Emergency Department Triage Assessment Adapted Australasian Triage Scale (ATS) for Nauru — Low-Resource Pacific Island Setting
🧮 Triage Calculator 📋 Triage Categories 📖 Quick Reference Guide
Triage Scoring Calculator Answer each question to determine the appropriate triage category. Select the option that best describes the patient's current condition. The calculator will automatically determine the triage level based on the cumulative score.
1. Airway Status Patent and clear Score: 0
No airway compromise
At risk — stridor, drooling, swelling Score: 3
Potential airway obstruction
Obstructed or absent gag reflex Score: 5
Immediate airway intervention needed
2. Breathing / Respiratory Status Normal rate and effort, SpO2 > 95% Score: 0
No respiratory distress
Mild distress, SpO2 90–95% Score: 1
Mild respiratory compromise
Moderate distress, SpO2 85–90%, accessory muscles Score: 3
Significant respiratory compromise
Severe distress, SpO2 < 85%, apnoeic episodes Score: 5
Life-threatening respiratory failure
3. Circulatory Status Normal BP, HR, warm peripheries, CRT < 2s Score: 0
Hemodynamically stable
Tachycardia or mild hypotension, CRT 2–4s Score: 1
Mild circulatory compromise
Hypotension (SBP < 90), tachycardia > 120, cool peripheries Score: 3
Significant shock
Unrecordable BP, absent pulses, cardiac arrest Score: 5
Circulatory collapse
4. Level of Consciousness (GCS / AVPU) Alert and oriented (GCS 15) Score: 0
Normal consciousness
Confused or agitated (GCS 13–14) Score: 1
Mild alteration
Responds to voice only (GCS 9–12) Score: 3
Significant alteration
Responds to pain only or unresponsive (GCS ≤ 8) Score: 5
Comatose — protect airway
5. Pain Severity (0–10 Scale) None or mild (0–3) Score: 0
Manageable pain
Moderate (4–6) Score: 1
Requires analgesia
Severe (7–8) Score: 2
Urgent pain management needed
Excruciating (9–10) Score: 3
Immediate pain management
6. Hemorrhage / Bleeding No active bleeding Score: 0
No hemorrhage
Minor bleeding — controlled with pressure Score: 1
Minor hemorrhage
Moderate bleeding — ongoing despite pressure Score: 3
Significant hemorrhage
Major uncontrolled hemorrhage Score: 5
Life-threatening hemorrhage
7. Temperature Normal (36.0–37.5°C) Score: 0
Normothermic
Mild fever (37.5–38.5°C) or mild hypothermia (35–36°C) Score: 1
Mild temperature abnormality
High fever (38.5–41°C) or moderate hypothermia (33–35°C) Score: 2
Significant temperature abnormality
Hyperpyrexia (> 41°C) or severe hypothermia (< 33°C) Score: 4
Life-threatening temperature
8. Mechanism of Injury / Risk Factors Low energy / no significant mechanism Score: 0
Low risk
Moderate mechanism (fall from height < 3m, MVA < 60km/h) Score: 1
Moderate risk
High energy mechanism (fall > 3m, MVA > 60km/h, penetrating injury) Score: 3
High risk — assume worst case
Total Score: 0 Calculate Triage Level Reset