Revised Triage Scale and Checklist

Revised Triage Scale

 

Three of the measures (eye opening, verbal response, motor response) are shared with the Glasgow Coma Scale.

 

Parameters for the revised triage scale:

(1) systolic blood pressure

(2) eye opening

(3) verbal response

(4) motor response

(5) extrication

(6) penetrating abdominal injury

(7) penetrating neck injury

(8) penetrating chest injury

(9) penetrating cranial injury

(10) motor cycle accident

(11) car or truck occupant

(12) flail chest

(13) fall from height

 

Parameter	Finding	Points
systolic blood pressure	>= 90 mm Hg	0
	< 90 mm Hg	1
eye opening	spontaneous	0
	to voice	2
	to pain	4
	no eye opening	6
verbal response	appropriate words	0
	inappropriate words	1
	incomprehensible sounds	2
	no verbal response	2
motor response	obeys commands	6
	purposeful movement to pain	5
	withdraws from pain	4
	flexion response	3
	extension response	2
	no motor response	1
extrication	not required	0
	required	1
penetrating abdominal injury	absent	0
	present	1
penetrating neck injury	absent	0
	present	1
penetrating chest injury	absent	0
	present	1
penetrating cranial injury	absent	0
	present	1
motorcycle injury	motorcyclist without blunt abdominal injury	0
	motorcyclist with blunt abdominal injury	1
car or truck occupant at time of accident	not involved in car or truck accident	1
	involved in a car or truck accident	0
flail chest	absent	0
	present	5
fall from height	none	0
	from <= 15 feet	0
	from > 15 feet	1

 

where:

• It appears that a motorcyclist could be scored both for the motorcycle injury and for not being an occupant of a car or truck.

 

total score =

= SUM(points for all of the parameters)

 

Interpretation:

• minimum score: 0

• maximum score: 28

• If the score is > 7, then the patient should be referred to a trauma center.

 

NOTE: The motor response scoring does not make sense. The footnote to Table IV (page 484) states that the scoring is not an error. It compensates for weighting of the verbal response and eye opening.

 

Revised Triage Checklist

 

Revised triage checklist:

(1) no spontaneous eye opening

(2) abnormal capillary refill

(3) penetrating cranial injuries

(4) penetrating neck injuries

(5) penetrating chest injuries

(6) penetrating abdominal injuries

(7) blunt thoracic trauma with systolic blood pressure less than 90 mm Hg

(8) involvement in motor vehicle vs pedestrian accidents (patient is a pedestrian) and sustaining blunt abdominal trauma

(9) flail chest

(10) involvement in motorcycle accident (as a motorcyclist) and sustaining blunt abdominal trauma

(11) fall greater than 15 feet

(12) age less than 5 or greater than 65 years

 

Interpretation:

• If any of the above is present, then refer the patient to a trauma center.