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Emergency Triage System - Comprehensive Exam Review for Emergency Physicians

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1. Definition and Historical Background

"Triage, or sorting by acuity, is by definition an abbreviated decision-making process that can never be completely safe because of the limited information available, the lack of time invested, and the variety of presentations of illness and injury." - Rosen's Emergency Medicine

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2. Core Principles of Triage

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3. Types of Triage Settings

A. Emergency Department (In-Hospital) Triage

B. Prehospital / Field Triage

C. Mass Casualty Incident (MCI) / Disaster Triage

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4. Emergency Department Triage Systems

4A. Emergency Severity Index (ESI) - USA Standard

• Step A: Is this patient requiring an immediate life-saving intervention? → ESI 1
• Step B: Is this a high-risk patient? Confused/lethargic/disoriented? In severe pain or distress? → ESI 2
• Step C: How many resources will this patient require? (0 → ESI 5; 1 → ESI 4; ≥2 → ESI 3)
• Step D: For ESI 3 patients, check vital signs. If vital signs fall in the "danger zone," consider escalating to ESI 2.

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4B. Manchester Triage System (MTS) - European Standard

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4C. Canadian Triage and Acuity Scale (CTAS)

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4D. Australasian Triage Scale (ATS)

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5. Prehospital / Field Triage Systems

5A. START Triage (Simple Triage and Rapid Treatment)

STEP 1: Ambulatory patients → WALKING?
        YES → Tag GREEN (Minor/"Walking wounded")

STEP 2: Non-ambulatory patients → Check RESPIRATIONS
        - No respirations → Reposition airway
            ○ Still no breathing → Tag BLACK (Expectant/Dead)
            ○ Resumes breathing → Tag RED (Immediate)
        - Respirations > 30/min → Tag RED (Immediate)
        - Respirations ≤ 30/min → Proceed to Step 3

STEP 3: PERFUSION (Radial pulse OR capillary refill)
        - No radial pulse OR cap refill > 2 sec → Tag RED (Immediate)
        - Pulse present OR cap refill ≤ 2 sec → Proceed to Step 4

STEP 4: MENTAL STATUS ("Can Do")
        - Cannot follow simple commands → Tag RED (Immediate)
        - Can follow simple commands → Tag YELLOW (Delayed)

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5B. JumpSTART Triage (Pediatric MCI - <8 years or <25 kg)

• Respiratory rate threshold: 15-45 breaths/min is normal (not >30)
• Apneic children: Give 5 rescue breaths before tagging black (children may have respiratory-driven apnea that is reversible)
• Mental status: Uses AVPU (Alert, Voice, Pain, Unresponsive) instead of "Can Do"
• Perfusion: Uses peripheral pulse rather than capillary refill (less reliable in kids)

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5C. SALT Triage (Sort, Assess, Lifesaving interventions, Treatment/Transport)

• Command all who can walk to move to a designated area → Minor (Green)
• Wave/purposeful movement but cannot walk → Assess next
• Still/apparent death → Assess last

• Control major hemorrhage (tourniquet)
• Open airway (manual/NPA)
• Chest decompression (tension pneumothorax)
• Auto-injector antidotes (chemical/biological agents)

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5D. CDC Field Triage Guidelines (Single-Incident Trauma)

• GCS <14, SBP <90 mmHg, RR <10 or >29/min → Transport to highest level trauma center

• Penetrating injury to head/neck/torso/proximal limbs, flail chest, two or more proximal long bone fractures, paralysis, open/depressed skull fracture, pelvic fracture, crushed/degloved/mangled extremity, amputation proximal to wrist/ankle

• Fall >20 feet (adult), >10 feet or 2-3x child's height (child), motorcycle crash >20 mph, auto crash with ejection, pedestrian struck by car, intrusion into passenger compartment >12 inches (occupant side)

• Age >55, anticoagulant use (lower threshold), pregnancy >20 weeks, burns with trauma, end-stage renal disease, EMS clinical judgment

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6. Disaster Triage Color Tags and the SALT Color System

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7. Triage Team Composition (Hospital-Based)

• Emergency physician (in command, identified by colored vest or garment)
• ED nurse (performs assessment)
• Admitting/medical records clerk (documentation, tagging)

• Patient name/identification
• Triage category
• Triage destination within the hospital
• Time of triage

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8. Pediatric Special Considerations in Triage

• Children are not small adults - normal vital signs differ by age; triage systems must account for age-specific ranges
• ESI v4 adds fever as a pediatric-specific triage criterion for children <36 months
• JumpSTART modifies START for physiological differences (higher respiratory rates, respiratory-driven arrest)
• Pediatric CTAS (PaedCTAS) is validated for children
• Children have higher rates of undertriage in adult systems - be vigilant
• Developmental stage affects pain assessment - use age-appropriate scales (FLACC, Wong-Baker FACES)

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9. Special Populations in ED Triage

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10. Triage Errors: Undertriage vs. Overtriage

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11. Comparison Table of Major Triage Systems

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12. Process Improvement and Quality Metrics in Triage

• Door-to-triage time: Time from patient arrival to initial triage assessment. Target ≤10 minutes (most systems aim <5 minutes for any patient)
• Door-to-physician time: ESI 1 = immediate; ESI 2 = ≤10 min; ESI 3 = ≤30 min
• Left without being seen (LWBS) rate: Reflects triage effectiveness and flow
• Triage accuracy audits: Regular review of triage categories vs. final disposition (admission, ICU, discharge)
• Inter-rater reliability: Measured by Cohen's kappa (κ). ESI and MTS moderate overall agreement (κ ~0.5); individual high-acuity levels have better agreement

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13. High-Yield Exam Points Summary

1. ESI Level 1 = immediate life-saving intervention needed (intubation, defibrillation)
2. ESI Level 2 = high-risk, lethargic, dangerous vital signs - see in ≤10 minutes
3. ESI Levels 3/4/5 are determined by resource count, not just severity
4. START uses the "30-2-Can Do" mnemonic (30 breaths/min, 2 sec cap refill, Can Do commands)
5. JumpSTART gives 5 rescue breaths to apneic children before tagging black
6. SALT uniquely allows LSIs (tourniquet, needle decompression, antidotes) at triage step
7. Undertriage ≤5% is the ACS-COT standard; overtriage up to 50% is acceptable
8. MTS uses 54 symptom-based flowcharts; does NOT require a diagnosis
9. Triage interventions in MCI = airway opening + hemorrhage control ONLY (no full resuscitation)
10. Black tag in MCI includes: full cardiac arrest, burns >95% BSA, septic shock with minimal survival chance, and those expected to die regardless of optimal care
11. The triage physician leads the team and must know all treatment options and in-hospital capacity
12. Triage is not permanent - patient condition must be reassessed at the casualty clearing area

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