Module 8.

3 Triage Severity

Study Questions: There has been an explosion and it is a mass casualty incident. Triage the
following clients. Determine the appropriate color tag and the corresponding ESI category.

1. Levi is a 25-year-old-male. He is able to follow commands but has trouble hearing. His
capillary refill is <2 seconds, radial pulse is nonexistent, can’t move due to a compound left
femur fracture, respirations are >30cpm and he is coughing. What color tag is he and why?

Patient L will be categorized as a red tag due to his inability to move as a result of a compound
left femur fracture. This classification excludes the possibility of assigning him a green tag.
Despite having a capillary refill time (CRT) of under 2 seconds and the ability to respond to
commands, which might make him eligible for a yellow tag, he exhibits respiratory rate
exceeding 30 breaths per minute and is experiencing coughing.

2. Mikasa is a 21-year-old-female. She can follow commands but is scared. Her capillary refill is
<2 seconds, has a radial pulse, respirations are < 30cpm with shortness of breath. She has a
sudden onset of chest pain. What color tag is she and why?

Patient M will be categorized as a red tag because she is experieniencing shortness of reath and
sudden onset of chest pain. Therefore, even though Levi can follow command, has regular
breathing, a normal capillary refill time, and a radial pulse, we cannot assign her a green or
yellow tag because she is experiencing SOB, which can compromise patient’s ABC.

3. Annie is a 35-year-old female. She is alert, glossy sheen to exposed skin, capillary refill is <2
seconds, respirations 16cpm, a cut on right forearm, minimal bleeding, some white glowing
powder seen on the casualty. What color tag is she and why?

Patient A has been designated as a green tag patient because she is fully conscious, her breathing
is normal, she has a regular capillary refill time, and she has a minor cut on her right forearm
that's only bleeding a little. Therefore, she falls into the category of "walking wounded," which
typically includes less severe cases.

4. Eren, a 51-year-old, installing a ceiling fan assisted by his friend. He was thrown back and his
friend immediately switched off the power and called an ambulance. He had a brief period of
loss of consciousness, alert when the ambulance arrived, in and out of consciousness during the
trip to the ED. BP = 150/90mmHg, PR = 88bpm, RR 20cpm, O2 sat = 96% HR = 110bpm, RR =
40cpm, O2 sat = 91%

Tag color = Red ESI category = ESI B

Rationale for color tag and ESI category:
Patient E will be marked with a red tag because he lost consciousness and experienced periods of
altered consciousness during transport to the Emergency Department. Despite having slightly
higher blood pressure, a regular pulse, and normal oxygen levels, his situation falls into the ESI
B category, indicating a high-risk scenario, primarily because of his intermittent loss of
consciousness.

5. Armin, a 7-year old, an Ilocano speaking child, is brought to the ED in her father’s car. You
are called to assist her to get out of the car. The father tells you she is “very sick” and you noted
that she is able to transfer to a wheelchair with minimal assistance but cringes and cries out when
her hips are moved. According to her father, she fell from her upper double-deck bed in their
house. HR = 110bpm, RR = 40cpm, O2 sat = 91%

Tag color = Red ESI category = ESI D

Rationale for color tag and ESI category:

Patient A will be tagged red given her abnormal vital signs, as well as she cringes and cries out
when her hips are moved which indicates that she is in great pain. Her breathing rate of 40
breaths per minute, oxygen saturation level of 91%, and heart rate of 110 bpm are all outside the
normal range, especially considering her age, indicating a critical condition that places her in
category D, danger zone.