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This presentation on Triage and transport deals with how we should we deal with the patients who are attending the emergency department and to provide best treatment for the needy patients at appropriate time.
I hope this will be helpful to nurses, paramedics, graduate and under graduate students and emergency doctors and team.
Dr.Suresh Babu Chaduvula
Department of Obstetrics & Gynecology
King Khalid University
Abha, Saudi Arabia
Triage is the term derived from the French
verb trier meaning ‘to sort’ or ‘to choose’
It’s the process by which patients are
classified according to the type and urgency
of their conditions to get the
Right patient to the
Right place at the
Right time with the
Right care provider
To treat the patients in the order of their
clinical urgency appropriately and timely
Non disaster: To provide the best care for
each individual patient.
Multi casualty/disaster: To provide the most
effective care for the greatest number of
Definition: an incident, either natural or
human-made, that produces patients in numbers
needing services beyond immediately available
resources. May involve a large no. of patients or
a small no. of patients requiring significant
demand on resources.
The key to successful disaster management is to
provide care to those who are in greatest need
first. Correct triage is essential to accomplish
1. Identify patients requiring immediate care.
2. Determine the appropriate area for
3. Facilitate patient flow through the ED and
avoid unnecessary congestion.
4. Provide continued assessment and
reassessment of arriving and waiting
5. Provide information and referrals to
patients and families.
6. Allay patient and family anxiety and
enhance public relations.
Allow for patients examination
Fully equipped with Emergency equipment
Should be completed in 10 minutes
If it is going beyond 15 minutes call for
Accurate triage is key to the efficient
Effective triage – is based on knowledge,
skills and attitude of the triage nurse.
Pediatric cases – record vital signs every 30
mts and others – 60 mts during reassessment.
Triage is an essential function of EDs
Urgency refers to the need for time –critical
Patients who are not critical with low acuity
categories –safe to wait for assessment and
treatment but still require admission.
“The eye’s don’t see
what the mind
1. Rapidly identify patients with urgent life
2. Assess/ determine severity and acuity of
3. Ensure that patients are treated in order of
4. Ensure that treatment is appropriate and
5. Allocate the patients appropriate and
6. Reevaluate who are in waiting area
1. Streamlines patient flow
2. Reduces risk of further injury/
3. Improves communication and public
4. Enhances team work
5. Identifies resource requirements
6. Establishes national benchmarks
The triage team
Triage of Victims
- first victims to arrive are frequently not
the most seriously injured. They are
1. Critical patients
2. Fatally Injured Patients
3. Non critical patients
4. Contaminated patients
Are divided into 5 levels or categories
depending on following acuity determinants
1. Chief complaint
2. Brief triage history
3. Injury/ illness
4. General appearance
5. Vital signs
The most urgent clinical feature that is
identified will determine ALS category
Level 1- Resuscitation
Level 2- Emergent
Level 3- urgent
Level 4- less urgent
Level 5- Non urgent
Resuscitation -- threat to life
Time to nurse assessment IMMEDIATE
Time to physician assessment IMMEDIATE
Cardiac and respiratory arrest
Potential threat to life, limb or function
Nurse Immediate , Physician <10 minutes
Decreased level of consciousness
Severe respiratory distress
Chest pain with cardiac suspicion
Over dose (conscious)
Severe abdominal pain
G.I. Bleed with abnormal vital signs
Chemical exposure to eye
Condition with significant distress
Time Nurse < 15min, physician < 30 min
Head injury without decrease of LOC but with
Mild to moderate respiratory distress
G.I. Bleed not actively bleed
Conditions with mild to moderate discomfort
Time for Nurse assessment < 30 minutes
Time for physician assessment < 1hour
Head injury, alert, no vomiting
Chest pain, no distress, no cardiac suspicion.
Depression with no suicidal attempt
Conditions can be delayed, no distress
Time for nurse 60 minutes
Physician assessment more than 2h or 120
Sore throat with temperature < 39 degree
Chronic medical illnesses.
An “across-the room” assessment
The triage history
The triage physical assessment
The triage decision
To identify obvious life threat conditions
• The triage nurse must scan the area where
patients enter the emergency door, even
while interviewing other patient.
Abnormal airway sounds, strider, wheezing
Unusual posture e.g.. Sniffing position,
inability to speak, drooling or inability to
Altered skin signs, cyanosis, dusky skin,
bradypnea, or apnea periods, retractions,
use accessory muscles, nasal flaring,
grunting, or audible wheezes
Altered skin signs, pale, mottling, flushing
Un controlled bleeding
Interaction with environment
Inability to recognize family members
Response to pain or stimuli
Flaccid or hyper active muscle tone
Extensive knowledge to emergency medical
Adequate training and competent skills,
Ability to use the critical thinker process
Good decision maker
Greet patients and identify your self.
Maintain privacy and confidentiality
Visualize all incoming patients even while
Maintain good communication between triage and
maintain excellent communication with waiting area.
Use all resources to maintain high standard of care.
Communicate with team leader and seek feed back
Reassess the patient within 1-2hours of
initial triage and continue to reassess on a
regular basis, patients who may have
presented without cardinal signs of severe
illness may develop them during long waits.
Patients who appear intoxicated actually may
have life threatening problems such as DKA,
and should not be permitted to keep it off in
the waiting room.
The last person in along line at triage may
have a serious medical problem that
requires immediate attention
Patient should wait no longer than 10
minutes for triage
If in doubt about a category, choose the
higher acuity to avoid under triaging a
With a trauma call involving a pregnant
patient, you have two patients:
The unborn fetus
Any trauma to the woman has a direct
effect on the fetus.
Pregnant women may be the victims of:
Motor vehicle crashes
Pregnant women also have an increased
risk of falls.
Pregnant women have an increased amount
of overall total blood volume and a 20%
increase in heart rate.
May have a significant amount of blood loss
before you will see signs of shock
Uterus is vulnerable to penetrating trauma
and blunt injuries.
When a pregnant woman is involved in a
motor vehicle crash, severe hemorrhage
may occur from injuries to the pregnant
Trauma is one of the leading causes of
Significant vaginal bleeding is common with
severe abdominal pain.
Focus is the same as with other patients.
Perform CPR and provide transport.
Notify the receiving facility personnel that
you are en route with a pregnant trauma
patient in cardiac arrest.
Follow these guidelines when treating a
pregnant trauma patient:
Maintain an open airway.
Administer high-flow oxygen.
Ensure adequate ventilation.
Transport the patient on her left side.
Some cultures may not permit a male
health care provider to assess or examine a
Respect these differences and honor requests
from the patient.
A competent, rational adult has the right to
refuse all or any part of your assessment or
The Golden Period is the time from injury
to definitive care.
Treatment of shock and traumatic injuries
Aim to assess, stabilize, package, and begin
transport within 10 minutes (“Platinum 10”).
Rapid scan assists in determining transport
High-priority patients include those with
any of the following conditions:
Poor general impression
Unresponsive with no gag or cough reflex
High-priority patients (cont’d):
Severe chest pain
Pale skin or other signs of poor perfusion
High-priority patients (cont’d):
Responsive but unable to follow commands
Severe pain in any area of the body
Inability to move any part of the body
Transport decisions should be made at this
point, based on:
Availability of advanced care
Distance of transport
Provide rapid transport for pregnant patients
Have significant bleeding and pain
Are having a seizure
Have an altered mental status
If there are signs of shock, control bleeding,
give oxygen, and keep the patient warm.
If delivery is imminent, prepare to deliver at
If delivery is not imminent, prepare the
patient for transport.