GUIDELINES ON THE IMPLEMENTATION OF THE AUSTRALASIAN

TRIAGE SCALE IN EMERGENCY DEPARTMENTS

Category 1 Category 2 Category 3 Category 4 Category 5

Airway Obstructed/partially Patent Patent Patent Patent
obstructed

Breathing Severe respiratory Moderate Mild No respiratory No respiratory

distress/absent respiratory respiratory distress distress
respiration/ distress distress
hypoventilation

Circulation Severe Moderate Mild Mild No

hemodynamic hemodynamic hemodynamic hemodynamic hemodynamic
compromise/absent compromise compromise compromise compromise
circulation
Uncontrolled
hemorrhage
Disability GCS <9 GCS 9–12 GCS >12 Normal GCS Normal GCS

1 Category 1: Immediately Life-threatening: Triage nurse must inform

ER doctor immediately to examine the patient (immediate + simultaneous
assessment and treatment).
Example:
1.1 Cardiac arrest (activate code blue)
1.2 Severe chest pain
1.3 Sudden loss of consciousness
1.4 Major trauma with hypotension
1.5 Major burns
1.6 Massive hematemesis or bleeding
1.7 Respiratory arrest
1.8 Prolonged seizure
1.9 IV over dose
1.10 Hypoventilation

2 Category 2: Imminently Life-threatening: Patient needs full

evaluation and treatment by ER doctor as soon as possible (within 10
minutes).
Example:
2.1 Acute abdominal pain
2.2 Severe pain
2.3 Acute confusion – drowsy & GCS 13
2.4 Severe localized trauma – major fracture.
2.5 Acute Stroke.
2.6 Suspected sepsis, Febrile neutropenia

(G24_04_Guidelines_on_Implementation_of_ATS_Jul-16.Pdf, n.d.)
3 Category 3: Potential life-threatening: Assessment and treatment
start within 30 minutes.
Example:
3.1 Severe hypertension
3.2 Moderate shortness of breath
3.3 Persistent vomiting with dehydration
3.4 Behavioral (psychiatric)
3.5 Very distressed – risk of self-harm
3.6 Agitated/withdrawn.
3.7 Suspected sepsis (physiologically stable).
3.8 Seizure(now alert)

4 Category 4: Potentially serious : Assessment and treatment started

within 60 minutes.
Example:
4.1 Mild hemorrhage
4.2 Minor head injury
4.3 Moderate pain
4.4 Vomiting and diarrhea without dehydration

5 Category 5 – Less Urgent -Assessment and treatment within 120

minutes, where no emergency medical condition or risk of developing one
Example:
5.1 Mild sore throat and fever
5.2 Minor wounds and abrasions
5.3 Medication
5.4 Abscess
5.5 Dressing
5.6 Routine check-up
5.7 Immunization

(G24_04_Guidelines_on_Implementation_of_ATS_Jul-16.Pdf, n.d.)