Patients present to the emergency department (ED) with a variety of complaints of varying severity. The process by which ED providers prioritize patient complaints is called “triage.” Triage originates from the French word trier , which means “to sort.” In this setting, the “sorting” is completed through assignment of an Emergency Severity Index (ESI) Score from 1 to 5 to each patient, where an ESI of 1 is reserved for patients requiring immediate, life-saving interventions. This system prioritizes the treatment of sicker patients (lower ESIs) ahead of the less acute patients (higher ESIs). Although triage is generally a nursing responsibility in the United States, the ED technician (EDT) should be able to recognize patients who require immediate attention to assist nursing with this important function. This chapter highlights common ED presentations, outlines actions that should be taken on the patient’s arrival, and describes “red flag” signs to recognize in order to more efficiently identify time-sensitive emergencies.
There are several core triage principles that should be applied to every patient to ensure rapid identification of emergent presentations.
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All patients should receive a complete set of vital signs on their arrival to the ED (heart rate, blood pressure [BP], respiratory rate, oxygen saturation, temperature). Abnormal vital signs suggest a patient should be seen quickly and assigned a more acute triage score (lower ESI). Marked abnormality of any vital sign or a combination of abnormal vital signs should prompt immediate notification of a provider.
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Red flags are those signs and symptoms that suggest the patient is suffering from a more severe illness. Red flags are disease specific and would justify placing the patient in a higher priority category.
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Time is of the essence in many patient presentations so the assignment of an accurate triage category is very important. All efforts should be made to expedite placing the patient into a treatment room (“rooming”) for provider assessment.
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Intravenous (IV) access, cardiac monitoring, and oxygen administration are the EDTs priorities in rooming a patient with abnormal vital signs or red flag symptoms.
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Patients who present with abnormal vital signs or with red flag symptoms that suggest a serious illness should not be allowed to eat or drink (i.e., made NPO, from the Latin non per os , meaning “nothing by mouth”), as there is a higher likelihood that they will require an invasive procedure or intervention.
Chest Pain
A 65-year-old man presents ambulatory to triage with a chief complaint of chest pain. He states that his pain began about 1 hour ago, and that it feels like a crushing substernal pressure that radiates to his left shoulder. You notice that he is sweating, short of breath, and appears uncomfortable.
Chest pain is the second most frequent nontraumatic complaint evaluated in the ED and can represent a wide range of pathologies, from benign to life-threatening. A primary function of the ED visit is to consider and rule out life-threatening illness and identify and treat the cause of the patient’s symptoms. Chest pain may be the first sign of acute coronary syndrome (blood clot in the coronary arteries that can lead to heart attack), heart rhythm disturbances (either slow or fast), pulmonary embolism (PE; a blood clot in the pulmonary arteries), aortic dissection (a tear in the aorta that can cause low blood flow to critical organs), pericarditis (inflammation of the membrane surrounding the heart), or pneumothorax (lung collapse). Chest pain may also have a noncardiac etiology that should be considered once more serious pathology has been ruled out. Costochondritis, an inflammation of the costal cartilage, is a common benign cause of chest pain that is reproducible on palpation of the chest wall. Gastroesophageal reflux and esophageal complaints may also present as chest pain often associated with eating and with nausea ( Table 28.1 ).
| Coronary artery disease/myocardial infarction | Midsternal, left-sided, worse with exertion, radiating to arm or jaw |
| Pneumothorax | Unilateral, pain with inspiration, often traumatic but may be spontaneous in tall individuals or those with chronic lung disease such as chronic obstructive pulmonary disease |
| Pulmonary embolism | Pain with inspiration occasionally accompanied by unilateral leg swelling, history of long travel, recent surgery, or estrogen use |
| Aortic dissection | Severe, sudden onset, radiating to back, hypertensive, asymmetric blood pressures |
| Pericarditis | Pain with inspiration, improves with leaning forward |
| Abdominal aortic aneurysm | Chest and abdominal pain, pulsating abdominal mass |
| Gastroesophageal reflux | Epigastric pain, worst after eating, nausea |
| Costochondritis (musculoskeletal) | Reproducible chest wall tenderness |
Critical Actions for the ED Technician
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Take vital signs.
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Electrocardiogram (ECG) should be taken within 10 minutes of arrival.
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Place the patient on the cardiac monitor. Continuous rhythm, rate, and saturation monitoring are key. Periodic BP cycling frequency should be discussed with the registered nurse or treating provider.
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Apply oxygen to any patient with oxygen saturation less than 92% or who is on home oxygen.
Red Flags
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Abnormal vital signs
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Altered mental status or neurologic signs
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Diaphoresis (sweating)
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Pallor (pale, cool skin)
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Increased work of breathing: tachypnea, accessory muscle use, tripod position, short sentences when speaking
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New or escalating oxygen requirement
Any patient with a complaint of chest pain should have an ECG within 10 minutes of arrival. Note that the computerized interpretation found on the ECG may not be accurate, so most EDs require a provider to review the ECG shortly after it is obtained.
It is important to anticipate what the providers may order given the complaint and to prepare accordingly when starting your care. In addition to an ECG, lab work (complete blood cell count, comprehensive metabolic panel, troponin, pro–brain natriuretic peptide) and a chest x-ray (CXR) are often ordered. Other lab studies, such as coagulation tests (how well the blood clots) or D-dimer test (a measure of excess clotting in the blood), may be ordered depending on the clinical suspicions of the provider. If in doubt of which tubes to draw, collect all tubes and follow the hospital’s process for labeling and storing extra samples.
Reliable IV access is key for these patients, particularly for patients requiring computed tomography (CT) with IV contrast (to evaluate for PE or aortic dissection), as IV contrast needs to be placed through a larger-bore catheter (20 gauge or larger in most hospitals) and located preferably in the antecubital fossa. Even if not going for a contrast study, many of these patients may receive IV fluids or medications requiring free-flowing, stable access.
Shortness of Breath in a Younger Person
A 25-year-old woman presents to the ED via emergency medical services (EMS) with a chief complaint of shortness of breath (SOB). EMS reports that she has a history of asthma and that she has had increasing wheezing during the past few days. They report that she has been using her albuterol inhaler more frequently until this morning when it was empty. On initial assessment, she has increased work of breathing and has audible wheezes. Her oxygen saturation is 89%.
Patients frequently present to the ED with SOB, and this complaint frequently indicates a significant illness. It most frequently indicates either a problem with the heart, a problem with the lungs, or both. Less frequently, SOB can be due to severe metabolic disturbance or as the result of an overdose (e.g., aspirin). A complaint of SOB can represent serious illness in both the young and old. In a younger population, SOB is often seen in asthma or pneumonia. In an older population, SOB may be a presenting complaint in chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), or pneumonia. Anxiety as a cause of SOB is a diagnosis of exclusion, meaning that other more dangerous etiologies must be considered and evaluated first, and deemed less likely, before ascribing a patient’s SOB to anxiety.
Critical Actions for the ED Technician
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Take vital signs.
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Initiate supplemental oxygen if Sp o 2 is less than 92%.
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Assess general work of breathing. This can be done through observation of the patient’s effort to breathe or talking to the patient if applicable to evaluate.
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Apply a pulse oximeter for continuous pulse oximetry measurement.
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Alert a provider if the patient appears to be in respiratory distress or requires supplemental oxygen.
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Use caution, as these patients may look well initially but may rapidly decompensate while in the ED.
Red Flags
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Previous history of intubation or intensive care unit (ICU) admission for asthma
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Increased work of breathing: intercostal retractions, accessory muscle use, tripod positioning
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Patient requires an increasing amount of supplemental oxygen to maintain the pulse ox above 92%
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Altered mental status
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Pallor
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Diaphoresis
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Cyanosis (bluish coloring of the skin)
The patient described above is most likely experiencing an acute asthma exacerbation. Providers may initiate some combination of bronchodilators (nebulized albuterol), ipratropium, steroids, magnesium, and epinephrine depending on the severity of the exacerbation. IV access is important in moderate to severe exacerbations. Ideally, a peak expiratory flow measurement (requires the patient to forcefully exhale into a device that measures airflow) would be completed before the treatments and then at regular intervals to monitor the patient’s improvement ( Fig. 28.1 ). It is sometimes difficult to obtain this measurement on patient arrival until their breathing improves with treatment.
