Emergency Response and Triage

Emergency nursing is a core component of the DOH (UAE) examination, testing your ability to rapidly assess, prioritise, and manage patients presenting with urgent and life-threatening conditions. UAE emergency departments (EDs) are among the busiest in the region, serving a diverse multicultural population with a wide range of conditions. Triage — the process of sorting patients by urgency — is the critical first step in emergency care, and accurate triage is a fundamental nursing competency that directly impacts patient outcomes.

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🟢 Lite — Quick Review (1h–1d)

Rapid summary for last-minute revision before your exam.

The 5-Level Triage System (ESI — Emergency Severity Index, used in many UAE facilities):

Level	Description	Examples	Target Time to Physician
Level 1	Resuscitation	Cardiac arrest, severe trauma, acute MI, stroke	Immediate
Level 2	Emergent	Chest pain, moderate trauma, severe abdominal pain, active labour	< 10 minutes
Level 3	Urgent	Abdominal pain, fever with cough, moderate respiratory distress	< 30 minutes
Level 4	Less Urgent	Minor trauma, simple fractures, mild infections	< 60 minutes
Level 5	Non-Urgent	Minor complaints, prescription refills	< 120 minutes

ABCDE Approach to Emergency Assessment:

• Airway (with C-spine protection if trauma)
• Breathing
• Circulation
• Disability (neurological assessment)
• Exposure (complete undress and examine; prevent hypothermia)

The Golden Hour in Trauma: Patients with life-threatening injuries who receive definitive care within the first 60 minutes after injury have significantly better outcomes. All UAE trauma centres follow this principle.

⚡ Exam Tip: In any emergency scenario in the DOH exam, the nurse’s first action is always to assess and secure the airway. Without a patent airway, no other intervention matters. If a patient is unconscious and lying supine, the first action is to open the airway using the jaw-thrust method (not head-tilt chin-lift if C-spine injury is suspected).

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🟡 Standard — Regular Study (2d–2mo)

Standard content for students with a few days to months.

1. Shock — Recognition and Initial Management

Types of Shock and Their Signs:

Type	Skin	HR	BP	JVP	Warm/Cold
Hypovolaemic	Cold, clammy	↑↑	↓↓	↓	Cold
Cardiogenic	Cold, clammy	↑	↓↓	↑↑	Cold
Septic (early)	Warm, flushed	↑	↓	↓	Warm
Septic (late)	Cold, mottled	↑↑	↓↓	↓	Cold
Anaphylactic	Urticaria, angioedema	↑	↓↓	↓	Warm/flushed
Neurogenic	Warm, dry	↓	↓↓	↓	Warm

Shock Management — The Core Principles:

1. Oxygen to maintain SpO₂ ≥ 94%
2. IV access — large-bore cannulas (16–18G) × 2 if possible
3. Fluid resuscitation — crystalloids (Normal Saline or Hartmann’s); 1–2 L boluses; reassess after each bolus
4. Identify and treat the underlying cause
5. Vasopressors if fluid-refractory shock (after adequate fluid resuscitation)
6. Monitoring — ECG, SpO₂, NIBP, urine output (target >0.5 mL/kg/hr)

2. Trauma Assessment

Primary Survey (ABCDE):

• Airway with C-spine protection: Assess patency; jaw thrust; C-spine immobilisation with hard collar
• Breathing: Look, listen, feel; identify tension pneumothorax (emergency needle decompression), open pneumothorax (3-sided dressing), massive haemothorax (chest drain)
• Circulation: Control external haemorrhage (direct pressure); 2 large-bore IVs; fluid resuscitation; identify shock
• Disability: GCS (see below); pupil size and reactivity; lateralising signs
• Exposure and Environment: Completely undress patient; log roll for back exam; prevent hypothermia

Glasgow Coma Scale (GCS):

Component	Score	Response
Eye Opening (E)	4	Spontaneous
	3	To voice
	2	To pain
	1	None
Verbal Response (V)	5	Oriented
	4	Confused
	3	Inappropriate words
	2	Incomprehensible sounds
	1	None
Motor Response (M)	6	Obeys commands
	5	Localises pain
	4	Withdraws from pain
	3	Abnormal flexion (decorticate)
	2	Extension (decerebrate)
	1	None

GCS = E + V + M (Total 3–15)

• < 8 = severe head injury; intubation for airway protection
• 9–12 = moderate; 13–15 = mild

3. Medical Emergencies

Acute Coronary Syndrome:

• ECG immediately (within 10 minutes of arrival in UAE EDs)
• MONA is outdated — current standard:
  • Morphine (if pain persists)
  • O₂ (if SpO₂ < 94%)
  • Nitrates (if BP > 90 systolic)
  • Aspirin 300 mg (chewed)
• PCI (primary angioplasty) within 90 min of arrival if STEMI

Stroke — Door-to-CT Target: < 25 minutes:

• Non-contrast CT head immediately to rule out haemorrhage
• If ischaemic and within window: Thrombolysis (IV alteplase) if eligible
• Stroke team activation = immediate neurology + radiology + ED

Anaphylaxis:

• IM Adrenaline 1:1000, 0.01 mg/kg (max 0.5 mg) into anterolateral thigh
• Repeat every 5–15 minutes if no response
• IV fluids (1–2 L crystalloid)
• Antihistamines (chlorpheniramine) and corticosteroids (hydrocortisone) — adjunctive
• bronchodilators if bronchospasm persists

Status Epilepticus:

• Definition: Continuous seizure >5 minutes, or ≥2 seizures without regaining consciousness
• Management: ABCs; IV lorazepam 0.1 mg/kg or diazepam; if refractory, phenytoin or levetiracetam; if further refractory, anaesthetic agents (propofol, midazolam infusion) and ICU

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🔴 Extended — Deep Study (3m+)

Comprehensive coverage for students on a longer study timeline.

4. Major Trauma in UAE

Road Traffic Accidents (RTAs):

• Leading cause of trauma deaths in young adults in UAE
• Types: Frontal (most common), lateral, rear-end, rollover, pedestrian vs vehicle
• Common injuries: Head injury (TBI), spinal injuries, thoracic injury (flail chest, cardiac contusion), abdominal injury (liver and splenic lacerations), pelvic fractures, extremity fractures

Injury Patterns by Impact Type:

• Frontal impact: Facial fractures, aortic injury, anterior rib fractures, liver/spleen injury
• Lateral impact: Lateral rib fractures, kidney injury, contralateral brain injury
• Rear impact: Cervical spine injury (whiplash), brain acceleration-deceleration injury

FAST Examination (Focused Assessment with Sonography for Trauma):

• Rapid bedside ultrasound to detect free intraperitoneal, pericardial, or pleural fluid
• Four windows: Hepatorenal (Morrison’s pouch), splenorenal, suprapubic (cul-de-sac), subxiphoid cardiac
• Positive FAST = operative intervention needed

Damage Control Surgery:

• Not all patients can undergo definitive surgery immediately
• In unstable patients with massive haemorrhage: Immediate control of bleeding (packing, clamps), then ICU resuscitation, then definitive surgery later when stable

5. Toxicological Emergencies

Common Intoxications in UAE:

Paracetamol (Acetaminophen) Overdose:

• Toxic dose: >150 mg/kg or >7.5 g in 24 hours
• Phases: Nausea/vomiting (0–24h) → apparent recovery (24–48h) → hepatic failure (72–96h)
• Hepatotoxicity: N-acetylcysteine (NAC) — the antidote; most effective when given within 8 hours
• Rumack-Matthew nomogram for risk assessment

Organophosphate Poisoning:

• Common: Insecticide self-poisoning (particularly among agricultural workers)
• Cholinergic excess (DUMBELS): Diarrhoea, Urination, Miosis, Bradycardia, Emesis, Lacrimation, Salivation
• Treatment: Atropine (large doses — titrate to drying secretions); pralidoxime (reactivates acetylcholinesterase); supportive care

Opioid Overdose:

• CNS depression, respiratory depression, miosis (pinpoint pupils), hypotension
• Treatment: Naloxone (opioid antagonist); repeat as needed; may require infusion if long-acting opioids

6. Emergency Nursing Priorities

The Nurse’s Role in Resuscitation:

• First responder: Initiates CPR/AED if cardiac arrest
• Medication administration (as per protocol or physician orders)
• Monitoring and documentation
• Family communication and support
• Post-resuscitation care

Communication in Emergencies — SBAR:

• Situation: What is happening right now?
• Background: What is the clinical context?
• Assessment: What do I think the problem is?
• Recommendation: What do I want/recommend?

Exam Watch: A DOH exam scenario frequently involves a patient who presents to triage with chest pain and shortness of breath. The nurse must triage this as Level 2 (Emergent) regardless of how the patient looks at the moment. Cardiac enzymes, ECG, and physician assessment cannot be delayed. Another common scenario: a febrile child with a seizure — the nurse must assess airway and breathing, then notify the physician, then consider the seizure’s cause (febrile seizure vs CNS infection vs metabolic).

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