Environment Assess temperature. Hypothermia and hyperthermia are important clinical indicators and need to be identified at triage.
Other considerations Other risk factors should be considered during the triage assessment. In the patient who has normal physiological parameters at triage, these include the following:
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• Extremes of age( very young or very old) entail physiological differences that increase the risk of serious illness and injury, as such patients have decreased physiological reserve and altered physiological responses, and may present with non-specific signs and symptoms.
• High-risk features including chronic illness, cognitive impairment, communication deficit, multiple co-morbidities, poisoning or severe pain may warrant allocation to a high ATS category.
• Patients with high risk alerts, such as a history of violence.
• Trauma patients should be allocated an ATS category based on clinical urgency. There are specific mechanisms of injury associated with risk of life-threatening injury that need to be incorporated in triage decisions. Examples include vehicle rollover, death of same-vehicle occupant, ejection from a vehicle, and fall from a height greater than three metres.
• The presence of a rash may also alert the Triage Nurse to the possibility of serious illness such as anaphylaxis or meningococcal disease; however, these types of presentations will usually have concurrent primary-survey abnormality.
• Re-triage – see definition in Chapter 1.
Department of Health and Ageing – Emergency Triage Education Kit