Triage Protocol

In emergency situations, triage protocol is your guide to quickly assessing and prioritising patients based on the severity of their injuries or conditions. It helps EMS teams make critical decisions on who needs immediate care, who can wait, and how to allocate limited resources effectively.

Triage Process (ABCDE Method)

Always assess patients using the ABCDE approach:

A – Airway: Ensure the airway is clear of obstructions.
B – Breathing: Assess respiratory rate and quality (regular vs. irregular).
C – Circulation: Check for a pulse, blood pressure, and signs of perfusion.
D – Disability/Diagnosis: Identify and treat any visible injuries or neurological deficits.
E – Exposure/Environment: Expose the patient as needed to assess for hidden injuries, infections, rashes, or environmental threats.

Triage Classifications

🟢 Green – Minor (Walking Wounded)

Patients with non-life-threatening injuries who can walk and care for themselves with minimal assistance.

Minor cuts and abrasions
Bruises
Sprains or twisted ankles

🟡 Yellow – Delayed (Moderate)

Stable patients who require treatment but are not in immediate danger. May need transport to a hospital.

Fractures (not compound)
Deep lacerations without severe bleeding
Stable vitals, but injury requires monitoring

🔴 Red – Immediate (Critical)

Patients in critical condition needing immediate life-saving intervention. Requires constant attention.

Multiple gunshot wounds (GSWs)
Severe blood loss or uncontrolled hemorrhaging
Unconscious with low/irregular vitals
Third- or fourth-degree burns
Life-threatening trauma

⚫ Black – Deceased/Expectant

Patients with injuries incompatible with life or confirmed dead on arrival (DOA). If applicable, attempt resuscitation once.

Decapitation
Evisceration or missing critical organs
Exsanguination (complete blood loss)
Signs of irreversible death

Emergency Codes & Alerts

Plain Language Preferred

Most states recommend plain language alerts for clarity. The only exception is:

Code Blue – Cardiac Arrest / No Signs of Life

Criteria to initiate Code Blue:

No pulse
Not breathing
Airway is clear (no visible obstruction)
No open chest wound

Steps for Response:

Begin CPR immediately (30 compressions, 2 breaths)
Remove upper clothing to expose the chest — ensure the skin is dry
Turn on and apply the AED (Automated External Defibrillator)
Follow AED instructions:
- If shock advised, deliver shock
- If no shock advised, continue CPR
Repeat for up to 3 shocks
If ROSC (Return of Spontaneous Circulation) not achieved, continue CPR while transporting to the hospital

⚠️ AED will determine the appropriate energy levels automatically.