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Lye Meng Hon
French noun derived from the verb trier, which
means to sift or sort.
the methods used to assess patients severity of
injury or illness within a short time after their
arrival, assign priorities, and transfer each patient
to the appropriate place for treatment.

Problems Faced in ED
The volume of admissions to a given emergency
department cannot be predicted with any great
Only a certain proportion of the patients have life
endangering or medically urgent conditions.
Patients with life-threatening injuries or illnesses
need to be reliably identified within minutes of
Patient overcrowding.
The demand for medical treatment significantly
outstrip available resources.
A study done in HUSM in year 2000 showed that 55% of ED visits
were inappropriate (problems which can be treated in in the primary
care services in the community).
To ensure that the patient receives the level
and quality of care appropriate to clinical need
(clinical justice).
Reduce unnecessary delay of treatment.
Departmental resources are most usefully
applied (efficiency).
Triage in Emergency
ED triage systems
Designed to identify the most urgent (or
potentially most serious) cases.
To ensure that they receive priority treatment,
followed by the less urgent cases.
First-come, first-served basis

Triage officers routinely assess all patients
who present for treatment to sort and prioritize
Types of Triage in ED
3-level triage system:
Level 1 = emergent
Level 2 = urgent
Level 3 = non-urgent
Lack of specificity and prone to subjectivity

5-level triage systems
Eg: Australian Triage Scale (ATS), Manchester
Triage Scale (MTS), Canadian Triage Acuity
Scale (CTAS), Emergency Severity Index (ESI)

Art of Triage
Complex and dynamic process
Obtaining adequate and relevant information
in a short amount of time
Decisions are made in a time-sensitive
environment with limited manpower and
Decision made based on pre-existing
guidelines and patients condition.
Roles of Triage Officer
Allocate triage category bases on patient
Initiate appropriate nursing interventions
First aid
Initiation of organizational guidelines, eg: x-ray,
Liaise with members of the public and other
healthcare professionals.
Escort patient and pass over relevant information
Provide patient and public education where
Process of Triage
Main complaint and brief history
Vital signs
Physical findings seen, heard, felt or smelt
Setting the priority status of the patient
Decision of preliminary diagnostic testing
should be done
Decision whether treatment should be started
at triage

SOAP System
Larry-Weed SOAP system
S (Subjective) main complaint and brief
O (Objective) physical finding and vital signs
A (Assessment) setting of the priority status
based on subjective and objective finding
P (Plan) preliminary diagnostic and

Malaysian Triage Category
MTC is designed for use in hospital
emergency services throughout Malaysia.
A scale for rating clinical urgency.
Directly relates triage category with a range of
outcome measures (inpatient length of stay,
ICU admission, mortality rate) and resource
consumption (staff time, cost).
Provides an opportunity for analysis of a
number of performance parameters in the
Emergency Department.
Red (Critical)
Yellow (Semi
Green (Non-Critical)
Critical (RED)
Conditions that are threats to life (or
imminent risk of deterioration) and
require immediate aggressive
The patient's condition is serious enough or
deteriorating so rapidly that there is the potential
of threat to life, or organ system failure, if not
treated within 15 minutes of arrival
The potential for time-critical treatment (e.g.
thrombolysis, antidote) to make a significant
effect on clinical outcome depends on treatment
commencing within a few minutes of the patient's
arrival in the ED
Critical (RED)
Patients with life threatening injuries or illness
which require immediate attention.
Assessment and treatment simultaneously
within 5 minutes.
R1 (immediate life-threatening)
R2 (life-threatening)
Clinical Descriptions
1. Code arrest (cardiac/ respiratory) or impending arrest
2. Hypoventilation: RR< 10/min
3. Shock state SBP < 80 (adult)or severely shocked child/infant
4. Airway compromise or immediate risk to airway
5. Severe respiratory distress. Tachypnoea and/or dyspnoea with SpO2 <95%
6. Seizuring patient (ongoing/prolonged) and post-ictal states with neurological deficits
7. Coma/ unconscious or responds to pain only (GCS<9/15)
8. Alleged poisoning or drug overdose with impairment of conscious level and need urgent intervention
9. Head injury with GCS 13/15 and below
10. Exsanguinating limb injuries (massive blood loss)
11. Severe crush injuries to limbs
12. Other immediate life threatening conditions
1. Severe or moderate asthma/ COAD
2. Polytrauma/ major trauma
3. Burns to more than 25% BSA regardless of depth and/ or more than 20% 2nd degree burns
4. Alleged near-drowning
5. Gun-shot/ stab wounds to head, neck, trunk or abdomen or trajectory undetermined
6. Arrhythmia with tachycardia/ bradycardia and unstable.
7. Hypertensive emergencies: SBP> 220 or DBP >120 with systemic symptoms
8. Chest pain visceral, non-traumatic associated with parasympathetic and sympathetic symptoms
9. Acute MI/ unstable angina diagnosed by referral
10. Acute abdomen, hemodynamically unstable
11. Hyperglycemia or hypoglycemia with altered conscious level or neurological/ systemic deficit
12. Baby< 3 months with fever > 38C
13. Other life threatening conditions
14. Obstetric emergency (Hamodynamically unstable)

Semi-Critical (YELLOW)
The patient's condition may progress to life or
limb threatening, or may lead to significant
morbidity, if assessment and treatment are
not commenced within thirty minutes of arrival
There is potential for adverse outcome if
time-critical treatment is not commenced
within thirty minutes
Humane practice mandates the relief of
severe discomfort or distress
Semi-Critical (YELLOW)
Assessment and treatment starts within 30
Usual presentation:
Unable to walk but airway is secure,
hemodynamically stable and on trolleys
Clinical Descriptions
1. Altered conscious level but not comatose. Head injury = 14/15 or GCS full but pupils unequal
2. Fractures of long bones of lower limbs/ pupils
3. Open fracture of upper limbs
4. Spine injuries (not in shock, no neurological deficit)
5. Eye injury with loss or impaired vison
6. Dislocation of major joints
7. Limb amputation: total or/ near-total (haemodynamically stale)
8. Burns 15-25% of BSA regardless of depth and/or 10-20% 3
degree burns with no compromise to
airway and circulation
9. Vascular injuries but hemodynamically stable
10. Patients with acute abdomen but hemodynamically stable
11. Chemical exposure involving eyes
12. Alleged poisoning/ drug overdose patient conscious and need no intervention
13. Severe pain:
Trauma: pain score: 8-10
Non-trauma: pain score 4-7/10
14. Allergic reaction moderate
15. Mild to moderate dyspnoea with saturation >95% and/or rate <40/ min
16. Hyperventilation and unable to maintain posture
17. Cheat pain visceral and not associated with other symptoms
18. Hepertensive urgencies: elevated SBP < 220mmHg or DBP <120mmHg with minimal systemic
symptoms but no neurological deficit.
19. Baby > 3 months with fever > 38C
20. Infant < 1 month regardless of any symptoms
21. Significant per vaginal bleed with hemodynamically stable
22. Other medical urgencies requiring intravenous intervention and intermittent monitoring only:
Dehydration, diarrhea with vomiting, pyrexia >40C, signs of infection, dialysis problem, acute
psychotic episodes, chemotherapy or immunocompromised, acute urinary retention.
Non-Critical (GREEN)
The patient's condition may deteriorate, or adverse
outcome may result, if assessment and treatment is not
commenced within one hour of arrival in ED. Symptoms
moderate or prolonged.
There is potential for adverse outcome if time-critical
treatment is not commenced within hour
Likely to require complex work-up and consultation
and/or inpatient management
Humane practice mandates the relief of discomfort or
distress within one hour
Non-Critical (GREEN)
Assessment and treatment starts within 90
Usual presentation:
Airway secure, hemodynamically stable patients
not in any distress and ambulant
G1 (fast line)
G2 (require initial management or first aid before seen
by doctor)
G3 (patients who can wait)
G4 (triage away to primary care or another center)
G5 (not seen in ED)
Non-Critical (GREEN)
G1 (Fast Lane)
Children < 2 years old
Senior citizen > 65 years old
Acute pain (trauma): pain score <4/10
Chest pain non-visceral, musculoskeletal and not associated with other symptoms
but with history of heart disease
Abuse/neglect/assault stable
Post seizure alert on arrival
POP complications
Elevated blood sugar without any major symptoms
Mild asthma
Closed fracture of upper limbs or ankle with major angulations
Dislocation of small joints
Foreign body
Hemodynamically stable per vaginal bleed
Non-Critical (GREEN)
G2 (Require initial management or 1
before seen by doctor)
Chest pain non-visceral, musculoskeletal
and not associated with other symptoms and
no previous heart disease
Minor allergic reaction
Non-Critical (GREEN)
G3 (patients who can wait)
Burn < 15% of BSA regardless of depth and/or
<10% 3
degree burns
Minor trauma
Head injury alert, no vomiting
Bumps and bruises
Closed fracture of upper limbs
Controllable bleeding with closed fracture of upper
limbs or ankle without major angulations
Nail prick
Simple cut
Non-Critical (GREEN)
G4 (for LOCUM or triage away to OPD or another center)
Chronic trauma injuries > 6 months
Diarrhea alone (no dehydration)
Vomiting alone (normal mental status with no dehydration)
Acute pyrexia <38C for adult < 65 years old or child between
2-12 years old
Simple skin diseases chronic
Menses related complaints
Chronic psychiatric complaints
General medicine conditions or minor illness not requiring
Sore throat no respiratory symptoms
Infective eye conditions
Non-Critical (GREEN)
G5 (not seen in ED)
Missed appointment
Medications exhausted
Second opinion seeking
Medical certificate
Specialist clinic cases
In US Unintentional Injury is leading cause of
death for person age 1-44 years.
Traumatic injury is fifth leading cause of death
Emergency medical services have a substantial
impact on the care of injured persons and on
public health.
At an injury scene, EMS providers determine the
severity of injury, initiate medical management,
and identify the most appropriate facility to which
to transport the patient.
Field Triage
Perform when number of casualties
overwhelms healthcare provider.
MCI (Mass-casualty incident)
Have time constraint, limited personnel &
limited resources
To sort victims based on their probability of
Mass-Casualty Incident
Number of patients and the nature of their
injuries make the normal level of stabilization
and care unachievable
Resources that can be brought to the field
within response time are insufficient to
manage the scene under normal operating
Stabilization capability of area hospital are
insufficient to handle all the patient.
Objectives of Field Triage
Save maximum number of victims (Do the
greatest good for the greatest number)
Prioritizing patients concentrate on
salvageable patients
Provide immediate critical care
Manage resources
Transfer patient to appropriate centers

Simple Triage And Rapid Treatment
Designed for first responders.
Gold standard for field adult multiple casualty
(MCI) triage in the US and numerous countries
around the world
Utilizes the standard four triage categories
Used for primary triage

Step-by-step triage and treatment method to
be used by the first rescuers responding to a
multi casualty incident.
Allows rescuers to identify victims at greatest
risk for early death and to provide basic
stabilization maneuvers

First Responders Responsibility
One member becomes Command
Other members starts the Triage process
Start calling for any additional resources
Initiate 5s
Safety assessment
Scene size-up
Send information
Set up
START Triage
Dead or
Position Airway
Over 30/min
Under 30/min
Cap refill
> 2 sec
Cap refill
< 2 sec.
Failure to follow
simple commands
Can follow
simple commands
Immediate Delayed
START: Step 1
Triage officer announces that all patients
that can walk should get up and walk to a
designated area for eventual secondary
All ambulatory patients are initially tagged
as Green.
START: Step 2
Triage officer assesses patients in the order in
which they are encountered
Assess for presence or absence of
spontaneous respirations
If breathing, move to Step 3
If apnoeic, open airway
If patient remains apnoeic, tag as Black
If patient starts breathing, tag as Red
START: Step 3
Assess respiratory rate
If 30, proceed to Step 4
If 30, tag patient as Red
START: Step 4
Assess capillary refill
If 2 seconds, move to Step 5
If 2 seconds, tag as Red
START: Step 5
Assess mental status
If able to obey commands, tag as Yellow
If unable to obey commands, tag as Red

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