Triage

Nursing Care of Clients in
Emergency Situations
Week 1
Emergency Care: TRIAGE
• French word “trier”- describe the process of sorting &
organization
• Categorize patients based on the severity of the injuries and
by the order in which multiple patients require care and
monitoring
• Originated in the military for field of doctors
• Universal goal: supply effective and prioritized care to patients
while optimizing resource usage and timing
Goals of Triage
• To rapidly identify patients with urgent, life threatening conditions
• To determine the most appropriate treatment area for patients
presenting to the ED
• To decrease congestion in emergency treatment areas
• To provide ongoing assessment of patients
• To provide information to patients and families regarding services
expected care and waiting times
Categories
• Canadian Triage &
Acuity Scale (CTAS)
• Emergency
Severity Index (ESI)
Emergency Severity Index Triage
What were the circumstances, Does the patient have any allergies
precipitating events, location & time of (latex, medications, eggs or nuts)
injury?
When did the symptoms appear? Does the patient use tobacco/
recreational drugs? (frequent, type, last
time used)
Was the patient unconscious after injury? Does the patient have any fears? Feel that
he or she is in danger/unsafe situation?
How did the patient get to the ED? When was the last meal eaten?
What was the health status of the patient When was the last menstrual period?
before injury or illness?
Is there history of medical illness/ Is the patient under a physician’s care? (
surgeries? Admission to the hospital? name & contact information)
Is the patient currently taking any What was the date of most recent tetanus
medications? Or using any immunization?
complementary of alternative therapies?
START Adult Triage Algorithm
• Developed by the Newport Beach Fire &
Marine Department and Hoag Hospital in
Newport Beach, California in 1983
• Ability to obey commands, respiratory
rate & capillary refill to assign triage
category
• Most commonly used mass casualty
triage algorithm in the US
Simplified START Triage Flowchart
JumpSTART Pediatric Triage Algorithm
• Pediatric version of START
• Miami, Florida Children’s Hospital in 1995
by Dr. Loy Romig
• Most commonly used pediatric mass
casualty triage algorithm in the US
SALT Mass Casualty Triage Algorithm
• Sort-Assess-Life saving interventions-
Treatment/or Transport
• National all hazards mass casualty initial
triage standard for all patients
Primary Survey (Initial Assessment)
• Designed to help emergency medical responder
detect all immediate threats to life
• Immediate life threats involves the patient ABCs, and
each is corrected as it is found
6 components
• Form a general impression of the patient
– Seriousness of the patient’s condition based on his level of
distress and mental status
• Assess the patient’s mental status: APVU scale
– Alert
– Verbal
– Painful
– Unresponsive
• Assess the patient’s airway
• Assess the patients
breathing
– Place ear over the
patient’s nose and
mouth and watch for
chest movement
– Listen and feel for the
presence of exhaled air
• Assess the patient’s circulation (pulse & bleeding)
– Check the carotid or radial pulse
– Bright red blood or darker red blood (profuse bleeding)
– Total amount of blood lost
– Check skin signs: color, temperature, and moisture
• Make a decision on the priority or urgency of the patient for
transport
Focused History and Physical Exam (Secondary
Survey)
• Performed after initial assessment
• Discover and care for patient’s specific injuries or medical
problems
• Rapid assessment: head, neck, chest, abdomen,
pelvis, extremities
• Focused assessment: specific injury or medical
complaint
Patient History
• SAMPLE
– Signs and symptoms
– Allergies
– Medications
– Pertinent past medical history
– Last oral intake
– Events leading to the illness or inury
• Head to toe examination of a trauma patient with significant
MOI: 2-3 minutes
– Neck - head
– Chest - abdomen
– Lower back - pelvis
– Genital region
References
• U.S. Department of Heath and Human Services. (2020). Triage Guidelines. Retrieved from
https://chemm.nlm.nih.gov/triage.htm?fbclid=IwAR0CMxuYqsWh6J3b_MaC4H9ZWud5gK0gnqL0uWMqhSvBQQQOVPehlnYF
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• Yancey, C.C., & O’Rourke, M.C. (2021). Emergency Department Triage. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK557583/?fbclid=IwAR2PYmeVe_N74GN4ewRAkF-
ttAbHwOxlZvuu1uCfdz4cnLakVxO3ALzHYOM

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