Emergency Department Triage Manual, P

Emergency Department Triage Manual, P

ED Triage Manual, P

Pain-Abdominal

1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
  • Dark green bilious emesis
  • Firm, distended abdomen
  • Peritoneal irritation
  • Unable to stand erect
  • Increased pain with
    ambulation
  • Age < 3 yrs with bloody diarrhea and crampy pain
  • Confirmed appendicitis
  • Pain score ≥ 8
  • < 8 wks post-partum*
  • Significant abdominal pain
  • Localized abdominal pain
  • Generalized abdominal pain
  • Constipation
Emesis without signs of dehydration
  • *< 8 wks post-partum c/o abdominal pain: complete full set of vital signs. If vital signs are stable, consult Attending for transfer to HUP.
  • ESI 1, 2 or 3: Inform child and family of NPO status and place NPO wrist band.

Pain-Chest

1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
  • Absent breath sounds
  • Muffled heart sounds
  • Hemodynamic compromise
  • Tachypnea
  • Respiratory distress
  • Palpitations
  • Significant tachycardia
  • Hx: cardiac disease
  • Diaphoresis
  • High velocity blunt trauma
  • Fever
  • Hx:
    • Foreign body
    • Trauma
    • Palpitations
  • Hyperventilation
  • Rales
  • Non-reproducible chest pain
  • Cough
  • Malaise
  • Reproducible pain with palpation

Pain-Headache

1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
Severe headache with acute mental status changes
See Critical Criteria
  • Severe headache
  • Focal neurologic findings:
    • Slurred speech
    • Nuchal rigidity
    • Atonia/hypotonia
    • Ataxia
 Headache not relieved by analgesics Baseline mental status

Pain-Earache

1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
Redness, swelling and pain over the mastoid area
  • Swelling, redness of the pinna
  • FB with unsuccessful removal by other provider
  • Drainage
  • Hearing loss
  • Visible foreign body

Pain-Neck

1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
Dystonic reaction with airway compromise
  • Severe headache
  • Nuchal rigidity
  • Ataxia
  • Hx: trauma with limited ROM neck, cervical tenderness*
  • Dystonic reaction
  • Bulging fontanelle
  • Fever, hx: fever ≥ 38°C (100.4°F) with torticollis
  • Large cervical adenopathy
  • Torticollis without fever or trauma
  • Cervical adenopathy
Lateral neck pain
*All patients with hx: trauma, limited ROM to neck, cervical tenderness should be collared and flat on stretcher

Penile/Scrotal Complaints

1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
  • Acute onset of moderate/severe testicular/scrotal pain or swelling in patients without penile complaints*
  • or
  • Acute onset of moderate testicular/scrotal pain with nausea/vomiting*
  • Priapism
  • Swelling of foreskin, shaft
  • Gradual onset of non-severe scrotal pain
  • Dysuria
  • Penile discharge
*Place NPO bracelet on patients meeting high-risk criteria, notify PEM for PE, US order as needed

Poisoning

Consult Poison Control Center (800-222-1222); document information, recommendations; triage accordingly.
1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
 
  • Medicinal or chemical exposure within 6 hrs PTA
  • Any symptomatic ingestion/exposure
  • Ingestion/exposure requiring immediate decontamination
  • Any ingestion/exposure associated with suicide attempt
  • Medicinal or chemical exposure > 6-12 hrs PTA
  • Lead poisoning
  • Medicinal or chemical exposure > 12 hrs PTA
  • Caretaker requests drug screen
Non-toxic exposure
  • Note: Exposures include ingestion, inhalation, injection, dermal or conjunctival contact.
  • Decontamination refers to GI decontamination or skin decontamination (showering), or ocular flushing.

Post-Op

1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
Profuse bleeding with hemodynamic compromise
  • Active bleeding
  • Incisional dehiscence
  • Vomiting and/or decreased PO's with:
    • Oliguria
    • Tacky mucous membranes
    • Tachycardia
    • Absent tears
    • Sunken eyes
    • Listlessness
  • Fever, hx: fever ≥ 38°C (100.4°F)
  • Vomiting
  • Incisional exudate
  • Incisional erythema
    Decreased PO's
  • Decreased appetite
Make all children NPO. Do not swab throat for culture.

Pregnancy

1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
  • Vaginal hemorrhage
  • Imminent delivery
  • Acute mental status change
  • Hypertension
All other complaints: complete full set of vital signs. If vital signs are stable, consult Attending for transfer to HUP.

Psychiatric Emergency

1 Critical 2 Acute 3 Urgent 4 Urgent 5 Non-Urgent
  • Psychosis
  • Aggressive behavior
  • Uncontrollable behavior
  • Violent behavior
  • Suicidal ideation
    • Hx:
      • Aggressive behavior
      • Uncontrollable behavior
      • Violent behavior
 Medical clearance Hx: acting out
  • Notify Social Work for Level 2 patients
  • Notify Security of aggressive patients