Breathing
Assessment of breathing includes determination of respiratory rate and work of breathing. Patients with evidence of respiratory dysfunction during the triage assessment warrant allocation to a high triage category( see Table 4.1).
Patients allocated to lower triage categories( ATS 4 or 5) should have normal respiratory function. It is important to detect hypoxaemia. This can be detected using pulse oximetry.
Circulation
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Assessment of circulation includes determining heart rate, pulse and pulse characteristics, skin indicators, oral intake and output. It is important that hypotension be detected during the triage assessment to facilitate early and aggressive intervention. Although it may not be possible to measure blood pressure at triage, other indicators of haemodynamic status should be considered, including peripheral pulses, skin status, conscious state and alterations in heart rate.
Patients with evidence of haemodynamic compromise( hypotension, severe hypertension, tachycardia or bradycardia) during the triage assessment warrant allocation to a high triage category( see Diagram 4.1).
Patients allocated to lower triage categories( ATS 4 or 5) should have normal circulatory function.
Disability
This assessment includes determining AVPU( see Figure 4.1) GCS and / or activity level, assessing for loss of consciousness, and pain assessment. Altered level of consciousness is an important indicator of risk for serious illness or injury. Patients with conscious-state abnormalities should be allocated to a high triage category( Diagram 4.1).
Department of Health and Ageing – Emergency Triage Education Kit