TRIAGE I

PREPARED BY:
CEZAR J. PANGALANGAN, RN MAN
 TRIAGE
•  
• The sorting of and allocation of
treatment to patients and
especially battle and disaster
victims according to a system of
priorities designed to maximize
the number of survivors.
• The sorting of patients (as in an
emergency room) according to
the urgency of their need for care.
Emergency Department Triage System
• A commonly used rating system in
an emergency department is a
three-tier system that uses the
categories of emergent, urgent,
and non- urgent; these categories
may be identified by color coding
or numbers.
• The nurse needs to be familiar
with the triage system of the
health care agency.
• When caring for a client who has
died, the nurse needs to recognize
the importance of family and
cultural and religious rituals and
provide sup- port to loved ones.
• Think survivability. If you are the
first responder to a scene of a
disaster, such as a train crash, the
priority victim is one whose life can
be saved
 Emergency Department Triage Classification

• a. Emergent (Red): Priority 1 (Highest)

• This classification is assigned to clients who have life-threatening injuries
and need immediate attention and continuous evaluation, but have a high
probability for survival when stabilized.
• Such clients include trauma victims, clients with chest pain, clients with
severe respiratory distress or cardiac arrest, clients with limb amputation,
clients with acute neurological deficits, and clients who have sustained
chemical splashes the eyes.
 Emergency Department Triage
Classification
• b. Urgent (Yellow): Priority 2
• This classification is assigned to clients who require treatment and whose
injuries have complications that are not life-threatening, provided that
they are treated within 1 to 2 hours; these clients require continuous
evaluation every 30 to 60 minutes thereafter. Such clients include clients
with a simple fracture, asthma without respiratory distress, fever,
hypertension, abdominal pain, or a renal stone.
•  
 Emergency Department Triage
Classification
• c. Nonurgent (Green): Priority 3
• This classification is assigned to clients with local injuries who do not have
immediate complications and who can wait several hours for medical treatment;
these clients require evaluation every 1 to 2 hours thereafter. Such clients
include clients with conditions such as a mi- nor laceration, sprain, or cold
symptoms. Note: Some triage systems include tagging a client “Black” if the
victim is dead or who soon will be deceased because of severe injuries; these
are victims that would not benefit from any care because of the severity of
injuries.
 Guidelines for Prioritizing

• 5. Client needs that are not related directly to the client's ill- ness or prognosis are low
priorities.
• 6. When providing care, the nurse needs to decide which needs or problems require
immediate action and which ones could be delayed until a later time because they are
not urgent
• 7. The nurse considers client problems that involve actual or life-threatening concerns
before potential health-threatening concerns.
• 8. When prioritizing care, the nurse must consider time constraints and available
resources.
• 9. Problems identified as important by the client must be given high priority.
 Guidelines for Prioritizing

• 1. The nurse and the client mutually rank the client's needs in order of
importance based on the client's preferences and expectations, safety, and
physical and psychological needs; what the client sees as his or her
priority needs.
• 2. Priorities are classified as high, intermediate, or low.
• 3. Client needs that are life-threatening or that could result in harm to the
client if they are left untreated are high priorities.
• 4. Nonemergency and non-life-threatening client needs are intermediate
priorities.
 Guidelines for Prioritizing

• 10. The nurse can use the ABCs-airway, breathing, and circulation-as a guide when
determining priority. (Exception: cardiopulmonary resuscitation, CAB guidelines are used).
• 11. The nurse can use Maslow's Hierarchy of Needs theory as a guide to determine priorities
and to identify the levels of physiological needs, safety, love and belonging, self-esteem, and
self-actualization (basic needs are met before moving to other needs in the hierarchy).
• 12. The nurse can use the steps of the nursing process as a guide to determine priorities,
remembering that assessment is the first step of the nursing process.
 Triaging Victims at the Site of an Accident The nurse is the first
responder at the scene of a school bus accident. The nurse triages the
victims from highest to lowest priority as follows:

• 1. Confused child with bright red blood pulsating from a leg wound
• 2. Child with a closed head wound and multiple compound fractures
of the arms and legs
• 3. Child with a simple fracture of the arm complaining of arm pain
• 4. Sobbing child with several minor lacerations on the face, arms, and
legs
 Mass Casualty Triage

• Medical control authorities have adopted a new mass casualty

triage system — Sort, Assess, Lifesaving Interventions,
Treatment/Transport (SALT), that provides nationwide triage
standardization and improved accuracy, as first responders sort and
categorize victims by injury severity. Although SALT is a low-
frequency-use tool, it addresses a high-risk situation and the need
for quick forward movement and prioritization after an incident.
 SALT Triage

• SALT applies in incidents with five or more

patients, such as a large motor vehicle crash. In
this circumstance, first responders need to assess
people quickly to determine who needs treatment
in what order and then alert the receiving hospital
so that medical staff can prepare for them.
In SALT, responders classify each victim involved
in a mass casualty incident into the following
categories for treatment needs:

• Green (minimal)
• Yellow (delayed)
• Red (immediate)
• Black (dead)
• SALT also includes a new category, Gray status, meaning that
responders expect the victim to die. This eliminates previous
consternation when a patient was dying, but not yet deceased.
• "A Gray tag means there's not any hope and that responders
need to concentrate efforts elsewhere. I have encountered a
victim in this status personally, and I had to move to another
patient for whom we had resources."
 SALT Triage Core Concepts
• 1. Voice commands to sort casualties at the scene.
• 2. Interventions including controlling hemorrhage, opening
airway, decom-pressing the chest (for tension pneumothorax),
and auto injecting antidotes for chemical injury.
• 3. Separation of expectant casualties from the dead.
Identification of expect-ant casualties is based on available
resources.
• 4. Simple application for casualties of any age and from any
type of mass casualty incident.
 Step 1: Global Sorting.
• . "Everyone who can hear me and who needs medical
attention, please move to a designated area)." The location to
which these ambulatory casualties are directed must be safe
and have some visible element of care. Their ability to walk
indicates that they are likely to have (1) intact airway,
breathing, and circulation and (2) intact mental status, at least
to the extent that they can follow commands. These casualties
are the third priority for individual assessment.
 Step 1: Global Sorting.
• "Everyone who can hear me, please raise an arm or a leg so
that we can come help you." This group is individually
assessed second. Airway, breathing, circulation, and mental
status in these casualties are at least adequate to allow them
to follow simple commands. However, since they are not
ambulatory, they may have mild hypotension, mild
hypoxemia, or significant musculoskeletal injuries.
 Step 1: Global Sorting.
• The remaining casualties are those who neither
walk nor wave, and remain still. These are
prioritized first for individual assessment and
fall into three groups critically
injured/salvageable, unsalvageable, and dead.
 Step2: Individual Assessment.
• The goal of this step is to provide immediate lifesaving
interventions to the critically injured/salvageable. It should
be remembered that sorting is an imperfect process, and
critically injured/salvageable casual-ties may be assigned to
noncritical groups; it should never be assumed that the
groups are completely accurate. Reassessment can enhance
accuracy and reduce errors.
 Four simple lifesaving
interventions
• 1. Controlling major hemorrhage can be done by using tourniquets or by having
another person or device provide direct pressure.
• 2. Opening the airway should be done only with simple positioning maneuvers
such as chin lift/jaw thrust or with insertion of a basic airway adjunct
(oropharyngeal, nasopharyngeal). If the casualty is a child who is not breathing,
two rescue breaths should be considered.
• 3. Decompressing the chest with a needle should be done for tension
pneumothorax.
• 4. Auto-injecting nerve agent antidotes should be done for symptomatic nerve
agent casualties.
 Evacuation and Transport
• 1. Urgent evacuation casualties are those who should be evacuated
within two hours to save life, limb, or eyesight.
• 2. Priority casualties are those who should be evacuated within four
hours because of concern for casualty deterioration beyond that point.
• 3. Routine casualties are those whose condition is not expected to
worsen significantly and who will require evacuation within the next
24 hours.
 Pitfalls in Triage
• Pre-Hospital
•  
• 1. Focusing on casualties, to the exclusion of scene considerations
• 2. Seeing casualty population as group of individual patients.
• 3. Letting severe anatomic injuries distract from physiologic screen.
• 4. Expecting walking wounded to stay at the scene
• 5. Performing more than essential life-saving
 Pitfalls in Triage
Hospital
• 1. Letting non-critical casualties into hospital
• 2. Not using expectant category
• 3. Performing history and physical, rather than physiologic
screen on each casualty
• 4. Not performing sequential triage (reassessment over time)
• 5. Using radiographs in initial casualty interventions assessment
 Population-Based Triage Methods for
Biologic Events
• Triage decisions for populations affected by biologic events are based on inter-
related information including illness severity, infectiousness, and duration of
illness.
• Conventional MCE triage is based on severity of illness or injury and does not
consider additional elements, such as exposure, duration, or infectiousness. Thus,
population triage during a biologic event assigns a priority to treatment while
attempting to prevent secondary transmission through the implementation of
nonmedical strategies (eg, social distancing, shelter-in-place, isolation,
quarantine, risk communication) and medical interventions (eg, immunization,
prophylactic medication, respiratory support).
 The mnemonic SEIRV can be used to categorize
members of the community during a biologic event.
• Susceptible: people who are not yet exposed but are susceptible
• Exposed: people who are susceptible and have been in contact with an infected
person; they may be infected but are not yet contagious.
• Infectious: casualties who are symptomatic and contagious.
• Removed: casualties who no longer can transmit the disease to others because they
have survived and developed immunity or died from the disease.
• Vaccinated (or medicated): people who have received prophylactic medical
intervention to protect them from infection.
QUESTIONS ??