DR-HANI SAMIR AL-HAITHAM
HEAD OF ED
SHIFA HOSPITAL
Definition of triage
 Triage is a French word that means to
sort.
 Napoleon’s surgeon is thought to be the first physician
to use triage on a battlefield in the 1800s to sort out
soldiers who could be treated in a nearby hospital and
returned to duty
How does triage occur at a scene?
 1 : the sorting of and allocation of treatment to
patients and especially battle and disaster victims
according to a system of priorities designed to
maximize the number of survivors
 2 : the sorting of patients (as in an emergency room)
according to the urgency of their need for care
EmergencySeverity Index
 The Emergency Severity Index (ESI) is a simple to use,
five-level triage instrument that categorizes emergency
department patients by evaluating both patient acuity
and resources.
 Initially the triage nurse assesses only acuity level. If a
patient does notmeet high acuity level criteria (ESI
level 1 or 2), the triage nurse then evaluates expected
resource needsto help determine a triage level (ESI
level 3, 4, or 5).
 In an MCI, field triage is expanded from solely
evaluating an individual patient to assessing priorities
to identify the sickest patients and ensure they are
transported and treated first
 Although several systems exist for triaging victims of
multicasualty incidents, the basic concept generally
identifies four groups of patients:
 Red (immediate): Critical or immediately life-
threatening illness or injury (e.g., tension
pneumothorax, hypovolemic shock)
 Yellow (delayed): Serious but not immediately
life-threatening illness or injury (e.g., most
types of fractures)
 Green (minor): “Walking wounded” (e.g.,
anxiety attack after witnessing event)

Black (dead/dying, or expectant): Dead or
resource-intensive victims (e.g., 100% total body
surface area burn).
 Triage tags or colored
tape is used to
clearly indicate the categories of
patients to assist in rapid assessment
on scene
What triage system is most
commonly used
 The triage system currently in most common use is
START (simple triage and rapid
treatment),
 A Centers for Disease Control and Prevention (CDC)
working group has also proposed a national triage
method referred to as SALT (sort,
saving interventions, and
treat/transport).
assess, life-
 Numerous other triage systems exist, such as
JumpSTART for pediatrics, MASS (move, assess, sort,
send) triage, Fire Department of New York (FDNY)
modified START triage, and Sacco triage method (STM).
 There is ongoing research to determine which system is
the most accurate.
 Variables such as age (very young or very old),
comorbidities, and type of incident (e.g., chemical
exposure) may influence the accuracy of currently
accepted triage methods.
Tell me more about START.
 is designed to triage a patient in less than 30 seconds
 . First, those able to ambulate are immediately
classified as walking wounded and sorted to a separate
area (green).
 Priority is then given to the remaining victims on the
ground
 The triage officer assesses for breathing and
spontaneous respirations. If breathing or circulation is
abnormal and the patient is alive (has a pulse), a basic
airway maneuver is attempted, such as a jaw thrust or
the insertion of an oropharyngeal airway (OPA), and
the patient is categorized as red
 if the patient is not breathing and has no pulse, he or
she is triaged into the black category.
 Assuming normalrespirations, perfusion is assessed by
radial pulse and capillary refill time (if absent radial
pulse and capillary refill >2 seconds, patient is triaged
as red).
 Finally, mental status is assessed by the patient’s
ability to follow commands (if no, triaged to red, and if
yes, triaged to yellow).
 An easy mnemonic used to remember this approach is
RPM: 30 to 2, can do, where RPM denotes
respirations, perfusion, and mental status, and 30 to 2,
can do indicates respiratory rate less than 30, capillary
refill less than 2 seconds, and ability to follow
commands
 Red patients are prioritized for transport, followed by
the yellow patients.
 Green patients may not actually need a formal
evaluation at the hospital, or may be able to be
transported en masse
 This sort of rapid assessment allows for maximum use
of the limited resources that are available at a disaster
scene.
What is the difference between
START and SALT triage systems?
 SALT first performs a global sorting by assessing for
the ability to ambulate.
 Those who can walk are assessed last. Next, if victims
can follow a simple command (such as “Raise your
hand if you can hear me”), they are considered less
emergent and assessed second.
 Priority for assessment is given to those not
responding, who are then triaged as either red, black,
or gray based on their injuries and response to simple
life-saving interventions (such as a needle
decompression for a tension pneumothorax).
 An important distinction between the two systems is
that SALT triage incorporates a gray color designation
for patients who are deemed expectant, meaning those
who have little likelihood to survive their injuries, even
with adequate resources. This also allows for palliative
interventions for these patients, so they are not simply
left to die
Which one is better, START or
SALT?
 Retrospective analysis has shown START to be a
reliable and easy-to-learn triage system for first
responders
 Studies comparing the START and SALT triage systems
have found START easier to learn and use in a real
disaster scenario.
 Notably, both are prone to overtriaging patients
(identifying victims as more sick than they really are),
which can be detrimental to the overall system
because it may divert limited resources to people who
do not truly need them