TRIAGE IN THE

EMERGENCY
DEPARTMENT
Triage
Point of entry into the
hospital.
Initial assessment based on

the degree of the urgency

severity of illness.
Purpose of triage
 Ensure patients assessment and treatment
based on clinical urgency.
 Treatment must be appropriate and prompt.

 Proper placement of patients in the clinical

area.
 Get the vital information for categorization

based on set criteria.

 Manage congestion in the ED.
Flowchart in Triage
Allocation of Triage Category
Arrival Assessment (2-5 minutes)

Determine the clinical urgency

Allocate triage scale code

Red – Yellow – Green
(1) (2) (3)

Directed to service department as:

(1) EMERGENT- prompt appropriate assessment
(2) URGENT- wait for further assessment
(3) NON-URGENT- proceed to OPD (daytime) or wait
Document details of triage assessment

 Date and time of assessment

 Name, Age, Sex, CS

 Chief Problems

 Limited Relevant history

 Initial triage category allocated

 V/S, first aid, initial treatment

continuous reassessment on waiting patient

for possible retriage
TS: Category 1- Emergent Cases
 Insult to ABC warrants intervention within 10 minutes.
 Unstable V/S (tachypneic, hypotensive, tachycardic,

labored breathing not fully awake)

 Life or limb threatening condition.

*Immediate simultaneous assessment and treatment within 10

minutes.
*Immediate life threatening condition (threat to life or organ
system failure)
*Important time-critical treatments (thrambolysis, antidote)
*Very severe pain
TS: Category 2- Urgent Cases
 Insult to ABC but intervention is given within two (2) hours.
 Stable v/s but needs reassessment
 Assessment and treatment starts within 30 minutes to 60
minutes.
 Potential life-threatening and serious condition, may progress
to life/limb threatening
 (time-critical treatment) situational urgency
 Significant complexity and severity requires complex work-
up/consultation, humane practice to relieve the
discomfort/distress within one hour.
TS: Category 3- Non-urgent cases

 Ambulatory case
 No threat to ABC
 No immediate risk of death or morbidity
 Less urgent (chronic or minor cases)
 Assessment and treatment start within 120 minutes
 Clinico-administrative problems:
results review, medical certification,
prescriptions only
Category 1- Clinical Descriptors
 Immediate risk to airway- severe stridor or drooling with distress, impending arrest.
 Respiratory rate < 10/minutes
 Severe to extreme respiratory distress
 Respiratory Arrest
 Circulatory compromise
 Clammy mottled skin, poor perfusion
 Heart rate less than 50 or more than 150 beats/minute (adult)
 Hypotension with hemodynamic effects, BP <80 systolic (adult) or severely shocked
child and infants
 Sever blood loss
 Chest pain of like cardiac nature
 Cardiac Arrest
 Drowsy, decreased responsiveness from any cause with Glasgow Coma Scale (GCS) of
less than 13
 Unresponsive or responsive to pain only (GCS <9)
 Category 1- Clinical Descriptors
 Very severe pain- any case
 Ongoing/Prolonged seizures
 Acute hemiparesis/dysphasia
 Fever with signs of lethargy (any age)
 Acid or alkali splash to eye- requiring irrigation
 Major multi trauma (requiring rapid organized team response)
 Severe localized trauma (requiring rapid organized team response)
 Severe localized trauma- major fracture, amputation
 High risk history: Non-modifiable risks such as too young or too old and co-morbidities
 Significant/dangerous envenomation
 Severe pain suggesting pulmonary embolism, abdominal aortic aneurysm or ectopic pregnancy
 Behavioral/Psychiatric
 Aggressive with immediate threat of dangerous violence to self or others
 Requires or has required restraint
 Severe agitation or aggression
 Category 2- Clinical Descriptors
 Severe hypertension
 Mild to moderately severe blood loss- any cause
 Mild to moderate shortness of breath, Foreign body aspiration
 SA02 90-95%
 Seizure (now alert)
 Any fever if immunosuppressed ex. Oncology patient, steriod Rx
 Persistent vomiting or diarrhea with some signs of dehydration
 Difficulty of swallowing, no respiratory disease
 Eye inflammation or foreign body- normal vision
 Mild to moderate head injury with short loss of consciousness- now alert
 Moderately severe pain- any cause-requiring analgesia with some risk features
 Chest pain likely non- cardiac and mild to moderate severity, no respiratory distress
 Abdominal pain without high risk features- moderate severe of patient age >65 years old
 Mild to moderate limb injury- sprained ankle, deformity, crush, severe laceration requiring investigation
or intervention with mild to moderate pain, normal vital signs
 Limb- altered sensation, acutely absent pulse, swollen “hot” joints.
Category 2- Clinical Descriptors
 Tight cast, no neurovascular impairment
 Trauma high- risk history with no other high risk features
 Stable neonate and child at risks
 Behavioral/Psychiatric
 Semi urgent mental problem
 Under observation with impending behavioral distress
 Acutely psychotic or thought disordered
 Situational crisis, deliberate harm
 Agitated, withdrawn, potentially aggressive
Category 3- Clinical Descriptors
 Minimal pain with no risk features
 Low-risk history and now asymptomatic
 Minor symptoms of existing stable illness
 Minor wounds- small abrasions, minor lacerations (not requiring sutures)
 Scheduled revisit ex. Wound review, complex dressing
 Immunization only
 Behavioral/Psychiatric:
 Known patient with chronic symptoms, e.g. Hypochondriacs
 Pseudo Psychosomatic Syndrome Reaction
Thank you po!
God bless