Triage (Chapter 1)

Learning objectives

After completion of this session the participant should be able to:
‘Triage’ means ‘sorting’

EMERGENCY [E] patient must be seen at once
may need life-safing treatment
PRIORITY [P] patient needs rapid assessment
needs to be seen soon
NON-URGENT* [Q] patient can safely wait to be seen
* NYI are never in this category


Emergencies are sent straight to the best place for resuscitation.

The ABCCCD concept is used to identify emergencies. This is a logical and quick way of identifying how sick a child is; it does not take the place of a thorough examination to make a diagnosis but is a screening tool to identify problems that require immediate attention.

For triage, we need to know:

Emergency Signs Emergency Treatment
Airway and Breathing Not breathing
Centrally cyanosed
Noisy breathing
Severe respiratory distress
Manage the airway
Give oxygen
If present, remove foreign body, BMV
Circulation Cold hands
Capillary refill of > 3secs
Weak and fast pulse
Manage the airway
Give oxygen
Start fluids 10ml/Kg IV
Coma/ Convulsions Unconscious
Low blood sugar
Manage the airway
Give oxygen
Give 10% Dextrose IV
Position the baby
Dehydration Lethargy
Sunken eyes
Prolonged skin pinch >2secs
No Malnutrition
Give IV fluids +NGT
Severe Malnutrition
Give NGT, try to avoid IV

Also see


Priorities are sent to the front of the queue to be seen quickly.

When emergencies have been excluded, signs and symptoms for priority are looked for. Priority signs can be remembered with the letters 3TPR, MOB. Remember that all infants less than 2 months of age are priorities. This is because infants can deteriorate rapidly; they are difficult to assess without a thorough examination; and to prevent them remaining in a queue exposed to infections from other children.

Priority signs are:

3Ts Tiny (less than 2 month of age)
Temperature (high temperature as judged by your hand)
3Ps Pain
3Rs Respiratory distress (not life threatening)
Referral (urgent)
MOB Malnutrition