Triage Index

where:

• shallow respiratory expansion is assigned 2 points in the original paper, but think that 1 point was intended

• eye opening + conversational ability + motor response correspond to the Glasgow Coma Score; the Glasgow Coma Score for eye opening is (4 - points above), for verbal response is (5 - points above), and for motor response is (6 - points above)

triage score =

= (points for respiratory expansion) + (points for capillary refill) + (points for eye opening) + (points for verbal response) + (points for motor response)

Interpretation:

• minimum score 0

• maximum score 16

Triage Algorithm

Historical Criteria:

(1) Has the patient been struck by an auto, bus, truck, train, etc.?

(2) Has the patient had a fall from more than 15 feet?

(3) Has the patient had an auto accident at more than 25 miles per hour?

(4) Has the patient been thrown from the vehicle?

(5) Has the patient had a motorcycle accident?

(6) Has the patient sustained a burn:

(6a) involving more than 20% of BSA (5% if child)

(6b) involving the hands, feet, face or perineum

(6c) with inhalation injuries

(6d) caused by electrical energy

(6e) associated with other trauma?

Vital Signs Criteria:

(1) Has the patient a Triage Score of 4 or more?

(2) Has the patient a systolic blood pressure < 90 mm Hg?

Physical Examination:

(1) Has the patient a head injury with depressed level of consciousness (Glasgow Coma Scale of 10 or less)?

(2) Has the patient a penetrating injury of the chest, abdomen, head, neck or groin?

(3) Has the patient a spinal cord injury?

(4) Has the patient a fractures of 3 or more long bones?

(5) Has the patient an amputation or degloving injury?

(6) Has the patient any injury involving 2 or more body systems (CNS, cardiovascular, pulmonary, GI, GU)?

Interpretation:

• If an answer to any of the questions above is affirmative, then the patient is triaged to Trauma Center

• If answers to all of the questions above are negative, then the patient is triaged to the Emergency Department