Triage front-load
Lead with information that changes triage priority, immediate management or destination decisions.
50 presentations
Abdominal pain
Onset/location. Sudden vs gradual. Migration/radiation.
Alcohol intoxication
Amount and last drink. Normal pattern. Co-ingestants.
Allergic reaction / anaphylaxis
Trigger and exposure time. Skin findings. Facial/tongue swelling.
Altered LOC / confusion
Last known normal. Cognitive baseline. GCS and trend.
Assault / penetrating trauma
Mechanism/weapon. Number/location of wounds. Blood loss.
Asthma exacerbation
Trigger/duration. Work of breathing. Speaking full sentences?
Back pain
Traumatic or atraumatic? Sudden/gradual. Midline vs muscular.
Burns
Mechanism/time. Thermal/chemical/electrical. Approximate TBSA/depth.
Cardiac arrest / ROSC
Witnessed? Collapse/downtime. Bystander CPR.
Chest pain / suspected ACS
Exact onset and activity at onset. Character/location/radiation. Persistent or resolved?
CHF / acute pulmonary edema
Acute vs progressive dyspnea. Orthopnea/PND. Edema/weight gain.
Choking / airway foreign body
Complete or partial obstruction? Object/food. Initially able to speak/cough?
COPD exacerbation
Baseline respiratory status and SpO2/O2. Change from baseline. Increased/change in sputum.
Diarrhea
Duration/frequency. Blood or melena? Abdominal pain.
Dizziness / vertigo
Clarify spinning vs lightheadedness vs imbalance. Sudden/gradual. Exact onset/last known well.
Epistaxis
Duration. Still bleeding? Unilateral/bilateral.
Extremity injury / suspected fracture
Mechanism. Open or closed? Deformity?
Fall
Cause/mechanism? Mechanical vs medical? Head strike?
Fever / suspected infection / sepsis
Suspected source. Duration/max temperature. Current temperature.
Flank pain / renal colic
Sudden onset. Unilateral? Radiation to groin.
Functional decline / inability to cope
What changed today? Acute complaint vs progressive decline. Baseline/current mobility and ADLs.
General weakness / malaise
Sudden or gradual? Global vs focal weakness? Baseline function?
GI bleed
Hematemesis, coffee-ground emesis, melena or hematochezia? Amount/frequency. Active bleeding?
Head injury
Mechanism. LOC? Amnesia?
Headache
Sudden or gradual? Thunderclap/maximal at onset? First/worst or different?
Heat / cold exposure
Type/duration of exposure. Environment. Core temp if available.
Hip / pelvic injury
Mechanism. Able to weight-bear? Pain location.
Hyperglycemia / possible DKA-HHS
BGL. Ketones if available. Diabetes type.
Hypertension
BP and trend. Why was it measured/called in? Headache?
Hypoglycemia
Initial BGL. Initial LOC/GCS. Seizure?
Hypotension / shock
BP and trend. Baseline if known. Poor perfusion?
Laceration / external hemorrhage
Location/mechanism. Active bleeding? Approximate blood loss.
Mental health / suicidal ideation
Primary concern. Suicidal thoughts? Plan, intent, access to means?
Motor vehicle collision
Collision type/speed. Restrained? Airbag?
Nausea / vomiting
Duration and frequency. Blood/coffee-ground material? Bilious?
Overdose / drug poisoning
Substance(s), amount, route and time. Intentional or accidental? Co-ingestants.
Palliative / end-of-life symptom crisis
Primary symptom. Known diagnosis. Goals of care/resuscitation status.
Palpitations / tachyarrhythmia
Sudden onset? Duration. Current rhythm/rate.
Pediatric fever / unwell child
Exact age. Duration/max temp. Appearance/interaction.
Pediatric respiratory distress
Onset. Work of breathing/retractions. Stridor, wheeze, barky cough or crackles.
Poisoning / toxic exposure
Agent, amount/concentration, route and exact time. Intentional vs accidental. Co-exposures.
Pregnancy / labour
Gestational age, gravida/para, due date. Contraction frequency/duration. Membranes ruptured - when/fluid colour.
Seizure
First seizure or known disorder? Witnessed? Duration?
Shortness of breath - undifferentiated
Sudden or gradual? Degree of distress. SpO2 on room air and now.
Stroke / TIA
Exact last-known-well. First deficit noticed. Face/arm/leg weakness, speech, vision, neglect/ataxia.
Submersion / drowning
Estimated submersion time. Witnessed? Water type/temp.
Syncope / presyncope
Complete LOC or near-syncope? Preceding symptoms? Exertional?
Unilateral swollen/red/painful leg
Acute vs chronic. Unilateral swelling, redness, warmth. Calf/thigh pain.
Urinary complaint / UTI / retention
Dysuria/frequency. Unable to void? Last urination.
Vaginal bleeding / gynecologic emergency
Pregnancy possible/confirmed? Gestational age. Amount/pads/clots.