mouth resuscita-
and skin tion.
absorption
Easily absorbed
as a vapor or
through the
skin or eyes
Sources: CDC, 2001; CDC, 2002.
(continued)
Pre-Hospital Triage of Mass Casualty Patients: Nerve Agents

Triage Priority Priority Description Current State Clinical Signs
Immediate Patients who require lifesaving care Unconscious Seizing or postictal

within a short period of time Talking but unable Severe respiratory
Emergency care must be available and to walk distress
of short duration Moderate to severe Cardiac arrest
This care may include emergency effects on two or (recovered)
measures that are performed more organs or
within a few minutes’ time, such as systems (e.g.,
intubation or antidote respiratory, GI)
administration
Delayed Patients with severe injuries in need Recovering from Diminished
of major surgery, require recent exposure secretions
hospitalization, or other care, but a or antidote Improving or stable
delay in care will not adversely administration respiratory status
affect the outcome of this patient,
e.g., internal stabilization of a
fracture
Minimal Patients who have minor injuries who Walking and Miosis
can be helped by nonmedical talking Rhinorrhea
personnel and who will not require Mild to moderate
hospitalization dyspnea
Expectant Patients with severe, life-threatening Unconscious Cardiac arrest
conditions who probably would Respiratory arrest
not survive even with the best of
medical attention
Patients with injuries that require
attention from many medical
personnel but low chance of
survival does not justify the use of
limited medical resources
As this mass casualty event changes,
these patients may be re-triaged
once additional medical resources
become available
Sources: CDC, 2001; ATSDR, 2001.
(continued)
234 Appendix Q
Pre-Hospital Antidote Management When Military Mark I Kits Are Not Available
Mild Symptoms (Localized
Sweating, Difficulty Breathing, Severe Symptoms (Apnea,
Nausea, Vomiting, Diarrhea, Seizures, Flaccid Paralysis,
Patient Age Muscle Fasciculations, Weakness) Unconsciousness)
Infant: 2 years old Atropine: 0.05 mg/kg IM Atropine: 0.1 mg/kg IM

2-PAM Cl: 15 mg/kg IM 2-PAM Cl: 25 mg/kg IM
Child: 2–10 years old Atropine: 1 mg IM Atropine: 2 mg IM
Adolescent: 10 years old Atropine: 2 mg IM Atropine: 4 mg IM
Adult Atropine: 2 to 4 mg IM Atropine: 6 mg IM
2-PAM Cl: 600 mg IM 2-PAM Cl: 1800 mg IM
Frail elderly Atropine: 1 mg IM Atropine: 2 to 4 mg IM
A L E R T S
• 2-PAM Cl solution needs to be reconstituted from the vial containing 1 g of desiccated
2-PAM Cl with 3 mL of saline, 5% distilled water, or sterile water; shake well. Resulting
solution is 3.3 mL of 300 mg/mL.
• Assisted ventilation should be started after the administration of the antidote for severe
cases of exposure.
• Repeat the atropine every 5 to 10 minutes until secretions have diminished and breathing
has returned to baseline.
(continued )
Emergency Department Antidote Management

Mild Symptoms (Localized
Sweating, Difficulty Breathing, Severe Symptoms (Apnea,
Nausea, Vomiting, Diarrhea, Seizures, Flaccid Paralysis,
Patient Age Muscle Fasciculations, Weakness) Unconsciousness)
Infant: 2 years old Atropine: 0.05 mg/kg IM or 0.02 Atropine: 0.1 mg/kg IM or 0.02
mg/kg IV mg/kg IV
2-PAM Cl: 15 mg/kg IV slowly 2-PAM Cl: 15 mg/kg IV slowly
Child: 2–10 years old Atropine: 1 mg IM Atropine: 2 mg IM
Adolescent: 10 years old Atropine: 2 mg IM Atropine: 4 mg IM
Adult Atropine: 2 to 4 mg IM Atropine: 6 mg IM
2-PAM Cl: 15 mg/kg (1 g) IV 2-PAM Cl: 15 mg/kg (1 g) IV
slowly slowly
Frail elderly Atropine: 1 mg IM Atropine: 2 mg IM
2-PAM Cl: 5 to 10 mg/kg IV 2-PAM Cl: 5 to 10 mg/kg IV
slowly slowly
A L E R T S
• 2-Pam Cl solution may need to be reconstituted from the vial containing 1 gram of des-
iccated 2-PAM Cl with 3 mL of saline, 5% distilled water, or sterile water; shake well.
Resulting solution is 3.3 mL of 300 mg/mL.
• Use phentolamine for hypertension induced by 2-PAM (5 mg IV for adults, 1 mg IV for
children).
• Use diazepam for seizure control (0.2 to 0.5 mg IV for children 5 years old; 1 mg IV
for children 5 years old; 5 mg IV for adults).
• Repeat atropine every 5 to 10 minutes until secretions have diminished & dyspnea
relieved (for infants, use 2 mg IM or 1 mg IV)
Appendix R
Communicable Diseases, Colds Versus Flu,

and Sexually Transmitted Diseases
Communicable Diseases
Incubation Period Contagious Period
Disease Mode of Transmission (Days) (Days)
Acquired Blood, breast milk, body Variable incubation Although unknown, it is

immunodeficiency tissues, fluids rates believed to begin just
syndrome exchanged during Virus exposure to after onset of HIV and
(AIDS)/human sexual contact seroconversion extend throughout life
immunodeficiency Other body fluids: (HIV): about 1 to
virus (HIV) saliva, urine, tears, 3 months
bronchial secretions HIV to AIDS: from
(especially if blood is 1 year to 10 years
present)
Botulism Contaminated food Within 12 to 36 hours Not contagious from sec-
products of consumption, ondary person-to-
up to several days person contact
Bronchiolitis Respiratory 4 to 6 days Onset of cough until
7 days
Chancroid Direct sexual contact 3 to 5 days, up to Until treated with antibi-
with open or draining 14 days otic and lesions
lesions healed—usually about
1 to 2 weeks
Chickenpox Direct person-to-person Commonly 14 to One to 5 days before the
(varicella) contact, respiratory 16 days onset of the rash until
droplets all sores have crusted
over—usually 10 to
21 days.
Chlamydia Sexual intercourse Approximately a Unknown
minimum of 7 to
14 days
(continued)
236
Communicable Diseases, Colds Versus Flu, and Sexually Transmitted Diseases 237
“Cold,” cough, croup Respiratory 2 to 5 days Onset of runny nose

and/or cough until
fever is gone
Conjunctivitis
Viral Direct or indirect contact 1 to 12 days 4 to 14 days after onset of
symptoms (minimally
contagious)
Bacterial Respiratory, direct con- 24 to 72 hours Until treated with antibi-
tact with eye drainage otics
Fifth disease Respiratory Variable; 4 to 20 days 7 days before rash devel-
ops, probably not com-
municable after rash
starts
Giardia Fecal contamination of 3 to 25 days Entire period of infection,
food or water often months
Gonorrhea Sexual contact 2 to 7 days Continues until treatment
begins
Hand, foot, and mouth Direct contact with 3 to 6 days Onset of mouth ulcers
disease (Coxsackie nasal or throat secre- until fever gone—
virus) tions, fecal material perhaps as long as
droplets several weeks with
fecal contamination
Hepatitis A Fecal-oral route, food 15 to 50 days During last half of incuba-
contamination tion period until after
first week of jaundice
Hepatitis B Blood, saliva, semen, 45 to 180 days Infective many weeks
vaginal fluid before onset of first
symptom, until com-
pletion of acute clinical
course of infection
Hepatitis C Blood and plasma, per- 2 weeks to 6 months From 1 weeks before
cutaneous exposure onset of Symptoms;
may persist indefinitely
Herpes simplex
Type 1 Saliva 2 to 12 days From onset of sores to
7 weeks after recovery
from stomatitis
Type 2 Sexual contact (oral or 2 to 12 days 7 to 12 days
genital)
(continued)
238 Appendix R
Herpes (varicella) Soiled dressings or Can be 2 to 3 weeks One to 5 days before the
zoster/shingles articles onset of the rash until
all sores have crusted
over—usually 10 to
21 days
Impetigo
Staph Hand-to-skin contact 4 to 10 days Until draining lesions heal
Strep Respiratory droplet, 1 to 3 days Untreated: weeks or
direct contact months; treated: 24
hours on antibiotics
Influenza Airborne, direct contact 1 to 3 days Children: 7 days; adults:
3 to 5 days
Kawasaki Unknown, seasonal Unknown Unknown
variation
Legionnaire Airborne 2 to 10 days Person-to-person: none
pneumonia
Lice
Head/body Direct contact, indirect 7 to 13 days Continuous if alive, until
contact with objects first treatment; live off
host for 7 to 21 days
Pubic (crabs) Sexual contact Egg-to-egg cycle lasts Live off host for 2 days
3 weeks
Lyme disease Tickborne 3 to 32 days Person-to-person: none
Measles (rubeola) Airborne, direct contact 7 to 18 days Before the onset of symp-
w/nasal secretions toms to 4 days after the
appearance of the rash
Meningitis
Bacterial: Direct contact, respira- 2 to 10 days Usually after 24 hours on
Meningococcal tory, droplet from antibiotic therapy
nose and mouth
Bacterial: Droplet from nose and 2 to 4 days Noncommunicable
Haemophilus mouth within 24 to 48 hours
on antibiotic therapy
Viral Varies with specific Variable; often approxi-
infectious agent mately 7 days
Mononucleosis Saliva 4 to 6 weeks Prolonged, possibly a year
Pertussis Direct contact, airborne 6 to 20 days Gradually decreases over
droplet 3 weeks
Pinworms Direct transfer (anus to 2 to 6 weeks As long as females are
mouth), indirect con- alive, eggs survive for
tact (infested bed, etc.) about 2 weeks
(continued)
Rabies Saliva, direct contact 3 to 8 weeks 3 to 7 days before the

(bite, scratch), indi- onset of symptoms
rect contact
Ringworm
Tinea capitis Direct skin-to-skin, indi- 10 to 14 days Viable fungus may persist
(scalp) rect contact (cloth on contaminated arti-
seats, combs, etc.) cles for long periods of
time
Tinea corporis Direct or indirect con- 4 to 10 days While lesions are present
(body) tact with infected and as long as viable
people, articles, fungus remains on
floors, benches, ani- articles
mals, shower stalls
Rocky Mountain Tickborne 3 to 14 days Noncommunicable
spotted fever person-to-person; tick
remains infective for
life, as long as
18 months
Roseola Unknown, possibly 10 to 15 days Onset of fever until rash
saliva is gone
Rotavirus Fecal-oral route, possi- 24 to 72 hours Average 4 to 6 days
ble respiratory
Rubella Direct contact with 14 to 23 days One week before to at
nasal secretions, least 4 days after onset
droplet of rash
Salmonella Ingestion of contami- 6 to 72 hours Throughout the course of
nated food infection
Scabies Direct skin-to-skin con- 2 to 6 weeks Until mites and eggs are
tact destroyed
Scarlet fever Large respiratory 1 to 3 days Untreated: 10 to 21 days;
droplet, direct contact treated: 24 hr of antibi-
otic therapy
Shigella Fecal-oral route, inges- 12 to 96 hours During acute infection
tion of contaminated until infectious agent
food no longer in feces
(about 4 weeks)
Sore throat
Strep Large respiratory 1 to 3 days Untreated: 10 to 21 days;
droplet, direct contact treated: after 24 hrs of
antibiotic therapy
(continued)
240 Appendix R
Viral Direct contact, inhalation 1 to 5 days Onset of sore throat until

of airborne droplet fever gone
Syphilis Direct contact with 10 days to 3 months Untreated: variable and
moist lesions and indefinite; treated: after
body fluids 24 to 48 hr of antibiotic
therapy
Tetanus Spores enter open 3 to 21 days Noncommunicable from
wound person-to-person
Trichomoniasis Sexual contact through 4 to 24 days Untreated: may be symp-
vaginal or urethral tom-free carrier for
secretions years
Tuberculosis Airborne droplet 4 to 12 weeks Degree of communicabil-
ity depends on many
factors; treated: within
a few weeks; children
usually not infectious
“Cold” Versus Flu Symptom Comparison

Symptom “Cold” Flu
Fever Rare Usually high (102°F to 104°F);

lasts 3 to 4 days
Headache Rare Yes
Body aches and pains Slight Often severe
Fatigue Mild Lasts 2 to 3 weeks
Extreme exhaustion No Early in illness; lasts a few days
Stuffy or runny nose Yes Occasionally
Sneezing Yes Occasionally
Sore throat Yes Occasionally
Chest discomfort and/or cough Mild to moderate; hacking Yes; may be severe
cough
Complications Sinus congestion, ear pain Bronchitis, pneumonia
Sexually Transmitted Diseases

Disease Clinical Presentation Complications and Long-Term Risks
AIDS/HIV May remain asymptomatic for many Disease progression (from HIV to
years AIDS) is variable from a few
Developing signs and symptoms months to 12 years. Early interven-
include fatigue, fever, poor appetite, tion is essential in preserving and
unexplained weight loss, general- maintaining optimal health status.
ized lymphadenopathy, persistent
diarrhea, night sweats
Chancroid Painful genital ulceration(s) with ten- Chancroid has been associated with
der inguinal adenopathy increased risk of acquiring HIV
Ulcers may be necrotic or erosive infection. Patients should be tested
for other infections that cause
ulcers (i.e., syphilis).
Chlamydial Yellow mucopurulent cervical exudate Untreated, may develop endometritis,
Cervicitis May or may not be symptomatic salpingitis, ectopic pregnancy, and/or
Male sexual partner will likely have subsequent infertility. High preva-
nongonococcal urethritis lence of coinfection with gonococcal
infection. Infection during preg-
nancy may lead to premature rup-
ture of membranes, pneumonia, or
conjunctivitis in the infant.
Enteric Infections Sexually transmissible enteric infec- Occurs frequently with oral-genital
tions, particularly among homosex- and oral-anal contact. Infections
ual males can be life threatening if they
Abdominal pain, fever, diarrhea, vom- become systemic. Organisms may
iting be shigella, hepatitis A, giardia.
Epididymitis May or may not be transmitted sexu- Usually caused by gonorrhea or
ally chlamydia. May be caused by
Can be asymptomatic Escherichia coli after anal inter-
Non-sexually transmitted, is associ- course. Must rule out a testicular
ated with a urinary tract infection torsion before making the diagnosis
Unilateral testicular pain, swelling of epididymitis.
Genital Warts Soft, fleshy, painless growth(s) around Caused by the human papillomavirus.
the anus, penis, vulvovaginal area, Must rule out other causes of
cervix, urethra, or perineum lesion(s) such as syphilis, etc.
Lesions may cause tissue destruc-
tion. Cervical warts are associated
with neoplasia.
Gonorrhea Males may have dysuria, urinary fre- Untreated, risk of arthritis, dermatitis,
quency, thin clear or yellow urethral bacteremia, meningitis, endocardi-
discharge tis. At risk: Males: epididymitis,
(continued)
242 Appendix R

Gonorrhea (cont’d ) Females may have mucopurulent vagi- infertility, urethral stricture, and
nal discharge, abnormal menses, sterility. Females: pelvic inflamma-
dysuria, or no symptoms tory disease. Newborns: ophthalmia
neonatorum, pneumonia
Hepatitis B Anorexia, malaise, nausea, vomiting, Chronic hepatitis, cirrhosis, liver can-
abdominal pain, jaundice, skin rash, cer, liver failure, death. Chronic car-
arthralgias, arthritis rier occurs in 6% to 10% of cases.
Infants born with hepatitis B are at
high risk for developing chronic
liver disease.
Herpes genitalis Clustered vesicles that rupture, leaving Other causes of genital ulcers
(Herpes simplex painful, shallow genital ulcer(s) that (syphilis, chancroid, etc.) must be
type 2) eventually crust ruled out.
Initial outbreak last for 14 to 21 days;
subsequent outbreaks are less severe
and last 8 to 12 days
Nongonococcal Dysuria, urinary frequency, mucoid to Can be caused by chlamydia,
Urethritis purulent urethral discharge mycoplasma, trichomonas, or her-
Some men may be asymptomatic pes simplex. Can cause urethral
Female sexual partners may have cer- strictures, prostatitis, epididymitis.
vicitis or PID
Pelvic Inflammatory Lower abdominal pain, fever, cervical Must rule out appendicitis or ectopic
Disease motion tenderness, dyspareunia, pregnancy. Risk for pelvic abscess,
purulent vaginal discharge, dysuria, future ectopic pregnancy, infertility,
increased abdominal pain while pelvic adhesions.
walking.
Proctitis Sexually transmitted gastrointestinal May be caused by chlamydia, gonor-
illnesses rhea, herpes simplex, and syphilis.
Proctitis occurs with anal intercourse, Among patients coinfected with
resulting in inflammation of the HIV, herpes proctitis may be severe.
rectum with anorectal pain, tenes-
mus, and rectal discharge
Proctocolitis Sexually transmitted gastrointestinal May be caused by campylobacter,
illnesses shigella, or chlamydia. Other oppor-
Proctocolitis occurs with either anal tunistic infections may be involved
intercourse or with oral-fecal con- among immunosuppressed HIV
tact, resulting in symptoms of proc- patients.
titis as well as diarrhea, abdominal
cramps, and inflammation of the
colonic mucosa
(continued)

Pubic Lice Slight discomfort to intense itching Sexual partners within the last month
May have pruritic, erythematous mac- should be treated. May develop lym-
ules, papules, or secondary excoria- phadenitis or a secondary bacterial
tion in the genital area infection of the skin or hair follicle.
If lice are found on the eyelashes, they
are usually pubic lice
Scabies The mite burrows under the skin of Sexual partners, household members,
the fingers, penis, and wrists and close contacts within the past
Scabies among adults may be sexually month should be examined and
transmitted, while usually not sexu- treated. May develop a secondary
ally transmitted among children infection, often with nephrotogenic
Itching (worse at night), papular erup- streptococci.
tions, and excoriation of the skin
Syphilis
Primary syphilis Painless, indurated ulcer (chancre) at All genital ulcers should be suspected
site of infection approximately to be syphilitic. Patients should be
10 days to 3 months after exposure tested for HIV and retested in
Secondary Rash, mucocutaneous lesions, lym- 3 months. At-risk sex partners are
syphilis phadenopathy, condylomata lata those within the past 3 months plus
Symptoms occur 4 to 6 weeks after duration of symptoms for primary
exposure and resolve spontaneously syphilis, and 6 months plus dura-
within weeks to 12 months tion of symptoms for secondary
syphilis.
Latent syphilis Seroreactive yet asymptomatic Should be clinically evaluated for ter-
Can be clinically latent for a period of tiary disease (i.e., aortitis, neu-
weeks to years rosyphilis, etc). At-risk sex partners
Latency sometimes lasts a lifetime are those within the past year for
early latent syphilis.
Tertiary/late May have cardiac, neurologic, oph-
syphilis thalmic, auditory, or gummatous
lesions
Neurosyphilis May see a variety of neurologic signs Diagnosis made based on a variety of
and symptoms, including ataxia, tests including: reactive serologic
bladder problems, confusion, test results, cerebrospinal fluid
meningitis, uveitis (CSF) protein or cell count abnor-
May be asymptomatic malities, positive VDRL on CSF.
Congenital Needs to be ruled out for infants born Syphilis frequently causes abortion,
syphilis to mothers with untreated syphilis, stillbirth, and complications of pre-
mothers who received incomplete maturity of infant. Treated infants
treatment, or insufficient follow-up must be followed very closely and
of reported treated syphilis retested every 2 to 3 months. Most
(continued)
244 Appendix R

Serologic tests for mother and infant infants are nonreactive by 6 months.
can be negative at delivery if mother Infants with positive CSF should be
was infected late in pregnancy retested every 6 months and be
retreated if still abnormal at 2 years.
Trichomoniasis Profuse, thin, foamy, greenish- yellow Trichomoniasis often coexists with
(Vaginitis) discharge with foul odor gonorrhea. Perform a complete
May be asymptomatic STD assessment if trichomoniasis is
Male partners may have urethritis diagnosed.
<axn>
Appendix S
Triage Skills Assessment

Time: Time:
Yes No N/A Yes No N/A
GREETING
●Greets patient courteously
●Utilizes proper opening script
(identifies self)
●Gathers appropriate
demographic data
●Comments:
ASSESSMENT
●Identifies emergency signs and
symptoms
●Measures vital signs
●Gathers appropriate patient his-
tory
●Upgrades patient to higher level
of urgency as needed (child,
confused adult, foreign-language
speaker)
●Makes assignment for care and
acuity within appropriate time
frame
●Identifies and documents patient
medications and allergies
●Orders appropriate medication
or diagnostic studies, per facility
protocol
●Offers and documents interim
care measures if not emergent
(splint, ice pack, emesis basin)
(continued)
245
246 Appendix S
Time: Time:
Yes No N/A Yes No N/A
● Documents appropriately,
including assessment, nursing
interventions, acuity, and dispo-
sition
● Comments:
COMMUNICATION SKILLS
●Conveys a positive image of
organization
●Maintains a courteous, calm,
professional demeanor
●Exhibits ability to adapt to differ-
ent personalities and emotions
●Assumes control of the inter-
view: listens attentively, inter-
jects appropriately, and elicits
necessary information
●Takes time with the patient when
appropriate; efficient without
compromising quality
●Uses simple, direct language that
the patient understands
●Does not interrupt
●Speaks at a moderate rate with
expressive modulation of tone
●Comments:
CLOSING
● Ends interview efficiently
● Informs patient of next step and
expected wait
● If patient has to wait, instructs
patient /family member to
inform triage nurse of any
changes or worsening of the
problem while waiting
● Comments:
RN Name: Reviewer: Date:

<axn>
Appendix T
Training Exercises
IDENTIFYING APPROPRIATE NURSING INTERVENTIONS AT TRIAGE

• Select 10 different protocols that would require Expected Outcome:
nursing interventions at triage based on your facil- _______________________________________
ity’s guidelines and procedures. Name of Facility Guideline:
• Indicate, in the space provided, the name of the _______________________________________
protocol, page number, intervention(s), expected
outcome and name of facility guideline. 3. Protocol: ___________________________
Page Number _______
Example: Intervention(s):
Protocol: Chest Pain _______________________________________
Page Number _______ Expected Outcome:
Intervention(s): Vital Signs, Pulse Oximetry, IV, EKG, _______________________________________
Oxygen, Monitor, Low -Dose Aspirin, Notify
Name of Facility Guideline:
Physician
_______________________________________
Expected Outcome: Reduce discomfort, reduce
damage to heart, rapidly identify potential lethal 4. Protocol: ___________________________
conditions, reduce time to reperfusion. Page Number _______
Facility Guideline: Nursing Standing Orders Intervention(s):
_______________________________________
1. Protocol: ___________________________
Expected Outcome:
Page Number _______
_______________________________________
Intervention(s):
_______________________________________ Name of Facility Guideline:
_______________________________________
Expected Outcome:
_______________________________________ 5. Protocol: ___________________________
Name of Facility Guideline: Page Number _______
_______________________________________ Intervention(s):
_______________________________________
2. Protocol: ___________________________ Expected Outcome:
Page Number _______ _______________________________________
Intervention(s): Name of Facility Guideline:
_______________________________________ _______________________________________
(continued)
247
248 Appendix T
6. Protocol: ___________________________ 9. Protocol: ___________________________

Page Number _______ Page Number _______
Intervention(s): Intervention(s):
_______________________________________ _______________________________________
Expected Outcome: Expected Outcome:
_______________________________________ _______________________________________
Name of Facility Guideline: Name of Facility Guideline:
_______________________________________ _______________________________________
7. Protocol: ___________________________
10. Protocol: ___________________________
Page Number _______
Page Number _______
Intervention(s):
Intervention(s):
_______________________________________
_______________________________________
Expected Outcome:
Expected Outcome:
_______________________________________
_______________________________________
_______________________________________
_______________________________________
8. Protocol: ___________________________
Page Number _______
Intervention(s):
_______________________________________
Name ________________ Date Completed________
Expected Outcome:
_______________________________________ Reviewed by___________ Date Reviewed_________
_______________________________________
IDENTIFYING HOW AGE AND CHRONIC ILLNESS IMPACT THE ASSIGNMENT OF AN ACUITY LEVEL
AND RISK FOR WAITING TO BE SEEN
• Select 10 different protocols that impact the acuity history of blood clotting problems; history of
level based on age, medical condition, or chronic diabetes; congestive heart failure or blood clotting
illness. problems
• Indicate, in the space provided, the name of the Acuity Level: Level 2
protocol, page number, condition that impacted Risk for Waiting: High risk
the acuity level, acuity level, risk for waiting, nurs- Nursing Considerations: Emergent, Refer for
ing considerations for referral to treatment. treatment within minutes
• Consider facility guidelines for appropriate waiting
1. Protocol: ___________________________
times for each category.
Page Number _______
Condition Impacting Acuity:
Example: _______________________________________
Protocol: Chest Pain
Acuity Level: ________________________
Page Number _______
Risk for Waiting:_____________________
Condition Impacting Acuity: Age 35 yr and heart
Nursing Consideration:
palpitations; recent trauma, childbirth, surgery, or
_______________________________________
Training Exercises 249

Condition Impacting Acuity: Condition Impacting Acuity:
_______________________________________ _______________________________________
Acuity Level: ________________________ Acuity Level: ________________________
Risk for Waiting:_____________________ Risk for Waiting:_____________________
Nursing Consideration: Nursing Consideration:
_______________________________________ _______________________________________

_______________________________________ _______________________________________
_______________________________________ _______________________________________

_______________________________________ _______________________________________
_______________________________________ _______________________________________

_______________________________________ _______________________________________
_______________________________________ _______________________________________
6. Protocol: ___________________________
Page Number _______
Condition Impacting Acuity:
Name ________________ Date Completed________
_______________________________________
Acuity Level: ________________________ Reviewed by___________ Date Reviewed_________
Risk for Waiting:_____________________
Nursing Consideration:
_______________________________________
(continued)
250 Appendix T
SCENARIO PRACTICE
The purpose of this exercise is to help the nurse tender nodes or exudate in the back of the throat.
orient to the triage protocols and teach new nurses He is able to swallow and handle his secretions
to recognize an emergent situation, appropriate well and speak in full sentences. He describes his
disposition, and what to anticipate in terms of pain as a 5/10 on the pain scale. His vital signs are
utilization of resources. In addition, it can assist the BP 114/76, P 70, R 18, T 98.6°F.
nurse in identifying when it is appropriate to initiate Acuity Level: _________ Triage Category: ______
diagnostic studies and interventions based on facility
Time Frame to Be Seen: ____________________
guidelines.
For each scenario described below, identify in the Nursing Considerations: ___________________
space provided: Protocol Referenced: _______ Page Number ____
• The acuity level and triage category based on the 5-
tier triage system 3. A 19-year-old male has a chief complaint of
• Time frame to be seen by the physician (consider nausea since this morning. He states he “threw
facility policy for semi-urgent and non-urgent up” once this morning. He denies diarrhea or
patients) abdominal pain. He has been able to tolerate
• Anticipated nursing considerations, interventions, fluids. His vital signs are BP 120/76, P 80, R 18,
medical diagnostics, procedures, and consultations T 98.4°F.
• The protocol used and associated page number Acuity Level: _________ Triage Category: ______
EXAMPLE: A 58-year-old male has a chief complaint Time Frame to Be Seen: ____________________
of midsternal chest pain, nausea, and diaphoresis Nursing Considerations: ___________________
for the past 2 hours. He describes his pain as 8/10
Protocol Referenced:_______ Page Number ____
on the pain scale. His vital signs are BP 140/90,
P 96, R 22.
4. A 42-year-old female has a chief complaint of a
Acuity Level: 2 High Risk Triage Category: Emergent severe headache, described as the “worst
Time Frame to Be Seen: Should not wait to be seen headache of my life,” that started 1 hour prior to
Nursing Considerations: Anticipate IV, labs, EKG, arrival. She describes her pain as 10/10 on the
monitor, medications, O2 pain scale. She is awake and alert but obviously
Protocol Referenced: Chest pain Page Number ______ uncomfortable. She denies a head injury or
history of headaches. Her vital signs are BP
150/80, P 90, R 20, T 98.2°F.
1. A 26-year-old female has a chief complaint of
urinary frequency and burning when she Acuity Level: _________ Triage Category: ______
urinates. She denies flank pain or vaginal Time Frame to Be Seen: ____________________
discharge. Her last menstrual period was 2 weeks Nursing Considerations: ___________________
ago. She is taking birth-control pills. Her vital
Protocol Referenced: _______ Page Number ____
signs are BP 118/72, P 70, R 18, T 97.6°F.
Acuity Level: _________ Triage Category: ______ 5. A 68-year-old male reportedly collapsed at the
Time Frame to Be Seen: ____________________ mall and has been brought in by the paramedics.
Nursing Considerations: ___________________ His wife states that he had been complaining
Protocol Referenced: _______ Page Number ____ about chest discomfort before collapsing. He was
defibrillated 3 times and CPR has been in
2. A 17-year-old male has a chief complaint of a progress for the past 20 minutes. His pupils
sore throat since yesterday. He denies swollen or remain reactive to light.
Acuity Level: _________ Triage Category: ______ 9. A 19-year-old male has a chief complaint that he
Time Frame to Be Seen: ____________________ was stabbed in the chest twice by his girlfriend
about 30 minutes ago. He states he is having
Nursing Considerations: ___________________
some difficulty catching his breath. He is pale
Protocol Referenced: _______ Page Number ____ and his vital signs are BP 70/40, P 128, R 26,
T 98.1°F.
6. A 24-year-old male injured his ankle while Acuity Level: _________ Triage Category: ______
playing basketball 2 hours ago. He reportedly
came down on his ankle and felt a pop. The ankle
is now painful, swollen, and ecchymotic. He states Nursing Considerations: ___________________
that he is unable to bear weight on that extremity Protocol Referenced: _______ Page Number ____
due to the discomfort. He describes the pain as
6/10 on the pain scale. His vital signs are BP 10. A 67-year-old male has a chief complaint of
110/60, P 80, R 20, T 98.2°F. sudden weakness on his left side. He has a
Acuity Level: _________ Triage Category: ______ noticeable facial droop and is unsteady on his
Time Frame to Be Seen: ____________________ feet. He states that the symptoms started about 1
hour prior to arrival. His vital signs are BP
Nursing Considerations: ___________________ 160/94, P 98, R 20, T 100.1°F.
Protocol Referenced: _______ Page Number ____ Acuity Level: _________ Triage Category: ______
7. A 24-year-old female has a chief complaint of Nursing Considerations: ___________________
dizziness and states her mind “feels fuzzy, she
can’t think straight.” She states she has a history Protocol Referenced:_______ Page Number ____
of diabetes and took her insulin this morning but
can’t remember whether or not she ate breakfast. 11. A 17-year-old male has a chief complaint of left
Her vital signs are BP 118/70, P 70, R 16, T 98.2°F. ear pain since last night. He states this happens
Acuity Level: _________ Triage Category: ______ every time he goes swimming, but this time he
can’t seem to shake it. His vital signs are BP
Time Frame to Be Seen: ____________________ 116/72, P 74, R 16, T 98.2°F.
Nursing Considerations: ___________________ Acuity Level: _________ Triage Category: ______
Protocol Referenced: _______ Page Number ____ Time Frame to Be Seen: ____________________
Nursing Considerations: ___________________
8. An 82-year-old female has a chief complaint of Protocol Referenced: _______ Page Number ____
“weakness, a little confused and has no appetite.”
Her daughter states that she has generally been
healthy and active up until the past few days. She 12. A 33-year-old male has a chief complaint of
also states that her mother had been complaining nausea, vomiting, and diarrhea for 3 days. He
of “some burning with urination.” Her vital signs states that he has been ill since returning from a
are BP 118/70, P 80, R 18, T 100.6°F. camping trip a few days ago. He has been unable
to keep anything down and nothing has worked
Acuity Level: _________ Triage Category: ______ to stop the vomiting or diarrhea. His vital signs
Time Frame to Be Seen: ____________________ are BP 106/62, P 88, R 18, T 98.4°F.
Nursing Considerations: ___________________ Acuity Level: _________ Triage Category: ______
Protocol Referenced: _______ Page Number ____ Time Frame to Be Seen: ____________________
(continued)
252 Appendix T
Nursing Considerations: ___________________ and breathing without difficulty. Her vital signs
Protocol Referenced: _______ Page Number ____ are BP 126/70, P 68, R 18, T 98.4°F. Pain scale
6/10.
13. A 72-year-old male has a chief complaint of Acuity Level: _________ Triage Category: ______
abdominal pain. He states it is “pretty bad” and Time Frame to Be Seen: ____________________
radiates into his back. His wife states that the pain Nursing Considerations: ___________________
started about 2 hours ago and he nearly fainted
several times prior to arrival in the Emergency
Department. His vital signs are BP 174/92, P 88,
R 20, T 98.2°F, Pain Scale 7/10. 17. A 28-year-old female has a chief complaint of a
headache, rated 7/10 on the pain scale. She has
Acuity Level: _________ Triage Category: ______
nausea and photophobia and states this episode is
Time Frame to Be Seen: ____________________ similar to other migraines she has experienced in
Nursing Considerations: ___________________ the past but this one has not responded to her
Protocol Referenced: _______ Page Number ____ usual homecare measures and pain medications.
Her vital signs are BP 118/68, P 88, R 22, T 98.2°F.
14. A 42-year-old male is concerned he may have an Acuity Level: _________ Triage Category: ______
allergic reaction to something he ate. He recently Time Frame to Be Seen: ____________________
ingested some peanut oil by accident and states Nursing Considerations: ___________________
he has had a severe allergy to peanuts in the past.
His vital signs are BP 144/88, P 108, R 24, T 98.2°F.
He suddenly collapses after you take his vital
signs. 18. A 34-year-old female has a chief complaint of
facial injuries, including ecchymosis to both eyes,
a swollen lip, and dried blood around the nose.
Time Frame to Be Seen: ____________________ She states a book fell off the shelf and hit her in
Nursing Considerations: ___________________ the face. Her vital signs are BP 138/78, P 88, R 22,
Protocol Referenced: _______ Page Number ____ T 98.2°F. Pain scale 5/10.
15. A 48-year-old male has a chief complaint of Time Frame to Be Seen: ____________________
vomiting blood and abdominal pain. He is pale Nursing Considerations: ___________________
and diaphoretic. His vital signs are BP 80/50,
P 118, R 24, T 98.2°F. Pain scale 6/10.
19. A 77-year-old female has a chief complaint of a
Time Frame to Be Seen: ____________________ shoulder injury. She states she tripped and fell
Nursing Considerations: ___________________ about 3 hours ago on her right shoulder. She is
Protocol Referenced: _______ Page Number ____ able to ambulate and has pain and swelling to the
right upper arm. She has limited range of motion
in the right arm. Her circulation, sensation, and
16. A 17-year-old female has a chief complaint of movement are intact. Her vital signs are BP
dental pain. She has a history of right upper 138/78, P 88, R 20, T 98.2°F. Pain scale 7/10.
molar pain and swelling for the past 10 days. She
states she has been unable to get in to see a Acuity Level: _________ Triage Category: ______
dentist for the past 2 weeks. She is alert, oriented, Time Frame to Be Seen: ____________________
Nursing Considerations: ___________________ the pain scale. His vital signs are BP 128/78, P 88,
Protocol Referenced: _______ Page Number ____ R 20, T 98.2°F.
20. A 28-year-old male has a chief complaint of
splashing cleaning fluid in both eyes 20 minutes Time Frame to Be Seen: ____________________
ago. He tried to splash cold water into his eyes Nursing Considerations: ___________________
immediately afterward. His eyes are reddened,
swollen, and painful. He rates his pain a 7/10 on Protocol Referenced: _______ Page Number ____
GRBQ052-ind[255-258].qxd 7/30/05 4:34 AM Page 255 pinnacle 27B:GRBQ052:Chapters:ind:
Index
Abdominal aortic aneurysm, 187 Antidote management, 235

Abdominal pain Anti-inflammatories, 214
in adult, 1–2 Anxiety, 13–14, 192. See also Chest pain
in child, 3–4 Appendicitis, 187
diagnosis of, 187–189 Arsenic, 211
during pregnancy, 129–130 Arsine, 231
Abuse Asthma, 15–16
alcohol, 5–6, 205
of anesthetics, 210 Back pain, 17–18
cocaine, 205 during pregnancy, 131–132
of depressants, 206–207 Barbiturates, 211
drug, 5–6, 205–210 Bee sting, 19–20
of hallucinogens, 207 Benzodiazepines, 212
of inhalants, 207–208 Beta blockers, 212
marijuana, 208 Biological agents, types of, 216–224
of narcotics, 208–209 Bites
of stimulants, 209–210 animal, 21–22
Accidents, car, 119–120 human, 21–22
Acetaminophen insect, 23–24
dosage chart for, 182 marine animal, 25–26
poisoning from, 211 snake, 27–28
Acquired immunodeficiency syndrome tick, 23–24
(AIDS), 236, 241 Blister agents, 229–230
Alcohol Blood agents, 231–232
abuse of, 5–6, 205 Body piercing, complications from, 29–35
poisoning from, 211 Botulism
Allergic reactions, 7–8 as communicable disease, 236
Altered mental status, 9–10 food borne, 217–218, 236
Amphetamines, 211 inhaled, 218
Anesthetics, abuse of, 210 intestinal, 219
Aneurysm, 190 wound, 219
Angina, 190 Bowel obstruction, 187
Animal bites, 21–22 Breast problems, 35–36
marine, 25–26 Breathing
snake, 27–28 asthmatic, 15–16
Ankle, injury to, 11–12 problems with, 37–38
Anthrax Bronchiolitis, 236
cutaneous, 216–217 Brucellosis
inhalation of, 216 food borne, 219–220
intestinal, 217 inhaled, 220
Anticholinergics, 211 wound, 220
Antidepressants, 215 Burns, 39–40
255
256 Index
Calcium-channel blockers, 212 Ethylene glycol, 212–213

Car accident. See Motor vehicle accident; MVA triage Extremity, injury to, 67–68
Carbon monoxide, 212 Eye, injury to, 69–70
Cardiac contusion, 190
Catheter. See Urinary catheter Fainting, 115–116
Cerebellar hemorrhage, 193 Febrile seizure, 147–148
Chancroid, 236, 241 Feeding tube, problems with, 71–72
Chemical agents, types of, 225–232 Fever, 73–74
Chest pain, 41–42. See also Anxiety Fifth disease, 237
diagnosis of, 190–192 Fingers, problems with, 75–76
Chickenpox, 236 Flu. See Influenza
Chlamydia, 236, 241 Foreign body
Chlorine, 228 in ear, 77–78
Cholecystitis, 187 ingestion of, 79–80
Cholelithiasis, 187 inhaled, 81–82
Choral hydrate, 212 in rectum/vagina, 83–84
Cluster headaches, 193 in skin, 85–86
Cocaine, abuse of, 205 Frostbite, 43–44
“Cold,” 237
flu v., 240
symptoms, 45–46 Gastroesophageal reflux disease (GERD), 191
Cold exposure, 43–44 Genital warts, 241
Communicable diseases, 236–240 Genitals, problems with
Confusion, 47–48 female, 83–84
Congestion, 153–154 male, 87–88
Conjunctivitis, viral, 237 GERD. See Gastroesophageal reflux disease
Constipation, 187 GF, 226–227
Contusion, 49–50 Giardia, 237
Costochondritis, 191 Gonorrhea, 237, 241–242
Cough, 51–52
Crying baby, 53–54 Hallucinogens
Cyanide, 212 abuse of, 207
Cyanogen chloride, 231 poisoning by, 213
Hand, foot, and mouth disease, 237
Depressants, abuse of, 206–207 Head injury, 91–92
Depression, 55–56 Headache, 89–90
Diabetes, problems from, 57–58 characteristics of, 193–194
Diarrhea Heart rate
in adults, 59–60 rapid, 93–94
in children, 61–62 slow, 95–96
Differential diagnosis Heart transplant, 190–191
of abdominal pain, 187–189 Heat exposure, 97–98
of chest pain, 190–192 Hepatitis, 237, 242
Digoxin, 212 Hernia, hiatal, 191
Drugs Herpes, 237–238, 242
abuse of, 5–6 Hip, injury to, 99–100
types of abused, 205–210 HIV. See Acquired immunodeficiency syndrome
Duodenal hematoma, 187 Hives, 101–102
Humans, bites from, 21–22
Ear Hydrocarbons, 213
foreign bodies in, 77–78 Hydrogen chloride, 232
problems with, 63–64 Hydrogen cyanide, 232
Electric shock, 65–66 Hypertension, 103–104
Enteric infections, 241 Hypoglycemic agents, 213
Epididymitis, 187, 241 Hypothermia, 43–44
Index 257
Ibuprofen, dosage chart for, 181 Nerve agents, 225–227, 233–235

Ileojejunal hematoma, 187 Nitrogen oxide, 227–228
Infant Nongonococcal urethritis, 242
crying, 53–54 Nosebleed, 125–126
jaundice in, 109–110 Noxious fumes, 191
vital signs of, 180
Infection. See Wound infection Orchitis, 188
Influenza, 238 Organophosphates, 214
cold v., 240 Ovarian cyst, ruptured, 188
Ingestion of foreign body, 79–80
Inhalants, abuse of, 207–208 Pancreatitis, 188
Inhalation of foreign body, 81–82 Pediatric vital signs, 180
Insect bites, 23–24 Pelvic inflammatory disease, 242
Intracranial pressure, 193 Pericarditis, 191
Intussusception, 188 Peritonitis, 188
Iron, 213 Phencyclidines, 214
Isoniazid, 213 Phenothiazines, 214
Itching without a rash, 105–106 Phenytoins, 214
Phosgene, 228–229
Jaundice, 107–108 Piercing, body, complications from, 29–35
newborn, 109–110 Pleural effusion, 191
Pneumonia, 192, 238
Kawasaki, 238 Pneumonic plague, 220–221
Knee, injury to, 111–112 Pneumothorax, 192
Poisoning, 127–128
acetaminophen, 211
Laceration, 113–114
alcohol, 211
Lead, poisoning from, 213
amphetamine, 211
Lewisite, 229–230
by anticholinergics, 211
Lice, 238, 243
antidepressant, 215
Lightheadedness, 115–116
by anti-inflammatories, 214
Lightning, injury from, 65–66
arsenic, 211
Lithium, 213
barbiturate, 211
Lyme disease, 238
benzodiazepine, 212
by beta-blockers, 212
Marijuana, abuse of, 208 calcium-channel, 212
Marine animal bites, 25–26 carbamazepine, 212
Measles, 238 carbon monoxide, 212
Meningitis, 193, 238 choral hydrate, 212
Menstrual problems, 117–118 cyanide, 212
Mental status digoxin, 212
altered, 9–10 ethylene glycol, 212–213
confused, 47–48 by hallucinogens, 213
Methanol, 213 hydrocarbon, 213
Migraines, 194 by hypoglycemic agents, 213
Mononucleosis, 238 iron, 213
Motor vehicle accident, 119–120 isoniazid, 213
Mouth, problems with, 121–122 lead, 213
Muscle strain, 191 lithium, 213
Mustard gas, 230 methanol, 213
MVA triage, questions for, 195–196 by organophosphates, 214
Myocardial infarction, 190 by phencyclidines, 214
by phenothiazines, 214
Narcotics, abuse of, 208–209 by phenytoins, 214
Neck pain, 123–124 salicylate, 214
258 Index
Poisoning (continued) Subarachnoid hemorrhage, 194

by sympathomimetics, 214 Suicidal behavior, 157–158
theophylline, 214 Sulfur dioxide, 228
toluene, 214 Sunburn, 159–160
types of, 211–215 Swelling
PQRSTT mnemonic assessment guide, 179 of ankle, 11–12
Pregnancy of hip, 99–100
abdominal pain during, 129–130 of knee, 111–112
back pain during, 131–132 of wrist, 175–176
tubal, 188 Sympathomimetics, 214
vaginal bleeding during, 133–134 Syphilis, 240, 243–244
vaginal discharge during, 135–136
vomiting during, 137–138 Tachydysrhythmias, 191
Proctitis, 242 Temperature conversion chart, 183–184
Proctocolitis, 242 Tension headache, 194
Pulmonary agents, 227–229 Testicular torsion, 189
Pulmonary embolism, 192 Tetanus, 240
Puncture wound, 139–140 Theophylline, 214
Tick bites, 23–24
Q fever, 224 Titanium tetrachloride, 229
Toes, problems with, 75–76
Rabies, 239 Toluene, 214
Rash, 141–142 Toothache/tooth injury, 161–162
Rectum Trauma injury, mechanisms of
foreign body in, 83–84 for adult, 197–198
problems with, 143–144 for infant, 203–204
Renal calculi, 188 for school age/adolescent, 199–200
Ringworm, 239 for toddler/preschooler, 201–202
Rocky mountain spotted fever, 239 Triage skills
Roseola, 239 assessment of, 245–246
Rotavirus, 239 training exercises for, 247–253
Rubella, 239 Trichomoniasis, 240, 244
Tubal pregnancy, 188
Salicylates, 214 Tuberculosis, 240
Salmonella, 239 Tularemia, 222
Sarin, 225 Ulcer, 189
Scabies, 239, 243 Urinary catheter, problems with, 163–164
Scarlet fever, 239 Urinary tract, infection of, 188
Seizure, 145–146 Urination, problems with, 165–166
febrile, 147–148
Sexual assault, 149–150 Vagina, foreign body in, 83–84
Sexually transmitted diseases, 241–244 Vaginal bleeding
Shigella, 239 abnormal, 167–168
Shoulder pain, 151–152 during pregnancy, 133–134
Sinus headache, 194 Vaginal discharge during pregnancy, 135–136
Sinus pain, 153–154 Viral hemorrhagic fevers (VHF), 223
Skin, foreign body in, 85–86 Vital signs, pediatric, 180
Smallpox, 221–222 Vomiting, 169–170
Smoke inhalation, 191 during pregnancy, 137–138
Snake bites, 27–28 VX, 225–226
Sore throat, 155–156
Staph, 238 Weakness, 171–172
RRC1009
Stimulants, abuse of, 209–210 Weight conversion chart, 185–186

Stings, bee, 19–20 Wound infection, 173–174
Strep, 239 Wrist pain, 175–176

(Julie K. Briggs, Valerie G.A. Grossman BSN CEN Emergency Nursing 5 Tier Triage Protocol

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(Julie K. Briggs, Valerie G.A. Grossman BSN CEN Emergency Nursing 5 Tier Triage Protocol

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GRBQ371R-FM.qxd 10/18/07 12:32 PM Page i Aptara Inc.

Julie K. Briggs, RN, BSN, MHA

Valerie G. A. Grossman, RN, BSN, CEN

Acquisitions Editor : Judy McCann

Copyright © 2006 by Lippincott Williams & Wilkins.

Library of Congress Cataloging-in-Publication Data

[DNLM: 1. Triage—methods—Handbooks. 2. Emergencies—nursing—Handbooks. 3. Emergency Service, Hospital—

Contributor and Reviewers

Protocols • Diabetic Problems, 57

• Laceration, 113 Bibliography, 177

Abdominal Pain, Adult

Acuity Level/Assessment Nursing Considerations

••• Level 2: High Risk Emergent

••• Level 3: Moderate Risk Urgent

2 Abdominal Pain, Adult

Acuity Level/Assessment Nursing Considerations

••• Level 4: Low Risk Semi-Urgent

••• Level 5: Lower Risk Non-Urgent

Abdominal Pain, Child

Acuity Level/Assessment Nursing Considerations

••• Level 2: High Risk Emergent

••• Level 3: Moderate Risk Urgent

4 Abdominal Pain, Child

Acuity Level/Assessment Nursing Considerations

••• Level 4: Low Risk Semi-Urgent

••• Level 5: Lower Risk Non-Urgent

Alcohol and Drug Use, Abuse,

Acuity Level/Assessment Nursing Considerations

••• Level 2: High Risk Emergent

••• Level 3: Moderate Risk Urgent

6 Alcohol and Drug Use, Abuse, and Dependence

Acuity Level/Assessment Nursing Considerations

••• Level 5: Lower Risk Non-Urgent

Acuity Level/Assessment Nursing Considerations

••• Level 2: High Risk Emergent

••• Level 3: Moderate Risk Urgent

Acuity Level/Assessment Nursing Considerations

••• Level 4: Low Risk Semi-Urgent

••• Level 5: Lower Risk Non-Urgent

Altered Mental Status

Acuity Level/Assessment Nursing Considerations

••• Level 2: High Risk Emergent

10 Altered Mental Status

Acuity Level/Assessment Nursing Considerations

••• Level 4: Low Risk Semi-Urgent

••• Level 5: Lower Risk Non-Urgent

Ankle Pain and Swelling (nontraumatic;

Acuity Level/Assessment Nursing Considerations

••• Level 2: High Risk Emergent

••• Level 3: Moderate Risk Urgent

12 Ankle Pain and Swelling

Acuity Level/Assessment Nursing Considerations

••• Level 5: Lower Risk Non-Urgent

Acuity Level/Assessment Nursing Considerations

••• Level 2: High Risk Emergent

••• Level 3: Moderate Risk Urgent

••• Level 4: Low Risk Semi-Urgent

Acuity Level/Assessment Nursing Considerations

Acuity Level/Assessment Nursing Considerations

••• Level 2: High Risk Emergent

••• Level 3: Moderate Risk Urgent

Acuity Level/Assessment Nursing Considerations

••• Level 5: Lower Risk Non-Urgent