Emergency Department Triage Manual, A-B

Emergency Department Triage Manual, A-B

ED Triage Manual, A-B

Abscess, Skin

Level 1, 2, 3 patients should be NPO.

1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
  • Immunocompromised
  • Concern for tissue necrosis (fasciitis)
  • Large abscess with
    severe pain
  • Febrile abscess with
    small area of surrounding redness, mild swelling, tender
  • Red streaks from site (lymphangitis)
  • Patients already on therapy
  • Location:
    • Facial
    • Perineal/perirectal
  • Large abscess with surrounding redness, swelling
  • Afebrile
  • Small (< 2 cm) with spontaneous drainage
  • I and D not likely
  • Afebrile
  • Minimal redness and swelling
  • Pimple

Allergic Reaction

Critical or Acute patients should receive epinephrine if needed as soon as possible.

1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
  • See Critical Criteria
  • Possible, Known or Suspected Exposure to Allergen with:
    • Respiratory compromise or stridor
    • Hypotension
    • Acute onset < 2 hrs
      • Intraoral swelling
      • Persistent GI symptoms/Severe abdominal pain
  • EPI Pen/Auvi-Q Given
    • ≤ 4 hrs
  • Likely or Known Exposure with only 1 of the following
    • With Facial/neck edema
    • Generalized urticaria
    • Vomiting/crampy abdominal pain
    • Wheezing
  • EPI Pen/Auvi-Q Given
    • > 4 hrs
    • No other symptoms
  • No Known Exposure
    • Generalized urticaria
    • No other symptoms

Apnea

Respiratory pause of any duration if there is an associated change in muscle tone, pallor or
cyanosis and/or bradycardia.

1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
History of apneic episode Home monitor apnea alarm without symptoms

Ataxia

Ataxia is defined as an impairment of the coordination of movement without the loss of muscle strength.
1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
See Critical Criteria
  • Confused/lethargic, disoriented
  • Headache
  • Vomiting
  • Nuchal rigidity
  • Slurred speech
  • Otherwise at baseline mental status

Bites

1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
  • Airway/neck injury with associated respiratory distress
  • Vascular injury with active hemorrhage
  • Snakebite
  • Mammalian bite with severe injury and/or severe pain
  • Mammalian bite requiring repair and rabies prophylaxis
  • Abrasion, small laceration minimal soft tissue injury not requiring repair from mammalian bite
  • Bat exposure
  • Rabies vaccine
  • Insect bites without signs of infection

BRUE Concern

1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
  • Patient is febrile age
    < 2 mos Vitals, appearance, and/or assessment are abnormal
  • Vitals and assessment are within normal limits patient back to baseline

Burns

Patients who meet critical criteria or present with an inhalation injury, altered mental status/LOC at scene, chest pain or arrhythmias and associated major trauma should be taken to the Resuscitation Room for immediate evaluation and treatment.

1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
  • Facial burns with:
    • Singed nasal hairs
    • Hoarseness
    • Oral edema
    • Dysphagia
  • Burns > 25% TBSA
  • Electrical burns with hx:
    • Altered mental status
    • Seizure
  • Any full-thickness burn
  • Partial thickness ≥ 15% TBSA
  • Burns to face, genitalia
  • Caustic chemicals to eyes
  • Circumferential burns
  • Significant burns of hands, feet
  • Any burn with significant pain
  • Caustic burns
  • Electrical burns with:
    • Loss of consciousness
    • Thrown from source or frozen to source
    • Entrance and exit wounds
    • Concern for abuse
  • Partial thickness > 5% TBSA
  • Infected burn
  • Burns requiring debridement
  • Social Work
  • < 5% partial thickness burn
  • Burn redress
  • Superficial burn
Palmar Method
Patient’s palm = 1% BSA