9. Quick Look Summary -- Triage Categories
Canadian Emergency Department Triage and Acuity Scale Implementation Guidelines
| Respiratory (RESP) | Severe airway compromise, penetrating or blunt chest trauma, obvious signs of respiratory distress Severe respiratory distress |
|---|---|
| Neurological (CNS) | Major head injury Unconscious Active seizure state |
| Musculo-skeletal (MSK) | Traumatic amputation — extremity Major cold injury — hypothermia |
| Gastrointestinal (GI) | Difficulty swallowing with respiratory distress Abdominal trauma — penetrating/blunt — signs/symptoms of shock |
| Code (C) | Code/arrest Major trauma Shock states |
| RESP | Foreign body aspiration with breathing difficulty, SOB, respiratory distress due to chronic cough, wheezing associated with respiratory difficulty, congested, or has a history of cardiac problems Active hemoptysis with signs of hypoxia and with or without cardiac/respiratory disease Inhalation of toxic substance with distress Smoke inhalation |
|---|---|
| CNS | Severe headache with high blood pressure, disorientation, sudden onset, altered LOC Sudden onset of confusion with associated weakness, headache Sudden onset of confusion with altered LOC Shunt dysfunction — patient appears ill Severe motor weakness — sudden onset, patient appears ill Sudden onset, low back pain, in distress; unable to move or feel extremities Head injury with altered mental state |
| MSK | Back pain with neuro deficit Open fracture, possible femur fracture, fracture with neuro vascular impairment Extremity pain with circulatory compromise Traumatic amputation (digit) Hemophiliac with obvious injury Extremity pain — client appears ill |
| SKIN | Bites, allergic reaction with respiratory difficulty Facial cellulitis, particularly periorbital area Laceration, severe nerve tendon or vascular injury Puncture wound Major burn, split/full thickness burn of neck, hands, feet, groin, face Frame burns Inhalation or electrical burns |
| GI | Abdominal pain — acute onset with vomiting, diarrhea, dehydration, bloody rectal mucous, >50 with visceral symptoms Rectal bleeding or prolapse — large amount bloody or tarry stool, signs/symptoms shock GI bleed with abnormal vital signs |
| Genitourinary (GU) | Post TURP bleeding, hemodynamically unstable |
| Gynecological (GYN) | Vaginal bleeding / ectopic pregnancy — patient unstable — hypotension Inability to urinate greater than 24 hours Possible sexual abuse <2 hours Flank pain — hematuria — pale — kidney stone Acute vaginal bleeding (Pain scale >3 ± abnormal vital signs) Possible ectopic, with normal vital signs |
| Eye/ear/nose/throat (EENT) | Sudden severe eye pain with headache, vomiting, decreased visual acuity Sudden loss of vision in one or both eyes Chemical substance in eyes Direct burn to eye Hyphema, puncture wound to globe Impaled object or amputation of external ear Tinnitus with history of ingestion of ASA Nasal injury with bloody/clear drainage Uncontrolled epistaxis Sore throat with drooling, stridor and/or difficulty swallowing Hoarseness — sudden onset — history of trauma to larynx |
| Cardiovascular (CVS) | Patient with sudden onset of cold painful extremity Severe trauma Chest pain — visceral ± associated symptom |
| Psychiatric (PSYCH) | Agitated symptoms and/or depression symptoms Known to require close observation Attempted suicide History of attempted suicide Aggressive and/or violent behaviour Symptoms of instability (pacing, muttering, clenched fists, etc.) Overdose (conscious) |
| Miscellaneous (MIS) | Fever (age ≤3 months) Temp >38.0°C Diabetic hypoglycemia, hyperglycemia Pain scale 8–10/10 |
| RESP | Foreign body aspiration, cough present, but no distress with swallowing Cough constant — appears distressed Known asthmatic with SOB or worsening of symptoms Inhalation of toxic substance — in no distress SOB — chronic respiratory problem — exacerbation O2 sats >95% History of coughing up pink mucous Congested with pain on deep inspiration No history of trauma |
|---|---|
| CNS | Headache — severe (mild-moderate distress, pain scale 8–10/10) Hit head — no LOC, vomiting Known seizure disorder — seizure prior to emergency visit, not actively seizuring Shunt dysfunction — patient irritable, not acutely ill |
| MSK | Probable extremity fracture Multiple joint pain with fever; hip pain with fever Tight cast with neurovascular impairment |
| SKIN | Bites Insect — systemic minor allergic response Cellulitis — patient appears ill Rash: 1) patient appears ill; fever / purpuric or petechial rash; 2) recent exposure to communicable disease Localized cold injury with blanching, cyanosis or pain Split and/or full thickness burns over less than 5% body surface Split thickness burns over trunk or less than 10% body surface Laceration requiring pressure to control bleeding |
| GI | Abdominal pain Rectal bleeding with abdominal pain, no signs/symptoms of shock Difficulty swallowing; possible foreign body; no respiratory distress Abdominal trauma — complaints of mild discomfort Sign/symptoms of appendicitis, abdominal pain ± fever Vomiting and/or diarrhea ≤2 years GI bleeding with normal vital signs |
| GU | Vaginal bleed — no signs of shock Possible sexual abuse >2 hours <12 hours Inguinal bulge — sudden onset; patient acutely distressed Non-painful testicular swelling Inability to urinate for more than 8 hours Gross swelling of penis; unable to void |
| EENT | Nasal injury with some respiratory difficulty Epistaxis with trauma and/or history of high blood pressure Allergy — hay fever causing congestion with history of respiratory problems Foreign body in nose causing pain or possibility of aspiration Bloody drainage from ear Hearing problem — acute onset Foreign body in ear Cold injury — partial tear to external ear Sudden severe eye pain with no associated trauma Sudden onset dyslopsis or change in vision in last 24 hours Periorbital swelling with fever Burn to eye area Amputated tongue tip or large section/cheek Puncture wound soft palate Tonsil pustules — difficulty swallowing Postoperative bleeding — tonsillectomy and/or adenoidectomy |
| CVS | Patient with gradual onset of cold, painful extremity Patient with gradual or acute onset of extremity pain associated with swelling and temperature change Moderate trauma Chest pain, no visceral symptoms |
| PSYCH | Acute psychosis ± suicidal ideation |
| MIS | Signs of serious infection Pain scale 8–10 with minor injuries |
| RESP | Foreign body aspiration — no cough — appears well Minor chest injury without rib pain or respiratory difficulty — no SOB — may have bruising Difficulty swallowing; no respiratory difficulty |
|---|---|
| CNS | Chronic or repeating headache (no acute distress) Minor head trauma — no LOC / no vomiting |
| MSK | Back pain — minor back pain (“pulled something”) — muscle spasms; localized back pain (4–7/10) Possible extremity fracture Swollen, “hot” joint Tight cast — no neurovascular impairment |
| SKIN | Localized cellulitis Cold injury — no discolouration — minimal pain |
| GI | Abdominal pain with vomiting or diarrhea (alone) — does not appear ill, no signs of dehydration Rectal bleeding — small amount; fever and/or diarrhea Constipation; not eating; cramps |
| GU | Possible sexual abuse >12 hours Possible UTI — hematuria, frequency, burning |
| EENT | Corneal foreign body Nasal injury — no respiratory difficulties Periodic epistaxis with signs of infection Ear drainage — purulent — fever Tinnitus with fever Gradual change in vision, visual acuity or visual fields Crusting, matting or drainage from eye Earache |
| PSYCH | Suicidal ideation, depression |
| CVS | Chest pain, age <30, no visceral symptoms |
| MISC | Minor trauma Pain scale 4–7 |
| RESP | Nasal congestion/discharge associated with cold symptoms |
|---|---|
| MSK | Chronic low back pain, minor discomfort (<4/10) |
| SKIN | Minor bites — puncture wounds, foreign body, scratches localized Localized rash Minor lacerations, abrasions, contusions |
| GI | Vomiting/diarrhea — no pain, no dehydration — normal mental state |
| GU | Discharge — penis, vaginal, urethral menses |
| EENT | Partial tongue lacerations or cheek bite Sore throat, laryngitis, minor mouth sores possible with fever Allergy — hay fever causing nasal congestion Sinus problems Hearing loss, gradual onset Vague eye pain; chronic eye pain |
| PSYCH | Chronic symptoms with no acute changes |
| CVS | Minor trauma, not necessarily acute |
| MISC | Minor symptoms Pain scale <4 |
