Emergency Department 5-Tier Triage Guidelines
Benchmark: 90% of patients evaluated within 10 minutes of registration
Imminent life-threat, unstable vital signs requiring immediate resuscitation.
Potentially life-threatening, borderline vitals with high risk of rapid deterioration.
Major condition with stable vitals but potential for progression.
Acute but stable, can wait safely without serious complications.
Minor, chronic or stable conditions suitable for primary care.
🫁 Airway, Respiration & Level of Consciousness Cat 1 / 2 Triggers
- Respiratory arrest, agonal gasping, RR < 10/min, central cyanosis, unable to speak
- Stridor, acute laryngeal edema, complete upper airway obstruction
- COPD patient on oxygen (≥ 2L/min) with SpO2 < 85%; non-COPD on oxygen with SpO2 < 90%
- Unresponsive or responding to pain stimulation only (AVPU: P or U)
- Moderate dyspnea: non-COPD room air SpO2 < 90%; COPD on 2L O2 with SpO2 85–90%
- Marked accessory muscle use, intercostal retractions, speaking in short phrases only
- Responds to verbal stimulation only (AVPU: V); acute focal deficit triggering Acute Stroke Protocol
🩸 Circulation, Hemodynamics & Major Trauma High Energy Mechanism
- Cardiac arrest, unrecordable BP, adult SBP < 90 mmHg with cold diaphoresis / collapse
- Cardiac arrhythmia with HR > 140 or < 50 bpm with hemodynamic compromise; ICD firing
- Flail chest, unstable pelvic fracture, ≥ 2 proximal long bone fractures, limb amputation
- High energy trauma: Fall > 6m (children > 3m), vehicle ejection, death in same compartment
- Compensated shock: HR > 120 bpm, capillary refill time (CRT) > 2 sec, cold clammy skin
- Hypertensive crisis: SBP > 180 or DBP > 100 mmHg with end-organ injury (angina, dyspnea, back pain)
- Suspected cardiac chest pain not relieved by sublingual NTG; severe neurovascular limb compromise
Adult Advanced Cardiovascular Life Support (ACLS Algorithm)
High-Quality CPR: Depth 5–6 cm, rate 100–120 bpm, allow full chest recoil, minimize pauses
⚡ Shockable Rhythms
VF / Pulseless VT🚫 Non-Shockable Rhythms
Asystole / PEA🔍 Reversible Causes Rapid Check: The 5 Hs & 5 Ts Click to toggle
- • Hypovolemia: Rapid fluid bolus, blood products, early TXA administration.
- • Hypoxia: 100% high-flow oxygen, airway patency, BVM ventilation.
- • Hydrogen Ion (Acidosis): Optimize ventilation/washout; consider NaHCO3 for severe metabolic acidosis.
- • Hypo/Hyperkalemia: Calcium chloride/gluconate + insulin-dextrose for severe hyperkalemia.
- • Hypothermia: Active external rewarming, warmed IV infusions.
- • Tension Pneumothorax: Immediate needle decompression (2nd intercostal MCL / 4th-5th AAL).
- • Tamponade (Cardiac): Emergent ultrasound-guided pericardiocentesis.
- • Toxins (Overdose): Specific antidotes (Naloxone, NaHCO3, Atropine, Fab fragments).
- • Thrombosis, Pulmonary (PE): Consider systemic thrombolytic therapy (tPA) or mechanical thrombectomy.
- • Thrombosis, Coronary (STEMI): Prompt cardiac cath lab activation for primary PCI.
Return of Spontaneous Circulation (ROSC: Post-Cardiac Arrest Care)
Goals: Maintain organ perfusion, prevent secondary brain injury, and treat underlying triggers
If hypotensive, infuse 1–2 L isotonic crystalloid; initiate Norepinephrine (0.1–0.5 mcg/kg/min) early if refractory.
Avoid hyperoxia (prevents free-radical injury); avoid hyperventilation (preserves venous return and cerebral perfusion).
If STEMI or high suspicion of acute coronary occlusion, activate emergency catheterization lab (Primary PCI).
If comatose after ROSC, maintain constant target temperature for ≥ 24 hours; strictly prevent pyrexia (> 37.7°C).
Operational Paramedic Clinical Protocols Pre-Hospital Clinical Standards
Cardiac Chest Pain Protocol ASA + NTG + Penthrox
Indication: Age > 12 years with chest discomfort suggestive of cardiac origin.
Dosage: Single dose of 200 mg chewable ASA orally.
Contraindications: Age ≤ 12, inability to swallow, pregnancy, allergy to ASA/NSAIDs, active uncontrollable bleeding, surgery within 1 week, self-taken Aspirin within 24 hours, LVAD patients.
Indication: Suspected cardiac chest pain in patients previously prescribed NTG/nitrates.
Dosage: 0.4 mg (1 puff) sublingually. Reassess every 5 mins, maximum 3 doses.
Four Absolute Contraindications:
- PDE5 inhibitor use within 72 hours (Viagra, Cialis, Levitra)
- Systolic Blood Pressure SBP < 100 mmHg
- Heart Rate HR > 150 bpm
- Hypersensitivity to nitrates
Glycemia Protocol Hypo ≤4.0 / Hyper >20.0 mmol/L
Establish IV line and infuse Normal Saline at 200 ml/hr en-route to hospital. No 2nd H'stix required.
Advanced Anaphylaxis Protocol Jext 300 / Piriton / Ventolin
Diagnostic Criteria: Acute skin manifestation (mandatory) + [Airway compromise OR SBP < 90 mmHg (child CRT > 2s)].
Tranexamic Acid (TXA) Protocol 1,000 mg IV over 10 mins
Indications (All must be fulfilled): Major trauma with suspected massive hemorrhage, injury onset within 3 hours, age ≥ 18 years, and SBP < 90 mmHg (LVAD CRT > 2s) OR ultrasound-confirmed hemothorax / free peritoneal fluid.
Hypovolemia Fluid Resuscitation Protocol Target SBP ≥ 90 mmHg
Primary Goal: Replenish vascular volume to maintain SBP ≥ 90 mmHg (or CRT ≤ 2s in LVAD patients).
- If initial SBP ≥ 90 mmHg: Infuse Normal Saline at 100 ml/hr to preserve organ perfusion.
- If SBP < 90 mmHg: Immediately administer a 500 ml N/S Rapid Infusion (full rate) without intra-bolus titration.
- Reassess blood pressure just prior to finishing the first 500 ml:
• If SBP recovers to ≥ 90 mmHg → switch to 500 ml/hr maintenance.
• If SBP remains < 90 mmHg → administer a 2nd 500 ml Rapid Infusion, then maintain at 500 ml/hr.
Venturi Controlled Oxygen Protocol COPD Target SpO2 90–94%
Target Patients: COPD patients with shortness of breath, long-term home O2 therapy with SpO2 < 90%, or room air SpO2 < 94%.
Reassess in 0.5–1 min if initial SpO2 < 85%; reassess in 1–2 mins if SpO2 is 85–89%.
Step-up sequence: 0.24 (3L) → 0.26 (3L) → 0.28 (3L) → 0.31 (6L) → 0.35 (6L) → 0.40 (6L) → 0.50 (6L).
If SpO2 remains below 90% despite FiO2 0.50, switch to Non-Rebreather Mask (NRB) and prepare assisted ventilation with BVM.
Respiratory Bronchodilator Protocol (MDI with LiteAire) Salbutamol + Atrovent
Indications: Bronchoconstriction / wheezing (Asthma, COPD, chemical irritant inhalation or tear gas exposure).
• 2 to < 5 yrs: 200 mcg (2 puffs)
• 5 to < 12 yrs: 300 mcg (3 puffs)
• ≥ 12 yrs / Adult: 400 mcg (4 puffs)
Repeat every 5 minutes if unresolved, up to 4 doses max.
Add 40 mcg (2 puffs) with 1st dose only.
Contraindications: < 12 yrs, acute glaucoma attack, atropine allergy. Do NOT repeat in subsequent doses.
Inhalation Technique: 1 puff into LiteAire, 2 slow breaths; after the final puff, breathe slowly 5 times.
Tramadol Analgesia Protocol CHEAP PAIN Contraindications
Indication: Conscious, fully oriented patient with severe acute trauma pain to trunk/limbs when Penthrox is inappropriate or contraindicated.
- • C: Cough mixture within past 2 weeks (TCM or codeine-containing)
- • H: Hypotension (SBP < 90 mmHg / LVAD CRT > 2s)
- • E: Epilepsy or seizure history
- • A: Age < 18 years
- • P: Psychiatric drugs/history within 2 weeks (prevents Serotonin Syndrome)
- • P: Pregnant or breastfeeding
- • A: Abuser (substance / opioid dependence history)
- • I: Intoxication with acute alcohol
- • N: Narcotics hypersensitivity
🧠 Glasgow Coma Scale Calculator (GCS)
Standard emergency neurological assessment: Eye Opening (E), Verbal (V), Motor (M)
🧪 Emergency Toxicology & Specific Antidotes
Source: Hospital Authority Emergency Triage Core Standards Appendix 3
| Poison / Substance | Specific Antidote | Clinical Mechanism & Key Considerations |
|---|---|---|
| Paracetamol (Acetaminophen) | N-acetylcysteine (NAC) | Restores hepatic glutathione stores; prevents fatal toxic centrilobular liver necrosis. |
| Opiates / Opioids (Morphine, Heroin) | Naloxone (Narcan) | Competitive antagonist at mu-opioid receptors; reverses respiratory depression and pinpoint pupils. |
| Benzodiazepines (BZD) | Flumazenil | GABA receptor antagonist; use with caution: may precipitate intractable seizures in chronic users. |
| Organophosphates / Carbamates | Atropine + Pralidoxime (PAM) | Atropine blocks muscarinic toxidromes (dry secretions, bronchodilation); PAM reactivates cholinesterase. |
| Beta-Blockers | Glucagon | Bypasses beta-adrenergic receptors to stimulate myocardial adenylate cyclase and increase cAMP. |
| Tricyclic Antidepressants (TCA) | Sodium Bicarbonate (NaHCO3) | Serum alkalinization and sodium loading overcome myocardial fast sodium channel blockade (QRS narrowing). |
| Cyanide (CN) | Hydroxocobalamin / Sodium Nitrite | Binds cyanide ions with higher affinity than cytochrome oxidase to form non-toxic cyanocobalamin (Vit B12). |
| Carbon Monoxide (CO) | 100% Normobaric O2 / Hyperbaric (HBO) | Accelerates carboxyhemoglobin (COHb) clearance; half-life reduced from 320 mins to 80 mins. |
| Digoxin | Digoxin-Specific Fab (Digibind) | Specific antigen-binding fragments directly bind and neutralize free intravascular digoxin. |
| Methanol / Ethylene Glycol | Fomepizole / Ethanol + Folate | Inhibits alcohol dehydrogenase (ADH), preventing toxic formic acid and oxalate accumulation. |
🛡️ Management of Suspected Elder Abuse in A&E
Definition: Persons aged 60 or above subjected to harm or neglect within an expectation of trust
- Unexplained bruises in clusters, patterns, or different colors indicating multistage injuries.
- Atypical fractures: spiral fractures of long bones (twisting), nightstick defense fractures.
- Maxillofacial, dental, and neck injuries (abuse victim incidence 67% vs non-abuse falls 28%).
- Cigarette burns, scald marks without splash splashdown, restraint wrist/ankle marks.
- Severe neglected pressure ulcers, severe dehydration, or marked malnutrition.
- Interview in Isolation: Must interview elder separately from the suspected caregiver to reduce intimidation.
- Immediate Safety Threats: Admit to EMW / M&G / Psychiatry if clinical condition requires or suicidal risk exists.
- Medical Social Worker (MSW): Refer all suspected cases to MSW (with patient consent) for welfare disposition.
- Hospital Liaison Doctor: Alert designated cluster Elder Abuse Liaison Doctor if the patient requires hospital admission.
Emergency Intubation & Rapid Sequence Induction (RSI Guide)
Indications: Inability to protect airway (GCS ≤ 8 / aspiration risk), hypoxic/ventilatory failure, expected rapid decline
📋 Equipment & Personnel Checklist (SOAP ME)
⚡ The 7 Ps of Rapid Sequence Induction (RSI Timeline)
Complete SOAP ME checklist, evaluate difficult airway criteria, brief team roles.
100% O2 via NRB 15 L/min + Nasal Cannula 15 L/min for 3 mins to denitrogenate lungs.
Optimize hemodynamics: bolus fluids or vasopressors to prevent post-induction arrest.
Rapid IV push of induction sedative (Ketamine) immediately followed by paralytic (Rocuronium).
Maintain continuous apneic oxygenation; avoid routine bag-mask ventilation to prevent gastric distension.
Direct visualization across vocal cords, inflate cuff, confirm with continuous Waveform ETCO2.
Secure tube depth (incisors 21–23 cm), connect ventilator, initiate post-intubation sedation, CXR.
💉 RSI Induction & Neuromuscular Blocker Quick Reference Weight-Adjusted Dosing
| Medication | Class | IV Dose | Onset / Duration | Key Clinical Features & Contraindications |
|---|---|---|---|---|
| Ketamine | Sedative / Dissociative | 1.5 – 2.0 mg/kg | 45–60 sec / 10–20 min | First choice for shock, sepsis, severe asthma (sympathomimetic preserves blood pressure, bronchodilator). |
| Etomidate | Sedative / Hypnotic | 0.3 mg/kg | 30–45 sec / 5–12 min | Hemodynamically neutral; causes transient adrenal cortical suppression (caution in severe sepsis). |
| Propofol | Sedative / Hypnotic | 1.5 – 2.5 mg/kg | 30–45 sec / 5–10 min | Rapid onset, potent anticonvulsant. Causes severe myocardial depression and vasodilation; avoid in hypotension. |
| Rocuronium | Non-depolarizing NMB | 1.2 mg/kg (RSI dose) | 60 sec / 45–60 min | Emergency first-line paralytic; no hyperkalemia risk. Can be rapidly reversed with Sugammadex (16 mg/kg). |
| Suxamethonium (Succinylcholine) | Depolarizing NMB | 1.5 – 2.0 mg/kg | 45 sec / 6–10 min | Fastest onset and short recovery. Contraindications: Hyperkalemia, burns/crush > 24h, denervation, malignant hyperthermia. |
⚠️ Difficult Airway Evaluation (LEMON Rule) Pre-Intubation
- • L - Look externally: Micrognathia, retrognathia, morbid obesity, short neck, facial trauma, facial burns.
- • E - Evaluate 3-3-2: Inter-incisor gap < 3 fingers, hyoid-mental distance < 3 fingers, thyroid-to-hyoid < 2 fingers.
- • M - Mallampati score: Class III or IV predicts difficulty in direct laryngeal visualization.
- • O - Obstruction / Obesity: Stridor, epiglottitis, laryngeal tumor, Ludwig's angina, severe obstructive apnea.
- • N - Neck mobility: Cervical spine immobilization, ankylosing spondylitis, severe degenerative disease.