Triage Of Adult Patients
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ADULT TRIAGE SCORE 3
2
1
Mobility
0
1
2
Walking
With Help
Stretcher/ Immobile
9-14
15-20
21-29
more than 29
RR
101-110
111-129
more than 129
HR
RR
less than 9
HR
less than 41
41-50
51-100
71–80
81-100
101-199
SBP
less than 71
35-38.4
OR
Mobility
SBP Temp
OR
Under 35
AVPU
3
more than 199 Hot
Cold
Temp
© South African Triage Group 2008
Over 38.4
Confused
Alert
Reacts to Voice
No
Yes
Trauma
Reacts to Pain
Unresponsive
AVPU Trauma
over 12 years / taller than 150cm Colour
RED
ORANGE
YELLOW
GREEN
BLUE
TEWS
7 or more
5-6
3-4
0-2
DEAD
Target time to treat
Immediate
less than 10 mins
less than 60 mins
less than 240 mins
Mechanism of injury
High energy transfer Shortness of breath - acute Coughing blood Chest pain Haemorrhage uncontrolled Seizure - current
Haemorrhage controlled
Seizure - post ictal Focal neurology acute Level of consciousness reduced Psychosis / Aggression Threatened limb Dislocation other joint Fracture compound Burn over 20%
Presentation
Burn – face / inhalation
Dislocation finger or toe Fracture closed
ALL OTHER PATIENTS
Burn - electrical Burn circumferential
Burn - other
Burn - chemical
Hypoglycaemia glucose less than 3
Poisoning / Overdose Diabetic glucose over 11 & ketonuria Vomiting fresh blood Pregnancy & abdominal trauma or pain
Pain
Severe
Abdominal pain Diabetic glucose over 17 (no ketonuria) Vomiting persistent Pregnancy & trauma Pregnancy & PV bleed Moderate
Senior Healthcare Professional’s Discretion
Mild
DEAD
2
1
Mobility
0
1
2
Walking
With Help
Stretcher/ Immobile
9-14
15-20
21-29
more than 29
RR
101-110
111-129
more than 129
HR
RR
less than 9
HR
less than 41
41-50
51-100
71–80
81-100
101-199
SBP
less than 71
35-38.4
OR
Mobility
SBP Temp
OR
Under 35
AVPU
3
more than 199 Hot
Cold
Temp
© South African Triage Group 2008
Over 38.4
Confused
Alert
Reacts to Voice
No
Yes
Trauma
Reacts to Pain
Unresponsive
AVPU Trauma
over 12 years / taller than 150cm Colour
RED
ORANGE
YELLOW
GREEN
BLUE
TEWS
7 or more
5-6
3-4
0-2
DEAD
Target time to treat
Immediate
less than 10 mins
less than 60 mins
less than 240 mins
Mechanism of injury
High energy transfer Shortness of breath - acute Coughing blood Chest pain Haemorrhage uncontrolled Seizure - current
Haemorrhage controlled
Seizure - post ictal Focal neurology acute Level of consciousness reduced Psychosis / Aggression Threatened limb Dislocation other joint Fracture compound Burn over 20%
Presentation
Burn – face / inhalation
Dislocation finger or toe Fracture closed
ALL OTHER PATIENTS
Burn - electrical Burn circumferential
Burn - other
Burn - chemical
Hypoglycaemia glucose less than 3
Poisoning / Overdose Diabetic glucose over 11 & ketonuria Vomiting fresh blood Pregnancy & abdominal trauma or pain
Pain
Severe
Abdominal pain Diabetic glucose over 17 (no ketonuria) Vomiting persistent Pregnancy & trauma Pregnancy & PV bleed Moderate
Senior Healthcare Professional’s Discretion
Mild
DEAD
