# Triage Systems Reference

## Overview

This skill integrates multiple international triage standards for standardized emergency assessment.

## Triage Levels

### Level 1 - Resuscitation (Red)
- **Response Time**: Immediate
- **Description**: Life-threatening conditions requiring immediate intervention
- **Examples**: 
  - Cardiac arrest
  - Severe trauma
  - Respiratory failure
  - Severe bleeding
  - Shock

### Level 2 - Emergent (Orange)
- **Response Time**: < 15 minutes
- **Description**: High-risk conditions requiring rapid evaluation
- **Examples**:
  - Chest pain (possible MI)
  - Severe abdominal pain
  - Altered mental status
  - High fever in infants
  - Severe asthma attack

### Level 3 - Urgent (Yellow)
- **Response Time**: < 30 minutes
- **Description**: Conditions requiring prompt attention
- **Examples**:
  - Moderate abdominal pain
  - Fever without red flags
  - Minor trauma
  - Vomiting/diarrhea
  - Urinary symptoms

### Level 4 - Less Urgent (Green)
- **Response Time**: < 60 minutes
- **Description**: Stable conditions that can wait
- **Examples**:
  - Minor injuries
  - Chronic symptoms
  - Stable chronic conditions
  - Prescription refills

### Level 5 - Non-urgent (Blue)
- **Response Time**: > 60 minutes
- **Description**: Non-urgent conditions suitable for primary care
- **Examples**:
  - Follow-up appointments
  - Minor complaints
  - Administrative requests

## Red Flag Symptoms

### Cardiovascular
- Chest pain/pressure
- Severe palpitations
- Syncope
- Signs of shock

### Neurological
- Altered consciousness
- Seizures
- Severe headache (thunderclap)
- Focal neurological deficits

### Respiratory
- Severe dyspnea
- Cyanosis
- Stridor
- Respiratory rate < 8 or > 30

### Other Critical Signs
- Severe bleeding
- Severe allergic reaction
- High fever with rash
- Suicidal ideation

## References

1. **ESI (Emergency Severity Index)**
   - 5-level triage algorithm
   - Resource-based classification
   - Used primarily in US emergency departments

2. **Manchester Triage System (MTS)**
   - International standard
   - Discriminator-based system
   - Widely used in Europe and globally

3. **CTAS (Canadian Triage and Acuity Scale)**
   - 5-level system
   - Time-to-physician benchmarks
   - Used across Canada

## Clinical Guidelines

- NICE (National Institute for Health and Care Excellence)
- WHO (World Health Organization)
- ACEP (American College of Emergency Physicians)