Emergency Department Triage Manual, R-S

ED Triage Manual, R-S

Rash
Respiratory Distress
Seizure
Sexual Abuse
Sickle Cell Anemia/Thalassemia
Sore Throat
STI Related Complaint
Stroke Suspected

Rash

1 Critical	2 Acute	3 Urgent	4 Urgent	5 Non-Urgent
Acute mental status change with fever and/or high-risk vital signs Generalized petechiae/purpura with altered mental status	Generalized erythematous rash with tachycardia and/or mucous membrane involvement Generalized petechiae/purpura	Focal petechiae		Generalized macular/papular rash Isolated papular lesions (bug bites) Vesicular rash along dermatome

Respiratory Distress

1 Critical	2 Acute	3 Urgent	4 Urgent	5 Non-Urgent
Severe Distress with: Severe tachypnea Bradypnea/apnea Severe retractions Grunting respirations Decreased muscle tone Lethargy +/- Wheezing/Stridor Absent breath sounds Pulse oximetry < 90% Agonal respirations	Moderate Distress with: Increased WOB Nasal flaring Tachypnea Retractions Prolonged expiration Intermittent grunt Moderate Wheezing Tripoding Head Bobbing Decreased aeration with moderate tachypnea and WOB Pulse oximetry < 92% Stridor at rest Asthmatic with Hx of intubation	Mild Distress with: Increased WOB Tachypnea Retractions Mild wheezing Stridor with agitation	Respiratory illness, no lower airway symptoms Pulse oximetry ≥ 95%

Seizure

1 Critical	2 Acute	3 Urgent	4 Urgent	5 Non-Urgent
Active seizure	Seizure ≤ 4 hrs PTA Multiple seizures the day of admit Seizure not back to baseline	Seizure > 4 hrs; ≤ 24 hrs PTA Increased seizure frequency	Seizure > 24 hrs PTA

Sexual Abuse

1 Critical	2 Acute	3 Urgent	4 Urgent	5 Non-Urgent
	Acute assault within 72 hrs Trauma Abdominal pain GU complaints Vaginal bleeding Dysuria Rectal pain	Return for positive cultures Minor physical complaints Time from last abuse unknown Psychosocial concerns	Caretaker concern No history No physical complaints
Contact Social Work at Triage Patients ≥ 16: Discuss with Attending for treatment/transfer guidance

Sickle Cell Anemia/Thalassemia

1 Critical	2 Acute	3 Urgent	4 Urgent	5 Non-Urgent
See Critical Criteria	Wheezing Increased WOB Chest pain Headache Abdominal pain Fever, hx: ≥ 38.4°C (101.1°F) Dactylitis Priapism Moderate to severe pain	Sclera more icteric Mild pain
Alert PEM if concern for stroke

Sore Throat

1 Critical	2 Acute	3 Urgent	4 Urgent	5 Non-Urgent
Marked stridor with acute respiratory or mental status changes	Stridor Drooling Dysphagia Maintains sniffing position	Suspected peritonsillar abscess	Pain with swallowing Cervical adenopathy Scarlatina rash

STI Related Complaint

1 Critical	2 Acute	3 Urgent	4 Urgent	5 Non-Urgent
	Pain Score ≥ 7 Peritoneal signs Reported vaginal bleeding unrelated to menses. Refer to Vaginal Bleeding Triage Criteria.	Vaginal/penile discharge Concern for STI with associated throat soreness, redness, fever and/or flu-like symptoms Significant abdominal pain	Previously diagnosed STI seeking treatment Concern for STI without current symptoms Dysuria

Stroke Suspected

1 Critical	2 Acute	3 Urgent	4 Urgent	5 Non-Urgent
Acute mental status change Extreme agitation Combative Unresponsive Active seizure	Confused, lethargic, disoriented New onset focal neurological deficits: Speech difficulty Difficulty walking Changes in vision Focal Weakness

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway, please contact us.

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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