Interagency Integrated Triage Tool: ≥12 years

INTERAGENCY INTEGRATED TRIAGE TOOL: Age ≥ 12

1 CHECK FOR RED CRITERIA 2 CHECK FOR YELLOW CRITERIA

• Unresponsive
AIRWAY & BREATHING
• Stridor
• Respiratory distress* or central cyanosis
CIRCULATION
• Capillary refill >3 sec
• Weak and fast pulse
• Heavy bleeding
• HR <50 or >150
DISABILITY
• Active convulsions
• Any two of:
- Altered mental status
- Stiff neck
• Hypoglycaemia
OTHER
• High-risk trauma*
AIRWAY & BREATHING
• Any swelling/mass of mouth, throat or neck
• Wheezing (no red criteria)
Patients with high-risk vital signs
or clinical concern need
CIRCULATION
up-triage or immediate review by
• Vomits everything or ongoing diarrhoea
• Unable to feed or drink supervising clinician
• Severe pallor (no red criteria)
• Ongoing bleeding (no red criteria)
• Recent fainting
YES
DISABILITY
- Hypothermia or fever • Altered mental status or agitation (no red criteria)
- Headache CHECK FOR HIGH-RISK
NO • Acute general weakness NO 3 VITAL SIGNS
• Acute focal neurologic complaint
• Acute visual disturbance
• Severe pain (no red criteria)
HR <60 or >130
2.2 Interagency Integrated Triage Tool

• Poisoning/ingestion or dangerous chemical exposure*

• Threatened limb* OTHER RR <10 or >30
• Snake bite • New rash worsening over hours or peeling (no red criteria)
• Acute chest or abdominal pain (>50 years old) • Visible acute limb deformity
• ECG with acute ischaemia (if done) • Open fracture Temp <36° or >39°
• Violent or aggressive • Suspected dislocation
PREGNANT WITH ANY OF: • Other trauma/burns (no red criteria) SpO2 <92%
• Known diagnosis requiring urgent surgical intervention
• Heavy bleeding • Sexual assault
• Severe abdominal pain • Acute testicular/scrotal pain or priapism AVPU other than A
• Seizures or altered mental status • Unable to pass urine
• Severe headache • Exposure requiring time-sensitive prophylaxis (eg.
• Visual changes animal bite, needlestick)
• SBP ≥160 or DBP ≥110 • Pregnancy, referred for complications
• Active labour NO
• Trauma

YES YES

MOVE TO HIGH ACUITY RESUSCITATION MOVE TO CLINICAL TREATMENT AREA MOVE TO LOW ACUITY
AREA IMMEDIATELY OR WAITING AREA

*See Reference Card Developed by World Health Organization, The International Committee of the Red Cross, Médecins Sans Frontières

2. Screening, triage and initial approach

13
 14
Interagency Integrated Triage Tool: < 12 years
INTERAGENCY INTEGRATED TRIAGE TOOL: Age < 12
1 CHECK FOR RED CRITERIA 2 CHECK FOR YELLOW CRITERIA

• Unresponsive
AIRWAY & BREATHING
AIRWAY & BREATHING
• Any swelling/mass of mouth, throat or neck
• Stridor • Wheezing (no red criteria)
• Respiratory distress* or central cyanosis Patients with high-risk vital signs
or clinical concern need
CIRCULATION CIRCULATION
up-triage or immediate review by
• Capillary refill >3 sec • Unable to feed or drink
supervising clinician

Clinical Care for Severe Acute Respiratory Infection—Toolkit

• Weak and fast pulse • Vomits everything
• Heavy bleeding • Ongoing diarrhoea
• Cold extremities • Dehydration
• Any two of: • Severe pallor (no red criteria)
YES
- Lethargy
- Sunken eyes DISABILITY
- Very slow skin pinch
- Drinks poorly • Restless, continuously irritable or lethargy CHECK FOR HIGH-RISK
NO • Severe pain NO 3 VITAL SIGNS
DISABILITY
• Active convulsions OTHER
Temp <36° or >39°
• Altered mental status (confused, restless, • Any infant 8 days to 6 months old
continuously irritable or lethargic) with stiff neck, • Malnutrition with visible severe wasting OR oedema
hypothermia or fever of both feet SpO2 < 92%
• Hypoglycaemia (if known) • Trauma/burn (no red criteria)
• Sexual assault AVPU other than A
OTHER • Known diagnosis requiring urgent surgical
• Any infant <8 days old intervention RR < 1 year 1-4 years 5-12 years
• Age <2 months and temp <36 or >39°C • New rash worsening over hours or peeling (no red High 50 40 30
• High-risk trauma* criteria)
Low 25 20 10
• Threatened limb* • Exposure requiring time-sensitive prophylaxis (e.g.
animal bite) HR < 1 year 1-4 years 5-12 years
• Acute testicular/scrotal pain or priapism
• Snake bite • Pregnancy (no red criteria) High 180 160 140
• Poisoning/ingestion or dangerous chemical • Headache (no red criteria) Low < 90 < 80 < 70
exposure*
• Pregnant with adult red criteria
NO

YES YES

MOVE TO HIGH ACUITY RESUSCITATION MOVE TO CLINICAL TREATMENT AREA MOVE TO LOW ACUITY
AREA IMMEDIATELY OR WAITING AREA

*See Reference Card Developed by World Health Organization, International Committee of the Red Cross, Médecins Sans Frontières