What is the structured protocol for starting triage in emergency situations?

Structured Protocol for Starting Triage in Emergency Situations

The structured protocol for starting triage in emergency situations should follow a multi-level approach that begins with primary triage in the pre-hospital setting, followed by secondary triage upon hospital arrival, and critical care (tertiary) triage when necessary, all within an established incident management system framework. 1

Triage System Framework

Incident Management System

• An incident management system (IMS) must be in place at the facility level, with standardized processes and procedures that all responders use to coordinate response actions 1
• The IMS structure should contain Emergency Executive Control Groups at facility, local, regional/state, and national levels 1
• Response activities should be coordinated with neighboring/regional facilities to ensure proper resource allocation 1

Levels of Triage

• Primary triage: Occurs in pre-hospital field, performed by paramedics using simple criteria that can be rapidly assessed 1, 2
• Secondary triage: Performed by emergency physicians or surgeons upon patient arrival at the hospital to prioritize patients for initial interventions 1, 2
• Critical care (tertiary) triage: Conducted by intensivists or surgeons to prioritize patients for definitive care in ICU or operating room during mass casualty events 1

Primary Assessment Protocol

Pediatric Assessment Triangle (PAT)

• Initial visual and auditory assessment focusing on appearance, breathing, and circulation 2
• Categorizes patients as stable or unstable 2
• Unstable conditions are further classified as life-threatening or non-life-threatening 2

Primary Assessment Pentagon (1-3 minutes)

• Detailed physical examination following the ABCDE approach: 2
  • Airway (A): Assess patency and provide immediate intervention if compromised 3
  • Breathing (B): Evaluate respiratory rate, effort, and oxygen saturation 3
  • Circulation (C): Control obvious external bleeding with direct pressure and monitor vital signs 3
  • Disability (D): Perform rapid neurological assessment including Glasgow Coma Scale 3
  • Exposure (E): Conduct head-to-toe examination 2

Triage Categorization Systems

Simple Triage and Rapid Treatment (START)

• Commonly used worldwide for mass casualty incidents 4
• Categorizes patients into four groups:
  • Immediate/Red: Require intervention within minutes to hours 4, 5
  • Delayed/Yellow: Can wait hours for definitive care 4, 6
  • Minor/Green: "Walking wounded" with minor injuries 4, 6
  • Deceased/Black: Expectant or deceased 4, 5
• While START has limitations in sensitivity and specificity, it shows 100% sensitivity for identifying immediate/deceased categories 4

Five-Level Triage Systems

• Manchester Triage System (MTS) and Emergency Severity Index (ESI) are validated five-level systems 7
• Patients are triaged into levels based on physiological abnormalities: 2
  • Level 1: Resuscitation needed
  • Level 2: Emergent care
  • Level 3: Urgent care
  • Level 4: Less urgent care
  • Level 5: Non-urgent care

Implementation in Different Scenarios

Normal Operations

• Standard triage protocols should be utilized 1
• Training and exercise of triage protocols should occur regularly 1

Mass Casualty Events (MCE)

• Triage should only be initiated when resources are or will be overwhelmed despite efforts to extend resources 1
• Central Triage Committee (CTC) should convene and conduct situational assessment 1
• Triage officers should be put on standby and the triage system made ready 1
• Every community should have a written protocol guiding EMS personnel in determining where to take patients 1

Cardiac Emergencies

• Patients with suspected ACS should be considered high-priority triage cases 1
• ECG should be performed immediately and evaluated by an experienced emergency medicine physician within 10 minutes of ED arrival 1, 3
• If STEMI is present, decision regarding fibrinolytic therapy or primary PCI should be made within the next 10 minutes 1

Common Pitfalls and Considerations

• Overtriage: Allocating critical care resources to patients who don't medically require such specialized care 1
• Undertriage: Failure to allocate resources to patients who meet inclusion criteria due to failure to recognize severity 1, 4
• Delayed Interventions: Avoid delaying critical interventions while waiting for diagnostic studies 3
• Transport Decisions: Patients with known STEMI and/or cardiogenic shock should be sent directly to hospitals with interventional and surgical capability 1, 3

Ethical Considerations

• Triage criteria should be objective, ethical, transparent, applied equitably, and publicly disclosed 1
• Developing fair policies for "the greatest good for the greatest number" may require restricting services to patients most likely to benefit 1
• Restrictions in treatment should be proportional to the realized or expected shortfall in resources 1