Manchester Triage System, START mass casualty triage, ABCDE primary survey, NEWS2 scoring, key time-critical interventions and GCC-specific triage contexts including Hajj mass gatherings.
Triage is the process of sorting patients by the urgency of their medical need to maximise survival and optimal outcomes when resources are limited. The word derives from the French trier (to sort). Triage is a dynamic, ongoing process — patient priority can change as condition evolves.
Core principle: Do the most good for the most patients. In mass casualty events, this may mean redirecting resources away from patients unlikely to survive, to those who will benefit most from immediate intervention.
Level 2 — VERY URGENT (Orange) — Target: 10 minutes. Severe pain, altered consciousness, major trauma. Examples: chest pain with ECG changes, stroke, sepsis, severe dyspnoea, major burns.
Level 4 — STANDARD (Green) — Target: 120 minutes. Mild distress, stable vital signs. Examples: minor lacerations, mild pain, urinary symptoms, minor soft tissue injury.
Level 5 — NON-URGENT (Blue) — Target: 240 minutes. No acute distress, chronic or minor complaints. Examples: medication review, minor rash, chronic pain follow-up.
START Triage (Mass Casualty)
Simple Triage and Rapid Treatment
Used in mass casualty incidents (MCIs) when patient numbers exceed normal ED capacity. Assessment takes <60 seconds per patient. Three sequential checks:
Step 1 — Breathing: Is patient breathing? If not → open airway → still not breathing = BLACK (expectant/dead). Breathing >30/min or <8/min = RED (immediate).
Step 2 — Perfusion (Radial Pulse/Capillary Refill): Radial pulse absent or capillary refill >2 seconds = RED. Control major haemorrhage.
Step 3 — Mental Status: Can patient follow simple commands? No = RED. Yes + walking wounded = GREEN (minor). Delayed non-urgent = YELLOW.
Tag Colour
Priority
Meaning
Action
BLACK
Expectant/Dead
Dead or unsurvivable injuries
Set aside; comfort only if resources permit
RED
Immediate
Life-threatening but salvageable
Treat immediately
YELLOW
Delayed
Serious but stable
Can wait 30–60 min for treatment
GREEN
Minor
Walking wounded, minor injuries
Self-treat or wait extended period
AVPU Scale
Rapid neurological assessment tool used in triage — quicker than GCS for initial sorting.
Level
Response
Equivalent GCS
A — Alert
Awake, aware, responds normally
GCS 15
V — Voice
Responds to voice only
GCS ~13
P — Pain
Responds to painful stimulus only
GCS ~8
U — Unresponsive
No response to any stimulus
GCS ~3
Primary Survey — ABCDE
Systematic ABCDE Assessment
Every acutely unwell patient receives a structured ABCDE assessment. Find and fix life-threatening problems at each step before proceeding to the next.
A
Airway + C-spine protection — Is airway patent? Look for stridor, gurgling, snoring. If unconscious, assume cervical spine injury until proven otherwise. Jaw thrust preferred over head tilt-chin lift in trauma. Consider airway adjuncts (OPA/NPA) or definitive airway (ETT) if needed.
B
Breathing — Assess respiratory rate, depth, symmetry, SpO₂, auscultation. Normal RR: 12–20/min. SpO₂ target ≥94% (≥88% in COPD). Look for tension pneumothorax (deviated trachea, absent breath sounds, hypotension = needle decompression). Apply O₂ if SpO₂ <94%.
C
Circulation — Heart rate, BP, capillary refill (<2 sec normal), skin colour/temperature. Control external haemorrhage (direct pressure, tourniquets). IV/IO access — two large-bore cannulas. If SBP <90 = shock — 250–500 mL crystalloid bolus and reassess.
D
Disability — GCS (Eyes 1–4, Verbal 1–5, Motor 1–6; total 3–15). Pupils: size, equality, reactivity. Blood glucose (BGL) — hypoglycaemia is easily reversible cause of altered consciousness. AVPU for rapid assessment. GCS ≤8 = unable to protect airway = intubation considered.
E
Exposure + Environment — Fully expose patient to identify all injuries (log roll for posterior assessment). Maintain dignity. Prevent hypothermia — apply warm blankets after examination. Check temperature, look for rashes, track marks, wounds, medical alert bracelets.
NEWS2 Scoring
National Early Warning Score 2
NEWS2 is a standardised early warning score used to detect clinical deterioration in adult patients. Each physiological parameter scores 0–3; total score guides escalation response.
Any patient with ST elevation on ECG in context of chest pain must be triaged as MTS Level 1 (Immediate) and the catheterisation lab activated immediately.
12-lead ECG within 10 minutes of ED arrival — do not delay
STEMI criteria: ≥1mm ST elevation in 2 contiguous limb leads, or ≥2mm in precordial leads
Activate cardiac cath lab — target PCI (primary percutaneous coronary intervention) within 90 minutes of first medical contact
Massive haemorrhage protocol (MHP): packed red cells : FFP : platelets in 1:1:1 ratio; tranexamic acid 1g IV within 3 hours of injury
Permissive hypotension (target SBP 80–90 mmHg) until surgical haemostasis achieved — prevents "popping the clot"
Damage control surgery: abbreviated surgery to stop bleeding/contamination, then ICU stabilisation before definitive repair
Paediatric Triage — Key Differences
Children are not small adults. Normal vital sign ranges vary by age and using adult thresholds risks under-triaging seriously ill children.
Age
Normal RR
Normal HR
Min SBP
Neonate (0–1 month)
30–60
100–160
50–70
Infant (1–12 months)
25–50
100–160
70–90
Toddler (1–3 years)
20–40
90–150
80–95
Child (4–12 years)
15–30
70–120
90–110
Use Paediatric Early Warning Score (PEWS) — incorporates behaviour, cardiovascular, and respiratory parameters. A child who is crying inconsolably or completely lethargic is a red flag regardless of vital signs.
Triage Pitfalls & Common Errors
Under-Triage
Assigning a lower priority category than warranted. Most dangerous error in triage — patients deteriorate without appropriate monitoring or intervention.
Silent MI in elderly diabetics — absent chest pain; may only present with dyspnoea or fatigue
Paediatric sepsis — children compensate physiologically until sudden decompensation
Aortic dissection — tearing back pain can mimic musculoskeletal; BP discrepancy between arms is key
Ectopic pregnancy — young woman with lower abdominal pain, vaginal bleeding; can rupture and exsanguinate
Meningococcal meningitis — non-blanching petechial rash may be subtle initially
Acceptable under-triage rate: <5%. Acceptable over-triage rate: <50% (over-triage is safer than under-triage).
Over-Triage
Assigning a higher priority than warranted — wastes resources but is safer than under-triage. Caused by patient/family anxiety, language barriers, poor pain tolerance thresholds.
Monitoring the Waiting Room
Regular re-triage of patients in waiting area — condition can deteriorate while waiting
Visual check of all waiting patients every 15–30 min minimum
Pain scores — patients in escalating pain need reassessment
Any patient waiting who develops new symptoms, syncope, or looks worse = immediate reassessment
Communication Failures in Triage
Language barriers — use certified interpreters; avoid using family members as interpreters for medical history
Clear documentation of triage time, category, vital signs, clinical findings and rationale
Closed-loop communication in team environments — read-back drug orders, confirm verbally
GCC-Specific Triage Context
Hajj — World's Largest Recurring Mass Casualty Scenario
The annual Hajj pilgrimage in Mecca, Saudi Arabia, brings 2–3 million pilgrims from over 180 countries, creating the world's largest recurring mass gathering event and an extraordinary triage challenge.
Mina and Arafat: Peak crowding in the tent cities of Mina and the plains of Arafat on Day 2 (Yawm Arafah) — highest risk of stampede, heat exhaustion, and respiratory emergencies
Heat emergencies: During summer Hajj, ambient temperature exceeds 45°C; heat stroke is a leading cause of Hajj mortality — mass triage at field hospitals uses START principles
Scale of medical response: Saudi MOH deploys 25,000+ healthcare workers; 147 hospitals and health centres; mobile ICUs; 5,000 ambulances along pilgrimage routes
Common triage presentations at Hajj: Heat stroke, crush injuries (Mina tunnel), respiratory infections (MERS-CoV, influenza), DKA (diabetics with altered diet/medication), MI, CVA, trauma
Hajj triage challenge: Pilgrims often remove ID wristbands for ritual purity reasons; multi-language barriers (Arabic, Urdu, Bengali, Indonesian, English, French); patients present at pilgrim hospital rather than nearest ER — creating surge demand.
Multi-Language Barriers in GCC Triage
GCC emergency departments serve one of the most linguistically diverse patient populations in the world. The nurse must be equipped for this.
Common languages in GCC EDs: Arabic (Gulf/Egyptian/Levantine dialects), Urdu/Hindi, Tagalog (Filipino), Malayalam (Kerala), Bengali, Sinhala, English
Mandatory use of certified medical interpreters — not family members — for clinical history taking and consent
Visual pain scales (numeric 0–10 face scales) and body diagrams support cross-language symptom communication
DHA/DOH/MOH require documentation of language used and interpreter ID when used
DHA/DOH Mandatory Triage Training Requirements ▼
Dubai Health Authority (DHA) and Department of Health Abu Dhabi (DOH) require all emergency nursing staff to complete MTS certification before independent triage practice
Annual competency reassessment for triage nurses — including NEWS2 documentation and escalation protocols
Mass casualty / disaster nursing training (including START triage) required for all emergency nurses in GCC accredited facilities
HAAD (now DOH) facilities must have documented mass casualty incident plans with triage annexes reviewed annually
GCC Heat Emergency Triage ▼
Heat exhaustion vs heat stroke must be distinguished at triage: heat stroke (core temp >40°C + CNS dysfunction) = MTS Level 1 Immediate
GCC summer triage volumes surge June–September — particularly outdoor construction workers presenting with heat illness
UAE "heat ban": outdoor work prohibited 12:30–3:00 PM (June 15–Sept 15) — violations reported to MOL; nurses in occupational health must understand this context
Active cooling initiated in triage area, not deferred to treatment room — cold wet towels, misting fans, cool IV fluids are first-line triage interventions
Construction & Industrial Trauma Triage in GCC ▼
GCC has one of the world's highest concentrations of construction workers — UAE, Qatar, KSA employ millions of low-income migrant workers on major infrastructure projects
Common triage presentations: fall from height (polytrauma), crush injury, electrical injury, heat exhaustion, chemical splash, penetrating injury
Language barriers (Urdu, Bengali, Nepalese, Tamil) frequently complicate triage history — use pain scale and mechanism-of-injury diagram
Nurses should be aware of occupational insurance/compensation systems — WORKMEN'S COMPENSATION ACT applies to expat workers in most GCC states
Qatar's Worker Support and Insurance System (implemented pre-2022 FIFA World Cup) provides occupational health pathways for injured migrant workers
Exam MCQs — DHA / DOH / SCFHS / QCHP
Q1. A 58-year-old man presents to the emergency department with sudden onset crushing chest pain radiating to his left arm for 45 minutes. His ECG shows 3mm ST elevation in leads V1–V4. He is diaphoretic and anxious. Using the Manchester Triage System, what is the CORRECT triage category?
The correct answer is B. ST elevation in 2+ contiguous leads in the context of chest pain = STEMI. This is a life-threatening emergency requiring IMMEDIATE (Red, Level 1) response. The STEMI pathway requires cardiac catheterisation lab activation and door-to-balloon time target of <90 minutes. Waiting for haemodynamic compromise before triaging as Immediate is incorrect — STEMI is immediately life-threatening regardless of current BP. Dual antiplatelet therapy must also be administered immediately.
Q2. You are triaging at a mass casualty incident following a building collapse during construction at a labour camp in Dubai. A young male worker is found unresponsive. You open his airway and he begins breathing at 32 breaths/minute. His radial pulse is absent and capillary refill is 4 seconds. Using START triage, what tag should he receive?
The correct answer is C. In START triage, a patient who breathes spontaneously after airway opening but has RR >30/min OR absent radial pulse (capillary refill >2 seconds) receives a RED (Immediate) tag. This patient meets BOTH criteria — RR 32/min AND absent radial pulse. RED tags receive priority treatment. BLACK tags are for those who do NOT breathe even after airway opening (or clearly unsurvivable injuries in austere conditions). An absent radial pulse alone does not indicate death — it indicates haemodynamic compromise requiring urgent intervention.
Q3. A 72-year-old woman with known COPD is transferred from a ward. Her NEWS2 score calculation gives: RR 24/min (score 2), SpO₂ 93% on 2L O₂ (score 1), BP 95/60 (score 2), HR 118 (score 2), Temperature 38.9°C (score 1), new confusion (score 3). What is her total NEWS2 score and the appropriate response?
The correct answer is B — wait, the total is actually correct in C. Calculation: RR(2) + SpO₂(1) + BP(2) + HR(2) + Temp(1) + Confusion(3) = 11. NEWS2 ≥7 = HIGH RISK requiring EMERGENCY response — immediate senior medical review, critical care team notification, and consideration of HDU/ICU transfer. This patient likely has sepsis (new confusion, low BP, tachycardia, elevated temperature) — initiate Sepsis-6 bundle: blood cultures, IV antibiotics within 1 hour, IV fluid bolus, serum lactate, urine output monitoring, supplemental oxygen. The correct answer is C.
Q4. During the ABCDE primary survey of a road traffic accident victim, you note the trachea is deviated to the LEFT, breath sounds are absent on the RIGHT, HR is 138, and BP is 72/40. The patient is in severe respiratory distress. What is the IMMEDIATE priority action?
The correct answer is C. The clinical picture is a classic tension pneumothorax: tracheal deviation AWAY from the affected side (trachea left = tension on right), absent breath sounds on the right, haemodynamic compromise (HR 138, BP 72/40). Tension pneumothorax is diagnosed CLINICALLY and treated IMMEDIATELY — do not wait for CXR. Needle decompression: 14–16G cannula at 2nd intercostal space, mid-clavicular line, upper border of 3rd rib (to avoid neurovascular bundle). This is a STEP B (Breathing) emergency in the ABCDE — circulatory collapse is SECONDARY to the tension pneumothorax and will resolve after decompression.