Gottschalk et al reported the Cape Triage Score, which was later released as the South African Trauma Scale. The authors are from the University of Cape Town.
Versions: adult (> 12 year or > 150 cm), child (3 to 12 years or 95-150 cm), infant (< 3 years or < 95 cm)
Parameters:
(1) Triage Early Warning System (TEWS)
(2) mechanism of injury (MOI)
(3) symptoms
(4) anatomy
(5) pain
Triage points:
(1) red (requires resuscitation, physiologically unstable)
(2) orange (serious)
(3) yellow (physiologically stable with significant problem)
(4) green (minor)
(5) blue (dead)
Criteria for red:
(1) TEWS >= 8
(2) entrapment mechanism of injury
(3) status asthmaticus
(4) unresponsive in AVPU (alert, voice, pain, unresponsive)
(5) current seizure
(6) facial burn or inhalation injury
(7) hypoglycemia < 2.2 mmol/L
(8) airway trauma
Criteria for orange:
(1) TEWS 6 or 7
(2) high impact mechanism of injury
(3) asthma, not status asthmaticus
(3) chest pain
(4) arterial hemorrhage
(5) responds to pain in AVPU
(6) post-ictal
(7) psychosis or aggression
(8) limb threatened
(8) dislocation major joint
(9) open fracture
(10) burn > 20%
(11) overdose or poisoning
(12) hematemesis with fresh blood
(13) pregnancy with trauma
(14) trauma to head, neck or torso/trunk
(15) evisceration
(16) severe pain
Criteria for yellow:
(1) TEWS 3 to 5
(2) low impact mechanism of injury
(3) responds to voice in AVPU
(4) dislocation of a minor joint
(5) closed fracture
(6) burn <= 20% or minor
(7) abdominal pain
(8) pregnancy vaginal bleeding
(9) trauma to limb
(10) moderate pain
Criteria for green:
(1) TEWS 0 to 2
(2) alert in AVPU
(3) mild pain
