TRIAGE & ACUITY SCALE CATEGORY 4) Eye pain; pain scale 8-10/10.

Chemical
exposures (acid or alkali) cause severe pain and
These lists of presenting complaints or case scenarios blurred vision.
are not all inclusive or absolute in their application. 5) Chest pain; This is one of the most difficult
Triage personnel are always encouraged to use their presenting symptoms for triage nurses and
experience & instincts to ‘up triage’ priority, even if the emergency physicians. There are so many ways
patient does not seem to fit exactly with the facts or in which cardiac ischemia presents that we are
definitions on the triage scale ‘if they look sick then they frequently faced with long and detailed
probably are’. assessments that don’t always lead to a definite
conclusion. Patients with non- traumatic, visceral
Level I Resuscitation pain are most likely to have significant coronary
syndromes(MI, Unstable angina).
Condition that are threats to life or limb (or imminent risk  Visceral pain is continuous (more than a few
of deterioration) requiring immediate aggressive seconds and almost always more than 2-5
interventions. min) and is described as pressure, ache,
squeezing, heavens, burning, or just a
Time to physician; IMMEDIATE “discomfort”. If there are associated
symptoms (such as sweat, nausea, and
Usual presentations: shortness of breath)
1) Code/arrest; patients with cardiac and/or  Sudden sharp pains; can be associated with
pulmonary arrest (or appears to be imminent) chest wall problem, but can also be duo to
2) Major trauma; Severe injury of any single body pulmonary embolus, aortic dissection,
system or multiple system injury, Severe burns, pneumonia, pneumothorax.
Chest/abdominal injury with any or all of; altered  Previous MI, Angina or Pulmonary
mental state, hypotension, tachycardia, sever embolus;Patients with a prior history of
pain, respiratory signs or symptoms. these conditions should be level II no matter
3) Shock states: Conditions where there is an what the character of the pain.
imbalance between Oxygen supply (cardiogenic,
pulmonary, blood loss,) and demand or 6) Overdose; these patients require early physician
utilization. Hypotension and or tachycardia and assessment.
possibly bradycardia. 7) Abdominal pain; Pain severity alone, cannot
4) Unconscious: Intoxication/overdoses, CNS predict whether serious surgical or medical
events, can all have an alteration of mental condition are present. Visceral pains (constant,
function from disorientation/confusion to ache, pressure, burning, squeezing) with
completely unresponsive or actively seizuring. associated symptoms (nausea, vomiting, sweat,
5) Severe Respiratory Distress: There are many radiation, bump or reverberating pain) with vital
causes for respiratory distress but benign sign abnormalities hypertension, hypotension,
reasons can only be diagnosed by exclusion. tachycardia, fever) are much more likely to be
Serious intracranial events, pneumothorax, near serious problems. Crampy, intermittent or sharp
death asthma.COPD exacerbations, CHF, brief pains without vital sign abnormality usually
anaphylaxis and severe metabolic disturbances may be delayed.
(renal failure, diabetic ketoacidosis). 8) GI Bleed; Upper GI causes are more likely to
cause instability. Vomiting gross blood, coffee
Typical patients: ground emesis and melena are typical of UGI
 Non responsive sources.
 Vital signs absent/unstable 9) CVA ; Patients with major neurological deficits
 Severe dehydration may require airway protection or emergent CT
 Severe respiratory distress. scanning.
10) Asthma; Severe asthma is best defined with a
Level II Emergent combination of objectives measures and clinical
factors which relate to the severity of symptoms.
Conditions that are a potential threat to life limb or 11) Dyspnoea; This is subjective and may correlate
function, requiring rapid medical intervention or poorly with lung function or deficits in oxygen
delegated acts. uptake and delivery. Depending on the age,
previous history and physical assessment.
Time to physician assessment/interview <15 min. 12) Anaphylaxis; Severe allergic reactions can
deteriorate rapidly. Patients with a history of
Usual presentations: asthma are at particularly high risk of death.
1) Altered mental state; infectious, inflammatory, 13) Serious infection; Patients with bacterial
ischemic, traumatic, poisoning, drug effects, infections or sepsis syndrome usually appear
metabolic disorders, dehydration…. Can all unwell.
affect sensorium from simple cognitive deficits to 14) Fever; Temperatures >39 with signs of lethargy.
agitation, lethargy, confusion, seizures, 15) Vomiting and diarrhoea; With suspicion or signs
paralysis, coma. of dehydration.
2) Head injury; this problem appears in several 16) Acute psychosis/extreme agitation;
triage levels 17) Diabetes; diabetics with hyper or hypoglycemia.
3) Severe trauma; Altered mental state, blurred vision, fever,
vomiting, abnormal pulse and respiration.
18) Hypertension or Hypotension; should prompt 8) Acute psychosis &/or suicidal ; psychiatric
immediate physician notification or assessment. problems, not really agitated but some
19) Headache; This presenting complaint appears in uncertainly as to whether they are threat to
multiple triage levels. themselves or others .
20) Abuse/neglect/assault; These patients may not 9) Acute pain severe ( 8-10/10); patient with minor
have life threatening problems but have very problems but self reported intense pain(8-10/10)
special needs that relate to their mental well should have either nursing intervention or early
being and specific requirements for the access to verbal physician assessment . Patient
collection of samples for evidence, or the with discogenic back pain usually have a very
activation of local protocols for the use of assault sudden pain while lifting or bending. Radiation of
teams and community services. pain to the legs is common. If neurological
21) Drug withdrawal-severe-(Delirium tremens or problems may be present and urgent physician
other); these patients may be sometimes assessment is necessary.
mistaken for acute psychiatric problems. 10) Acute pain moderate(4-7/10); patients with
Seizures, coma, hallucinations, confusion, migraine or renal colic can present with
agitation (shakes, tremors), tachycardia, moderate pain but deteriorate rapidly. These
hypertension, hyperpyrexia), chest/abdominal patients would probably benefit from earlier
pain, vomiting, diarrhoea. intervention.
22) Chemotherapy; Patients on chemotherapy or 11) Dialysis (or transplant patients); Electrolyte and
immunocompromised patients (HIV, known fluid balance problems are common in these
immune deficiency, malignancy) with or without patients. This increases the risk for arrhythmias
a fever are at higher risk of serious problems. and rapid deterioration.
These patients can deteriorate quickly.
Level IV Less Urgent
Level III Urgent
Conditions that related to patient age, distress, or
Condition that could potentially progress to a serious potential for deterioration or complications would benefit
problem requiring emergency intervention. May be from intervention or reassurance within 1-2hours.
associated with significant discomfort or affecting ability
to function at work or activities of daily living. Time to physician < 1 hour.

Time to physician <30 min. 1) Head Injury; Minor head injury, alert (GCS 15),
on vomiting, neck symptom and normal vital
1) Head injury; these patients may have had a signs, may require brief period of observation,
high- risk mechanism. The y should be alert depending on time of injury in relation to ED
(GCS15) moderate pain (<8/10) and nausea or visit.
vomiting. Should be changed to level II if If time interval from accident >4-6 hours and has
deteriorating or just appears unwell. remained free of symptom, a neuro check and head
2) Moderate trauma; Patients with fractures or routine sheet may be all that necessary.
dislocations or spines with severe pain (8-
10/10). Dislocations should be reduced 2) Minor trauma; Minor fractures, sprains,
promptly, so physician assessment should occur contusions, abrasions, lacerations, requiring
in <30 min. investigation or intervention. Normal vital signs,
3) Asthma, mild/moderate; Patients with mild – moderate (4-7/10).
moderate shortness of breath with the exertion, 3) Abdominal pain; Acute pain of moderate
frequent cough or awakening (unable to lie down intensity (4-7/10). The severity of pain for
flat without symptoms). Mild asthmatics can appendicitis or cholecystitis or other potentially
have severe attacks & severe asthmatics can serious problems is not a reliable means of
have mild attacks. excluding these problems. Vital signs should be
4) Dyspneoa, moderate ; patients with pneumonia , normal and the patient should not appear to in
COPD , URIS , croup…. May complain of , or acute distress. Constipation can cause very
appear to be short of breath. severe pain or on occasion be confused with
5) Chest pain; sharp localized pains, worse with other more serious problems.
deep breathing, cough, movement or palpitation 4) Headache; Not sudden, not severe, not
not associated with shortness of breath or other migraine, no associated high- risk features (see
signs that might suggest significant heart or lung level II &III headache). Infectious problems like
disease. Theses are usually due to chest wall sinusitis, URI, or flu like illnesses may cause
problems or irritation on one of the “ linings “ these. Pain should no more than (4-7/10) &
inside (pleurisy or even pericarditis). If a patient normal vital signs.
is elderly or has had an AMI or angina, & have 5) Ear ache; Otitis media & externa can cause
this type of pain they should still probably be moderate (4-7/10) to severe(8-10/10) pain &
triaged as level II. these patients should receive analgesics either
6) GI bleed; upper or lower GI bleed, not actively as part of nursing protocol/ intervention or with a
bleeding , with normal vital signs. There is verbal order from the physician. if the patient
always potential for deterioration , so a repeat either has severe pain or is in acute distress, the
set of vital signs should be done within 30 min. triage level should be III .
or if there is any change in status/symptoms. 6) Chest pain; These patients should have no
7) Seizure; known seizure disorders or new onset acute distress, pain (4-7/10), no shortness of
but brief .
 breath, no visceral features, no previous heart or instinct. The fundamental principle, when deciding
problems, normal vital signs. triage level, is that patient should be treated as though
7) Suicidal/ Depressed; Patients complaining of they were close friends or family members. Patients who
suicidal thoughts or have made gestures but do have a similar ‘administrative presentation’ such as
not seem agitated. Normal vital signs. All ‘recheck’ or for ‘test’ or ‘booked procedures’ are not all
providers should show empathy & try to have the same in terms of their need for care or amount of
the patients placed in a quiet & secure area. resources.
8) Corneal Foreign body; If pain is mild or
moderate (4-7/10) & no change in visual acuity. Pearl of wisdom; If patients look sick & you are not sure,
9) Back pain, chronic; These patients may be very triage them as level I or II.
challenging &should always be assessed as
though their problem has never been seen Level I Continuous care
before. Occasionally patients may have Level II Within 15 minutes
substance abuse problems and the sole purpose Level III Within 30 minutes
of the visit is to seek a narcotic prescription. It is Level IV Within 60 minutes
unwise to label people or be judgmental unless Level V Within 120 minutes
there is clear evidence that you are dealing with
substance abuse as opposed to drug addiction
& chronic pain syndromes.s
10) URI symptoms; Patients with upper airway
congestion, cough, aches, fever, sore throat are
frequent visitors to ED’s. Unfortunately patients
with strep throat, mono, peritonsillar abscess,
epiglottitis, pneumonia, Or other serious
illnesses can not always be identified in routine
or quick look assessments. Flu like illnesses
with generalized symptoms can be serious for
patients who are elderly.
11) Vomiting & or diarrhoea no signs of dehydration;
The risk of dehydration increases with vomiting
& diarrhoea together.
The question in triage should attempt to clearly define
the onset & course of the episodes of diarrhoea &
vomiting. Knowing how many times someone had
vomited, whether it occurred only when eating or
drinking & when the last episode was (exact times), The
same for diarrhoea. If there are less than 5 loose bowel
movements per day then dehydration or electrolyte
imbalances are unlikely. It is also important to appreciate
that vomiting can be a sign of other problems such as
CNS abnormalities, cardiac disease, drug effect, renal
failure, hepatic disturbances, diabetes, disorders of
pregnancy…

Level V Non Urgent

Conditions that may be acute but non-urgent as well as

conditions which may be part of a chronic problem with
or without evidence of deterioration.

Time to physician < 2 hours.

1) Minor trauma; contusions, abrasions, minor
lacerations (not requiring closure by any means),
overuse syndromes (tendonitis), & sprains.
2) Sore throat, URI; Patients with minor complaints, not
severe & no respiratory symptoms/compromise.
Typical viral illnesses, with normal vital signs or low-
grade fever < 39
3) Abdominal pain; Mild pain (< 4) which is chronic or
recurring, with normal vital signs
4) Vomiting alone, Diarrhoea alone; no signs of
dehydration. These patients should have normal
mental status & vital signs.

Patient who are hard to group;

If a patient seems difficult to assign a triage level
because they don’t seem to fit any of the categories, the
provider needs to either discuss the case with a
colleague or make a judgment based on their experience