檢傷: 分級 急診疾病特定檢傷分類 陳輝財 醫師 新光醫院急診醫學科 國際上較通用的方式為四級的分類 和一開始針對大量傷患的分級相似 有些國家使用五級或三級的分法 衛生署 檢傷一級 病況危急 應儘速處理 檢傷二級 無立即生命危險 應在二十 分鐘內處理 檢傷三級 應在六十分鐘內處理 檢傷四級 可延後處理或門診治療 一位中年男子因胸 痛 冒冷汗求診 因其症狀疑似心肌 梗塞 請問這個病患應該 檢傷幾級 重點精神在於快速決定病患的嚴重程度 級治療優先順序 一名機車車禍傷患 由EMT至於長背板上推 入 主訴右膝嚴重疼痛 檢傷血壓86/50mmHg 心跳 80BPM 請問檢傷幾級 若檢查發現 病患有內出血現象 懷疑脾臟 破裂 若檢查發現 病患無任何內 出血現象 病史詢問該病患 從小一打針就暈倒 兩個診斷為心肌梗塞的病患 其中一名 病患到院時生命徵象穩定 另一名則到 院時已呈心因性休克狀態 請問兩名病患的嚴重度相同嗎
目的 強調檢傷是個動態的過程 做出疾病診斷及治療後 以通行之疾病 嚴重指標作re-triage 試圖充分反映疾 病的嚴重度 針對治療後病患病情的變化改變檢傷級 數 直接反映病情嚴重度及治療成效 特定疾病檢傷 disease-specific triage 指標性疾病 慢性阻塞性肺疾病 氣喘 胰臟炎 心衰竭 中風 慢性阻塞性肺疾病 GOLD (Global Initiative for Chronic Obstructive Lung Disease) stages NHLBI (National Heart, Lung, and Blood Institute) - WHO, 00 GOLD stages Stage Characteristics : At Risk Normal spirometry Chronic symptoms (cough, sputum production) : Mild COPD FEV/FVC < 70%, FEV 80% predicted With or without chronic symptoms (cough, sputum production) : Moderate COPD FEV/FVC < 70%, 0% FEV < 80% predicted (IIA: 50% FEV < 80% predicted) (IIB: 0% FEV < 50% predicted) With or without chronic symptoms (cough, sputum production, dyspnea) : Severe COPD FEV/FVC < 70%, FEV < 0% predicted, or the presence of respiratory failure,* or clinical signs of right heart failure FEV and FVC FEV Forced Expiratory Volume in second, 一秒內用力呼氣量 男性 FEV (公升) 正常 = 0.09身高 (公分) 0.00年齡.97 女性 FEV (公升) 正常 = 0.066身高 (公分) 0.090年齡.57 FVC Forced Vital Capacity, 用力肺 活量 * Respiratory failure: PaO < 8.0 kpa (60 mm Hg) with or without PaCO > 6.7 kpa (50 mm Hg) while breathing air at sea level.
The National Asthma Education and Prevention Program (NAEPP ), 997 一級 Severe Persistent Asthma Symptoms: Continual symptoms after inhalation treatment for times, Severe dyspnea without activity, Impending respiratory failure Lung Function: FEV or PEFR <60% predicted, PEFR variability >0% 二級 Moderate Persistent Asthma Symptoms: Limited physical activity, Dyspnea after mild activity, Frequent exacerbations, Daily symptoms, Daily use of inhaled short-acting beta-agonist, Exacerbations or more times a week; may last days Lung Function: FEV or PEFR >60%-<80% predicted, PEFR variability >0% 三級 Mild Persistent Asthma Symptoms: Dyspnea on exertion, Symptoms > times a week but < time a day, Exacerbations affect activity, Nighttime > times a month Lung Function: FEV or PEFR >80% predicted, PEFR variability 0-0% 四級 Mild Intermittent Asthma Symptoms: Asymptomatic but occasional exacerbations, Symptoms < times a week, Exacerbations brief (from a few hours to a few days); intensity may vary, Nighttime < times a month Lung Function: FEV or PEFR >80% predicted, PEFR variability <0% APACHE scoring systems British Thoracic Society (BTS) rule Only two categories severely ill and not so severely ill American Thoracic Society (ATS) rule CURB-65 score, Thorax 00 Pneumonia Severity Index, NEJM 997 Depends on variables only available in hospital
CURB-65 severity score CURB-65 severity score management groups when urea is available One point given for each feature present Initial C U R B 65 Description Mental Confusion. Disorientation in person, place or time. (AMT score of 8 or less.) Blood Urea > 7 mmol/l Respiratory Rate >= 0/min Low Blood Pressure. Diastolic blood pressure (DBP) <= 60 mmhg or systolic blood pressure (SBP) < 90 mmhg. Age >= 65 years CURB-65 score 0 or Description Mortality low (.5%). Likely suitable for home treatment. Mortality intermediate (9.%). Consider hospital supervised treatment. Options may include short stay in patient or hospital supervised outpatient. or or 5 Mortality high (%). Manage in hospital as severe pneumonia. Assess for ICU (intensive care unit) admission especially if CURB-65 score = or 5. PSI - pneumonia severity index Demographic factors Age: Males: Age (in years) Females: Age (in years) -0 Nursing home resident: - pneumonia severity index Comorbid illnesses Neoplastic disease: Liver disease: Congestive heart failure Cerebrovascular disease: Renal disease: +0 - pneumonia severity index Physical examination findings Altered mental status: Respiratory rate 0/minute or more: Systolic blood pressure <90 mmhg: Temperature <5 or 0 or more: +5 Pulse 5/minute or more:
- pneumonia severity index Laboratory findings ph <7.5: BUN >0.7 mmol/l: Sodium <0 meq/l: Glucose >.9 mmol/l: Hematocrit <0 percent: PO <60 mmhg (): Pleural effusion: +0 一級 >0 total points 二級 9-0 total points 三級 7-90 total points Mortality Range: 7.0~9. Mortality Range: 8.~9. Mortality Range: 0.9~.8 四級 70 or fewer points Mortality Range: 0.~0.6 胰臟炎 Pancreatitis Ranson s criteria APACHE II scoring systems Balthazar Computed Tomography Severity Index APACHE II CT Severity Index Element Finding grade of acute pancreatitis normal pancreas 0 pancreatic enlargement inflammation involving pancreas and peripancreatic fat single fluid collection or phlegmon two or more fluid collections or phlegmons no necrosis 0 necrosis of / of pancreas necrosis of / of the pancreas necrosis of more than / of the pancreas 6 degree of pancreatic necrosis Points 5
CT Severity Index 胰臟炎 Pancreatitis 利用Ranson s criteria: Classfication severity index mortality complications 0-0% 0% - % 8% -6 6% 5% 7-0 7% 9% 胰臟炎 Pancreatitis 心衰竭 Ranson s criteria 一級 > 6 Predicted mortality of 00% 二級 5-6 Predicted mortality of 0% 三級 - Predicted mortality of 5% 四級 < Predicted mortality about % 心衰竭 NYHC Classification Class IV patients who should be at complete rest, confined to bed or chair; any physical activity brings on discomfort and symptoms occur at rest. Class III patients with marked limitation of activity; they are comfortable only at rest. Class II patients with slight, mild limitation of activity; they are comfortable with rest or with mild exertion Class I patients with no limitation of activities; they suffer no symptoms from ordinary activities 6