POPGUNS Benchmarque JTebomi

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POPGUNS

Resources for Triage

A B C D E F
• Chest pain • Fitting • Injured limb/possible • Unwell child/elderly • Unwell child with: • Adult with persistent
fracture patient with: fever but otherwise well
• Difficulty • Spinal or head injury - Fever
breathing/trouble talking trauma • Poisoning/overdose - Fever • Post-op problems
- Vomiting
• Facial swelling & rash • Severe allergic reaction • Unable to urinate - Vomiting • Ear or eye
- Diarrhoea
(not anaphylaxis) infections/pain
• Facial/limb weakness • Eye injuries/chemical in - Diarrhoea
- Pain for less than 24hrs
• Persistent or heavy the eye • Adult with continuous
• Collapsed/altered level - Pain for over 24hrs
bleeding • Rash (severe) vomiting and/or
of consciousness • Acute neurological
• Pregnancy: diarrhoea for greater than
• Heart palpitations and changes not indicative of • Dehydration risk
•Extensive burns 24hrs
stable at time of stroke but also including - Pain or bleeding
• Bleeding
interaction behavioural changes
- Reduced foetal
• Cut/laceration
• In labour/ ruptured • Child with lethargy movement
membranes • Eye infections
• Unwell floppy infant • Abuse or assault
• Neck stiffness/altered • Severe flu-like
• Pain (severe) • Visual disturbances
consciousness symptoms
• Patient or carer with
extreme concern
• Psychological distress

“Call 000” “Go to Emegency Put call or direct “Come to the “Come to the clinic Make an appointment
Department now” patient to GP or Nurse clinic now” today and call back if within 24 hrs and call
If reception staff taking
If reception staff interrupt now it gets worse” back if it gets worse”
the call or with the If reception staff discuss
patient, then call GP/nurse immediately Advise GP/nurse now call with GP/nurse Reception staff advise Reception staff advise
GP/nurse for help • Retrieve patient file immediately GP/nurse within 30mins GP/nurse
immediately • Retrieve patient file
• Nurse control bleeding • Retrieve patient file • Retrieve patient file • Retrieve patient file
• Retrieve patient file • Nurse commence
if patient is present, baseline observations if • Consider enacting • Nurse to call patient if • Nurse to call patient if
• Nurse commence commence baseline the patient. If concerned Covid-19 policy/plan if concerned about triage concerned about triage
baseline observations if observations, if upgrade to Category B or needed handover by reception handover by reception
the patient is present, if competent insert IV A. Pay particular staff and upgrade to staff and upgrade to
access and if palpitations • Once in clinic, nurse
competent insert IV attention to the floppy another Category if another Category if
take 12 lead ECG. commence baseline
access, if chest pain take infant. required. required; eg. Post-op
Continue to monitor for observations. If
12 Lead ECG and hernia repair incision may
anaphylaxis if relevant • Document concerned upgrade to • Document
administer medications as be found to be grossly
and upgrade to Category Category B or A. Eg the
ordered. If anaphylaxis dehisced and the patient
A if deemed necessary. visual disturbance of a
administer adrenaline IM should be seen now.
sudden curtain over
as per protocol. • Document superior vision may be • Document
• Document caused by a retinal
detachment and ED
presentation at eg. the
Vic Eye & Ear hospital is
warranted.
• Document Adapted from Adelaide PHN (2021)

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