What are the signs and symptoms that would help you determine the triage category of a patient?

Physical Examination

Observation is important when evaluating the acutely ill child. Most observational data that the pediatrician gathers should focus on assessing the child's response to stimuli. Does the child awaken easily? Does the child smile and interact with the parent, or with the examiner? Evaluating these responses requires knowledge of normal child development and an understanding of the manner in which normal responses are elicited, depending on the child's age.

During the physical examination, the pediatric practitioner seeks evidence of illness. The portions of the exam that require the child to be most cooperative are completed first. Initially, it is best to seat the child on the parent's lap; the older child may be seated on the examination table. It is also important to assess the child's willingness to move, as well as ease of movement. It is reassuring to see the child moving about on the parent's lap with ease and without discomfort.Vital signs are often overlooked but are invaluable in assessing ill children. The presence of tachycardia out of proportion to fever and the presence of tachypnea and blood pressure abnormalities raise the suspicion for more serious illness. The respiratory evaluation includes determining respiratory rate, noting the presence or absence of hypoxia by Spo2, and noting any evidence of inspiratory stridor, expiratory wheezing, grunting, coughing, or increased work of breathing (e.g., retractions, nasal flaring, accessory muscle use). Theskin should be carefully examined for rashes. Frequently, viral infections cause an exanthem, and many of these eruptions are diagnostic, such as the reticulated rash and slapped-cheek appearance of parvovirus infections and the stereotypical appearance of hand-foot-and-mouth disease caused by coxsackieviruses, as well as measles, chickenpox, and roseola. The skin examination may also yield evidence of more serious infections, including petechiae and purpura associated with bacteremia and erythroderma associated with a toxin-producing systemic infection. Cutaneous perfusion should be assessed by warmth and capillary refill time. The extremities may then be evaluated not only for ease of movement but also for the presence of swelling, warmth, tenderness, or alterations in perfusion. Such abnormalities may indicate focal infections (e.g., cellulitis, bone/joint infection) or vascular changes (e.g., arterial or venous thromboembolus).

When an infant is seated and is least perturbed, the examiner should assess the anterior fontanel to determine whether it is depressed, flat, or bulging. While the child is calm and cooperative, theeyes should be examined to identify features that might indicate an infectious or neurologic process. Often, viral infections result in watery discharge or redness of the bulbar conjunctivae. Bacterial infection, if superficial, results in purulent drainage; if the infection is more deep-seated, tenderness, swelling, and redness of the tissues surrounding the eye may be present, as well as proptosis, altered visual acuity, and impaired extraocular movement. Abnormalities in pupillary response or extraocular movements may also be indicators of cranial nerve abnormalities and if new, are indications for head imaging.

Introduction and Background

Triage is the prioritization of patient care (or victims during a disaster) based on illness/injury, severity, prognosis, and resource availability. The purpose of triage is to identify patients needing immediate resuscitation; to assign patients to a predesignated patient care area, thereby prioritizing their care; and to initiate diagnostic/therapeutic measures as appropriate.

The term triage originated from the French verb trier which means to sort. During the time of Napoleon, the French military used triage to serve as a battlefield clearing hospital for wounded soldiers. The U.S. military's first use of triage was during the Civil War. Triage on the battlefield was a distribution center from which injured soldiers were sorted or distributed to various hospitals. For the military during World Wars I and II, triage was the procedure that determined which injured soldiers were able to be returned to the battlefield. Military triage continued to evolve during the Korean and Vietnam wars with the tenet of doing the “greatest good for the greatest number of wounded and injured.”1 Refinements in battlefield medicine and military triage have continued during more recent conflicts, including Iraq.

Other situations in which the triage process has been employed, in addition to the battlefield, are during disasters, following mass casualty incidents (MCI), and in emergency departments (EDs). Triage during a disaster involves field triage, which sorts disaster victims into categories ranging from the walking wounded to those with injuries who are salvageable to the unsalvageable and the dead.

Risk Assessment and Triage

The initial evaluation of the patient with possible or suspected ACS should focus on an assessment of the patient’s risk of acutely sustaining a cardiac ischemic event (death, MI, or recurrent ischemia).5 Patients considered to be at low risk for a cardiac ischemic event may be observed in a chest pain evaluation unit for several hours, with repeated troponin level and ECG. If the findings of that brief evaluation are normal, the patient should be discharged home, with further evaluation performed on an outpatient basis.

Noninvasive cardiac testing performed within 3 days of the initial presentation is associated with a modestly reduced subsequent risk of serious cardiac events, but its value in patients with normal troponin levels is likely small.5b Conversely, patients not at low risk should be hospitalized for further evaluation and treatment. The availability of high-sensitivity cardiac troponin assays has significantly impacted the initial triage for patients with symptoms suggestive of an ACS (Fig. 63-2), and a negative test at presentation and 1-3 hours later is associated with a sufficiently low risk as to permit discharge with a 0.4% 30-day risk of myocardial infarction or death.6,6b,A2b In making this assessment, the greatest safety comes from continued observation or admission of patients who have a positive troponin level on presentation or at serial testing, have evidence of ischemia on their ECG, or have symptoms indicative of an acute exacerbation of prior coronary disease.7,7b

After the initial triage decision is made, therapeutic interventions are based on the risk of adverse events in the ensuing hours, days, weeks, and months—estimated by either the Thrombolysis in Myocardial Infarction (TIMI) or Global Registry of Acute Coronary Events (GRACE) risk algorithm—balanced against the risk of a bleeding complication from intensive medical therapy (Table 63-1) or an adverse event from an invasive cardiac procedure. On the basis of this initial assessment, the patient’s therapy should be tailored to minimize the likelihood of adverse events.

Although serum markers of myonecrosis represent only one of the TIMI or GRACE risk variables, the presence of this variable alone identifies the patient as being at high risk. However, although elevated serum markers indicate myonecrosis, they provide no insight into its cause because myonecrosis can occur with disease entities other than coronary artery disease (e.g., pulmonary embolism, decompensated heart failure, severe hypertension or tachycardia, anemia, sepsis). Thus, in evaluation of the patient with possible ACS, the presence of elevated serum markers should be assessed in conjunction with other variables.

What On-Site/Hospital Documentation Will Be Used?

The triage tag, a minimal document that can be attached to each casualty, might be the only practical method of communicating findings, interventions, and so on, as countless casualties are passed through a chain of emergency care. However, it has been argued that triage tags are impractical to use, and geographic triage (see later) can obviate the need for tags.3 In a disaster, hundreds or thousands of tags for each triage category must be immediately available to the responders, who need to be exceptionally familiar with the tags to use them properly under trying circumstances, and frenzied casualties may not take proper care of the tags. After an enormous disaster (thousands of casualties), tags might be especially challenging to use properly, although they could also be especially useful.

Consideration of the use of triage tags requires some research on the part of the customer, since there are over 120 triage label systems in use internationally.42 Hogan and Burstein47 suggested the following criteria for the optimal triage tag: (1) It must attach securely to each casualty’s body, (2) it must be easy to write on, (3) it must be weather-proof, and (4) it should permit the documentation of the patient’s name, gender, injuries, interventions, care-provider IDs, casualty triage score, and an easily visible overall triage category. It must also permit changes to be made, because triage is always dynamic. One unfortunate potential limitation for such a tag is the presence of contamination that may limit the ability of the triage tag to persist through hospital-based decontamination efforts if the patient is not decontaminated prior to transport.

Prehospital Field Triage

In the United States, in-hospital and 1-year mortality are significantly lower in trauma patients treated at trauma centers compared with those treated at nontrauma centers. Having a predetermined system in place to address injuries and triage patients saves lives. Trauma centers are divided into different tiers based on their capabilities. Level I trauma facilities have the resources for all-encompassing trauma care, including subspecialty providers, research capabilities, education, outreach, prevention, and rehabilitation. Level II trauma centers retain almost equivalent resources and can provide resuscitation and stabilization of patients, but do not provide similar education and research opportunities. Level III trauma centers have more limited resources and staff. They are able to treat minor traumas and possess the capability to stabilize and transfer more severely injured patients to a higher level of care. Allocation of trauma patients into these systems requires the use of thoughtful triage parameters in the field. Proper triage in the prehospital setting can lead to expedient transfer of the most tenuous patients to definitive care. The key is to maintain a balance between guaranteeing that the majority of critically ill patients are transported to a higher level of care facility and ensuring that these systems are not overburdened with patients who have sustained minimal injuries. A 50% overtriage rate is tolerated to attain a 5% or lower undertriage rate per the ACS-COT.

Prehospital triage situations can be divided into field triage and mass casualty. As per the Centers for Disease Control and Prevention (CDC) Guidelines for Field Triage of Injured Patients, a step-by-step algorithm is critical to filtering patients into appropriate avenues of treatment (Fig. 2). When measuring vitals and assessing GCS, patients with an SBP of less than 90 mm Hg, a respiratory rate of less than 10 or more than 29 breaths/min (<20 breaths/min in infants aged <1 year), the need for ventilator support, or a GCS score of less than 14 should be transported preferentially to the highest level of care available within the defined trauma system.

Similarly, EMTs assess anatomy and location of injury and mechanism and evidence of high impact. Specific injury patterns require evaluation in a Level I trauma center or at an institution with the most advanced care within that trauma system. The particular injuries of concern include penetrating trauma to the head, neck, torso, and extremities proximal to the elbows and knees; flail chest; two or more proximal long bone fractures; crushed, degloved, or mangled extremities; amputations proximal to the wrist or ankle; pelvic fractures; open or depressed skull fractures; and paralysis.

Depending on the particular trauma system, if the patient does not have the aforementioned clinical signs or anatomic indications, he or she does not necessarily need to be transported to the highest level of care. Indications for transfer to at least a lower-level trauma center include high-impact mechanisms such as falls from higher than 20 feet (2 stories) in adults or more than 10 feet in children; intrusion of more than 12 inches in the occupant site or more than 18 inches in any site; ejection from a vehicle; death in a compartment; speed greater than 20 mph or patient thrown or run over in an automobile versus pedestrian or bicycle collision; and motorcycle collision at a speed greater than 20 mph. Decisions about transport to a trauma center or hospital capable of trauma management also should consider comorbidities; age, particularly older adults and children; burns; pregnancy greater than 20 weeks; premorbid conditions such as congestive heart failure and end-stage renal disease; an anticoagulation therapy are based on EMS judgment.

COMMENTS

Effective triage is a unifying thread through a functioning trauma system. Systems that perform daily care and train disciplines together provide the best preparation for mass casualty incidents—surge capacity and capability are practiced regularly. The Institute of Medicine's 2006 Report on The Future of Emergency Care offers a cautionary assessment of the current state of emergency and trauma care in the United States: the current situation of overcrowding, fragmentation, and resource shortages must be replaced with system planning, coordination, and financing, so that the needs of acutely injured patients are met individually and as a population.

Triage

Triage

Triage is a classification of patients according to their urgencies. There are many triage systems such as Emergency Severity Index (ESI), Canadian Triage and Acuity Scale, Manchester Triage System, and levels classified as three-level, four-level, and five-level triages (Moll, 2010). The classifications are made via algorithms or criteria based methods. ESI is a five-level algorithm-based triage system which uses the data of the resources, vitals, risks, and status of the patient (Wuerz et al., 2001). An e-triage system can predict a patient’s prognosis and predict a risk-avoiding overtriage or undertriage; it provides assistance for making decisions about patient triage, particularly for the ESI-3 level (Levin et al., 2018).

One of the examples of data mining in the past 5 years is about the prediction of triage waiting times at the department of gynecology and obstetrics (Pereira et al., 2016). That study addressed problems like wrong triage outcomes and triage waiting times and revealed a mean success rate of 94% for five different models using data mining. For the aim to reduce waiting times in pediatric emergency care, a 1205 patients dataset was used with machine-learning techniques to predict lox complexity pediatric emergency patients with a good validity and accuracy results (Caicedo-Torres et al., 2016). Machine-learning methods were used in triaging the abdominal pathology patients with support vector machines and decision tree hierarchical structure models (Butler et al., 2016). The used methods showed 50.9%–67.6% accuracy for correctly diagnosing abdominal pathology (Butler et al., 2016). Another abdominal pain triage for predicting the ESI-4 score was a comparison study between human and artificial intelligence and the overall accuracy was higher in clustering and neural network methods (Farahmand et al., 2017). Not only the hospital triage but also the prehospital environment is studied in which a wearable remote triage system is used with machine-learning methods (Kim et al., 2018). Both triage and survival prediction was found having up to 89% accuracy with artificial intelligence methods such as random forest and deep learning. Artificial intelligence-aided symptom-based triage was tested by Razzaki et al. (2018), compared with human outcomes and found safer than human decisions.

Triage and First Aid

Triage is a process whereby patients are sorted according to treatment priority, the purpose of which is to do the greatest good for the greatest number. Several schemes exist to define levels of triage. The Advanced Disaster Medical Response course37 is field oriented and outlines the following:

Level 1 triage occurs at the point of injury.

Level 2 triage occurs at the scene (or nearby) by the most experienced medical provider.

Level 3 triage is performed to determine evacuation priorities.

The Fundamental Disaster Management course37 is ICU oriented and describes the following levels of triage:

Primary triage occurs at the scene.

Secondary triage occurs upon arrival at the hospital.

Tertiary triage occurs in the ICU.

Finally, the ABA approach is burn center oriented and defines the following:

Primary triage is that occurring at the disaster scene or at the ED of the first receiving hospital.

Secondary triage is the selection for transfer of burn patients from one burn center to another when surge capacity is reached.

Clearly, triage is not a one-time operation but has to be repeated at each step of the way. There are several different algorithms for triage. Paramedics may use simple triage and rapid treatment (START) in both emergency medicine and mass casualties. The sensitivity for START varies from 85%38 to 62%.39 Medic in-field triage is another approach. This is done in an established triage area by medics assisted by teams of helpers. It consists of a brief history (time of accident, mechanism of injury, condition, how the patient was found, primary measures taken, actual discomfort, preexisting condition, medications, and allergies) and a quick head-to-toe examination:

Physical examination—external bleeding; penetrating injuries; thermal burns; chemical burns; neurologic status; and investigation of head, spine, thorax, abdomen, pelvis, and extremities

Vital signs, including respiration rate, pulse oximetry, and temperature

Burn size is estimated by the rule of nines, and there is evaluation of suspected inhalation injury and of the need for intubation.

Triage classifies patients according to the following treatment urgency groups shown in Table 5.1. An easy-to-remember acronym is DIME, which stands for delayed, immediate, minimal, and expectant. The main factors to consider in burn patient triage are TBSA burn and age.

Emergency treatment at the scene is done in a treatment area by appropriately trained providers. Burns needing treatment for shock or intubation should be classified for urgent treatment. Because of the need to resuscitate as soon as possible, resuscitation should begin here!

In mass casualties, cardiopulmonary resuscitation (CPR) is not performed as it binds resources for mostly futile efforts for victims initially classified as dead (no ventilation after airway opened, no pulse). This is especially after rescue from indoor fires (because deadly CO poisoning can be assumed) and in the setting of massive trauma.40

Triage group 4 (in Austria, Germany, Switzerland, and some other countries) includes the unsalvageable, who deserve “expectant” treatment. This may be controversial because the duration of the disparity between supply and demand should be short and, when the period is over, this group's priority may change to 1 or 2. Group 4 needs staff at least for comfort care. Dead victims need neither staff nor transports in the acute phase.

If available, tags are attached to each patient. Tags are used not only to indicate triage category but also to provide each patient with a unique number. These tags facilitate victim identification and registration; tell about patients' history, medical treatment, injuries, urgency of treatment, and classification of injury; and specify the hospital for treatment. The tags must not be removed until all the following have occurred: hospital arrival, identifying the patient, and registering the tag number and treatment data.

Disaster Triage

Triage is the process of prioritizing casualties according to the level of care they require. It is the most important, and psychologically most difficult, mission of disaster medical response, both in the prehospital and hospital phases of the disaster. Disaster triage requires a fundamental change in the approach to the medical care of victims.1,3,5,6 The objective of conventional civilian triage is to do the greatest good for the individual patient. Severity of injury/disease is the major determinant for medical care. The objective of disaster triage is to do the greatest good for the greatest number of patients. The determinants of triage in disasters are, however, based on three parameters:

Severity of injury

Likelihood of survival

Available resources (logistics, personnel, evacuation assets).

The major objective and challenge of triage is to rapidly identify the small minority of critically injured patients who require urgent life-saving interventions, including operative interventions, from the larger majority of noncritical casualties that characterize most disasters. In a mass casualty event, the critical patients with the greatest chance of survival with the least expenditure of time and resources are prioritized to be treated first.

Triage is a dynamic decision-making process of matching victims needs with available resources. Many MCIs will have multiple different levels of triage as patients move from the disaster scene to definitive medical care. Disaster medical triage may be conducted at three different levels depending on the level of casualties (injuries) to capabilities (resources).1,4,5