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

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