Emergency Department Triage Manual, T-U

ED Triage Manual, T-U

Trauma – Extremity
Trauma – Face
Trauma – Head
Trauma – Neck
Trauma – Torso
Urine Output

Trauma Activation Criteria do not affect your ESI Triage level.
Activation criteria determines how the patient will be treated.

Trauma – Extremity

1 Critical	2 Acute	3 Urgent	4 Urgent	5 Non-Urgent
Trauma with uncontrollable bleeding or hemodynamic compromise	Digit amputation Open fracture Femoral point tenderness, edema Impaired distal neurovascular status Absent perfusion to extremity	Laceration repair needing X-ray or sedation Nailbed injury Dislocated distal joint Displaced fracture Dislocated proximal joint	Suspected Nursemaid’s elbow Suspected clavicle fracture Mild swelling without deformity of ankle in children > 13 yrs of age Edema over injury Simple laceration repair Point tenderness	Abrasion
Assess and document skin integrity and neurovascular status distal to the injury.

Trauma – Face

1 Critical	2 Acute	3 Urgent	4 Urgent	5 Non-Urgent
Uncontrolled bleeding or airway compromise See Critical Criteria	Significant facial swelling or bruising Facial deformity Inability to close mouth Possible globe injury Inability to assess eye Injury to secondary tooth Palatal injury/bleeding	Laceration requiring sedation	Simple laceration Active epistaxis	Superficial abrasions and contusions with minor mechanism
See Triage Trauma – Head, Neck, and Dental Emergencies

Trauma – Head

1 Critical	2 Acute	3 Urgent	4 Urgent	5 Non-Urgent
Mental Status Changes GCS < 14 Combative Hard to arouse Inconsolable Bulging fontanelle Laceration with uncontrolled bleeding See Critical Criteria Hemophilia Symptomatic No correction at home	Head trauma with any of the following: Age < 3 mos LOC/amnesia Post-traumatic seizures Persistent vomiting (> 2 episodes of vomiting or any vomiting in the ED) Significant or severe headache GCS = 14 PE Irritable/change in behavior Periorbital bruising Bruising over mastoid Fluid or blood from the ear History of coagulopathy Cervical spine tenderness Parathesias Weakness Any suspicion for non-accidental trauma Ataxia Hemophilia Asymptomatic and Correction at home	Normal mental status: Any age Large non-frontal hematoma < 12 mos Any large hematoma < 2 yrs Non-frontal hematoma	Age > 3 mos – 2 yrs with normal PE or small frontal hematoma	> 2 yrs with minor mechanism, well-appearing, with small hematoma or abrasion Trauma history > 12 hrs ago with normal PE
See Trauma - Neck

Trauma – Neck

1 Critical	2 Acute	3 Urgent	4 Urgent	5 Non-Urgent
Penetrating trauma with respiratory compromise Uncontrolled bleeding See Critical Criteria	Neck pain Significant mechanism of injury Blunt injury to neck with: Weakness Paresthesias Numbness Change in voice Cervical spine tenderness* Significant injury and inability to assess neck due to age* Penetrating Trauma			Minor mechanism with no physical findings Minor hematomas or contusions of neck Abrasions
*See Triage Trauma – Head All patients with hx: trauma, limited ROM to neck, cervical tenderness should be collared and flat on stretcher.

Trauma – Torso

1 Critical	2 Acute	3 Urgent	4 Urgent	5 Non-Urgent
Cardiac or respiratory compromise Mental status change Gross hemorrhage Laceration with uncontrollable bleeding Muffled heart sounds Decreased breath sounds Peritoneal signs Penetrating trauma to torso	High-velocity blunt trauma to torso Tachycardia Chest pain Difficulty voiding Scrotal edema, pain Abdominal pain Gross hematuria Significant contusion or abrasion with suspected underlying injury	Laceration without suspected underlying injury requiring sedation	Point tender clavicle after low mechanism injury Simple laceration without suspected underlying injury not needing sedation Rib tenderness with no respiratory symptoms	Superficial abrasion or contusion without suspected underlying injury

Urine Output

1 Critical	2 Acute	3 Urgent	4 Urgent	5 Non-Urgent
	Hypertension Altered mental status with 2 or more: Polyuria Polyphagia Polydipsia Weight loss Anuria with: Pitting edema Facial edema	Normal PE with reported high blood sugar +/- ketones in urine Normal PE with 2 or more: Polyuria Polyphagia Polydipsia Weight loss Oliguria with: Tacky mucous membranes Tachycardia Decreased tears Unable to cath self Hematuria with: Flank pain	Urgency Increased frequency Dysuria Fever Hematuria Polyuria

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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