TRIAGE

OBJECTIVES:

 To ensure immediate medical intervention in life

threatening situations
 To ensure that patients are prioritized for treatment in
accordance with the severity of their medical condition
 To reduce morbidity through early medical intervention
What is TRIAGE?
 French word trier meaning “to sort”
 Used to identify those patients whose conditions
are most seriously compromised so that they are
first to receive medical intervention
 The process of rapidly determining patient acuity
 The triage process is based on the premise that
patients who have a threat to life, vision or limb
should be treated before other patients
TRIAGE SYSTEM (Tanabe, Gimbel, Yarnold, et al., 2004)

⋄ Resuscitation
⋄ Emergent
⋄ Urgent
⋄ Nonurgent
⋄ Minor
Emergency Severity Index

A five level triage system that

incorporates concepts of illness, severity
and resource utilization to determine who
should be treated first
 Definition ESI-1 ESI-2 ESI-3 ESI-4 ESI-5

Stability of Unstable Threatened Stable Stable Stable

vital functions
(ABC)

Life threat or Obvious Likely but not Unlikely but No No

organ threat always obvious possible

How soon Immediately Minutes Up to 1 hour Could be Could be

should patient delayed delayed
be seen by
physician?

Expected High resource High resource Medium/High Low resource Low resource
resource intensity intensity resource intensity intensity
intensity intensity
S IMPLE
T RIAGE
A ND
R APID
T REATMENT
 PRIORITY 1
 These victims have a reasonable chance of survival only
if they receive immediate treatment

 Victims with respiratory insufficiency, cardiac arrest,

hemorrhage, and severe abdominal injury
 PRIORITY 2
 These victims can wait for transportation after they
received initial emergency treatment
 Immobilized closed fractures, soft tissues injuries
without hemorrhage, and burns less than 40% of
the body

 This classification is given to clients who require

treatment and whose injuries have complications
that are not life threatening, provided they are
treated within 1-2 hours.
 PRIORITY 3
 Victims are ambulatory, have minor tissue injuries
and maybe dazed
 Can be treated by non-professionals and held for
observations if necessary
 This classification is given to clients with local
injuries who do not have immediate complications
and who can wait several hours for medical
treatment.
 DEAD
 Used for the deceased and for those whose injuries
are so extensive that they will not be able to survive
given the care that is available
Patient walks over to you and
has an obvious broken arm

Respirations are 22

Pulse is 124 (Radial)

He is awake, alert, and crying

Patient gurgles but can’t
maintain an open airway
and Is not breathing

Weak Carotid Pulse

She is unresponsive
Patient states he can’t
move or feel his legs

Respirations are 26

Pulse is 110 (Radial)

He is awake and oriented

Patient has an open head
Wound, bleeding controlled

Respirations are 16

Pulse is 88 (Radial)

He is unconscious
REFERENCES:

⋄ Quiambao-Udan, J. (2017).Medical-surgical
nursing concepts and clinical applications. 3rd ed.
⋄ Brunners & Suddarth’s Medical Surgical
Nursing 11th ed.
 THANK YOU
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