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Complaint Oriented Triage COT (English Canada Version 02.02)

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Presentation on theme: "Complaint Oriented Triage COT (English Canada Version 02.02)"— Presentation transcript:

1 Complaint Oriented Triage COT 2012 - (English Canada Version 02.02)
based on the Canadian Triage and Acuity Score (CTAS 2012), Pediatric CTAS (Ped-CTAS 2012) and the Canadian Emergency Department Information System (CEDIS) 2012 Chief Complaint list v2.0 Edited by Bernard Unger, Michael Bullard, David Meurer CTAS National Working Group © Canadian Association of Emergency Physicians

2 COT Contributors

3 Age selection < 17 years old 17 + years old
Complaint Oriented Triage 2008 – Canadian Triage and Acuity Score 2008 Age selection < 17 years old 17 + years old

4 Go to Title page Master list Reference: Grafstein E, Bullard MJ, Warren D, Unger B, the CTAS National Working Group. Revision of the Canadian Emergency Department Information System (CEDIS) presenting complaint list version 1.1. CJEM 2008;10:151-61

5 Go to Title page Master list Reference: Grafstein E, Bullard MJ, Warren D, Unger B, the CTAS National Working Group. Revision of the Canadian Emergency Department Information System (CEDIS) presenting complaint list version 1.1. CJEM 2008;10:151-61

6 Colour schemes

7 Vital Signs 1st order modifiers
Modifiers Adult

8 Adults: Respiratory Modifiers
CTAS Level Level of Respiratory Distress O2 Sat PEFR predicted 1 Severe: Fatigue from excessive work of breathing, cyanosis, single-word speech, unable to speak, upper airway obstruction, lethargic or confused. <90% - 2 Moderate: Increased work of breathing, speaking phrases or clipped sentences, significant or worsening stridor but airway protected. <92% <40% 3 Mild: Dyspnea, tachypnea, shortness of breath on exertion, no obvious increased work of breathing, able to speak in sentences, stridor without any obvious airway obstruction. % % Severe: Fatigue from excessive work of breathing, cyanosis, single-word speech, unable to speak, upper airway obstruction, lethargic or confused Moderate: Increased work of breathing, speaking phrases or clipped sentences, significant or worsening stridor but airway protected. Mild/Moderate: Dyspnea, tachypnea, shortness of breath on exertion, no obvious increased work of breathing, able to speak in sentences, stridor without any obvious airway obstruction.

9 Adults: Hemodynamic Modifiers
CTAS Level Circulatory Status 1 Shock: evidence of severe end-organ hypoperfusion: marked pallor, cool skin, diaphoresis, weak or thready pulse, hypotension, postural syncope, significant tachycardia or bradycardia, ineffective ventilation or oxygenation, decreased level of consciousness. Could also appear as flushed, febrile, toxic, as in septic shock. 2 Hemodynamic compromise: evidence of borderline perfusion; pale, history of diaphoresis, unexplained tachycardia, postural hypotension (by history), feeling faint on sitting and standing, or suspected hypotension (lower than normal blood pressure or expected blood pressure for a given patient) (hemodynamic compromise) 3 Vital signs at the upper and lower ends of normal as they relate to the presenting complaint, especially if they differ from the usual values for the specific patient Shock - Evidence of severe end-organ hypoperfusion: marked pallor, cool skin, diaphoresis, weak or thready pulse, hypotension, postural syncope, significant tachycardia or bradycardia, ineffective ventilation or oxygenation, decreased level of consciousness. Could also appear as flushed, febrile, toxic, as in septic shock. Hemodynamic compromise - Evidence of borderline perfusion; pale, history of diaphoresis, unexplained tachycardia, postural hypotension (by history), feeling faint on sitting and standing, or suspected hypotension (lower than normal blood pressure or expected blood pressure for a given patient) (hemodynamic compromise)

10 Adults: Level of Consciousness
CTAS Level Level of Consciousness GCS 1 Unconscious: unable to protect airway, response to pain or loud noise only and without purpose, continuous seizure or progressive deterioration in level of consciousness 3 – 9 2 Altered level of consciousness: response inappropriate to verbal stimuli; loss of orientation to person place or time; new impairment of recent memory; altered behaviour 10 – 13 Unconscious: unable to protect airway, response to pain or loud noise only and without purpose, continuous seizure or progressive deterioration in level of consciousness Altered level of consciousness: response inappropriate to verbal stimuli; loss of orientation to person place or time; new impairment of recent memory; altered behavior Normal: other modifiers (vital signs, mechanism of injury, pain or 2 nd order modifiers) are used to define the CTAS level GCS definitions

11 Adults: Temperature / Sepsis
CTAS Level Fever >38. 0 C (age ≥17 years) 2 Immunocompromised: neutropenia (or suspected), chemotherapy or on immunosupressive drugs including steroids. Looks septic: has 3 positive SIRS criteria or hemodynamic compromise, moderate respiratory distress or altered level of consciousness. 3 Looks unwell: has < 3 positive SIRS criteria but appears ill-looking (flushed, lethargic, anxious or agitated. 4 Looks well: has fever as the only positive SIRS criterion and appears comfortable and in no distress. SIRS is the systemic inflammatory response to a variety of severe clinical insults. The response is manifested by 2 or more of the following criteria: -temperature >38°C or <36°C; -heart rate >90 beats/minute; -respiratory rate >20 breaths/minute or PaCO2 <32 torr (<4.3 kPa); -WBC >12000 cells/mm3, < cells/mm3 or >10% immature (band) forms. Sepsis is defined as the systemic response to infection, manifested by 2 or more of the SIRS criteria as a result of infection. Severe sepsis is defined as sepsis associated with organ dysfunction, hypoperfusion or hypotension; hypoperfusion and perfusion abnormalities may include, but are not limited to, lactic acidosis, oliguria or an acute alteration in mental status. Immunocompromised (neutropenia, transplant, steroids) Looks septic (hemodynamic compromise) Looks unwell - Fever, looks flushed, is in a hyperdynamic state (rapid bounding pulse with a widened pulse pressure) and is anxious, agitated or confused. Looks well – Fever, looks comfortable, in no distress, with normal pulse quality, alert and oriented

12 Adults: Pain Severity Modifier
SEVERE 8 -10 2 Central pain originates within a body cavity or organ and may be associated with life- or limb- threatening conditions. Peripheral pain originates in the skin, soft tissues, axial skeleton or superficial organs where dangerous diagnoses are less likely to be missed. *Caveat: A patient presenting with apparent peripheral pain in whom the triage nurse suspects a life or limb threatening condition should score based on “central” pain. Acute pain is a new onset pain and is more likely to prove dangerous (prior to a diagnostic work-up) than chronic pain. Chronic pain is a well-recognized continuing or recurring pain syndrome manifesting the same pattern (changes in pattern or severity = acute). ACUTE MODERATE 4 - 7 3 MILD < 4 4 CENTRAL SEVERE 8 -10 3 CHRONIC MODERATE 4 - 7 4 MILD < 4 5 SEVERE 8 -10 3 ACUTE MODERATE 4 - 7 4 The triage nurse needs to apply a pain scale and note (record) the patient’s self reported level of pain. However the triage nurse should base the triage level on both the reported pain scale and other objective observations. In general patients have some physiologic changes associated with their pain, and give the appearance of some degree of distress. Patients may have significant pain and deny this, yet show overt signs of pain such as tachycardia, facial grimacing, distraction and remoteness. On the other hand the reverse may be true and the patient report a high level for their pain yet not exhibit any distress or physiologic changes. Triage nurse should record both their observations and the patient reported pain scale to arrive at a CTAS level. MILD < 4 5 PERIPHERAL SEVERE 8 -10 4 CHRONIC MILD / MOD < 8 5

13 Adults: Bleeding disorder (congenital or acquired)
Life or Limb Threatening Moderate/Minor CTAS level 2 CTAS level 3 Head (intracranial) & neck Nose (epistaxis) Chest,abdomen,pelvis,spine Mouth (including gums) Massive vaginal hemorrhage Joints (hemarthroses) Iliopsoas muscle & hip Menorrhagia Extremity muscle compartments Abrasions Fractures & dislocations Superficial lacerations Deep lacerations Any uncontrolled bleeding

14 Adults: Mechanism of Injury
MOI CTAS Level 2 General Trauma MVC: Ejection from vehicle, rollover, extrication time>20 minutes, significant intrusion into passenger’s space, death in the same passenger compartment, impact >40 km/h (unrestrained) or impact>60 km/h (restrained) MCC: Where impact with a car>30 km/hr, especially if rider is separated from motorcycle Pedestrian or bicyclist Run over or struck by vehicle at >10 km/h Fall: of >18 ft (>6 m) or 5 stairs Penetrating injury: To head, neck, torso or extremities prox to elbow and knee Head Trauma MVC: ejection from vehicle, unrestrained passenger striking head on windshield Pedestrian: struck by vehicle Fall: from >3 ft (>1 m) or 5 stairs Assault: With blunt object other than fist or feet Neck Trauma MVC: ejection from vehicle, rollover, high speed (esp. if driver unrestrained) MCC: impact with a car > 30 km/hr, especially if rider is separated from motorcycle Axial load to the head General trauma: MVC: Ejection from vehicle, rollover, extrication time>20 minutes, significant intrusion into passenger’s space, death in the same passenger compartment, impact >40km/h (unrestrained) or impact>60km/h (restrained) MCC: Where impact with a car>30km/hr, especially if rider is separated from motorcycle Pedestrian or bicyclist Run over or struck by vehicle at >10km/h Fall: of > 18 feet (6m) Penetrating injury To head, neck, torso or extremities proximal to elbow and knee Head Trauma MVC: ejection from vehicle, unrestrained passenger striking head on windshield Pedestrian: struck by vehicle Fall: from >3 feet (1m) or 5 stairs Assault: With blunt object other than fist or feet Neck Trauma: MVC: ejection from vehicle, rollover, high speed (esp. if driver unrestrained) MCC Axial load to the head

15 Def: suicidality, anxiety, agitation
Suicidal Term Definition Suicide attempt Self injurious behavior with a non fatal outcome accompanied by evidence (explicit or implicit) that the person attempted to die. Suicide intent Subjective expectation and desire for self-destructive act that would end in death. Suicidal ideation Thought of serving as an agent of one’s own death, may vary in seriousness depending on specificity of plans and degree of suicidal intent. Uncertain flight or safety risk Patients threatening violence towards themselves or others; patients exhibiting uncontrolled anger, restlessness, paranoia, or hallucinatory behavior; or patients unable or unwilling to cooperate with suicide risk assessment and who pose a flight risk. Need close observation based on site resources. (If family member willing to observe & both parties agree ‘hospital-assigned’ close observation may not be required.) Anxiety / Agitation Definition Severe anxiety / agitation Extreme unease, apprehension or worry with signs of tachycardia or agitation; or dangerously agitated and uncooperative and does not calm down when asked Moderate anxiety / agitation Clear unease, apprehension, or worry, but no obvious tachycardia or tremulousness; or signs of agitation, and does not consistently obey commands (e.g. will sit or calm down when asked, but soon becomes restless and agitated again Mild anxiety / agitation Mild unease, apprehension or worry, but can be reassured; or restless but cooperative; obeys commands.

16 Def: Psychosis, paranoia, hallucinations, chronic, Bizarre behaviour
Delusion Definition Acute psychosis May present with extreme self neglect, disordered or racing thoughts or both, speech pattern impairments, impaired reality testing with ‘lack of insight’, may be responding to hallucinatory or delusional thoughts or both, which may be accompanied by hostility. Paranoia Delusions of a persecutory nature - being followed, poisoned, or harmed in some way. Ideas of reference - the belief that people are talking about you. May be accompanied by extreme fear, agitation or hostility. Chronic hallucinations Known history of hallucinations with no recent change in nature, and/or frequency, or in patient’s level of distress related to them. Chronic, non-urgent condition Patient is well known to the ED and triage nurse with a recurrent complaint that has either been fully dealt with, or patient is just looking for food, warmth or temporary shelter. Bizarre Behavior Definition Uncontrolled Bizarre, disoriented or irrational behavior, not controlled by verbal communication and reasoning, and placing the patient or others in physical danger Controlled Bizarre, irrational behavior that is viewed as threatening but controllable through verbal support and reasoning; patient is accompanied by a friend or family member. Harmless behavior Bizarre or eccentric behavior (usually of long standing with no recent change from patient’s norm) that is of no threat to the patient or others and requires no acute intervention.

17 Substance misuse / Intoxication
Overdose ingestion Substance withdrawal

18 Mental health and psychosocial issues
Anxiety / Situational crisis Social problem Hallucinations / Delusions Bizarre behaviour Insomnia Concern for patient's welfare Violent / Homicidal behaviour Pediatric Disruptive behaviour Depression / Suicidal / Deliberate self harm

19 Neurologic Altered level of consciousness
Extremity weakness / Symptoms of CVA Confusion Head injury Vertigo Tremor Headache Sensory loss / Parasthesias Seizure Floppy child Gait disturbance / Ataxia

20 Ophthalmology Chemical exposure, eye Photophobia Foreign body, eye
Diplopia Visual disturbance Periorbital swelling Eye pain Eye trauma Red Eye, discharge Re-check eye

21 Nasal congestion / Hay fever
Ent-nose Epistaxis Nasal congestion / Hay fever Foreign body, nose URTI complaints Nasal trauma

22 ENT- Ears Earache Foreign body ear Loss of hearing Tinnitus
Discharge, ear Ear injury

23 ENT – Mouth, Throat, Neck Dental / Gum problems Facial trauma
Sore throat Neck swelling / pain Neck trauma Difficulty swallowing / Dysphagia Facial pain (non-traumatic / non-dental)

24 Respiratory Shortness of breath Respiratory foreign body
Respiratory arrest Allergic reaction Hyperventilation Stridor Hemoptysis Apneic spells in infants Cough / Congestion Wheezing – no other complaints

25 Cardiovascular Cardiac arrest (non traumatic) General weakness
Cardiac arrest (traumatic) Syncope / Pre-syncope Chest pain (cardiac features) Edema, generalized Chest pain (non cardiac features) Bilateral leg swelling / Edema Palpitations / Irregular heart beat Cool pulseless limb Hypertension Unilateral reddened hot limb

26 Gastrointestinal Abdominal pain Vomiting blood Anorexia
Blood in stool / Melena Constipation Jaundice Foreign body in rectum Hiccoughs Groin pain / mass Abdominal mass / distention Vomiting and/or nausea Anal / Rectal trauma Rectal / Perineal pain Oral / Esophageal Foreign Diarrhea Feeding difficulties in newborn Neonatal jaundice

27 Obstetrics-gynecology
Menstrual problems Vaginal bleed Foreign body, vagina Labial swelling Vaginal discharge Pregnancy issues < 20 wks Vaginal pain / itch Pregnancy issues > 20 wks Sexual assault

28 Genito-urinary Flank pain Urinary retention Hematuria UTI complaints
Genital discharge / lesion Oliguria Penile swelling Polyuria Scrotal pain and/or swelling Genital trauma

29 Orthopedic Back pain Upper extremity injury
Traumatic back / spine injury Lower extremity injury Amputation Joint(s) swelling Upper extremity pain Cast check Lower extremity pain Pediatric gait disorder / painful walk

30 Trauma Major trauma – penetrating Major trauma – blunt
Isolated chest trauma – penetrating Isolated chest trauma – blunt Isolated abdominal trauma – penetrating Isolated abdominal trauma – blunt

31 Frostbite / Cold injury
Environmental Frostbite / Cold injury Noxious inhalation Electrical injury Chemical exposure Hypothermia Near Drowning

32 Skin Rash Sting Redness / tenderness, breast Abrasion
Bite Rash Sting Redness / tenderness, breast Abrasion Localized swelling / redness Laceration / Puncture Lumps, bumps, calluses Burn Rule out infestation Blood and body fluid exposure Cyanosis Foreign body, skin Spontaneous bruising Wound check Pruritis Removal staples / sutures Other skin conditions

33 General & Minor Fever Ring removal Hyperglycemia Abnormal lab values
Exposure to communicable disease Prescription / Medication request Fever Ring removal Hyperglycemia Abnormal lab values Hypoglycemia Pallor / anemia Direct referral for consultation Post-operative complications Dressing change Inconsolable crying in infants Imaging tests Congenital problem in children Medical device problem Minor complaints NOS Newly born *NOS: not otherwise specified

34 Cardiac arrest (non traumatic)
1 Cardiac arrest (non-traumatic)

35 Cardiac arrest (traumatic)
1 Cardiac arrest (traumatic) Cardiac arrest (traumatic)

36 Chest pain (cardiac features)
1 VS 2 Chest Pain with cardiac features Chest pain (cardiac features)

37 Chest pain (non cardiac features)
1 VS 2 VS, PSC Other significant chest pain (ripping, tearing) 3 VS, PSC, PSP, chronicity 4 5 Chest pain, non cardiac Note with chest wall pain the pain is peripheral

38 Palpitations / Irregular heart beat
1 VS 2 With chest pain cardiac features History or documented evidence of potential lethal dysrhythmia 3 Acute onset, ongoing 4 History of palpitations, presently resolved

39 1 VS 2 HTN (SBP >= 220 or DBP >= 130) with symptoms+ any of (SOB, chest pain, confusion, sudden HA, N/V) 3 HTN (SBP >= 220 or DBP >= 130) with no other presenting symptoms HTN (SBP and DBP ) with hypertensive symptoms 4 HTN (SBP and DBP ) with no symptoms Hypertension SBP=SYSTOLIC BLOOD PRESSURE DBP=DIASTOLIC BLOOD PRESSURE

40 VS, Moderate dehydration
General weakness 1 VS, Severe dehydration 2 VS, Moderate dehydration 3 VS, Acute inability to ambulate Mild dehydration 4 VS, Potential for dehydration Chronic weakness If considering a CVA go to: Symptoms of a CVA

41 1 VS 2 3 4 New onset dysrhythmia, irregular pulse &/or change in rate
No prodromal symptoms Occurring during exercise 3 With prodromal symptoms or sudden position change 4 Normal vitals, symptoms resolved Syncope / Pre-syncope

42 Edema, generalized, normal vitals
1 VS 2 3 4 Edema, generalized, normal vitals Edema, generalized

43 Bilateral leg swelling / Edema
2 VS 3 VS, PSP 4 VS, PSP + chronicity 5 Edema/bilateral leg swelling, chronic Bilateral leg swelling / Edema

44 1 VS 2 Cool Pulseless Limb Cool pulseless limb

45 Unilateral reddened hot limb
2 VS 3 VS, PSP Extensive inflammation 4 Localized inflammation Unilateral reddened hot limb

46 3 VS, PSP 4 VS, PSP, + chronicity 5 Earache with mild pain Earache

47 Acute peripheral severe pain (8-10)
3 Acute peripheral severe pain (8-10) 4 Acute peripheral moderate pain ( 4- 7) 5 Foreign body ear, mild pain (<4) Foreign body ear

48 Hearing loss, sudden onset
3 Hearing loss, sudden onset 5 Hearing loss, gradual onset Loss of hearing

49 Suspected aspirin ingestion
2 Suspected aspirin ingestion 4 Tinnitus Tinnitus

50 3 VS 4 Discharge, ear

51 Cold injury severe with blanching, cyanosis
2 VS Amputation 3 VS, PSP, BD Cold injury severe with blanching, cyanosis 4 VS, PSP Cold injury, minor with no discoloration Laceration requiring sutures 5 Laceration/abrasion not requiring sutures PSP Ear injury

52 Dental avulsion (recent with intact tooth present)
2 Dental avulsion (recent with intact tooth present) 3 PSP + BD 4 PSP + chronicity 5 Dental/gum problem minor problem Dental / Gum problems

53 1 VS 2 VS, MOI 3 VS, PSP, BD 4 VS, PSP Facial trauma

54 Obvious edema/swelling of lips, tongue or oropharynx
1 VS 2 VS, PSC Drooling or stridor Obvious edema/swelling of lips, tongue or oropharynx 3 Difficulty swallowing 4 VS, PSC, chronicity 5 Minor sore throat +/- laryngitis Sore throat

55 Neck stiffness / meningismus +/- fever
1 VS 2 VS, PSC Neck stiffness / meningismus +/- fever 3 4 VS, PSC, chronicity 5 Neck swelling/pain with chronic central mild pain (< 4) Neck swelling / pain

56 Paresthesias, neurological signs
1 VS 2 VS, PSC, BD Paresthesias, neurological signs Hoarseness and dysphasia 3 4 VS, PSC, Neck trauma

57 Difficulty swallowing / Dysphagia
1 VS 2 VS, PSC Drooling or stridor 3 Possible foreign body Difficulty swallowing / Dysphagia

58 Facial pain (non-traumatic / non-dental)
2 VS 3 VS, PSP, chronicity 4 5 PSP, chronicity Facial pain (non-traumatic / non-dental)

59 Uncontrolled epistaxis (despite appropriate pressure)
1 VS 2 VS, BD Uncontrolled epistaxis (despite appropriate pressure) 3 Bleeding controlled with pressure 4 Acute epistaxis, no active bleeding 5 Periodic / recurrent, no active bleeding Epistaxis

60 Nasal congestion / Hay fever
5 Nasal congestion / hay fever Nasal congestion / Hay fever

61 Moderate respiratory distress
2 Moderate respiratory distress 3 VS, PSP 4 5 Foreign body, nose with acute peripheral mild pain Foreign body, nose

62 2 VS 3 VS, PSP 4 5 Appears well, no fever URTI complaints

63 Uncontrolled epistaxis (despite appropriate pressure)
2 VS, BD Uncontrolled epistaxis (despite appropriate pressure) 3 VS, PSP, BD 4 VS, PSP 5 PSP Nasal trauma

64 Frostbite / Cold injury
2 Cold pulseless limb 3 PSP Blanching of skin 4 PSP, chronicity 5 Frostbite/cold injury Frostbite / Cold injury

65 Smoke inhalation, or other, no distress
1 VS 2 3 Smoke inhalation, or other, no distress 4 Remote exposure, no symptoms Noxious inhalation

66 Obvious cutaneous injury
1 VS 2 Obvious cutaneous injury 3 VS, PS No obvious cutaneous injury Electrical injury

67 Major burn hand, feet, groin or face
1 VS Major burn >25% BSA 2 Major burn hand, feet, groin or face Symptomatic eye 'splash' Chemical exposure The minimum level is 2 to ensure early decontamination and identification of the substances as toxic or not BSA estimation

68 Hypothermia, Core temperature < 32 °C
1 VS 2 Hypothermia, Core temperature < 32 °C 3 Core temperature °C 4 No frostbite, normal VS Hypothermia

69 Hypothermia, Core temperature < 32 °C
1 VS 2 Hypothermia, Core temperature < 32 °C 3 Core temperature °C Near Drowning

70 Chronic mild abdominal pain
1 VS 2 VS, PSC 3 VS, PSC, chronicity 4 5 Chronic mild abdominal pain Abdominal pain

71 Significant weight loss
2 VS 3 Significant weight loss 4 Anorexia, looks well Anorexia

72 2 VS, PSC 3 VS, PSC, chronicity 4 5 Simple constipation Constipation

73 VS, moderate dehydration
1 VS, severe dehydration 2 VS, moderate dehydration 3 Uncontrolled bloody diarrhea VS, Mild dehydration 4 VS 5 Chronic diarrhea, normal VS Diarrhea If a BD exist with presence of bloody diarrhea then go to Blood in stool/melena

74 2 VS 3 VS, PSP 4 5 Foreign body in rectum Foreign body in rectum

75 2 VS, PSC 3 VS, PSC, chronicity 4 5 Groin pain / mass

76 Vomiting and/or nausea
1 VS, severe dehydration 2 Active significant hematemesis VS, moderate dehydration 3 Coffee ground emesis / melena VS, mild dehydration 4 VS, potential for dehydration 5 Chronic vomiting and/or nausea, normal VS Vomiting and/or nausea If a BD exist with presence of Coffee ground emesis / melena go to “Vomiting blood”

77 Chronic mild rectal/perineal pain
2 VS, PSP 3 VS, PSP, chronicity 4 5 Chronic mild rectal/perineal pain Rectal / Perineal pain

78 Active or significant hematemesis
1 VS 2 Active or significant hematemesis 3 Coffee ground emesis/melena Small amount, normal vital signs Vomiting blood

79 Large amount of melena or rectal bleeding
1 VS 2 Large amount of melena or rectal bleeding 3 Moderate amount of melena or rectal bleeding 4 Rectal bleeding small amount Blood in stool / Melena

80 2 VS, PSC 3 VS, PSC, chronicity 4 5 Jaundice, looks well Jaundice

81 Fever (appears unwell), PSP
3 Fever (appears unwell), PSP 4 Fever (appears well), PSP 5 Hiccoughs, chronic no distress Hiccoughs

82 Abdominal mass / distention
1 VS 2 VS, PSC 3 VS, PSC, chronicity Persistent vomiting 4 5 Chronic abdominal mass/distention, looks well Abdominal mass / distention

83 2 VS, PSC, BD 3 4 VS, PSC 5 Anal/rectal trauma
Patients in shock from rectal trauma should be documented under “Major trauma-penetrating

84 Oral / Esophageal Foreign Body
1 VS 2 Drooling or stridor Hoarseness and dysphasia VS, PSC 3 Persistent vomiting 4 No swallowing or respiratory difficulty Oral / Esophageal Foreign Body

85 Feeding difficulties in newborn
Peds specific go to pediatric COT

86 Peds specific go to pediatric COT
Neonatal jaundice Peds specific go to pediatric COT

87 Chronic mild flank pain
1 VS 2 VS, PSC 3 VS, PSC, chronicity 4 5 Chronic mild flank pain Flank pain

88 VS, PSC, PSP, BD, chronicity
1 VS 2 VS, PSC, BD 3 VS, PSC, PSP, BD, chronicity 4 VS, PSC, PSP, chronicity 5 Chronic mild central or moderate to mild peripheral pain Hematuria

89 Genital discharge / lesion
3 VS, PSP, chronicity 4 5 Genital discharge / lesion Genital discharge / lesion

90 Paraphimosis (retracted foreskin, unable to reduce)
2 Priapism Paraphimosis (retracted foreskin, unable to reduce) VS, PSP 3 VS, PSP, chronicity 4 5 Penile Swelling, mild or chronic pain Penile swelling

91 Scrotal pain and/or swelling
2 VS, PSC 3 VS, PSC, chronicity 4 5 Scrotal pain and/or swelling Scrotal pain and/or swelling

92 If the patient is unstable choose another complaint
2 VS, PSC 3 VS, PSC, chronicity 4 Urinary retention Urinary retention If the patient is unstable choose another complaint

93 Chronic, mild UTI complaints/symptoms
2 VS, PSC 3 VS, PSC, PSP, chronicity 4 5 Chronic, mild UTI complaints/symptoms UTI complaints If the pain is suspected from the bladder or above choose “central” pain, if suspected from urethra then use “peripheral” pain

94 1 VS 2 VS, PSC 3 4 Oliguria Oliguria

95 1 VS 2 VS, PSC 3 4 Polyuria Polyuria

96 1 VS 2 VS, PSC, BD 3 Sexual assault, stable 4 VS, PS 5
Genital trauma, no pain Genital trauma

97 Depression / Suicidal / Deliberate self harm
2 attempted suicide or clear suicide plan active suicidal intent uncertain flight or safety risk 3 suicidal ideation, no plan 4 depressed, no suicidal ideation Depression / Suicidal / Deliberate self harm Suicidal Term Definition Suicide attempt Self injurious behavior with a non fatal outcome accompanied by evidence (explicit or implicit) that the person attempted to die. Suicide intent Subjective expectation and desire for self-destructive act that would end in death. Suicidal ideation Thought of serving as an agent of one’s own death, may vary in seriousness depending on specificity of plans and degree of suicidal intent. Uncertain flight or safety risk Patients threatening violence towards themselves or others; patients exhibiting uncontrolled anger, restlessness, paranoia, or hallucinatory behavior; or patients unable or unwilling to cooperate with suicide risk assessment and who pose a flight risk. Need close observation based on site resources. (If family member willing to observe & both parties agree ‘hospital-assigned’ close observation may not be required.) Note: In Quebec this complaint is separated in 3 distinct complaints

98 Anxiety / Situational crisis
2 severe anxiety / agitation uncertain flight or safety risk 3 moderate anxiety / agitation 4 mild anxiety / agitation Anxiety / Situational crisis Anxiety / Agitation Definition Severe anxiety / agitation Extreme unease, apprehension or worry with signs of excessive circulating catecholamines; or dangerously agitated and uncooperative and does not calm down when asked Moderate anxiety / agitation Clear unease, apprehension, or worry, but no obvious tachycardia or tremulousness; or signs of agitation, and does not consistently obey commands (e.g. will sit or calm down when asked, but soon becomes restless and agitated again Mild anxiety / agitation Mild unease, apprehension or worry, but can be reassured; or restless but cooperative; obeys commands.

99 Hallucinations / Delusions
2 VS acute psychosis, severe anxiety / agitation , uncertain flight or safety risk 3 VS, moderate anxiety / agitation or with paranoia 4 VS, mild agitation, stable 5 mild anxiety / agitation, chronic hallucinations Hallucinations / Delusions Hallucination / Delusion Definition Acute psychosis May present with extreme self neglect, disordered or racing thoughts or both, speech pattern impairments, impaired reality testing with ‘lack of insight’, may be responding to hallucinatory or delusional thoughts or both, which may be accompanied by hostility. Paranoia Delusions of a persecutory nature - being followed, poisoned, or harmed in some way. Ideas of reference - the belief that people are talking about you. May be accompanied by extreme fear, agitation or hostility. Chronic hallucinations Known history of hallucinations with no recent change in nature, and/or frequency, or in patient’s level of distress related to them. Chronic, non-urgent condition Patient is well known to the ED and triage nurse with a recurrent complaint that has either been fully dealt with, or patient is just looking for food, warmth or temporary shelter.

100 4 Acute insomnia 5 Chronic insomnia Insomnia

101 Violent / Homicidal behaviour
1 imminent harm to self or others or specific plans 2 uncertain flight or safety risk 3 violent ideation, no plan Violent / Homicidal behaviour

102 abuse physical, mental, high emotional stress
3 abuse physical, mental, high emotional stress 4 unable to cope 5 chronic, non urgent condition Social problem

103 uncertain flight or safety risk
1 uncontrolled 2 VS uncertain flight or safety risk 3 controlled 4 harmless behaviour 5 chronic, non urgent condition Bizarre behaviour Bizarre Behavior Definition Uncontrolled Bizarre, disoriented or irrational behavior, not controlled by verbal communication and reasoning, and placing the patient or others in physical danger Controlled Bizarre, irrational behavior that is viewed as threatening but controllable through verbal support and reasoning; patient is accompanied by a friend or family member. Harmless behavior Bizarre or eccentric behavior (usually of long standing with no recent change from patient’s norm) that is of no threat to the patient or others and requires no acute intervention.

104 Concern for patient's welfare
1 conflict or unstable situation 2 risk of flight or ongoing abuse 3 physical or sexual assault 4 history / signs of abuse or maltreatment Concern for patient's welfare Complaint to be used for patients in whom the nurse suspects abuse or neglect and there is no acute medical problem.

105 Pediatric Disruptive behaviour
Peds specific go to pediatric COT

106 Altered level of consciousness
1 VS 2 VS, MOI BS<3 mmol/L &/or symptomatic 3 Altered level of consciousness

107 BS <3 mmol/L &/or symptomatic
2 VS BS <3 mmol/L &/or symptomatic acute , with headache or altered LOC 3 acute without headache or altered LOC 4 chronic, no change from usual state Confusion LOC in this slide is Level of Consciousness

108 not positional +/- other neurological findings
1 VS 2 not positional +/- other neurological findings 3 positional, no other neuro symptoms Vertigo

109 sudden, severe, worst ever
1 VS 2 sudden, severe, worst ever visual acuity disturbance +/- eye pain VS, PSC 3 VS, PSC, chronicity 4 5 Chronic or recurring headache Headache

110 Resolved, normal level of alertness
1 Actively seizing VS 2 Post-ictal VS, PSC 3 Resolved, normal level of alertness VS, PSC, chronicity Seizure

111 Gait disturbance / Ataxia
1 VS 2 Time of onset < 3 hrs 3 4 Gait disturbance / Ataxia If considering a CVA go to: Symptoms of a CVA

112 New focal neurologic findings
1 VS 2 VS, PSC, MOI New focal neurologic findings 3 VS, PSC History of LOC Prolonged spinal immobilization 4 No history of LOC Head injury LOC on this slide = Loss of consciousness

113 2 VS 3 4 Chronic tremor Tremor

114 Extremity weakness / Symptoms of CVA
1 VS 2 VS, PSC, BD Time of onset < 3 hours 3 > 3 hours or resolved Extremity weakness / Symptoms of CVA Note: as of 2008 in some institutions Time of onset is < 4.5 hrs May use pain scales if headache is present

115 Sensory loss / Parasthesias
3 New onset sensory loss/paresthesias 4 Chronic sensory loss/paresthesias Sensory loss / Parasthesias If considering a CVA go to: Symptoms of a CVA

116 Peds specific go to pediatric COT
Floppy child Peds specific go to pediatric COT

117 This implies symptoms normally associated with menses
1 VS 2 VS, PSC 3 4 Menstrual problems Menstrual problems This implies symptoms normally associated with menses

118 1 VS 2 VS, PSP 3 4 5 Foreign body, vagina Foreign body, vagina

119 2 VS, PSP 3 4 5 Mild symptoms Vaginal discharge

120 >= 2 hours and < 12 hours
VS 2 VS, PSC < 2 hours 3 >= 2 hours and < 12 hours 4 >= 12 hours; no injury Sexual assault Suggested not to post this complaint on the tracking screen or board, but choose a non offensive code word.

121 Heavy vaginal bleeding +/- pregnancy
1 VS 2 VS, PSC, BD Heavy vaginal bleeding +/- pregnancy 3 Vaginal bleeding – normal VS 4 Vaginal bleeding - minor/spotting Vaginal bleed

122 2 VS, PSP 3 4 5 Labial swelling Labial swelling

123 3 PSP 4 5 Vaginal pain, itch Vaginal pain / itch

124 Pregnancy issues > 20 wks
1 VS Presenting fetal parts, prolapsed cord Vaginal bleeding 3rd trimester 2 VS, PSC, BD, MOI Active labor (contractions <2 min) Pregnancy issues > 20 weeks no fetal movement / no fetal heart tones Pregnancy issues > 20 weeks headache+/- edema+/- abdo pain+/-hypertension Post delivery 3 VS, PSC, BD Active labor (contractions > 2 min) Pregnancy issues > 20 weeks possible leaking amniotic fluid 4 Pregnancy issues > 20 weeks Pregnancy issues > 20 wks

125 Pregnancy issues < 20 wks
1 VS 2 VS, PSC, BD Heavy vaginal bleeding +/- pregnancy 3 Vaginal bleeding - normal VS 4 Vaginal bleeding - minor / spotting Pregnancy issues < 20 weeks Pregnancy issues < 20 wks

126 2 Chemical exposure, eye Chemical exposure, eye

127 Penetrating foreign body
2 Penetrating foreign body Acute or abrupt change in vision 3 PSP 4 5 Acute peripheral mild pain Foreign body, eye This includes corneal abrasions and corneal foreign body

128 acute or abrupt change in vision
2 acute or abrupt change in vision 4 chronic/gradual change in vision Visual disturbance

129 Acute or abrupt change in vision
2 PSC Acute or abrupt change in vision 3 PSC, Chronicity 4 5 Eye pain, chronic Eye pain

130 Red eye / discharge, acute
3 PSP, Chronicity 4 Red eye / discharge, acute 5 Red eye / discharge, chronic Red Eye, discharge

131 2 PSC 3 4 Photophobia Photophobia

132 3 Acute onset 4 Chronic diplopia
If considering a CVA go to: Symptoms of a CVA

133 2 VS, PSP 3 4 5 Periorbital swelling Periorbital swelling

134 Penetrating injury, chemical or direct thermal burn
2 PSC, BD, MOI Penetrating injury, chemical or direct thermal burn Blunt mechanism of injury with visual loss Acute or abrupt change in vision Nurse unable to visualize eye 3 4 Eye trauma, Acute central mild pain (< 4) Eye trauma

135 Acute or abrupt change in vision
2 Acute or abrupt change in vision 3 PSP 4 5 Re-check eye Re-check eye

136 Neuro-deficit +/- bowel bladder problems
1 VS 2 Neuro-deficit +/- bowel bladder problems VS, PSC 3 VS, PSC, chronicity 4 5 Back pain Back pain

137 Traumatic back / spine injury
1 VS 2 Neuro-deficit +/- bowel bladder problems VS, PSC, BD, MOI 3 VS, PSC, BD 4 Traumatic back/spine injury, mild central pain Traumatic back / spine injury

138 Traumatic amputation of an extremity.
1 VS Traumatic amputation of an extremity. 2 VS, MOI, BD Traumatic amputation of a digit. 3 Amputation Amputation

139 Upper extremity injury
1 VS 2 VS, MOI, BD Open fracture or neuro-vascular compromise 3 Obvious deformity VS, PSP, BD Tight cast with neuro-vascular compromise 4 VS, PSP, Chronicity Tight cast with no neuro-vascular compromise 5 Upper extremity trauma, chronic mild pain Upper extremity injury

140 Lower extremity injury
1 VS 2 VS, BD, MOI Open fracture or neuro-vascular compromise 3 Obvious deformity VS, PSP, BD Tight cast with neuro-vascular compromise 4 VS, PSP, Chronicity Tight cast with no neuro-vascular compromise 5 Lower extremity trauma, chronic mild pain Lower extremity injury

141 Neuro-vascular compromise
1 VS 2 VS, BD Neuro-vascular compromise 3 VS, PSP Tight cast with neuro-vascular compromise 4 VS, PSP, Chronicity Tight cast with no neuro-vascular compromise 5 Upper extremity chronic mild pain Upper extremity pain

142 Tight cast with neuro-vascular compromise
1 VS 2 VS, BD 3 VS, PSP Tight cast with neuro-vascular compromise 4 VS, PSP, Chronicity Tight cast with no neuro-vascular compromise 5 Lower extremity chronic mild pain Lower extremity pain

143 2 VS 3 VS, PSP, BD 4 VS, PSP, Chronicity 5 Joint swelling
Joint(s) swelling

144 Pediatric gait disorder / painful walk
Peds specific go to pediatric COT

145 Tight cast with neuro-vascular compromise
3 PSP Tight cast with neuro-vascular compromise 4 Tight cast with no neuro-vascular compromise 5 Cast check or cast change Cast check

146 1 VS 2 Known asthmatic with FEV1 or PEFR <40% predicted (severe) 3 Known asthmatic with FEV1 or PEFR 40-60% predicted (moderate) 4 Known asthmatic with FEV1 or PEFR >60% predicted (mild) SOB - shortness of breath, in no distress Shortness of breath

147 1 Respiratory arrest Respiratory arrest

148 Chronic cough / congestion with normal vital signs
2 VS 3 4 5 Chronic cough / congestion with normal vital signs Cough / Congestion

149 Hyperventilation resolved, appears well
1 VS 2 3 4 Hyperventilation resolved, appears well Hyperventilation

150 Hemoptysis, appears well
1 VS 2 VS, BD 3 4 Hemoptysis, appears well Hemoptysis

151 Respiratory foreign body
1 VS 2 VS, PSC Drooling or stridor Hoarseness and dysphasia 3 No distress but with difficulty swallowing 4 Respiratory - foreign body, mild pain, appears in no distress Respiratory foreign body

152 Previous severe reaction
1 VS 2 Previous severe reaction 3 VS, PSP 4 5 Hay fever causing nasal congestion Allergic reaction

153 Peds specific go to pediatric COT
Stridor Peds specific go to pediatric COT

154 Wheezing – no other complaints
Peds specific go to pediatric COT

155 Apneic spells in infants
Peds specific go to pediatric COT

156 Previous severe reaction
1 VS 2 Previous severe reaction 3 VS, PSP 4 5 Minor bite Bite

157 Previous severe reaction
1 VS 2 Previous severe reaction 3 VS, PSP 4 5 Sting Sting

158 3 PSP 4 5 Minor abrasion Abrasion

159 Complex wound with neurovascular compromise
1 VS 2 VS, BD Complex wound with neurovascular compromise 3 VS, PSP, BD Active bleeding 4 VS, PSP Bleeding resolved/controlled Sutures required 5 No sutures required Laceration / Puncture

160 Burn >25% Body surface area (BSA)
1 VS 2 Burn >25% Body surface area (BSA) Partial/full thickness to hands, feet, face, perineum 3 VS, PSP Burn 5 -25% BSA 4 <5% BSA Full; or <10% BSA partial thickness 5 Burn mild pain Burn BSA estimation

161 Blood and body fluid exposure
2 High risk exposure: defined as needle stick, hollow bore needle, known or suspected HIV or hepatitis +ve source High risk unless known low risk source 3 Low risk exposure: defined as non hollow bore needle or fluid splash from low risk source Blood and body fluid exposure

162 3 PSP 4 5 Pruritis Pruritis

163 Facial cellulitis, particularly periorbital area
2 VS Facial cellulitis, particularly periorbital area Purpuric or petechial rash; appears ill 3 VS, PSP 4 Localized cellulitis 5 Localized rash Rash

164 Localized swelling / redness
1 VS 2 Facial cellulitis, particularly periorbital area Purpuric or petechial rash; appears ill 3 VS, PSP 4 Localized cellulitis 5 Localized rash Localized swelling / redness

165 3 VS, PSP 4 5 Wound check Wound check

166 3 VS, PSP 4 5 Other skin conditions Other skin conditions

167 2 VS 3 VS, PSP 4 5 Lumps, bumps calluses Lumps, bumps, calluses

168 Redness / tenderness, breast
2 VS 3 VS, PSP 4 5 Redness / tenderness, breast Redness / tenderness, breast

169 3 PSP 4 5 Rule out infestation Rule out infestation

170 1 VS 2 3 Cyanosis Cyanosis

171 1 VS 2 VS, BD 3 Spontaneous bruising Spontaneous bruising

172 3 VS, PSP 4 5 Foreign body, skin Foreign body, skin

173 Removal staples / sutures
3 VS, PSP 4 5 Removal of staples / sutures Removal staples / sutures

174 Substance misuse / Intoxication
1 VS 2 High risk substance / unknown substance Uncertain flight or safety risk 3 4 Known low risk substance Substance misuse / Intoxication

175 High risk substance / unknown substance
1 VS 2 High risk substance / unknown substance Uncertain flight or safety risk Attempted suicide, clear plan 3 Suicidal ideation, no plan 4 Overdose ingestion Overdose ingestion

176 Recent seizures, post ictal, agitated
1 VS Actively seizing 2 Recent seizures, post ictal, agitated Uncertain flight or safety risk Severe anxiety/agitation 3 Moderate anxiety/agitation 4 Mild anxiety/agitation Substance withdrawal

177 Major trauma – penetrating
1 VS 2 VS, PSC, BD, MOI Neurovascular compromise of extremity Penetrating head, chest, abdomen 3 Major trauma - penetrating Major trauma – penetrating

178 Neurovascular compromise of extremity
1 VS 2 VS, PSC, BD, MOI Neurovascular compromise of extremity 3 Prolonged spinal immobilization VS, PSC, BD 4 Major trauma-blunt Major trauma – blunt

179 Isolated chest trauma – penetrating
1 VS 2 VS, BD Isolated chest trauma - penetrating Isolated chest trauma – penetrating

180 Isolated chest trauma – blunt
1 VS 2 VS, PSC, BD, MOI 3 VS, PSC, PSP for chest wall pain, BD 4 Isolated chest trauma - blunt (appears well) Isolated chest trauma – blunt

181 Isolated abdominal trauma – penetrating
1 VS 2 Isolated abdominal trauma - penetrating Isolated abdominal trauma – penetrating

182 Isolated abdominal trauma – blunt
1 VS 2 VS, PSC, BD, MOI 3 VS, PSC, BD 4 Isolated abdominal blunt trauma Isolated abdominal trauma – blunt

183 Exposure to communicable disease
5 Exposure to communicable disease Exposure to communicable disease

184 1 VS 2 Petechial rash 3 4 Fever Fever

185 >18 mmol/L symptomatic
VS 2 >18 mmol/L symptomatic 3 >18 mmol/L not symptomatic Hyperglycemia

186 <3 mmol/L symptomatic
1 VS 2 <3 mmol/L symptomatic 3 <3 mmol/L not symptomatic Hypoglycemia

187 Direct referral for consultation
1 VS 2 VS, PSC, PSP 3 VS, PSC, PSP, Chronicity 4 5 Direct referral for consultation Direct referral for consultation

188 3 VS, PSP 4 5 Dressing change Dressing change

189 5 Imaging test Imaging tests

190 Medical device problem
1 VS 2 VS, PSC, PSP 3 4 Medical device problem; 'asymptomatic' or 'no distress' Medical device problem

191 Prescription / Medication request
5 Prescription / medication request Prescription / Medication request

192 Neuro-vascular compromise
2 Neuro-vascular compromise 3 VS, PSP 4 5 Ring removal Ring removal

193 Normal VS, critical value
2 VS, BD 3 Normal VS, critical value 4 VS 5 Normal VS, non critical value Abnormal lab values

194 Post-operative complications
2 VS, PSC, BD 3 VS, PSC, PSP, BD 4 VS, PSC, PSP Normal VS, no pain, routine check Post-operative complications

195 1 VS 2 VS, BD 3 4 Pallor / Anemia Pallor / Anemia

196 Inconsolable crying in infants
Peds specific go to pediatric COT

197 Congenital problem in children
Peds specific go to pediatric COT

198 Minor complaints, unspecified
2 VS, PSC, PSP 3 VS, PSC, PSP, Chronicity 4 5 Minor complaints, unspecified Minor complaints NOS

199 VS, moderate dehydration
1 VS, severe dehydration 2 VS, moderate dehydration 3 Uncontrolled bloody diarrhea VS, Mild dehydration 4 VS Diarrhea & Fever (Qc) Note: In Quebec the MSSS has designated “Diarrhea and fever” as a separate complaint from Diarrhea or Fever

200 uncertain flight or safety risk
2 uncertain flight or safety risk 4 depressed, no suicidal ideation Depression (Qc) Suicidal Term Definition Suicide attempt Self injurious behavior with a non fatal outcome accompanied by evidence (explicit or implicit) that the person attempted to die. Suicide intent Subjective expectation and desire for self-destructive act that would end in death. Suicidal ideation Thought of serving as an agent of one’s own death, may vary in seriousness depending on specificity of plans and degree of suicidal intent. Uncertain flight or safety risk Patients threatening violence towards themselves or others; patients exhibiting uncontrolled anger, restlessness, paranoia, or hallucinatory behavior; or patients unable or unwilling to cooperate with suicide risk assessment and who pose a flight risk. Need close observation based on site resources. (If family member willing to observe & both parties agree ‘hospital-assigned’ close observation may not be required.) Note: In Quebec Depression / Suicidal / Deliberate self harm is separated in 3 distinct complaints

201 Suicidal ideations (Qc)
2 clear suicide plan active suicidal intent uncertain flight or safety risk 3 suicidal ideation, no plan Suicidal ideations (Qc) Suicidal Term Definition Suicide attempt Self injurious behavior with a non fatal outcome accompanied by evidence (explicit or implicit) that the person attempted to die. Suicide intent Subjective expectation and desire for self-destructive act that would end in death. Suicidal ideation Thought of serving as an agent of one’s own death, may vary in seriousness depending on specificity of plans and degree of suicidal intent. Uncertain flight or safety risk Patients threatening violence towards themselves or others; patients exhibiting uncontrolled anger, restlessness, paranoia, or hallucinatory behavior; or patients unable or unwilling to cooperate with suicide risk assessment and who pose a flight risk. Need close observation based on site resources. (If family member willing to observe & both parties agree ‘hospital-assigned’ close observation may not be required.) Note: In Quebec Depression / Suicidal / Deliberate self harm is separated in 3 distinct complaints

202 uncertain flight or safety risk
2 attempted suicide uncertain flight or safety risk Suicide attempt (Qc) Suicidal Term Definition Suicide attempt Self injurious behavior with a non fatal outcome accompanied by evidence (explicit or implicit) that the person attempted to die. Suicide intent Subjective expectation and desire for self-destructive act that would end in death. Suicidal ideation Thought of serving as an agent of one’s own death, may vary in seriousness depending on specificity of plans and degree of suicidal intent. Uncertain flight or safety risk Patients threatening violence towards themselves or others; patients exhibiting uncontrolled anger, restlessness, paranoia, or hallucinatory behavior; or patients unable or unwilling to cooperate with suicide risk assessment and who pose a flight risk. Need close observation based on site resources. (If family member willing to observe & both parties agree ‘hospital-assigned’ close observation may not be required.) Note: In Quebec Depression / Suicidal / Deliberate self harm is separated in 3 distinct complaints

203 2 VS 3 4 Cough and Fever (Qc) Note: In Quebec “Cough and fever” is a separate complaint from Cough or Fever

204

205 Colour schemes

206 Pediatrics: Critical Look
1st step 2nd step Master list Work of Breathing PRESENTING COMPLAINT General Appearance CRITICAL LOOK For critically ill patients/children the critical first look is often done by EMS providers and that information passed to triage prearrival to help prepare for rapid assessment and treatment on arrival . Critical look is a 5-15 second rapid assessment. The educator should discuss the relationship between the first look/across the room and ask that the learners participate in providing examples. The learner should relate the “first look” to the Pediatric Assessment Triangle (PAT). The triangle is a first look at the Pediatric patient to determine illness based on appearance, breathing and circulation. At any stage of triage if critical illness is suspected, the triage process must be aborted and the patient escorted to a resuscitation area for immediate care. The EMS assessment may suggest critical illness and must elicit the same response. When there is no obvious Level I condition at the time of initial contact, the triage nurse should proceed to complete the Pediatric Assessment Triangle (PAT). The Pediatric Assessment Triangle summarizes the most important components of the First Look. The educator should discuss the components of the First Look in detail. It is imperative that learners know and understand the subtle signs and symptoms of critical childhood illness. Circulation

207 Critical look: Vital signs Other 1st order modifiers
Peds: Modifiers Critical look: Vital signs Other 1st order modifiers

208 Peds: Respiratory modifiers
CTAS Peds: Level of Respiratory Distress O2 Sat PEFR 1 Severe: excessive work of breathing, cyanosis; lethargy, confusion,inability to recognize caregiver, decreased response to pain; single word or no speech; tachycardia or bradycardia; tachypnea or bradypnea, apnea, irregular respirations; exaggerated retractions, nasal flaring; grunting; absent or decreased breath sounds; upper airway obstruction (dysphagia, drooling, muffled voice, laboured respirations and stridor); unprotected airway (weak to absent cough or gag reflex); poor muscle tone <90% - 2 Moderate: increased work of breathing, restlessness, anxiety or combativeness; tachypnea; hyperpnea; mild increased use of accessory muscles, retractions, flaring, speaking phrases or clipped sentences, stridor but airway protected, prolonged expiratory phase. <92% <40% 3 Mild: Dyspnea; tachypnea; shortness of breath on exertion; no obvious increased work if breathing; able to speak in sentences; stridor without obvious airway obstruction; mild shortness of breath on exertion; frequent cough % %

209 Peds: Hemodynamic modifiers
CTAS Circulatory Status 1 Shock: evidence of severe end-organ hypoperfusion, marked pallor, cool skin, diaphoresis, weak or thready pulse, hypotension, postural syncope, significant tachycardia or bradycardia, ineffective ventilation or oxygenation, decreased level of consciousness; could also appear as flushed, febrile, toxic, as in septic shock 2 Hemodynamic compromise: delayed capillary refill, tachycardia, decreased urine production and skin changes suggest poor tissue perfusion; vomiting and diarrhea secondary to gastrointestinal infection are a common etiology; the signs of dehydration are not always reliable, particularly in younger patients; hemorrhage in moderate trauma may be masked by a child’s ability to maintain his or her blood pressure 3 Volume depletion with abnormal vital signs

210 Peds: Level of consciousness
CTAS Level Level of Consciousness GCS 1 Unconscious: unresponsive; responds to pain or loud noise only and without purpose; flexion or extension position; continuous seizing; progressive deterioration in level of consciousness; unable to protect airway 3 - 9 2 Altered level of consciousness: a change from one’s “normal” level of consciousness; lethargic; obtunded; localizes to painful stimulus; confused; disoriented; restless; irritable; agitated or combative; inconsolable, poor feeding in an infant; able to protect his/her airway; alert with minor behavioural or vital sign alterations from normal GCS definitions

211 Peds: Mechanism of injury modifiers
MOI CTAS Level 2 General Trauma MVC: Ejection from vehicle, rollover, extrication time>20 minutes, significant intrusion into passenger’s space, death in the same passenger compartment, impact >40 km/h (unrestrained) or impact>60 km/h (restrained) MCC: Where impact with a car>30 km/hr, especially if rider is separated from motorcycle Pedestrian or bicyclist Run over or struck by vehicle at >10 km/h Fall: of >3 ft (>1 m) or 5 stairs Penetrating injury: To head, neck, torso or extremities proximal to elbow and knee Head Trauma MVC: ejection from vehicle, unrestrained passenger striking head on windshield Pedestrian: struck by vehicle Fall: from >3 ft (>1 m) or 5 stairs Assault: With blunt object other than fist or feet Neck Trauma MVC: ejection from vehicle, rollover, high speed (esp. if driver unrestrained) MCC: impact with a car > 30 km/hr, especially if rider is separated from motorcycle Axial load to the head

212 Peds: Fever 2 3 4 (age <17 years)
CTAS Level (age <17 years) 2 Immunocompromised: neutropenia (or suspected), chemotherapy or on immunosupressive drugs including steroids. <3 months, T < 36°C OR >38°C 3-36 months, T <32°C OR >38.5°C , & appearing unwell (toxic) 3 3-36 months, T 32-35°C OR >38.5°C & appearing well (non-toxic) >36 months, T >38.5°C , & appearing unwell (toxic) 4 >36 months, T >38.5°C & appearing well (non-toxic)

213 Peds: Pain PAIN SEVERE 8 -10 2 ACUTE MODERATE 4 - 7 3 MILD 0 - 3 4 3
CHRONIC MODERATE 4 - 7 4 MILD < 4 5

214 Peds: Bleeding disorder (congen. / acq.)
Life or Limb Threatening Moderate or minor CTAS level 2 CTAS level 3 Head (intracranial) & neck Nose (epistaxis) Chest,abdomen,pelvis,spine Mouth (including gums) Massive vaginal hemorrhage Joints (hemarthroses) Iliopsoas muscle & hip Menorrhagia Extremity muscle compartments Abrasions Fractures & dislocations Superficial lacerations Deep lacerations Any uncontrolled bleeding

215 Def: suicidality, anxiety, agitation
Suicidal Term Definition Suicide attempt Self injurious behavior with a non fatal outcome accompanied by evidence (explicit or implicit) that the person attempted to die. Suicide intent Subjective expectation and desire for self-destructive act that would end in death. Suicidal ideation Thought of serving as an agent of one’s own death, may vary in seriousness depending on specificity of plans and degree of suicidal intent. Uncertain flight or safety risk Patients threatening violence towards themselves or others; patients exhibiting uncontrolled anger, restlessness, paranoia, or hallucinatory behavior; or patients unable or unwilling to cooperate with suicide risk assessment and who pose a flight risk. Need close observation based on site resources. (If family member willing to observe & both parties agree ‘hospital-assigned’ close observation may not be required.) Anxiety / Agitation Definition Severe anxiety / agitation Extreme unease, apprehension or worry with signs of tachycardia, agitiation; or dangerously agitated and uncooperative and does not calm down when asked Moderate anxiety / agitation Clear unease, apprehension, or worry, but no obvious tachycardia or tremulousness; or signs of agitation, and does not consistently obey commands (e.g. will sit or calm down when asked, but soon becomes restless and agitated again Mild anxiety / agitation Mild unease, apprehension or worry, but can be reassured; or restless but cooperative; obeys commands.

216 Def: Psychosis, paranoia, hallucinations, chronic, Bizarre behaviour
Delusion Definition Acute psychosis May present with extreme self neglect, disordered or racing thoughts or both, speech pattern impairments, impaired reality testing with ‘lack of insight’, may be responding to hallucinatory or delusional thoughts or both, which may be accompanied by hostility. Paranoia Delusions of a persecutory nature - being followed, poisoned, or harmed in some way. Ideas of reference - the belief that people are talking about you. May be accompanied by extreme fear, agitation or hostility. Chronic hallucinations Known history of hallucinations with no recent change in nature, and/or frequency, or in patient’s level of distress related to them. Chronic, non-urgent condition Patient is well known to the ED and triage nurse with a recurrent complaint that has either been fully dealt with, or patient is just looking for food, warmth or temporary shelter. Bizarre Behavior Definition Uncontrolled Bizarre, disoriented or irrational behavior, not controlled by verbal communication and reasoning, and placing the patient or others in physical danger Controlled Bizarre, irrational behavior that is viewed as threatening but controllable through verbal support and reasoning; patient is accompanied by a friend or family member. Harmless behavior Bizarre or eccentric behavior (usually of long standing with no recent change from patient’s norm) that is of no threat to the patient or others and requires no acute intervention.

217 Substance misuse / Intoxication
Overdose ingestion Substance withdrawal

218 Mental health and psychosocial issues
Anxiety / Situational crisis Social problem Hallucinations / Delusions Bizarre behaviour Insomnia Concern for patient's welfare Violent / Homicidal behaviour Pediatric Disruptive behaviour Depression / Suicidal / Deliberate self harm

219 Neurologic Altered level of consciousness
Extremity weakness / Symptoms of CVA Confusion Head injury Vertigo Tremor Headache Sensory loss / Parasthesias Seizure Floppy child Gait disturbance / Ataxia

220 Ophthalmology Chemical exposure, eye Photophobia Foreign body, eye
Diplopia Visual disturbance Periorbital swelling Eye pain Eye trauma Red Eye, discharge Re-check eye

221 Nasal congestion / Hay fever
Ent-nose Epistaxis Nasal congestion / Hay fever Foreign body, nose URTI complaints Nasal trauma

222 ENT- Ears Earache Foreign body ear Loss of hearing Tinnitus
Discharge, ear Ear injury

223 ENT – Mouth, Throat, Neck Dental / Gum problems Facial trauma
Sore throat Neck swelling / pain Neck trauma Difficulty swallowing / Dysphagia Facial pain (non-traumatic / non-dental)

224 Respiratory Shortness of breath Respiratory foreign body
Respiratory arrest Allergic reaction Hyperventilation Stridor Hemoptysis Apneic spells in infants Cough / Congestion Wheezing – no other complaints

225 Cardiovascular Cardiac arrest (non traumatic) General weakness
Cardiac arrest (traumatic) Syncope / Pre-syncope Chest pain (cardiac features) Edema, generalized Chest pain (non cardiac features) Bilateral leg swelling / Edema Palpitations / Irregular heart beat Cool pulseless limb Hypertension Unilateral reddened hot limb

226 Gastrointestinal Abdominal pain Vomiting blood Anorexia
Blood in stool / Melena Constipation Jaundice Foreign body in rectum Hiccoughs Groin pain / mass Abdominal mass / distention Vomiting and/or nausea Anal / Rectal trauma Rectal / Perineal pain Oral / Esophageal Foreign Diarrhea Feeding difficulties in newborn Neonatal jaundice

227 Obstetrics-gynecology
Menstrual problems Vaginal bleed Foreign body, vagina Labial swelling Vaginal discharge Pregnancy issues < 20 wks Vaginal pain / itch Pregnancy issues > 20 wks Sexual assault

228 Genito-urinary Flank pain Urinary retention Hematuria UTI complaints
Genital discharge / lesion Oliguria Penile swelling Polyuria Scrotal pain and/or swelling Genital trauma

229 Orthopedic Back pain Upper extremity injury
Traumatic back / spine injury Lower extremity injury Amputation Joint(s) swelling Upper extremity pain Cast check Lower extremity pain Pediatric gait disorder / painful walk

230 Trauma Major trauma – penetrating Major trauma – blunt
Isolated chest trauma – penetrating Isolated chest trauma – blunt Isolated abdominal trauma – penetrating Isolated abdominal trauma – blunt

231 Frostbite / Cold injury
Environmental Frostbite / Cold injury Noxious inhalation Electrical injury Chemical exposure Hypothermia Near Drowning

232 Skin Rash Sting Redness / tenderness, breast Abrasion
Bite Rash Sting Redness / tenderness, breast Abrasion Localized swelling / redness Laceration / Puncture Lumps, bumps, calluses Burn Rule out infestation Blood and body fluid exposure Cyanosis Foreign body, skin Spontaneous bruising Wound check Pruritis Removal staples / sutures Other skin conditions

233 General & Minor Fever Ring removal Hyperglycemia Abnormal lab values
Exposure to communicable disease Prescription / Medication request Fever Ring removal Hyperglycemia Abnormal lab values Hypoglycemia Pallor / anemia Direct referral for consultation Post-operative complications Dressing change Inconsolable crying in infants Imaging tests Congenital problem in children Medical device problem Minor complaints NOS Newly Born

234 Cardiac arrest (non traumatic)
1 Cardiac arrest (non-traumatic) Cardiac arrest (non traumatic)

235 Cardiac arrest (traumatic)
1 Cardiac arrest (traumatic) Cardiac arrest (traumatic)

236 Chest pain (cardiac features)
1 VS 2 Chest Pain with cardiac features Chest pain (cardiac features)

237 Chest pain (non cardiac features)
1 VS 2 VS, PS Other significant chest pain (ripping, tearing) 3 VS, PS, chronicity 4 5 Chest pain, non cardiac Chest pain (non cardiac features) Note with chest wall pain the pain is peripheral

238 Palpitations / Irregular heart beat
1 VS 2 With chest pain cardiac features History or documented evidence of potential lethal dysrhythmia 3 Acute onset, ongoing 4 History of palpitations, presently resolved Palpitations / Irregular heart beat

239 Hypertension In children blood pressure is a late indicator of a serious circulatory volume problem

240 Go to Dehydration definition
1 VS, Severe dehydration 2 VS, Moderate dehydration 3 VS, Acute inability to ambulate Mild dehydration 4 VS, Potential for dehydration Chronic weakness General weakness If considering a CVA go to: Symptoms of a CVA Go to Dehydration definition

241 1 VS 2 3 4 New onset dysrhythmia, irregular pulse &/or change in rate
No prodromal symptoms Occurring during exercise 3 With prodromal symptoms or sudden position change 4 Normal vitals, symptoms resolved Syncope / Pre-syncope

242 Edema, generalized, normal vitals
1 VS 2 3 4 Edema, generalized, normal vitals Edema, generalized

243 Bilateral leg swelling / Edema
2 VS, PS 3 4 VS, PS + chronicity 5 Edema/bilateral leg swelling, chronic Bilateral leg swelling / Edema

244 1 VS 2 Cool Pulseless Limb Cool pulseless limb

245 Unilateral reddened hot limb
2 VS, PS 3 Extensive inflammation 4 Localized inflammation Unilateral reddened hot limb

246 2 VS, PS 3 VS, PS, + Chronicity 4 5 PS + Chronicity Earache

247 Acute peripheral severe pain (8-10)
2 Acute peripheral severe pain (8-10) 3 Acute peripheral moderate pain ( 4- 7) 4 Foreign body ear, mild pain (<4) Foreign body ear

248 Hearing loss, sudden onset
3 Hearing loss, sudden onset 5 Hearing loss, gradual onset Loss of hearing

249 Suspected aspirin ingestion
2 Suspected aspirin ingestion 4 Tinnitus Tinnitus

250 Discharge, ear 2 VS 3 4

251 Cold injury severe with blanching, cyanosis
2 VS, PS Amputation 3 VS, PS, BD Cold injury severe with blanching, cyanosis 4 Cold injury, minor with no discoloration Laceration requiring sutures 5 Laceration/abrasion not requiring sutures Ear injury

252 Dental avulsion (recent with intact tooth present)
2 PS Dental avulsion (recent with intact tooth present) 3 PS + chronicity, BD 4 PS + chronicity 5 Dental/gum problem minor problem Dental / Gum problems

253 1 VS 2 VS, PS, MOI 3 VS, PS, BD 4 VS, PS Facial trauma

254 Obvious edema/swelling of lips, tongue or oropharynx
1 VS 2 VS, PS Drooling or stridor Obvious edema/swelling of lips, tongue or oropharynx 3 Difficulty swallowing 4 VS, PS, chronicity 5 Minor sore throat +/- laryngitis Sore throat

255 Neck stiffness / meningismus +/- fever
1 VS 2 VS, PS Neck stiffness / meningismus +/- fever 3 4 VS, PS, chronicity 5 Neck swelling/pain with chronic central mild pain (< 4) Neck swelling / pain

256 Paresthesias, neurological signs
1 VS 2 VS, PS, BD Paresthesias, neurological signs Hoarseness and dysphasia 3 4 VS, PS Neck trauma

257 Difficulty swallowing / Dysphagia
1 VS 2 VS, PS Drooling or stridor 3 Possible foreign body Difficulty swallowing / Dysphagia

258 Facial pain (non-traumatic / non-dental)
2 VS, PS 3 VS, PS, chronicity 4 5 PS, chronicity Facial pain (non-traumatic / non-dental)

259 Uncontrolled epistaxis (despite appropriate pressure)
1 VS 2 VS, BD Uncontrolled epistaxis (despite appropriate pressure) 3 Bleeding controlled with pressure 4 Acute epistaxis, no active bleeding 5 Periodic / recurrent, no active bleeding Epistaxis

260 Nasal congestion / Hay fever
5 Nasal congestion / hay fever Nasal congestion / Hay fever

261 Moderate respiratory distress
2 VS, PS Moderate respiratory distress 3 4 Foreign body, nose with acute mild pain Foreign body, nose

262 2 VS, PS 3 4 5 Appears well, no fever URTI complaints

263 Uncontrolled epistaxis (despite appropriate pressure)
2 VS, PS, BD Uncontrolled epistaxis (despite appropriate pressure) 3 4 VS, PS 5 PS Nasal trauma

264 Frostbite / Cold injury
2 PS Cold pulseless limb 3 Blanching of skin 4 PS, chronicity 5 Frostbite/cold injury Frostbite / Cold injury

265 Smoke inhalation, or other, no distress
1 VS 2 3 Smoke inhalation, or other, no distress 4 Remote exposure, no symptoms Noxious inhalation

266 Obvious cutaneous injury
1 VS 2 VS, PS Obvious cutaneous injury 3 No obvious cutaneous injury Electrical injury

267 Major burn hand, feet, groin or face
1 VS Major burn >25% BSA 2 Major burn hand, feet, groin or face Symptomatic eye 'splash' Chemical exposure The minimum level is 2 to ensure early decontamination and identification of the substances as toxic or not BSA estimation

268 Hypothermia, Core temperature < 32 °C
1 VS 2 Hypothermia, Core temperature < 32 °C 3 Core temperature °C 4 No frostbite, normal VS Hypothermia

269 Hypothermia, Core temperature < 32 °C
1 VS 2 Hypothermia, Core temperature < 32 °C 3 Core temperature °C Near Drowning

270 Chronic mild abdominal pain
1 VS 2 VS, PS 3 VS, PS, chronicity 4 5 Chronic mild abdominal pain Abdominal pain

271 Significant weight loss
2 VS 3 Significant weight loss 4 Anorexia, looks well Anorexia

272 2 VS, PS 3 VS, PS, chronicity 4 5 Simple constipation Constipation

273 Go to Dehydration definition
1 VS, severe dehydration 2 VS, moderate dehydration 3 Uncontrolled bloody diarrhea VS, Mild dehydration 4 VS 5 Chronic diarrhea, normal VS Diarrhea If a BD exist with presence of bloody diarrhea then go to Blood in stool/melena Go to Dehydration definition

274 2 VS, PS 3 4 5 Foreign body in rectum Foreign body in rectum

275 2 VS, PS 3 VS, PS, chronicity 4 5 Groin pain / mass Groin pain / mass

276 Vomiting and/or nausea
1 VS, severe dehydration 2 Active significant hematemesis VS, moderate dehydration 3 Coffee ground emesis / melena VS, mild dehydration 4 VS, potential for dehydration 5 Chronic vomiting and/or nausea, normal VS Vomiting and/or nausea Go to Dehydration definition If a BD exist with presence of Coffee ground emesis / melena go to “Vomiting blood”

277 Chronic mild rectal/perineal pain
2 VS, PS 3 VS, PS, chronicity 4 5 Chronic mild rectal/perineal pain Rectal / Perineal pain

278 Active or significant hematemesis
1 VS 2 Active or significant hematemesis 3 Coffee ground emesis/melena Small amount, normal vital signs Vomiting blood

279 Large amount of melena or rectal bleeding
1 VS 2 Large amount of melena or rectal bleeding 3 Moderate amount of melena or rectal bleeding 4 Rectal bleeding small amount Blood in stool / Melena

280 2 VS, PS 3 VS, PS, chronicity 4 5 Jaundice, looks well Jaundice

281 Fever (appears unwell), PS
2 Fever, PS 3 Fever (appears unwell), PS 4 Hiccoughs, chronic no distress Hiccoughs

282 Abdominal mass / distention
1 VS 2 VS, PS 3 VS, PS, chronicity Persistent vomiting 4 5 Chronic abdominal mass/distention, looks well Abdominal mass / distention

283 2 VS, PS, BD 3 4 VS, PS 5 Anal/rectal trauma
Patients in shock from rectal trauma should be documented under “Major trauma-penetrating

284 Oral / Esophageal Foreign Body
1 VS 2 Drooling or stridor Hoarseness and dysphasia VS, PS 3 Persistent vomiting 4 No swallowing or respiratory difficulty Oral / Esophageal Foreign Body

285 Feeding difficulties in newborn
1 VS 2 Refusing oral feeds 3 Decreased oral intake Feeding difficulties in newborn

286 1 VS 2 Infant < 7 days of age 3 Infant > 7 days of age
Neonatal jaundice

287 Chronic mild flank pain
1 VS 2 VS, PS 3 VS, PS, chronicity 4 5 Chronic mild flank pain Flank pain

288 1 VS 2 VS, PS, BD 3 VS, PS, BD, chronicity 4 VS, PS, chronicity 5
Chronic mild pain Hematuria

289 Genital discharge / lesion
3 VS, PS, chronicity 4 5 Genital discharge / lesion Genital discharge / lesion

290 Paraphimosis (retracted foreskin, unable to reduce)
2 Priapism Paraphimosis (retracted foreskin, unable to reduce) VS, PS 3 VS, PS, chronicity 4 5 Penile Swelling, mild or chronic pain Penile swelling

291 Scrotal pain and/or swelling
2 VS, PS 3 VS, PS, chronicity 4 5 Scrotal pain and/or swelling Scrotal pain and/or swelling

292 If the patient is unstable choose another complaint
2 VS, PS 3 VS, PS, chronicity 4 Urinary retention Urinary retention If the patient is unstable choose another complaint

293 Chronic, mild UTI complaints/symptoms
2 VS, PS 3 VS, PS, chronicity 4 5 Chronic, mild UTI complaints/symptoms UTI complaints

294 1 VS 2 VS, PS 3 4 Oliguria Oliguria

295 1 VS 2 VS, PS 3 4 Polyuria Polyuria

296 1 VS 2 VS, PS, BD 3 Sexual assault, stable 4 VS, PS 5
Genital trauma, no pain Genital trauma

297 Depression / Suicidal / Deliberate self harm
2 attempted suicide or clear suicide plan active suicidal intent uncertain flight or safety risk 3 suicidal ideation, no plan 4 depressed, no suicidal ideation Depression / Suicidal / Deliberate self harm Suicidal Term Definition Suicide attempt Self injurious behavior with a non fatal outcome accompanied by evidence (explicit or implicit) that the person attempted to die. Suicide intent Subjective expectation and desire for self-destructive act that would end in death. Suicidal ideation Thought of serving as an agent of one’s own death, may vary in seriousness depending on specificity of plans and degree of suicidal intent. Uncertain flight or safety risk Patients threatening violence towards themselves or others; patients exhibiting uncontrolled anger, restlessness, paranoia, or hallucinatory behavior; or patients unable or unwilling to cooperate with suicide risk assessment and who pose a flight risk. Need close observation based on site resources. (If family member willing to observe & both parties agree ‘hospital-assigned’ close observation may not be required.) Note: In Quebec this complaint is separated in 3 distinct complaints

298 Anxiety / Situational crisis
2 severe anxiety / agitation uncertain flight or safety risk 3 moderate anxiety / agitation 4 mild anxiety / agitation Anxiety / Agitation Definition Severe anxiety / agitation Extreme unease, apprehension or worry with signs of excessive circulating catecholamines; or dangerously agitated and uncooperative and does not calm down when asked Moderate anxiety / agitation Clear unease, apprehension, or worry, but no obvious tachycardia or tremulousness; or signs of agitation, and does not consistently obey commands (e.g. will sit or calm down when asked, but soon becomes restless and agitated again Mild anxiety / agitation Mild unease, apprehension or worry, but can be reassured; or restless but cooperative; obeys commands.

299 Hallucinations / Delusions
2 VS acute psychosis, severe anxiety / agitation , uncertain flight or safety risk 3 VS, moderate anxiety / agitation or with paranoia 4 VS, mild agitation, stable 5 mild anxiety / agitation, chronic hallucinations Hallucinations / Delusions Hallucination / Delusion Definition Acute psychosis May present with extreme self neglect, disordered or racing thoughts or both, speech pattern impairments, impaired reality testing with ‘lack of insight’, may be responding to hallucinatory or delusional thoughts or both, which may be accompanied by hostility. Paranoia Delusions of a persecutory nature - being followed, poisoned, or harmed in some way. Ideas of reference - the belief that people are talking about you. May be accompanied by extreme fear, agitation or hostility. Chronic hallucinations Known history of hallucinations with no recent change in nature, and/or frequency, or in patient’s level of distress related to them. Chronic, non-urgent condition Patient is well known to the ED and triage nurse with a recurrent complaint that has either been fully dealt with, or patient is just looking for food, warmth or temporary shelter.

300 4 Acute insomnia 5 Chronic insomnia Insomnia

301 Violent / Homicidal behaviour
1 imminent harm to self or others or specific plans 2 uncertain flight or safety risk 3 violent ideation, no plan Violent / Homicidal behaviour

302 abuse physical, mental, high emotional stress
3 abuse physical, mental, high emotional stress 4 unable to cope 5 chronic, non urgent condition Social problem

303 uncertain flight or safety risk
1 uncontrolled 2 VS uncertain flight or safety risk 3 controlled 4 harmless behaviour 5 chronic, non urgent condition Bizarre behaviour

304 Concern for patient's welfare
1 Conflict or unstable situation 2 Risk of flight or ongoing abuse 3 Physical or sexual assault 4 History/signs of abuse or maltreatment Concern for patient's welfare Complaint to be used for patients in whom the nurse suspects abuse or neglect and there is no acute medical problem.

305 Pediatric Disruptive behaviour
2 Uncertain flight or safety risk/family distress 3 Acute difficulties with others/environment 4 Persistent problematic behavior 5 Chronic, unchanged behavior Pediatric Disruptive behaviour

306 Altered level of consciousness
1 VS 2 VS, MOI BS<3 mmol/L &/or symptomatic 3 Altered level of consciousness

307 BS <3 mmol/L &/or symptomatic
1 VS 2 BS <3 mmol/L &/or symptomatic acute , with headache or altered LOC 3 acute without headache or altered LOC 4 chronic, no change from usual state Confusion LOC on this slide = Level of consciousness

308 not positional +/- other neurological findings
1 VS 2 not positional +/- other neurological findings 3 positional, no other neuro symptoms Vertigo

309 sudden, severe, worst ever
1 VS 2 sudden, severe, worst ever visual acuity disturbance +/- eye pain VS, PS 3 VS, PS, chronicity 4 5 Chronic or recurring headache Headache

310 Resolved, normal level of alertness
1 Actively seizing VS 2 Post-ictal VS, PS 3 Resolved, normal level of alertness VS, PS, chronicity Seizure

311 Gait disturbance / Ataxia
1 VS 2 Time of onset < 3 hrs 3 4 Gait disturbance / Ataxia If considering a CVA go to: Symptoms of a CVA

312 New focal neurologic findings
1 VS 2 VS, PS, BD, MOI New focal neurologic findings 3 VS, PS, BD History of LOC Prolonged spinal immobilization 4 No history of LOC Head injury LOC on this slide is Loss of consciousness

313 2 VS 3 4 Chronic tremor Tremor

314 Extremity weakness / Symptoms of CVA
1 VS 2 VS, PS, BD Time of onset < 3 hours 3 > 3 hours or resolved Extremity weakness / Symptoms of CVA May use pain scales if headache is present

315 Sensory loss / Parasthesias
3 New onset sensory loss/paresthesias 4 Chronic sensory loss/paresthesias Sensory loss / Parasthesias If considering a CVA go to: Symptoms of a CVA

316 No tone, unable to support head
1 VS 2 VS, BD No tone, unable to support head 3 Limited/less than expected muscle tone Floppy child

317 This implies symptoms normally associated with menses
1 VS 2 VS, PS 3 4 Menstrual problems Menstrual problems This implies symptoms normally associated with menses

318 1 VS 2 VS, PS 3 4 5 Foreign body, vagina Foreign body, vagina

319 2 VS, PS 3 4 5 Mild symptoms Vaginal discharge

320 >= 2 hours and < 12 hours
VS 2 VS, PS < 2 hours 3 >= 2 hours and < 12 hours 4 >= 12 hours; no injury Sexual assault Suggested not to post this complaint on the tracking screen or board, but choose a non offensive code word.

321 Heavy vaginal bleeding +/- pregnancy
1 VS 2 VS, PSC, BD Heavy vaginal bleeding +/- pregnancy 3 Vaginal bleeding – normal VS 4 Vaginal bleeding - minor/spotting Vaginal bleed

322 2 VS, PS 3 4 5 Labial swelling Labial swelling

323 2 PS 3 4 Vaginal pain, itch Vaginal pain / itch

324 Pregnancy issues > 20 wks
1 VS Presenting fetal parts, prolapsed cord Vaginal bleeding 3rd trimester 2 VS, PS, BD, MOI Active labor (contractions <2 min) Pregnancy issues > 20 weeks no fetal movement / no fetal heart tones Pregnancy issues > 20 weeks headache+/- edema+/- abdo pain+/-hypertension Post delivery 3 VS, PS, BD Active labor (contractions > 2 min) Pregnancy issues > 20 weeks possible leaking amniotic fluid 4 Pregnancy issues > 20 weeks Pregnancy issues > 20 wks

325 Pregnancy issues < 20 wks
1 VS 2 VS, PS, BD Heavy vaginal bleeding +/- pregnancy 3 Vaginal bleeding - normal VS 4 Vaginal bleeding - minor / spotting Pregnancy issues < 20 weeks Pregnancy issues < 20 wks

326 2 Chemical exposure, eye Chemical exposure, eye

327 Penetrating foreign body
2 PS Penetrating foreign body Acute or abrupt change in vision 3 4 5 Acute peripheral mild pain Foreign body, eye This includes corneal abrasions and corneal foreign body

328 acute or abrupt change in vision
2 acute or abrupt change in vision 4 chronic/gradual change in vision Visual disturbance

329 Acute or abrupt change in vision
2 PS Acute or abrupt change in vision 3 PS, Chronicity 4 5 Eye pain, chronic Eye pain

330 Red eye / discharge, acute
2 PS 3 PS, Chronicity 4 Red eye / discharge, acute 5 Red eye / discharge, chronic Red Eye, discharge

331 2 PS 3 4 Photophobia Photophobia

332 3 Acute onset 4 Chronic diplopia
If considering a CVA go to: Symptoms of a CVA

333 2 VS, PS 3 4 5 Periorbital swelling Periorbital swelling

334 Penetrating injury, chemical or direct thermal burn
2 PS, BD, MOI Penetrating injury, chemical or direct thermal burn Blunt mechanism of injury with visual loss Acute or abrupt change in vision Nurse unable to visualize eye 3 4 Eye trauma, Acute mild pain (< 4) Eye trauma

335 Acute or abrupt change in vision
2 PS Acute or abrupt change in vision 3 4 5 Re-check eye Re-check eye

336 Neuro-deficit +/- bowel bladder problems
1 VS 2 Neuro-deficit +/- bowel bladder problems VS, PS 3 VS, PS, chronicity 4 5 Back pain Back pain

337 Traumatic back / spine injury
1 VS 2 Neuro-deficit +/- bowel bladder problems VS, PS, BD, MOI 3 VS, PS, BD 4 Traumatic back/spine injury, mild central pain Traumatic back / spine injury

338 Traumatic amputation of an extremity.
1 VS Traumatic amputation of an extremity. 2 VS, MOI, BD Traumatic amputation of a digit. 3 Amputation Amputation

339 Upper extremity injury
1 VS 2 VS, PS, MOI, BD Open fracture or neuro-vascular compromise 3 Obvious deformity VS, PS, BD Tight cast with neuro-vascular compromise 4 VS, PS, Chronicity Tight cast with no neuro-vascular compromise 5 Upper extremity trauma, chronic mild pain Upper extremity injury

340 Lower extremity injury
1 VS 2 VS, PS, MOI, BD Open fracture or neuro-vascular compromise 3 Obvious deformity VS, PS, BD Tight cast with neuro-vascular compromise 4 VS, PS, Chronicity Tight cast with no neuro-vascular compromise 5 Lower extremity trauma, chronic mild pain Lower extremity injury

341 Neuro-vascular compromise
1 VS 2 VS, PS, BD Neuro-vascular compromise 3 VS, PS Tight cast with neuro-vascular compromise 4 VS, PS, Chronicity Tight cast with no neuro-vascular compromise 5 Upper extremity chronic mild pain Upper extremity pain

342 Tight cast with neuro-vascular compromise
1 VS 2 VS, PS, BD 3 VS, PS Tight cast with neuro-vascular compromise 4 VS, PS, Chronicity Tight cast with no neuro-vascular compromise 5 PS, Chronicity Lower extremity chronic mild pain Lower extremity pain

343 2 VS, PS 3 VS, PS, BD, Chronicity 4 VS, PS, Chronicity 5
Joint swelling Joint(s) swelling

344 Pediatric gait disorder / painful walk
2 VS, PS, BD 3 Limp problems with fever 4 VS, PS Walking with difficulty 5 PS, Chronicity Pediatric gait disorder / painful walk

345 Tight cast with neuro-vascular compromise
2 PS 3 Tight cast with neuro-vascular compromise 4 Tight cast with no neuro-vascular compromise 5 Cast check or cast change Cast check

346 1 VS 2 Known asthmatic with FEV1 or PEFR <40% predicted (severe) 3 Known asthmatic with FEV1 or PEFR 40-60% predicted (moderate) 4 Known asthmatic with FEV1 or PEFR >60% predicted (mild) SOB - shortness of breath, in no distress Shortness of breath

347 1 Respiratory arrest Respiratory arrest

348 Chronic cough / congestion with normal vital signs
2 VS 3 4 5 Chronic cough / congestion with normal vital signs Cough / Congestion

349 Hyperventilation resolved, appears well
1 VS 2 3 4 Hyperventilation resolved, appears well Hyperventilation

350 Hemoptysis, appears well
1 VS 2 VS, BD 3 4 Hemoptysis, appears well Hemoptysis

351 Respiratory foreign body
1 VS 2 VS, PS Drooling or stridor Hoarseness and dysphasia 3 No distress but with difficulty swallowing 4 Respiratory - foreign body, mild pain, appears in no distress Respiratory foreign body

352 Previous severe reaction
1 VS 2 VS, PS Previous severe reaction 3 4 5 Hay fever causing nasal congestion Allergic reaction

353 1 VS Airway compromise 2 Marked stridor 3 Audible stridor Stridor

354 Wheezing – no other complaints
1 VS 2 3 Wheezing – no other complaints Wheezing – no other complaints

355 Apneic spells in infants
1 VS Apneic episode on presentation 2 Infant < 7 days of age Recent spell consistent with apnea or respiratory compromise 3 History of spell consistent with apnea Apneic spells in infants

356 Previous severe reaction
1 VS 2 VS, PS Previous severe reaction 3 4 5 Minor bite Bite

357 Previous severe reaction
1 VS 2 VS, PS Previous severe reaction 3 4 5 Sting Sting

358 2 PS 3 4 Minor abrasion Abrasion

359 Complex wound with neurovascular compromise
1 VS 2 VS, PS, BD Complex wound with neurovascular compromise 3 Active bleeding 4 VS, PS Bleeding resolved/controlled Sutures required 5 No sutures required Laceration / Puncture

360 Burn >25% Body surface area (BSA)
1 VS 2 VS, PS Burn >25% Body surface area (BSA) Partial/full thickness to hands, feet, face, perineum 3 Burn 5 -25% BSA 4 <5% BSA Full; or <10% BSA partial thickness 5 Painless minor burn Burn BSA estimation

361 Blood and body fluid exposure
2 High risk exposure: defined as needle stick, hollow bore needle, known or suspected HIV or hepatitis +ve source High risk unless known low risk source 3 Low risk exposure: defined as non hollow bore needle or fluid splash from low risk source Blood and body fluid exposure

362 3 PS 4 5 Pruritis Pruritis

363 Facial cellulitis, particularly periorbital area
2 VS, PS Facial cellulitis, particularly periorbital area Purpuric or petechial rash; appears ill 3 4 Localized cellulitis 5 Localized rash Rash

364 Localized swelling / redness
1 VS 2 VS, PS Facial cellulitis, particularly periorbital area Purpuric or petechial rash; appears ill 3 4 Localized cellulitis 5 Localized rash Localized swelling / redness

365 3 VS, PS 4 5 Wound check Wound check

366 3 VS, PS 4 5 Other skin conditions Other skin conditions

367 2 VS, PS 3 4 5 Lumps, bumps calluses Lumps, bumps, calluses

368 Redness / tenderness, breast
2 VS, PS 3 4 5 Redness / tenderness, breast Redness / tenderness, breast

369 3 PS 4 5 Rule out infestation Rule out infestation

370 1 VS 2 3 Cyanosis Cyanosis

371 1 VS 2 VS, BD 3 Spontaneous bruising Spontaneous bruising

372 3 VS, PS 4 5 Foreign body, skin Foreign body, skin

373 Removal staples / sutures
3 VS, PS 4 5 Removal of staples / sutures Removal staples / sutures

374 Substance misuse / Intoxication
1 VS 2 High risk substance / unknown substance Uncertain flight or safety risk 3 4 Known low risk substance Substance misuse / Intoxication

375 High risk substance / unknown substance
1 VS 2 High risk substance / unknown substance Uncertain flight or safety risk Attempted suicide, clear plan 3 Suicidal ideation, no plan 4 Overdose ingestion Overdose ingestion

376 Recent seizures, post ictal, agitated
1 VS Actively seizing 2 Recent seizures, post ictal, agitated Uncertain flight or safety risk Severe anxiety/agitation 3 Moderate anxiety/agitation 4 Mild anxiety/agitation Substance withdrawal

377 Major trauma – penetrating
1 VS, PS 2 VS, PS, MOI, BD Neurovascular compromise of extremity Penetrating head, chest, abdomen 3 VS, PS, BD Major trauma - penetrating Major trauma – penetrating

378 Neurovascular compromise of extremity
1 VS 2 VS, PS, MOI, BD Neurovascular compromise of extremity 3 Prolonged spinal immobilization VS, PS, BD 4 Major trauma-blunt Major trauma – blunt

379 Isolated chest trauma – penetrating
1 VS 2 VS, PS, BD Isolated chest trauma - penetrating Isolated chest trauma – penetrating

380 Isolated chest trauma – blunt
1 VS 2 VS, PS, BD, MOI 3 VS, PS, BD 4 Isolated chest trauma - blunt (appears well) Isolated chest trauma – blunt

381 Isolated abdominal trauma – penetrating
1 VS 2 VS, PS, BD, MOI Isolated abdominal trauma - penetrating Isolated abdominal trauma – penetrating

382 Isolated abdominal trauma – blunt
1 VS 2 VS, PS, BD, MOI 3 VS, PS, BD 4 Isolated abdominal blunt trauma Isolated abdominal trauma – blunt

383 Exposure to communicable disease
5 Exposure to communicable disease Exposure to communicable disease

384 1 VS 2 Petechial rash 3 4 Fever Fever

385 >18 mmol/L symptomatic, Dyspnea, dehydration, weakness
VS 2 >18 mmol/L symptomatic, Dyspnea, dehydration, weakness 3 >18 mmol/L not symptomatic Hyperglycemia

386 <3 mmol/L not symptomatic
1 VS 2 <3 mmol/L symptomatic, Confusion, diaphoresis, behavioral change, seizure, infant < 1 yr 3 <3 mmol/L not symptomatic Hypoglycemia

387 Direct referral for consultation
1 VS 2 VS, PS 3 VS, PS, Chronicity 4 5 Direct referral for consultation Direct referral for consultation

388 3 VS, PS 4 5 Dressing change Dressing change

389 5 Imaging test Imaging tests

390 Medical device problem
1 VS 2 VS, PS 3 4 Medical device problem; 'asymptomatic' or 'no distress' PS Medical device problem

391 Prescription / Medication request
5 Prescription / medication request Prescription / Medication request

392 Neuro-vascular compromise
2 VS, PS Neuro-vascular compromise 3 4 VS, Ring removal Ring removal

393 Normal VS, critical value
2 VS, BD 3 Normal VS, critical value 4 VS 5 Normal VS, non critical value Abnormal lab values

394 Post-operative complications
2 VS, PS, BD 3 4 VS, PS Normal VS, no pain, routine check Post-operative complications

395 1 VS 2 VS, BD 3 4 Pallor / Anemia Pallor / Anemia

396 Inconsolable crying in infants
1 VS 2 Inconsolable infant - abnormal vital signs 3 Inconsolable infant - vital signs stable 4 Irritable but consolable Inconsolable crying in infants

397 Congenital problem in children
1 VS 2 VS, BD Conditions and protocol letters identifying concerns for rapid deterioration or need for immediate therapy Vomiting/diarrhea in a child with inherited metabolic disease, type 1 diabetes or adrenal insufficiency 3 Caregivers identifying need for care 4 VS, Stable child with congenital disease with potential for problems Congenital problem in children

398 Minor complaints, unspecified
2 VS, PS 3 VS, PS, Chronicity 4 5 Minor complaints, unspecified Minor complaints NOS

399 VS, moderate dehydration
1 VS, severe dehydration 2 VS, moderate dehydration 3 Uncontrolled bloody diarrhea VS, Mild dehydration 4 VS Diarrhea & Fever (Qc) Note: In Quebec the MSSS has designated “Diarrhea and fever” as a separate complaint from Diarrhea or Fever

400 2 uncertain flight or safety risk 4 depressed, no suicidal ideation Depression (Qc) Suicidal Term Definition Suicide attempt Self injurious behavior with a non fatal outcome accompanied by evidence (explicit or implicit) that the person attempted to die. Suicide intent Subjective expectation and desire for self-destructive act that would end in death. Suicidal ideation Thought of serving as an agent of one’s own death, may vary in seriousness depending on specificity of plans and degree of suicidal intent. Uncertain flight or safety risk Patients threatening violence towards themselves or others; patients exhibiting uncontrolled anger, restlessness, paranoia, or hallucinatory behavior; or patients unable or unwilling to cooperate with suicide risk assessment and who pose a flight risk. Need close observation based on site resources. (If family member willing to observe & both parties agree ‘hospital-assigned’ close observation may not be required.) Note: In Quebec the MSSS has “Depression / Suicidal / Deliberate self harm” separated in 3 different complaints

401 Suicidal ideations (Qc)
2 clear suicide plan active suicidal intent uncertain flight or safety risk 3 suicidal ideation, no plan Suicidal ideations (Qc) Suicidal Term Definition Suicide attempt Self injurious behavior with a non fatal outcome accompanied by evidence (explicit or implicit) that the person attempted to die. Suicide intent Subjective expectation and desire for self-destructive act that would end in death. Suicidal ideation Thought of serving as an agent of one’s own death, may vary in seriousness depending on specificity of plans and degree of suicidal intent. Uncertain flight or safety risk Patients threatening violence towards themselves or others; patients exhibiting uncontrolled anger, restlessness, paranoia, or hallucinatory behavior; or patients unable or unwilling to cooperate with suicide risk assessment and who pose a flight risk. Need close observation based on site resources. (If family member willing to observe & both parties agree ‘hospital-assigned’ close observation may not be required.) Note: In Quebec the MSSS has “Depression / Suicidal / Deliberate self harm” separated in 3 different complaints

402 uncertain flight or safety risk
2 attempted suicide uncertain flight or safety risk Suicide attempt (Qc) Suicidal Term Definition Suicide attempt Self injurious behavior with a non fatal outcome accompanied by evidence (explicit or implicit) that the person attempted to die. Suicide intent Subjective expectation and desire for self-destructive act that would end in death. Suicidal ideation Thought of serving as an agent of one’s own death, may vary in seriousness depending on specificity of plans and degree of suicidal intent. Uncertain flight or safety risk Patients threatening violence towards themselves or others; patients exhibiting uncontrolled anger, restlessness, paranoia, or hallucinatory behavior; or patients unable or unwilling to cooperate with suicide risk assessment and who pose a flight risk. Need close observation based on site resources. (If family member willing to observe & both parties agree ‘hospital-assigned’ close observation may not be required.) Note: In Quebec the MSSS has “Depression / Suicidal / Deliberate self harm” separated in 3 different complaints

403 2 VS 3 4 Cough and Fever (Qc) Note: In Quebec the MSSS has designated “Cough and fever” as a separate complaint from Cough or Fever

404 Peds: Dehydration Peds: dehydration CTAS Level Peds: Level of Dehydration 1 Severe dehydration: marked volume loss with classic signs of dehydration and signs and symptoms of shock 2 Moderate dehydration: dry mucous membranes, tachycardia, plus or minus decreased skin turgor and decreased urine output. 3 Mild dehydration: stable vital signs with complaints of increasing thirst and concentrated urine & a history of decreased fluid intake or increased fluid loss or both. 4 Potential dehydration: no symptoms of dehydration but presenting cause of fluid loss ongoing or difficulty tolerating oral fluids.

405 COT: Complaint oriented triage VS: Vital signs PS: Pain Scale
Complaint Oriented Triage 2008 – Canadian Triage and Acuity Score 2008 405 Go to Pediatric COT Substabuse Mental Health Neuro Ophth Nose Ears ENT - other Resp Cardio Vasc G. I. OB-GYN Gen- Urin Ortho Trauma Environment Skin Gene ral Definitions Go to Adult COT Substabuse Mental Health Neuro Ophth Nose Ears ENT - other Resp Cardio Vasc G. I. OB-GYN Gen- Urin Ortho Trauma Environment Skin Gene ral PedS COT Abbreviations: COT: Complaint oriented triage VS: Vital signs PS: Pain Scale PSP: Pain Scale, Peripheral PSC: Pain Scale, Central BD: Bleeding disorder MOI: Mechanism of injury Chronicity: Chronicity component ADULT COT Ped mod Mod Adult Critic look CNS CNS Hemodyn Hemodyn Resp Resp Temp Temp Pain Pain Bleed Bleed MOI MOI Last slide viewed

406 Complaint Oriented Triage 2008 – Canadian Triage and Acuity Score 2008
406 Lund-Browder chart (for children) and Rule of nines (for adults) for estimating extent of burns. BSA Anterior Posterior <1 yr 1 yr 5 yr 10 yr 15yr A: ½ of head 9.5% 8.5% 6.5% 5.5% 4.5% B: ½ of a thigh 2.75% 3.25% 4.0% 4.25% C: ½ of a lower leg 2.5% 3.0% Last slide viewed

407 Complaint Oriented Triage 2008 – Canadian Triage and Acuity Score 2008
407 Go to Pediatric COT Substabuse Mental Health Neuro Ophth Nose Ears ENT - other Resp Cardio Vasc G. I. OB-GYN Gen- Urin Ortho Trauma Environment Skin Gene ral Glascow Definitions Go to Adult COT Substabuse Mental Health Neuro Ophth Nose Ears ENT - other Resp Cardio Vasc G. I. OB-GYN Gen- Urin Ortho Trauma Environment Skin Gene ral PedS COT ADULT COT Ped mod Mod Adult Critic look CNS CNS Hemodyn Hemodyn Resp Resp Temp Temp Pain Pain Bleed Bleed MOI MOI Last slide viewed

408 Newly Born 1 VS 2 Newly Born

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