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Table 1 The mJTAS triage scale. The triage nurse checks each domain and determines the patient’s triage level based on the domain with the most significant triage level

From: Validation of the modified Japanese Triage and Acuity Scale-based triage system emphasizing the physiologic variables or mechanism of injuries

Triage level Resuscitation Emergency Urgency Low urgency Non-urgency
Consciousness GCS <9 GCS 10–13 GCS 14 Alert  
Breathing SpO2 <90 %
or
speak only single word
or
upper airway obstruction
SpO2 <92 %
or
labored breathing
SpO2 <94 %
or
respiratory rate >22
SpO2 >95 %
and
breathing normally
 
Circulation Shock (systolic blood pressure under 80 mmHg or shock index (systolic blood pressure/heart rate) <1)
or
weak pulse
Diaphoresis
or
tachycardia (over 120 beats per minute)
or
history of orthostatic hypotension
Apparently abnormal blood pressure (systolic blood pressure >160 or <100 mmHg) Normal blood pressure  
Thermal status   SIRS criteria more than 3/4, including a fever higher than 38.5°
or
known to have neutropenia or a steroid user
SIRS criteria 2/4, including a fever higher than 38.5° Fever only  
Pain    Pain scale
>8/10
Pain scale
4–8/10
 
Bleeding   Active bleeding from head, neck, or trunk
or
accompanied with an open fracture
Epistaxis
or
active bleeding from oral cavity
Stopped bleeding  
Mechanism of injury   Ejected from a vehicle over 40 km/h
or
pedestrian hit by a vehicle
or
Fall from over 6 m
or
penetration injury
Motor vehicle accidents which do not meet the description within the left column Bicycle accidents  
Special situation Cardiopulmonary arrest Acute chest pain
or
hemiparesis
   Stable symptom(s) over 8 weeks
  1. SIRS systemic inflammatory response syndrome