ES/ Triage Algorithm, v4
requires immediate A
yes
life-saving intervention?
l
high risk situation? B
or yes
+ - - - - -.
confused/lethargic/disoriented?
or
severe pain/distress?
l no @
how many different resources are needed?
c
none one many
t t D
CI> (j) danger zone
vitals?
consider
A. 1mme1jate ljfe-savjng intervention reguj!'ftd: airway, emergency medications, or
otherhemO<lynamic interventions (IV, supplemental 02, monitor. ECG or labs DO
NOT count); and/or any of the following clinical conditions: intubated, apneic,
pulseess, severe respiratory distress, SP02<90, acute mental status changes, or
unresponsive.
l Jprg.oonsjvenm is defined as a patient that is either:
(1) nonverbal and not following commands (acutely); or
(2) requires noxious stimulus (PU on AVPU) scale.
B. Hjgh dsk sjtuatjon is a patient you would put in your last open bed.
sftXf9 ~jannldjstres.-c:
grea er
is determined by clinical observation and/or patient rating of
or equal to 7 on 0- 1Opain scale.
C. ~: Count the number of diffetent types of resources. not the individual
tests ·Jr x-rays (examples: CBC. electrolytes and coags equals one resource; CBC
plus chest x-ray equals two resources).
Resources Not Resources
·Labs~. udne) •Hi&ocy& physical {including peMc)
•ECG,X-<• •Point~testing
<CT-M~ult<asound-.angiogcaphy
·fVflum{hydcatior\I •Salineor heplock
•fl/orlMor nebuliz:ed medicatio~ •PO medicatio~
·TWn~immunaation
•PfeSOCiptionfefil~
'8peciattyoonsuttation ·Phonecallto PCP
-Sil'OPl'apcooec::IUC'e=1 •Simptawoundcac-e
j:hsst'.QS.
ll>o
-CO~pcocec::IUC'e-2
~~
""'""' )
·Crutohes, splints, sli~
D. Danger Zone yjtal Sjgns
Consder uptriage to ESI 2 if any vital sign criterion is exceeded.
Pedj;jrjc Fever Consjderatjons
1 to 28 days of age: assign at least ESI 2 if temp >38.0 C (100.4F)
1-3 months of age: consider assigning ESI 2 if temp Xl8.0 C (1 00.4F)
3 months to 3 yrs of age: consider assigning ESI 3 if: temp >39.0 C (102.2 F), or
incomplete immunizations, or no obvious source of fever
© ESITriageRGe:an::hTe:am,2004 -1,Referto teaching materialsforfurtherclarificcrtion)
