INTERAGENCY INTEGRATED TRIAGE TOOL: Age ≥ 12

Check for RED criteria

◊ Unresponsive Patients with

Check for YELLOW criteria
Airway & Breathing high-risk vital
signs
◊ Stridor Airway & Breathing or clinical concern

S
◊ Respiratory distress* or central cyanosis ◊ Any swelling/mass of mouth, throat or neck need up-triage or

YE
Circulation ◊ Wheezing (no red criteria) immediate review
◊ Capillary refill >3 sec Circulation by supervising
◊ Weak and fast pulse ◊ Vomits everything or ongoing diarrhoea clinician
◊ Heavy bleeding ◊ Unable to feed or drink
◊ HR <50 or >150 ◊ Severe pallor (no red criteria)
Disability ◊ Ongoing bleeding (no red criteria)
◊ Active convulsions
◊ Any two of: ◊ Recent fainting
◊ Altered mental status Disability Check for high-
◊ Stiff neck
◊ Hypothermia or fever
◊ Altered mental status or agitation (no red criteria) risk vital signs
◊ Acute general weakness

◊
◊ Headache
Hypoglycaemia
◊ Acute focal neurologic complaint NO HR <60 or >130
Other NO ◊ Acute visual disturbance
◊ Severe pain (no red criteria)
RR <10 or >30
◊ High-risk trauma* Temp <36° or >39°
◊ Poisoning/ingestion or dangerous chemical exposure* Other
◊ Threatened limb* ◊ New rash worsening over hours or peeling (no red criteria) SpO2 <92%
◊ Snake bite ◊ Visible acute limb deformity AVPU other than A
◊ Acute chest or abdominal pain (>50 years old)
◊ Open fracture
◊ ECG with acute ischaemia (if done)
◊ Suspected dislocation
◊ Violent or aggressive
◊ Other trauma/burns (no red criteria)
Pregnant with any of: ◊ Known diagnosis requiring urgent surgical intervention
◊ Heavy bleeding ◊ Sexual assault
◊ Severe abdominal pain ◊ Acute testicular/scrotal pain or priapism
◊ Seizures or altered mental status
◊ Severe headache ◊ Unable to pass urine
◊ Visual changes

NO
◊ Exposure requiring time-sensitive prophylaxis (eg. animal
◊ SBP ≥160 or DBP ≥110 bite, needlestick)
◊ Active labour ◊ Pregnancy, referred for complications
◊ Trauma
YES
YES Move to Low Acuity
or Waiting Area

Move to High Acuity Resuscitation Move to Clinical Treatment Area

Area immediately (developed by WHO, ICRC, MSF)
 INTERAGENCY INTEGRATED TRIAGE TOOL: <12
Patients with
Check for RED criteria high-risk vital signs

S
◊ Unresponsive or clinical concern

YE
Airway & Breathing Check for YELLOW criteria need up-triage or
immediate review by
◊ Stridor supervising clinician
◊ Respiratory distress* or central cyanosis Airway & Breathing
Circulation ◊ Any swelling/mass of mouth, throat or neck
◊ Capillary refill >3 sec ◊ Wheezing (no red criteria)
◊ Weak and fast pulse Circulation
◊ Heavy bleeding ◊ Unable to feed or drink Check for high-risk
◊ Cold extremities ◊ Vomits everything vital signs
◊ Any two of: ◊ Ongoing diarrhoea
- Lethargy Temp <36° or >39°
- Sunken eyes ◊ Dehydration
SpO2 <92%
- Very slow skin pinch ◊ Severe pallor (no red criteria)
- Drinks poorly Disability AVPU other than A
◊ Restless, continuously irritable or lethargy
Disability
◊ Active convulsions NO ◊ Severe pain
NO
RR <1 year 1-4 years 5-12 years

◊ Altered mental status (confused, restless, Other

continuously irritable or lethargic) with stiff neck, High 50 40 30
◊ Any infant 8 days to 6 months old
hypothermia or fever ◊ Malnutrition with visible severe wasting OR Low 25 20 10
◊ Hypoglycaemia (if known) oedema of both feet
Other
◊ Trauma/burn (no red criteria) HR <1 year 1-4 years 5-12 years
◊ Any infant <8 days old
◊ Age <2 months and temp <36 or >39°C ◊ Sexual assault
◊ High-risk trauma* ◊ Known diagnosis requiring urgent surgical High 180 160 140
◊ Threatened limb* intervention
Low < 90 < 80 < 70
◊ Acute testicular/scrotal pain or priapism ◊ New rash worsening over hours or peeling (no
◊ Snake bite red criteria)
◊ Poisoning/ingestion or dangerous chemical ◊ Exposure requiring time-sensitive prophylaxis
exposure* (e.g. animal bite)
◊ Pregnant with adult red criteria
◊ Pregnancy (no red criteria)
◊ Headache (no red criteria)

YES

NO
YES
Move to Low Acuity
Move to Clinical Treatment Area or Waiting Area
Move to High Acuity Resuscitation
Area immediately
(developed by WHO, ICRC, MSF)
 INTERAGENCY INTEGRATED TRIAGE: MASS CASUALTY

Context-relevant screening as needed

NOT WALKING WALKING

MORGUE
75,$*(32,17
Deceased

H
• Monitor for decompensation
• Priority reassessment for patients with
altered mental status
EMERGENCY UNIT/DEPARTMENT • Treatment when available

• Acute life/limb threatening conditions* Not meeting criteria for GREEN

RED
• Unresponsive red or green

YELLOW
• Respiratory distress*
• Requires ABCD intervention YES
• Signs of toxic exposure that upgrade to red* CHECK FOR HIGH-RISK VITAL SIGNS
• Cardiac arrest with reversible cause HOLD IN EMERGENCY UNIT & REASSES IF:
• Requires curative treatment beyond current Adult 5-12 years 1-4 years < 1 year
BLUE

capacity (transfer as below)

(≥ 12 years)

RR <10, >30 <10, >30 <20, >40 <25, >50

• Requires palliative services HR <60, >130 <70, >140 <80, >160 <90, >180
• Meets criteria for medical futility CHECK
◊ O2 sat <92%
◊ Any evidence of poor perfusion (or
SBP <90 mmHg in adult)
• CRITICAL CARE ◊ Temp <36°C or >39°C
• OPERATING THEATRE
WARDS
• Transfer patients needing higher level of care
when available NO
• Monitoring, treatment, palliation
• Expectant patients may become an immediate
treatment priority as additional resources
become available
(developed by WHO, ICRC, MSF)
 INTERAGENCY INTEGRATED TRIAGE: PREHOSPITAL

• Unresponsive
• Requires ABCD intervention • High priority transport
• Respiratory distress* • Continuous observation/monitoring
• Massive hemorrhage, uncontrolled
bleeding, or tourniquet in place
• High-risk trauma*

• Transport
Not meeting criteria for red or green • Monitor for decompensation

• Consider transport
• Walking (if needed/when available)
• Talking without difficulty • In mass casualty incidents, refer to
• Breathing without distress designated low-acuity area for
care and monitoring

For prehospital mass casualty conditions,

«expectant» is not an initial category as it *During mass casualty incidents:
requires advanced clinical judgement. Consider use other red criteria to prioritize Pre-hospital determination of death
transition to the facility mass casualty tool as among multiple patients with a as per local regulation
higher-level providers become available. High-risk trauma mechanism.
(developed by WHO, ICRC, MSF)
 INTERAGENCY INTEGRATED TRIAGE TOOL
*Reference card
High-Risk Trauma Criteria
General Trauma Road Traffic
Fall from twice person’s height High speed motor vehicle crash
Penetrating trauma excluding distal to knee/ Pedestrian or cyclist hit by vehicle
elbow with bleeding controlled
Crush injury Other person in same vehicle died at scene
Polytrauma (injuries in multiple body areas) Motor vehicle crash without a seatbelt
Patient with bleeding disorder or on Trapped or thrown from vehicle (including
anticoagulation motorcycle)
Pregnant

Major Burns
(the below criteria refer to partial or full thickness burns)

Greater than 15% body surface area Inhalation injury

Circumferential or involving face or neck Any burn in age < 2 or age > 70
Threatened Limb
A patient presenting with a limb that is:
-pulseless OR
-painful and one of the following: pale, weak, numb, or with massive swelling after trauma.

Ingestion/exposure
Use of clinical signs alone may not identify all those who need time-dependent intervention.
Patients with high risk ingestion or exposure should initially be up-triaged to Red for early
clinical assessment.
Signs of Respiratory Distress
Adult Child
Very fast or very slow breathing Very fast breathing
Inability to talk or walk unaided Inability to talk, eat or breastfeed
Confused, sleepy or agitated Nasal flaring, grunting
Accessory muscle use (neck, Accessory muscle use (e.g., head
intercostal, abdominal) nodding, chest indrawing)

Draft January 2020