Triage is a method of classifying all incoming ED patients, based on their chief complaint and the results of a physical assessment, in order to set priorities of care. It includes primary and secondary assessment.
| Parameter | Assessment | Interventions |
|---|
| Airway | | - To open airway, make sure that neck is midline and stabilized; then perform jaw-thrust maneuver.
|
| Breathing | - Respirations (rate, depth, effort)
- Breath sounds
- Chest wall movement and chest injury
- Position of trachea (midline or deviation)
| - Administer 100% oxygen with bag-valve mask.
- Use airway adjuncts (oral or nasal airway, ET tube, esophageal-tracheal combitube, cricothyrotomy).
- Suction as needed.
- Remove foreign bodies that may obstruct breathing.
- Treat life-threatening conditions.
|
| Circulation | - Pulse and BP
- Bleeding or hemorrhage
- Capillary refill, color of skin and mucous membranes
- Cardiac rhythm
| - Administer CPR, medications, and defibrillation or synchronized cardioversion.
- Control hemorrhaging with direct pressure or pneumatic devices.
- Establish I.V. access and fluid therapy (isotonic fluids and blood).
- Treat life-threatening conditions.
|
| Disability | - Neurologic assessment, including LOC, pupils' reactivity to light, and motor and sensory function
| - Immobilize cervical spine until X-rays confirm absence of cervical spine injury.
|
| Exposure and environment | - Injuries and environmental exposure (extreme cold or heat)
| - Institute warming therapy for hypothermia or cooling therapy for hyperthermia.
|