HEATS Manual

HOSPITAL KUALA LUMPUR
EMERGENCY

ASSESSMENT FOR

TRIAGE

SEVERITY (H.E.A.T.S) TRIAGE MANUAL

JABATAN KECEMASAN
DAN TRAUMA
HOSPITAL
KUALA LUMPUR

Hospital Kuala Lumpur
Emergency Assessment For Triage Severity
(H.E.A.T.S)
TABLE OF CONTENT

Chapter 1 HEATS user manual 4
Chapter 2 Introduction
2.1 Overview statement 5
2.2 Triage definition 5
2.3 Triage objective 5
2.3.1 General Objective 5
2.3.2 Specific Objective 6
2.4 HKL Emergency Assessment Triage Severity (HEATS) 6
Chapter 3 Workflow at Primary Triage ETDHKL 7
Chapter 4 General Statement
4.1 The triage assessment 8
4.2 Time to treatment 8
4.3 Treatment Zones 9
4.3.1 Red zone (Critical I zone) 9
4.3.2 Amber zone (Critical II zone) 9
4.3.3 Yellow zone (Semi-critical zone) 9
4.3.4 Green zone (Non-critical zone) 10
4.3.5 Decontamination Zone 11
4.4 Presenting complaints 12
Chapter 5 Paediatric Assessment Triangle (PAT) 15
Chapter 6 Presenting Complaints Triage Table 17
Appendix 1 Glossary of terms 38
Appendix 2 Vital sign for children 44
Appendix 3 Disability assessment in adult and children 45
Appendix 4 Pain assessment tool in children 48
Appendix 5 Evidence of high energy impact/ mechanism in trauma 50
Appendix 6 Rule of 9’s in burn 51
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Appendix 7 Possible life threatening causes/ emergencies 52

Appendix 8 Triage Course Module 63
Index 64
References 65

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CHAPTER 1
HEATS USER MANUAL

STEP 1:

Assess each patient who presented to primary triage with first look and gentle touch approach
(Peadiatric: chapter 5)

STEP 2:
Identify the main presenting complaint/s and determine the severity to aid decision for triage (chapter 6)

STEP 3:
Understand the specific discriminator used in presenting complaints triage table (appendix 1)

STEP 4:
Use universal vital signs chart reference (appendix 2-4)

STEP 5:
Understand the definition and capacity of each clinical zone in ETDHKL (chapter 4)

STEP 6:
Identify possible life threatening differential diagnosis for the presenting complaint to aid justification of triage to
clinical zone (appendix 7)
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CHAPTER 2
INTRODUCTION

2.1 OVERVIEW STATEMENT

• Triaging services counter shall be the first point of contact for all patients accessing the Emergency and Trauma Department
care.

2.2 TRIAGE DEFINITION

• Triage = to sort or to choose

• Triage = methods used to assess patients’ severity of injury or illness within a short time after their arrival, assign priorities,
and transfer each patient to the appropriate place for treatment. 6

• Triage is the process by which patients classified according to the type and urgency of their conditions to get the
RIGHT PATIENT to the RIGHT PLACE at the RIGHT TIME with the RIGHT CARE provider.

2.3 TRIAGE OBJECTIVES

2.3.1 General Objectives
i. Provide the best efficient care professionally to patients from their first encounter in Emergency Department
ii. Improve patient satisfaction

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2.3.2 Specific Objectives

i. Identify critical patients requiring immediate care
ii. Determine the appropriate area for treatment
iii. Facilitate patient flow through Emergency Department and avoid unnecessary congestion

2.4 HKL EMERGENCY ASSESSMENT FOR TRIAGE SEVERITY (HEATS)
• Incorporating both Malaysian Triage Category (MTC) and Manchester Triage System (MTS).
• Syndromic approach based on patient symptomatology.
• Consist of systematic subjective and objective evaluation of patients.
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CHAPTER 3
WORK FLOW AT PRIMARY TRIAGE ETDHKL

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CHAPTER 4
GENERAL STATEMENT

4.1 THE TRIAGE ASSESSMENT

• Essence of triage = SPEED and THOROUGHNESS
• Should take no more than 2-5 minutes
• Involves a combination of general appearance and the presenting problem of the patient, may be combined with pertinent
physiological observations (vital signs)
• Not intended to make a diagnosis

4.2 TIME TO TREATMENT

• Ideal maximum time to first contact with treating clinician
• Any delays to assessment and treatment beyond the above recommended times might affect the clinical outcome of the patients

MALAYSIAN TRIAGE MANCHESTER TRIAGE HKL Emergency Assessment for Triage
CATEGORY 1 SYSTEM 3 Severity (HEATS)

Zone Time (min) Time (min) Time (min)

Red 0 – 3 0 0

Amber <10 <10 <10

Yellow <30 <60 <30

Green <180 <120 <90

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4.3 TREATMENT ZONES

4.3.1 RED ZONE (CRITICAL 1 ZONE)

• Cardiac arrest
• Respiratory arrest
• Compromised Airway (A), Breathing (B) or Circulation (C) – need immediate life saving intervention

• APPLY TO ALL CASES

a. ANY cases involving AIRWAY COMPROMISE à triage RED

b. ANY cases involving 2 OR MORE SYSTEMS with or without AIRWAY COMPROMISE à triage RED

4.3.2 AMBER ZONE (CRITICAL II ZONE)

• Airway: Patient with stable airway
• Breathing: Required oxygen support including Non-Invasive ventilation (NIV)
• Circulation: Required fluid resuscitation including patient in Compensated Shock with or without single inotropic support

4.3.3 YELLOW ZONE (SEMI-CRITICAL ZONE)

• Stable Airway, Breathing and Circulation but in moderate pain and unable to ambulate

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4.3.4 GREEN ZONE (NON-CRITICAL ZONE)

• Stable Airway, Breathing, Circulation and no alteration of mental status.
• Ambulating unaided or ambulate with wheelchair.
• Green zone patients is further divided into sub-categories:
i. Green category 1 (Fast lane) – seen less than 10 minutes
ii. Green category 2 (require initial management of first aid treatment before seen by a doctor)
iii. Green category 3 (others than the above)

Green zone subcategories Criteria
G1 • Children age less than 2-year-old
(Fast Lane) • Senior citizen age more than 65-year-old
• OKU (Orang Kurang Upaya) or disabled person with OKU card
• Patient brought in by police (ie OKT or Orang Kena Tahan)
• Recent chest pain with normal ECG
• Post seizure with more than 24 hours fit free and no neurological deficit
• Dislocation of small joints (below ankle and below elbow)
• Acute abdominal pain / back pain / flank pain with pain score 1-4

G2 • All stable upper limb fracture ankle fracture requiring immobilization
(require initial • All acute pain (pain score 1-4) requiring analgesia
management and first aid) • Acute retention of urine requiring catheterization of bladder and drainage (CBD)
• Foreign body removal – ear/ nose/ fingers
• POP complication
• Stable bleeding patient require pressure bandage and dressing
• Minor trauma with abrasion require dressing
• Eye foreign body require eye irrigation
G3 • All other green zone patients
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4.3.5 DECONTAMINATION ZONE

• Can accommodate any patient with haemodynamically compromise including those require intubation and resuscitation.

• All highly infectious diseases
o Meningococcaemia
o MERSCOV
o Ebola
o Diphtheria
o Measles

• All high lethality environmental toxin exposure
o Paraquat
o Organophosphate

• All HAZMAT cases
o Hazardous materials including exposure to chemicals, nuclear waste products, biological and radiological agent

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4.4 PRESENTING COMPLAINTS

• Chief symptoms identified by patient, relative or caregiver.

MALAYSIAN TRIAGE CATEGORY1 MANCHESTER TRIAGE SYSTEM3 HKL EMERGENCY ASSESSMENT FOR
TRIAGE SEVERITY (HEATS)
1. Abdominal pain 1. Abdominal pain in adults 1. Abdominal pain in adults
2. Asthma 2. Abdominal pain in children 2. Abdominal pain in pregnancy-related
3. Back pain 3. Abscesses and local infections 3. Abdominal pain in children
4. Burn 4. Abused or neglected child 4. Allergy
5. Diarrhoea and vomiting 5. Allergy 5. Altered behavior
6. Diabetes 6. Apparently drunk 6. Back pain
7. Epistaxis 7. Assault 7. Bites and sting
8. Eye problems 8. Asthma 8. Burns and scalds
9. Fever 9. Back pain 9. Chest pain
10. Fits 10. Behaving strangely 10. Collapse adult
11. Fracture 11. Bites and stings 11. Crying baby
12. Headache 12. Burns and scalds 12. Dental problem
13. Hypertension 13. Chemical exposure 13. Diarrhoea and vomiting
14. Joint dislocation 14. Chest pain 14. Ear problems
15. OSCC 15. Collapse adult 15. Eye problems
16. Overdose and poisoning 16. Crying baby 16. Falls
17. Shortness of breath 17. Dental problems 17. Fever
18. Trauma – major 18. Diabetes 18. Fever (suspected dengue fever)
19. Trauma – minor 19. Diarrhea and vomiting 19. Fits
20. Ear problems 20. GI bleeding – upper GI
21. Eye problems 21. GI bleeding – lower GI
22. Falls 22. Headache
23. Fits 23. Irritable child
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24. Foreign body 24. Lethargic / body weakness in adult
25. Gastrointestinal (GI) bleeding 25. Lethargic / unwell in children
26. Headache 26. Limping child
27. Head injury 27. OSCC
28. Irritable child 28. Overdose and poisoning
29. Limb problems 29. Palpitation
30. Limping child 30. Per vaginal (PV) bleed
31. Major trauma 31. Pregnancy-related complaint
32. Mental illness 32. Psychiatric disorder
33. Neck pain 33. Rashes
34. Overdose and poisoning 34. Shortness of breath in adult
35. Palpitations 35. Shortness of breath in children
36. Pregnancy 36. Testicular pain
37. Per vaginal (PV) bleeding 37. Trauma – head / facial injury
38. Rashes 38. Trauma – penetrating injury
39. Self harm 39. Trauma – blunt injury
40. Sexually acquired infection 40. Trauma – Upper limb injury
41. Shortness of breath in adults 41. Trauma – lower limb injury
42. Shortness of breath in children 42. Wound
43. Sore throat
44. Testicular pain
45. Torso injury
46. Unwell adult
47. Unwell baby (<1 year)
48. Unwell child (>1 year)
49. Unwell newborn (<30 days)
50. Urinary problems
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51. Worries parent
52. Wounds
53. Major incidents – primary
54. Major incident – secondary

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CHAPTER 5
PEADIATRIC ASSESSMENT TRIANGLE (PAT)

(Tools for First Look & Gentle Touches in Peadiatrics)

Appearance Work of breathing Circulation
• Tone • Abnormal airway sounds • Pallor
• Interactiveness • Abnormal positioning • Mottling
• Consolability • Retractions • Cyanosis
• Look / Gaze • Flaring
• Speech / cry

Peadiatric Assessment Triangle

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Characteristic of each Component in Peadiatric Assessment Triangle

Appearance
Tone • Movement or vigorously resisting examination?
• Good muscle tone?
• Limp or flaccid?
Interactiveness • Alert?
• Attentiveness to surrounding?
• Interest to play or reach for item?
• Uninterested to surrounding or play?
Consolability • Ability to be consoled or comforted by caregiver?
• Crying or agitated that is unrelieved by reassurance?
Look / Gaze • Gaze fixed to a face?
• Blank stare?
Speech / Cry • Speech or cry quality?
Work of Breathing
Abnormal airway sound • Snoring, muffled or hoarseness speech
• Stridor, grunting, wheezing
Abnormal positioning • Sniffing position, tripod position, refuse to lie down
Retractions • Supraclavicular, intercostal or substernal retractions of chest wall
• Head bobbing for infants
Flaring • Nasal flaring on inspiration
Circulation
Pallor • White or pale mucus membrane / sole / palm
Mottling • Patchy skin discolouration (lace-like)
Cyanosis • Bluish discolouration of skin or mucus membrane (ie mouth, lips, fingers)

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CHAPTER 6
PRESENTING COMPLAINT TRIAGE TABLE

Note!
1. Please refer to appendix 1 (Glossary of Terms) for description of the specific discriminator with this * mark.
2. Please refer to appendix 7 for possible life threatening causes for any presenting symptoms with this mark.

No CHIEF CRITICAL 1 CRITICAL II SEMI-CRITICAL NON-CRITICAL
COMPLAINTS (RED) (AMBER) (YELLOW) (GREEN)
Subjective Objective Subjective Objective Subjective Objective Subjective Objective

1 Abdominal pain in - airway - severe pain - vomiting blood - Temp >40 - history of - moderate pain - vomiting - pain score 1- 4
adult compromise* (pain score 8- acutely (pain score 5-7)
10) - PR bleeding - tense or rigid vomit blood - recent mild
- inadequate abdomen - elderly age pain
breathing* decompensated - persistent >65 yo
shock* - compensated vomiting* - recent
- shock* shock* problem
- possibly
pregnant - walk in
unaided
- shoulder tip
pain

2 Abdominal pain in - airway - severe pain - h/o trauma - moderate pain *Criteria to send to PAC:
pregnancy-related compromise* (pain score 8- (pain score 5-7) 1. If registered pregnancy with
10) stable ABC and vital signs – send to
- inadequate - compensated PAC.
breathing* - in labour shock*
2. no history of trauma
- shock*
3. Regular abdominal contraction

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Abdominal pain in 4. Ceasarean or episiotomy wound
pregnancy-related breakdown within 40 days
(cont) postpartum

3 Abdominal pain in - airway - severe pain - persistent - moderate pain - intermittent - stable age- - recent mild
children compromise* vomiting* vomiting appropriate pain
- age 0 – 30 day - Temp >38 vital sign –
- inadequate with bilious - non toxic - recent
breathing* vomiting looking - visible ¶refer problem
abdominal appendix 2
- shock* - poor / feeble mass
pulse volume
- irritable /
inconsolable
crying
¶age- ¶same
- severe appropriate evaluation

lethargic unstable vital with critical
sign – refer but involve
- toxic looking appendix 2 single system
except airway
- history of
acutely vomit
blood

- black / red /
redcurrent
jelly-like stool

4 Allergy - airway - stridor - no sweating or - widespread rash - bilateral - able to ambulate - local
compromise* paleness or blistering oedema urticarial rashes
- unresponsive >10% of body of limbs - speaking in full only
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Allergy (cont) - inadequate - altered - involving 1 surface area sentences
breathing* conscious level systems except
airway - unable to
- shock* - periorbital / ambulate
facial oedema

- unable to
swallow saliva

- tongue oedema

- unable to talk in
sentences

- cyanosis

- new onset
arrhythmia*

5 Abnormal / altered - airway - unresponsive - suspected - respond to - h/o - new - recent problem - no neurological
compromise* chemical verbal stimuli unconsciousness neurological deficit
behavior
- respond to pain inhalational deficit* >24
- inadequate stimuli in exposure - new - significant co- hours
breathing* children neurological morbids
- high risk of self deficit <24 hrs - DXT <3 mmol/L
- shock* - new harm
neurological - fever >38°C
deficit* ≤ 3
hours

- sign of acute
stroke*

6 - airway - Abdominal pain - New - direct trauma to - unable to - Recent mild pain - able to ambulate
Back pain
compromise* neurological the back ambulate

deficit* <24 hour - unable to pass - mild pain

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Back pain (cont) - inadequate - pain score 8-10 - colicky pain - new urine (pain score 1-4)
breathing* neurological
deficit* > 24hr
- shock*
- moderate pain
(pain score 5-7)

7 Bites and Stings - airway - stridor - altered - uncontrollable - uncontrollable - local infection
compromise* conscious major minor
- exsanguinating level* haemorrhage haemorrhage - local
- inadequate haemorrhage* inflammation
breathing* - significant h/o - severe pain / - wide spread
- facial oedema allergy* itch rash
- shock* or blistering
- oedema of the - Rhonchi (>10% of TBA)
- unresponsive tongue
- sign of - moderate pain /
- sensation of neurovascular itch
lump at throat compromise of
affected limbs*

8 Burns and Scalds - Airway - Stridor - significant - altered - smoke exposure - 2nd or 3rd degree - recent problem - 1st degree burn
compromise mechanism of conscious burn <15% TBA
- 2nd and 3rd injury level in adult - Local
- inadequate degree facial inflammation
breathing area burn - Electrical injury - 2nd or 3rd degree - 2nd or 3rd degree
burn 15 -20 % burn <10% TBA
- Shock - 2nd or 3rd degree TBA in adult in children
burn >20% TBA
- Unresponsive in adult - 2nd or 3rd degree ¶Refer
burn 10-15% appendix 6

- Thunder strike - 2nd or 3rd degree TBA in
injury burn >15% TBA children
in children
- Inhalational ¶Refer ¶Refer
injury appendix 6 appendix 6
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9 - airway - severe pain - cardiac pain* - new abnormal - persistent - pleuritic pain* - recent mild pain - normal ECG
Chest Pain
compromise* (pain score 8-10) onset vomiting*
- pain score 5-7 arrhythmia* - pain score 1-4 - recent problem
- inadequate - ST elevation on - significant
breathing* ECG - HR <60 or >100 cardiac
(for adult) history*
- shock*

- clammy

- diaphoresis

10 Collapse adult / - airway - currently fitting - new - h/o unconscious - new - recent problem - normal
compromise* neurological neurological neurological
Syncope
- significant h/o deficit * <24 deficit *>24 hrs
- inadequate allergy* hours - normal
breathing* heamodynamic
- new abnormal
- shock* arrhythmia
– HR <60, >100
- cardiac pain* (for adult)

- Abnormal limb - purpura*
movement
- non blanching
rash*

11 - airway - Floppy - h/o - temp >38°C - inappropriate - prolonged or - atypical Temp <38°C
Crying baby
compromise* unconsciousness history* uninterrupted behaviour*

- responds to crying (>2

- inadequate voice - unable to feed hours) - recent sign of

breathing* or pain only mild pain

- inconsolable by

- shock* - purpura* parents - recent problem

(triage: Decon)

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Crying baby (cont) - unresponsive - non blanching
rash*

- sign of severe
pain
¶Refer
appendix 4

12 Dental problem - airway - gross facial - able to talk - controllable - acutely avulsed - uncontrollable - facial swelling - mild pain
compromise* oedema major tooth (avulsed minor (pain score 1-4)
haemorrhage intact <24 hrs) haemorrhage - recent mild pain
- inadequate - uncontrollable
breathing* major - pain score 8-10 v require for - pain score 5-7
haemorrhage reimplantation
- shock*
- pain >8/10

- stridor or
abnormal
breathing

13 Diarrhoea & Vomiting - Airway - floppy child - altered - severe pain - history of acutely - moderate pain - intermittent - mild pain
compromise* conscious (pain vomiting blood (pain score 5-7) vomiting (pain score 1-4)

- vomiting blood level* in adult score 8-10)
- inadequate - persistent - recent mild pain
breathing* - passing fresh - sign of vomiting*
blood PR dehydration in
- shock* child *
- restless/
- unresponsive irritable child

- altered - mottled skin
conscious
level* in children

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14 - Airway - altered - h/o head injury - uncontrollable - vertigo - auricular
Ear problems
compromise* conscious minor haematoma

level* - persistent haemorrhage - recent hearing

- inadequate vomiting* loss

breathing* - uncontrollable - moderate pain

major - recent mild pain
- shock* haemorrhage (pain score 5-7)

- unresponsive - severe pain
child (pain score 8-10)

15 - acute chemical - acute complete - severe pain - recent mild pain
Eye problems
eye injury loss of vision (pain score 8- - red eye
(<12 hours) (<24 hours) 10) - recent reduce
visual acuity - diplopia
- penetrating eye (<7 days)
injury
- foreign body
sensation

16 Falls - Airway - currently fitting - significant - DXT < 3mmol/L - h/o - uncontrollable - recent mild pain - limb deformity
compromise* mechanism of unconsciousness minor
injury - new abnormal haemorrhage - recent problem - limb swelling
- inadequate ¶Refer arrhythmia*
breathing* appendix 5 (HR <60, > 100, - new - mild pain
irregular) neurological (pain score 1-4)
- shock* deficit *>24
- uncontrollable hours
- unresponsive major
haemorrhage - gross deformity
of limbs
- altered
conscious - open fracture
level*
- moderate pain
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Falls (cont) - new (pain score 5-7)
neurological
deficit* <24 hr

- severe pain
(pain score 8-10)

17 Fever8 - Airway - mottled skin - altered level of - cool peripheries - fever >5 days in - swelling in a - normal
compromise* consciousness* children limb/ joint in hydration
- non blanching - poor pulse children
- inadequate rash* volume - haemo-
breathing* - non weight dynamically
- severe lethargic - sign of bearing in stable
- shock* in children compensated children
shock*
- unresponsive - currently fitting

- new
neurological
sign*

- sign of
decompensated
shock*

18 Fever - Airway - gasping *Compensated (vital signs for Presence of (vital signs for Have co-morbids:
(suspected Dengue compromise* dengue shock adult): warning sign: adult): - elderly >65
Fever)9 - using accessory - abdominal pain
- inadequate muscle - RR > 20 - RR <20 - Infant
breathing* - persistent
- pale - spo2 <95% vomiting ≥3/ - Spo2 > 95% - DM/ HPT/ IHD
- shock* day
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- jaundice - SBP <100 - SBP >100 - congestive heart
- unresponsive - lethargic failure
- cyanose - HR <120 - HR < 90
*Severe dengue - dizzy/ fainting - CKD
- mottled skin - narrowing pulse episode - Plat <50
*Decompensated pressure 20-30 - chronic liver
dengue shock - active bleeding *dengue fever - hct male >45, disease
- shock index* >1 with warning female >40
- cold/ clammy sign - immune-
compromise
- weak pulse *Compensated (refer appendix
dengue shock 2 for paediatric - obese
(vital signs for vital sign)
adult): (refer appendix - pregnant
- CRT >2 s 2 for paediatric
vital sign) - h/o previous
- RR >30 dengue

- SBP < 90 - on anticoagulant

- HR >120 * dengue fever
without
- narrow pulse warning
pressure <20 sign in special
population
- Shock Index* > 1

(refer appendix
2 for paediatric
vital sign)

19 Fits - Airway - DXT <3 mmol/L - h/o overdose or - response to - h/o head trauma - Awake but - headache - Alert
compromise* poisoning verbal stimuli confuse
- ongoing fitting - on anticoagulant - recent problem - no new
- inadequate - new - new (h/o fitting >24 neurological
breathing* - response to pain neurological neurological hrs ago) deficit
deficit* <24 hrs deficit* >24 hrs
- shock* - BP > 220/ 110
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(for adult) - neck stiffness
- unresponsive
- purpura* - non-blanching
(triage: Decon) rash*

20 GI bleed – Upper GI - Airway - Exsanguinating* - h/o acutely - Severe pain - Bleeding - No active - Recent mild pain - no active
compromise* heamatemesis vomiting blood (pain score 8-10) disorder heamatemesis heamatemesis
(within 24 hrs) - Recent problem
- Inadequate - Actively - Altered - moderate pain - pink
breathing* vomiting blood conscious level* (pain score 5-7)
- Significant h/o - mild pain
- Shock* - pale UGIB (pain score 1-4)

- Unresponsive

21 GI bleed – Lower GI - Airway - Exsanguinating* - h/o acutely - Severe pain - Bleeding - No active PR - Recent mild pain - no active
compromise* maleana / fresh passing blood (pain score 8-10) disorder bleed malena/ PR

PR blood per rectum - Recent problem bleed
- Inadequate (within 24 hrs) - Altered - on anticoagulant - Moderate pain
breathing* - pale conscious level* (pain score 5-7) - pink

- Shock* - Significant h/o
lower GI bleed
- Unresponsive

22 - Airway - Currently fitting - abrupt onset - altered - Recent reduce - new - recent mild pain - intermittent
Headache
compromise* (within seconds conscious level* visual acuity neurological vomiting

- sign of or minutes) (within 7 days) deficit* >24 hrs - recent problem

- Inadequate meningism* - new

breathing* - acute complete neurological - h/o - temporal scalp

- non-blanching loss of vision deficit* <24 hrs unconsciousness tenderness

- Shock* rash* (within 24 hrs)

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- severe pain - persistent
Headache (cont) - Unresponsive - purpura* (pain score 8-10) vomiting*

(Triage: Decon) - SBP >220, - moderate pain
DBP >110 with (pain score 5-7)
systemic
symptom* - SBP >220,
(for adult) DBP >110
without
systemic
symptom*
(for adult)

23 Irritable child - Airway * - Unresponsive - h/o overdose or - severe pain - prolonged or - moderate pain - atypical
compromise poisoning ¶Refer uninterrupted ¶Refer behaviour
- Responds to appendix 4 crying appendix 4
- Inadequate voice or pain (continuously for - recent sign of
breathing* only 2 hours) mild pain
¶Refer
- Shock* - Hypoglyceamia - Not feeding appendix 4

(DXT <3 mmol/L)
- Not distractible - Recent problem
- signs of
meningism* _ Inappropriate
history*
- purpura*
(triage Decon)

* non
blanching rash

24 Lethargic / body - Airway - new - known or likely - hypoglyceamia - significant - new - recent problem - able to walk
weakness / unwell in compromise* neurological immune- DXT <3 mmol/L heamatological neurological
deficit* <3 hours suppression* history* deficit* >24 hrs
adult
- Inadequate - new abnormal

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Lethargic/ body breathing* - sign of acute - special risk of arrhythmia* - widespread
weakness/ unwell in stroke* infection* HR >100 or <60 discharge or
adult (cont) - Shock* (Triage Decon) blistering
- altered (>10% of TBA)
conscious level*
- moderate pain
- new (pain score 5-7)
neurological
deficit* <24 hrs

- severe pain
(pain score 8-10)

25 Lethargic/ unwell in - Airway - Currently fitting - known or likely - moderate pain - Not feeding - mild pain - Recent problem
compromise* immune- ¶Refer ¶Refer
children13
- DXT <3 mmol/L suppression* appendix 4 - Inappropriate appendix 4
- Inadequate history**
breathing* - Responds to - sign of
voice or pain dehydration* - significant
- Shock* only heamatological
history
- Unresponsive - sign of
meningism* - atypical
- Fail to react to behavior*
parents - purpura*
(triage Decon)

- severe pain
¶Refer
appendix 4

26 - airway - purpura* - vascular - bleeding - hot joint - recent mild pain - limp / joint
Limping child
compromise* (Triage Decon) compromise disorder deformity

[- pallor] - pain on joint - recent problem

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Limping child (cont) - inadequate - on-blanching [- coldness] - inappropriate movement - limp / joint
breathing* rash* [- altered history* swelling
- shock* sensation] - moderate pain - warm
[- pain ¶Refer
with/without appendix 4 - mild pain
absent pulses ¶Refer
distal to the appendix 4

injury]

- severe pain
¶Refer
appendix 4

27 OSCC14,15 - airway - Responds to - marked distress - uncontrollable - history of ** stable
compromise* voice or pain minor unconsciousness survivor
only haemorrhage triage to
- inadequate - h/o head injury OSCC Room
breathing* - uncontrollable - widespread rash
major or blistering
- shock* haemorrhage >10% of TBA

- unresponsive - severe pain - vaginal trauma
(pain score 8-10)
- moderate pain
(pain score 5-7)

- sign of
dehydration

28 Overdose and - airway - unresponsive - moderate - new abnormal - marked distress - Awake but - calm - Alert
poisoning compromise* lethality arrhythmia* confuse
- currently fitting (HR >100, - history of - cooperative
- inadequate - significant <60) unconsciousness
29
(H.E.A.T.S)

Overdose and poisoning breathing* - DXT <3mmol/L psychiatric
(cont) history* - altered
- shock* - Response to conscious level*
pain
- pungent smell - Response to
verbal
- high lethality*
(ie paraquat,
organophospate)
¶Triage to
decontamination
room

29 Palpitations - airway - new abnormal - acutely short of - new abnormal - h/o - HR 60-100 - recent problem
compromise* arrhythmia breath arrhythmia unconsciousness (in adult)
(HR <50, >150) (HR >60, <150)
- inadequate in adult - history of in adult - awake but
breathing* overdose or confuse
poisoning - altered
- shock* conscious level*
- current
- cardiac pain* palpitation

- significant
cardiac history*

30 Per vaginal (PV) - airway - exsanguinating - heavy PV blood - severe pain - vaginal trauma - moderate pain - recent mild pain - mild pain
compromise* haemorrhage* loss (pain score 8-10) (pain score 5-7) (pain score 1-4)
bleed
(large clots or - pregnant <20 w - recent problem
- inadequate - altered constant flow) - abdominal pain
breathing* conscious level* - possible
- pregnant - shoulder tip pregnancy
- shock* 20weeks or more pain

- unresponsive

30
(H.E.A.T.S)


31 Pregnancy-related - airway Pregnancy age All pregnancy Pregnancy age *Criteria to send to PAC:
compromise* ≥20w: age: <20w: 1. If registered pregnancy with
complaint
- ongoing fitting - moderate
stable ABC and vital signs – send
- inadequate or recent fitting abdominal pain Persistent
to PAC.
breathing* (<24 hrs) (pain score 5-7) vomiting*

- shock* - SBP >140 with - Temp >39°C 2. No history of trauma
epigastric pain
- unresponsive 3. Labour pain
- severe
abdominal pain 4. Ceasarean or episiotomy wound
(pain score 8-10)
breakdown within 40 days

- in labour
postpartum

Pregnancy age
<20w:
- massive PV
bleeding

- severe
abdominal pain
(pain score 8-10)

32 Psychiatric disorder - airway - DXT <3 mmol/L ** triage to - altered - not aggressive
compromise* Psychiatric conscious level*
cubicle - with - no suicidal
- inadequate close ideation
breathing* observation**

- shock* - moderate to high
risk of self harm
- unresponsive*
- moderate to high
risk of harm
to others
31
(H.E.A.T.S)

Psychiatric disorder
(cont) - marked distress

- significant
psychiatric
history*

- disruptive

33 - Airway - Stridor - Significant h/o - Altered - Inappropriate - widespread - recent mild pain
Rashes
compromise* allergy* conscious level* history* discharge or or itch
- Oedema of the blistering >10%
- Inadequate tongue - Purpura* TBA - recent problem
breathing* (Triage Decon)
- Facial oedema - moderate pain
- Shock* - non or itch
blanching rash*
- Acutely short of
breath - Severe pain or
itch
- Unresponsive

34 Shortness of breath in - Airway - pallor - Significant - New abnormal - Pleuritic pain* - RR <20 - Recent problem
compromise* respiratory arrhythmia
adult
- cyanosis history* (HR >100, <60) - Chest injury - spo2 >95% on

- Inadequate air
breathing* - cold clammy - Acute onset after - RR 20-40 **mild audible
skin injury wheeze in
- Shock* (immediately - intact conscious otherwise stable
- sweating within 24 hours level patient - triage
- Exhaustion post trauma) ARDZ
- RR >40, <10
- Reduce - Cardiac pain*
conscious level - spo2 <90% on
air
32
(H.E.A.T.S)


- weak
respiratory
effort

- Stridor

- Drooling

- Unable to talk in
sentences

- cyanosis

- tripod position

- tracheal tug

- intercostal
recession

35 Shortness of breath in - Airway _ spo2 <90% on - significant - able to speak in - poor feeding - spo2 >95% on - recent problem
compromise* air respiratory sentences air
children
history* (ie NIV,

- Inadequate - Stridor intubation, ICU) - alert

breathing*

- Drooling - acute onset after - wheezing

- Shock* injury

- Respond to - spo2 90- 95 %

- Unresponsive voice and pain on air

only

- Unable to talk in

sentences - tripod position

- Increased work

of breathing

33
(H.E.A.T.S)

Shortness of breath in - grunting
children (cont)
- nose flaring
- chest recession

- abdominal
breathing

- accessory
muscle use

36 - Airway - sudden onset - severe pain - persistent - Scrotal cellulitis - Scrotal trauma - vomiting
Testicular pain
compromise* (<24 hrs) (pain score 8-10) vomiting*

- moderate pain - recent mild pain
- inadequate - scrotal gangrene - colicky pain (pain score 5-7)
breathing*

- shock*

37 Trauma – head/ face - airway - GCS <8 - high impact - GCS 9-12 - history of - GCS 13-14 - GCS 15
injury compromise* mechanism unconsciousness
- exsanguinating ¶Refer - uncontrollable - uncontrollable
- inadequate haemorrhage* appendix 5 major minor
breathing* haemorrhage haemorrhage
- Response to
- shock* pain - Response to
verbal
- unresponsive - Combative
- paralysis
- polytrauma - SBP <90
(in adult)

- RR <10 or >30
(in adult)

- open or
34
(H.E.A.T.S)

depressed skull
fracture

38 Trauma – penetrating - airway - exsanguinating - high impact - uncontrollable
injury compromise* haemorrhage* mechanism major
¶Refer haemorrhage
(including stab/ gun - inadequate appendix 5
breathing*
shot wound)

- shock*

- unresponsive

- all penetrating
injury to head,
neck, torso,
abdomen and
extremities
proximal to
elbow and knee

- polytrauma

39 Trauma – blunt injury - airway - significant facial - high impact - uncontrollable - age >65 year old - uncontrollable
compromise* injury mechanism major minor

¶Refer haemorrhage - on anticoagulant haemorrhage
- inadequate - chest wall appendix 5
breathing* instability/ - known bleeding
deformity - pregnancy >20 w tendencies
- shock*
- pelvic fracture - pregnancy <20w
- unresponsive

- polytrauma

35
(H.E.A.T.S)


40 Trauma – Upper Limb - airway - Crushed/ - bilateral - new - bleeding - fingers - abrasion
compromise* degloved / humerus neurological disorder amputation
Injury
mangled fracture deficit* <24 hrs - mild pain

- inadequate extremities - shoulder or (pain score <5)
breathing* - ≥1 long bone - uncontrollable elbow
- amputation fracture (ie major dislocation - deformity
- shock* proximal to humerus and haemorrhage
wrist femur) - open fracture - swelling
- polytrauma - severe pain
- exsanguinating - neurovascular (pain score 8-10) - gross deformity - dislocation of
haemorrhage* compromise* small joints
- sign of
threatened limb - uncontrollable
(pain, pallor, minor
pulselessness, haemorrhage
paralysis, delay
CRT, cold to - moderate pain
touch) (pain score 5-7)

41 Trauma – Lower Limb - airway - bilateral femur - neurovascular - new - bleeding - toes amputation - deformity
compromise* fracture compromise * neurological disorder
Injury
deficit* <24 hrs - open fracture - swelling

- inadequate - amputation - ≥1 long bone
breathing* proximal to fracture (ie - uncontrollable - gross deformity - dislocation of
ankle humerus and major small joints
- shock* femur) haemorrhage - knee or ankle
- exsanguinating dislocation - abrasion
- polytrauma haemorrhage* - hip dislocation - sign of
threatened limb - uncontrollable - mild pain
(pain, pallor, minor (pain score <5)
pulselessness, haemorrhage
paralysis, delay
CRT, cold to - moderate pain
touch) (pain score 5-7)
36
(H.E.A.T.S)


42 Wounds - airway - exsanguinating - uncontrollable - uncontrollable - local infection - mild pain
compromise* haemorrhage* major minor (pain score 1-4)
haemorrhage haemorrhage - local
- inadequate inflammation
breathing* - distal vascular - new
compromise* neurological
- shock* deficit *>24 hour
- new
neurological - moderate pain
deficit* <24hrs (pain score 5-7)

- severe pain
(pain score 8-10)

37
(H.E.A.T.S)
APPENDIX 1
GLOSSARY OF TERMS

Specific discriminator Explanation

Airway compromise • Partial obstruction
- agitated, stridor, no tracheal shift on palpation

• Complete obstruction
- obtunded, hoarseness of voice, Tracheal shift on palpation

Inadequate MILD MODERATE SEVERE
breathing18
Accessory muscle Not used Usually used Paradoxical movement
(Respiratory distress) Verbal Talks in sentences Talks in phrases Talks in words,
gasping
Breathlessness Walking, can lie down While talking, prefers to At rest, hunched over
sit
Respiratory rate 14-20 20-30 30-40 or <10
Conscious level Normal Usually agitated Drowsy and confused
Pulse (bpm) <100 100-120 <60 or >120

Wheeze Mild Moderate Loud or absent
38
(H.E.A.T.S)

Shock9 Normal Compensated Decompensated
Conscious Alert Alert Restless/ Lethargic
Capillary refill time <2 sec, warm and pink >2 sec Mottled skin
(CRT) CRT very prolonged
Pulse Volume Good Weak, thready pulse Feeble or absent
peripheral pulse
Respiratory rate 14-20 20-30 30-40
Heart Rate (bpm) <100 100-120 <60 or >120
Blood pressure SBP >120 SBP normal, raised SBP <90 or
DBP unrecordable
Pulse Pressure Normal: 30-40 mmHg Narrowing: 20-30 Narrowed: <20 mmHg
mmHg

Parameter in grey box is to be done in Primary Triage as part of First Look & Gentle
Touch

Altered conscious level Not fully alert. Either responding to voice or pain only or unresponsive

Atypical behaviour Children who are behaving in a way that is not usual in the given situation (Not being themselves)

Cardiac pain Classically a severe dull ‘gripping’ or ‘heavy’ pain in the center of the chest, radiating to the left arm or to the
neck. May be associated with sweating and nausea. Beware of atypical cardiac pain in elderly, female,
diabetic group – may present with Right sided chest pain, epigastric pain, SOB only or lethargic.

Distal vascular Combination of pallor, coldness, altered sensation and pain with or without absent pulses distal to the injury
compromise
39
(H.E.A.T.S)

Exsanguinating Massive haemorrhage, with initial blood loss of >40% and ongoing bleeding, if not surgically controlled will
haemorrhage lead to death.

High BP with systemic Combination of High BP with either acute heart failure, acute coronary syndrome, stroke or TIA, absent of
symptoms major peripheral pulses

High lethality Lethality is the potential of the substance/ chemical to cause harm. Advice may be required to establish the
level of risk. If in doubt, assume a high risk. Ie Paraquat, organophosphate

Immunosuppression Low immune system (ie on long term steroid, on chemotherapy, RVD positive, post transplant patient, on
immunosuppressant treatment)

Inappropriate history When the history given does not explain the physical findings. This is important, as it is a marker of
safeguarding concerns in both adults and children.

Neurological deficit Any loss of neurological function, which include altered or lost sensation, weakness of the limbs (either
transient or permanent), slurred speech, facial drooping and alterations in bladder or bowel function (ie
incontinence)

Neurovascular Combination of pallor, coldness, altered sensation, pain with or without absent pulses distal to the injury,
compromise of a limb pain on passive stretching, paralysis

New onset arrhythmia Any tachycardia or bradycardia which not known to patient before.
This includes any wide or narrow complex arrhythmia or irregular arrhythmia.

Non blanching rash A rash that does not blanch (go white) when pressure is applied to it.

Not distractible Children who are distressed by pain or other things who cannot be distracted by conversation or play.
40
(H.E.A.T.S)

Persistent vomiting Vomiting that is continuous or that occurs without any respite between episodes.

Pleuritic pain A sharp, localised pain in the chest that worsens on breathing, coughing, sneezing or movement.

Purpura A rash on any part of the body that is caused by small haemorrhages under the skin – highly suspicious
meningococceamia (highly infectious)

Scrotal gangrene Dead, blackened skin around scrotum and groin. Early gangrene may not be black but appear like a full-
thickness burn with or without flaking

Sign of acute stroke As per Cincinnati Stroke Scale (FAST)
(F) Facial Drooping (A) Arm weakness (S) Slurred speech (T) Time of onset <3 hours
41
(H.E.A.T.S)

Sign of dehydration in
children10

Signs of meningism Stiff neck with headache and photophobia

Significant cardiac A known recurrent dysrhythmia that has life-threatening effects is significant, as is a known cardiac
history condition which may deteriorate rapidly

Significant A patient with a haematological disorder that is known to deteriorate rapidly (ie history of tumour lysis
heamatological history syndrome, myeloid leukaemia, superior vena cava obstruction, disseminated intravascular coagulation,
bleeding disorder.
42
(H.E.A.T.S)

Significant history of A known allergy with severe reaction (ie angioedema required intubation, anaphylactic shock)
allergy

Significant history of Any history of massive GI bleeding or of any GI bleed associated with oesophageal varices
UGIB

Special risk of infection Known exposure to dangerous pathogen, or travel to an area with an identified, current, serious infection
(ie MERSCOV, Ebola, Diphtheria, Measles)

Significant psychiatric A history of major psychiatric illness or event (ie suicidal attempt)
history

Significant respiratory NIV, intubation, history of ICU admission
history

Shock index Indicate level of occult shock. Shock index = HR/SBP. Normal value: 0.5 – 0.7. Shock index >1 indicate shock.

Tripod position Leaning forward, hands on knees position occurred in respiratory distress.

Vertigo An acute feeling of spinning or dizziness, possibly accompanied by nausea and vomiting.

43
(H.E.A.T.S)
APPENDIX 2
VITAL SIGN FOR CHILDREN19

44
(H.E.A.T.S)
APPENDIX 3
DISABILITY ASSESSMENT IN ADULT AND CHILDREN

4.1 DISABILITY ASSESSMENT IN ADULT TRAUMA18

A. AVPU B. GLASGOW COMA SCALE (GCS)

ASSESSMENT AREA SCORE
A Alert Eye opening (E)
V Response to Verbal stimuli Spontaneous 4
P Response to Pain stimuli To speech 3
U Unresponsive To pain 2
None 1
Verbal response (V)
Orientated 5
Confused conversation 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Best motor response (M)
Obeys commands 6
Localized pain 5
Flexion withdrawal to pain 4
Abnormal flexion (decorticate) 3
Extension (decerebrate) 2
None (flaccid) 1
GCS Score = (E[4] + V[5] + M[6] = Best possible score 15; Worst possible

score3.
45
(H.E.A.T.S)
4.2 DISABILITY ASSESSMENT IN PAEDIATRICS TRAUMA18

A. PEDIATRIC VERBAL SCORE B. MODIFIED GLASGOW COMA SCALE FOR CHILD AND INFANT

CHILD INFANT SCORE
VERBAL RESPONSE V-SCORE Eye Spontaneous Spontaneous 4
Appropriate words or social smile, fixes and 5 opening To speech To speech 3
follows To pain only To pain only 2
Cries, but consolable 4 No response No response 1
Persistently irritable 3
Restless, agitated 2 Best Orientated, Coos and 5
None 1 verbal appropriate babbles 4
response Confused Irritable cries 3
Inappropriate Cries to pain 2
words Moans to pain 1
Incomprehensible No response
sounds
No response
Best Obeys commands Moves 6
motor Localizes painful spontaneously 5
response stimulus and 4
Withdraws in purposefully 3
response to pain Withdraws to 2
Flexion in touch 1
response to pain Withdraws to
Extension in pain stimuli
response to pain Abnormal
No response flexion to pain
stimuli
46
(H.E.A.T.S)
A. PEDIATRIC VERBAL SCORE B. MODIFIED GLASGOW COMA SCALE FOR CHILD AND INFANT

Abnormal
extension to
pain stimuli
No response

Motor response is the most important component in GCS.
GCS Score = (E[4] + V[5] + M[6] = Best possible score 15; Worst possible

score3.
47
(H.E.A.T.S)
APPENDIX 4
PAIN ASSESSMENT TOOL IN CHILDREN

1. Numerical Rating Scale (for children 5 years and above)

2. The Faces Pain Scale (for children 3 years and above)

3. Behavioural Scale - FLACC (for infants, non-verbal children and children up to 7 years)

1. NUMERICAL RATING SCALE 2. THE FACES PAIN SCALE11

48
(H.E.A.T.S)
3. BEHAVIOURAL SCALE – FLACC (Face/ Legs/ Activity/ Cry / Consolability)12

Categories Scoring
0 1 2
Face No particular Occasional grimace Frequent to constant frown,
expression or smile or frown, withdrawn, clenched jaw, quivering chin
disinterested
Legs Normal position or Uneasy, restless, Kicking or legs drawn up
relaxed tense

Activity Lying quietly, normal Squirming, shifting Arched, rigid, jerking
position, moves easily back and forth, tense

Cry No cry Moans or whimpers, Crying steadily, screams or
(awake or asleep) Occasional complaint sobs, frequent complaints

Consolability Content, relaxed Reassured by Difficult to console or confort
occasional touching,
hugging, or being
talk to, distractable

Each of the 5 categories (F) Face, (L) Legs, (A) Activity, (C) Cry, (C) Consolability is score from 0-2, which result in total
score of between 0 and 10.

0 : relaxed and comfortable
1 - 3 : mild discomfort
4 - 6 : moderate pain
7 - 10 : severe discomfort/ pain

49
(H.E.A.T.S)
APPENDIX 5
EVIDENCE OF HIGH ENERGY IMPACT / MECHANISM IN TRAUMA

ADULT16 CHILDREN17

1. Falls 1. Falls >0.9m (3 feet) for child <2yo
- Adults: >6 meters (one storey is equal to 3 meters)
2. Fall >1.5m (5 feet) for 2yo – 18yo
2. High risk auto crash
- Intrusion: >30cm occupant site or >46cm any site 3. Motor vehicle crash with patient ejection, death of
- Ejection (partial or complete) from automobile another passenger
- Death in same passenger compartment
- Vehicle telemetry data consistent with high risk of 4. Motor vehicle crash with rollover
injury
5. Pedestrian or bicyclist without helmet struck by a
3. Automobile vs pedestrian / bicyclist motorized vehicle

4. Thrown, run over, or with significant (>30km/h) 6. Head struck by a high-impact object
impact

5. Motorcycle crash >30km/h

50
(H.E.A.T.S)
APPENDIX 6
RULE OF 9’S IN BURN

51
(H.E.A.T.S)
APPENDIX 7
POSSIBLE LIFE THREATENING CAUSES/ EMERGENCIES

CLINICAL PRESENTATION POSSIBLE LIFE THREATING CAUSES / EMERGENCIES

Abdominal pain in adult • Abdominal aortic aneurysm
• Mesenteric ischeamia
• Perforation of GI tract
• Acute bowel obstruction
• Volvulus
• Acute pancreatitis
• Ruptured ectopic pregnancy
• Placental abruption (in pregnancy)
• Myocardial infarction

Abdominal pain in children • Rupture appendicitis
• Bowel obstruction (from volvulus, intussusception, bowel adhesion)
• Primary bacterial peritonitis with nephrotic syndrome
• DKA
• Trauma – solid organ laceration or perforated viscus
• Incarcerated inguinal hernia
• Testicular torsion (referred pain)

52
(H.E.A.T.S)

Abnormal / Altered • Hypoxia
behaviour • Hypoglyceamia
• Sepsis
• Hypertensive encephalopathy
• Wernicke’s encephalopathy
• Overdose
• CNS infection (ie meningitis / encephalitis )
• CNS trauma
• Intracranial haemorrhage (ie subarachnoid / subdural)
• Epilepsy (ie non-convulsive status epilepticus)

Back pain • Abdominal aortic aneurysm
• Ectopic pregnancy

Chest pain • Acute coronary syndrome
• Aortic dissection
• Pulmonary embolism
• Tension pneumothorax
• Pericardial tamponade
• Mediastinitis (ie oesophageal rupture)

Collapse / Syncope • Cardiac arrhythmia
53
(H.E.A.T.S)

Crying baby • Sepsis (ie pneumonia, UTI)
• Cerebral infection (ie meningitis)
• Strangulated hernia
• Intussusception
• Hair tourniquet

Diarrhoea and vomiting • Gastroenteritis (ie Cholera, Rota virus infection)
• Upper / lower intestinal tract bleeding
• Mesenteric ischeamia

Pinna EAC Middle ear
Ear problems • Perichondritis • Foreign body • Trauma to TM • Sudden sensory
• Auricular • Malignant otitis • AOM neural hearing
heamatoma externa • Acute mastoiditis loss

Eye problems • Ocular chemical burns
• Orbital compartment syndrome
• Acute angle closure glaucoma
• Open globe injury
• Traumatic hyphema
• Central retinal artery or vein occlusion
• Acute 3rd nerve palsy
• Corneal microbial keratitis
54
(H.E.A.T.S)

• Orbital cellulitis

GI bleeding – Upper GI • Gastric and/or duodenal ulcer
• Oesophagogastric varices
• Severe or erosive oesophagitis/ duodenitis/ gastritis
• Portal hypertensive gastropathy
• Angiodysplasia

GI bleeding – lower GI • Diverticulosis
• Bowel ischeamia
• Angiodysplasia
• Heamorrhoids/ anal fissure/ rectal ulcer
• Neoplasia (polyps/ cancer)

Headache Characteristic of headache with serious underlying pathology:
History:
• Explosive onset and severe at onset
• No similar headache in the past
• Concomitant infection
• Altered mental status
• Headache with exertion (cough/ exercise/ Valsalva maneuver)
• Age over 50
• Immunosuppression

55
(H.E.A.T.S)

Headache (cont) Physical examination:
• Neurological abnormality
• Meningism
• Decreased level of consciousness
• Toxic appearance
• Papilloedema

Life Threatening Cause:
• Subarachnoid haemorrhage
• Space occupaying lesion
• Meningitis
• Cerebral abscess

Lethargic/ Body weakness/ • Sepsis
Unwell in adult • Acute stroke
• Acute coronary syndrome (in elderly/ female/ diabetic)
• Carbon monoxide (CO) poisoning
• Adrenal insufficiency
• Electrolytes imbalance

56
(H.E.A.T.S)

Lethargic / Unwell in Causes of lethargic by peadiatrics age group9
children

57
(H.E.A.T.S)

Lethargic / Unwell in children
(cont)

Limping child • Septic arthritis
• Malignancies
• Psoas abscess
• Osteomyelitis
• Fracture
58
(H.E.A.T.S)

Limping child (cont) • Slipped capital femoral epiphysis
• Meningitis
• Epidural abscess of the spine
• Abdominal pain (≥20w pregnancy)

Pregnancy-related complaint - abruption abruptio
- rupture uterus

• Abdominal pain (<20w pregnancy)
- rupture ectopic pregnancy

• Fitting (≥20w pregnancy until D40 postpartum)
- eclampsia

• Epigastric pain with SBP >140 (≥20w pregnancy until D40 postpartum)
- pre-eclampsia

• PV bleed (≥20w pregnancy)
- placenta previa
- abruptio placenta

• PV bleed (<20w pregnancy)
- miscarriage

• PV bleed (post partum)
- post partum haemorrhage
- Retained product of conception
59
(H.E.A.T.S)

Per vaginal (PV) bleed • Rupture ectopic pregnancy
• Retained products of conception
• Placenta abruption
• Placenta previa
• Uterine rupture
• Postpartum haemorrhage
• Acute severe menorrhagia

Rashes • Necrotizing fasciitis
• Stevens-Johnson syndrome
• Toxic epidermal necrolysis

Shortness of breath in adult Respiratory system Cardiovascular system Metabolic

• Bronchospasm (ie • Acute myocardial • DKA
Asthma, COAD) ischeamia
• Pulmonary embolism • Heart Failure
• Pneumothorax • Cardiac tamponade
• Pulmonary infection
(ie bronchitis,
pneumonia)
• Upper airway
obstruction (ie

aspiration, anaphylaxis)
60
(H.E.A.T.S)

Shortness of breath in Respiratory system Cardiovascular system Nervous system/ Metabolic
children
• Epiglottitis • Congenital heart disease • DKA
• Severe asthma • Acute decompensated
• Anaphylaxis heart failure • Depressed ventilation (ie
• Upper airway foreign • Myocarditis drug ingestion, CNS
body • Arrhythmia trauma, seizures, CNS
• Pneumothorax • Shock infection)
• Smoke inhalation • Cardiac tamponade • Hypotonia
• Drowning/ near
drowning
• Chemical agent exposure
(ie chlorine, cyanide)

Testicular pain • Fournier’s gangrene
• Testicular torsion
• Strangulated scrotal hernia
• Incarcerated scrotal hernia

Trauma • Airway obstruction
• Tension Pneumothorax
• Open pneumothorax
• Massive heamothorax
• Tracheobronchial injury
61
(H.E.A.T.S)

Trauma (cont) • Cardiac tamponade
• Traumatic circulatory arrest

Trauma - limbs • Crush injury
• Crush syndrome
• Compartment syndrome
• Arterial injury

62
(H.E.A.T.S)
APPENDIX 8
TRIAGE COURSE MODULE

i. Triage course is a 1-day course
ii. HEATS manual is a compulsory pre-course reading material
iii. Participants per course – 28 to 30, involving Assistant Medical Officers, Staff Nurses, Medical Officers
iv. Core activities:
a. introduction lecture on Core Concept to Ed Triage and HEATS
b. activities in small group – 7 or 8 participant per group
c. pre-test and post-test questions (passing mark ≥ 60%)
d. ED Triage case-based-discussion (CBD) – trauma and medical scenarios
e. ED Triage case-simulation station (SimX) – trauma and medical scenarios
f. Feedback session

v. Station rotation for each group

Medical CBD Trauma CBD Medical SimX Trauma SimX
Group A Group B Group C Group D
Group D Group A Group B Group C
Group C Group D Group A Group B
Group B Group C Group D Group A

63
(H.E.A.T.S)
INDEX FOR PRESENTING COMPLAINT

N0 PRESENTING COMPLAINT PAGE NO PRESENTING COMPLAINT PAGE
1 Abdominal pain in adult…………………………….. 17 22 Headache………………………………………………………….….. 26
2 Abdominal pain in pregnancy…………………….. 17 23 Irritable child……………………………………………………….. 27
3 Abdominal pain children…………………………… 18 24 Lethargic/ body weakness/ unwell in adult………….... 27
4 Allergy……………………………………………………… 18 25 Lethargic / unwell in children……………………………….. 28
5 Altered behavior……………………………………….. 19 26 Limping child……………………………………………………….. 28
6 Back pain………………………………………………….. 19 27 OSCC……………………………………………………………………. 29
7 Bites and stings…………………………………………. 20 28 Overdose and poisoning……………………………………….. 29
8 Burns and scalds……………………………………….. 20 29 Palpitation……………………………………………………………. 30
9 Chest pain…………………………………………………. 21 30 Per vaginal (PV) bleed…………………………………………... 30
10 Collapse adult…………………………………………… 21 31 Pregnancy- related complaint……………………………….. 31
11 Crying baby……………………………………………..... 21 32 Psychiatric disorder……………………………………………… 31
12 Dental problem…………………………………………. 22 33 Rashes…………………………………………………………………. 32
13 Diarrhoea and vomiting….………….……………… 22 34 Shortness of breath in adult………………………………….. 32
14 Ear problems…………………………………………….. 23 35 Shortness of breath in children……………………………… 33
15 Eye problems……………………………………………. 23 36 Testicular pain……………………………………………………… 34
16 Falls………………………………………………………….. 23 37 Trauma – Head/ facial injury………………………………… 34
17 Fever………………………………………………………… 24 38 Trauma – Penetrating injury…………………………………. 35
18 Fever (suspected dengue fever)…………………. 24 39 Trauma – Blunt injury…………………………………………... 35
19 Fits…………………………………………………………… 25 40 Trauma – Upper limb injury………………………………….. 36
20 GI bleeding – upper GI……………………………….. 26 41 Trauma – Lower limb injury…………………………………. 36
21 GI bleeding – lower GI……………………………….. 26 42 Wounds……………………………………………………………….. 37

64
(H.E.A.T.S)
REFERENCES

1. Malaysia Triage Category
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HOSPITAL KUALA LUMPUR

Appendix 7 Possible life threatening causes/ emergencies 52

2.3.2 Specific Objectives

4.3 TREATMENT ZONES

4.3.4 GREEN ZONE (NON-CRITICAL ZONE)

4.3.5 DECONTAMINATION ZONE

4.4 PRESENTING COMPLAINTS

Characteristic of each Component in Peadiatric Assessment Triangle

No CHIEF CRITICAL 1 CRITICAL II SEMI-CRITICAL NON-CRITICAL

- severe appropriate evaluation

No CHIEF CRITICAL 1 CRITICAL II SEMI-CRITICAL NON-CRITICAL

No CHIEF CRITICAL 1 CRITICAL II SEMI-CRITICAL NON-CRITICAL

burn 10-15% appendix 6

injury appendix 6 appendix 6

No CHIEF CRITICAL 1 CRITICAL II SEMI-CRITICAL NON-CRITICAL

No CHIEF CRITICAL 1 CRITICAL II SEMI-CRITICAL NON-CRITICAL

No CHIEF CRITICAL 1 CRITICAL II SEMI-CRITICAL NON-CRITICAL

No CHIEF CRITICAL 1 CRITICAL II SEMI-CRITICAL NON-CRITICAL

No CHIEF CRITICAL 1 CRITICAL II SEMI-CRITICAL NON-CRITICAL

No CHIEF CRITICAL 1 CRITICAL II SEMI-CRITICAL NON-CRITICAL

No CHIEF CRITICAL 1 CRITICAL II SEMI-CRITICAL NON-CRITICAL

- Shock* - Hypoglyceamia - Not feeding appendix 4

No CHIEF CRITICAL 1 CRITICAL II SEMI-CRITICAL NON-CRITICAL

No CHIEF CRITICAL 1 CRITICAL II SEMI-CRITICAL NON-CRITICAL

distal to the appendix 4

No CHIEF CRITICAL 1 CRITICAL II SEMI-CRITICAL NON-CRITICAL

No CHIEF CRITICAL 1 CRITICAL II SEMI-CRITICAL NON-CRITICAL

No CHIEF CRITICAL 1 CRITICAL II SEMI-CRITICAL NON-CRITICAL

No CHIEF CRITICAL 1 CRITICAL II SEMI-CRITICAL NON-CRITICAL

No CHIEF CRITICAL 1 CRITICAL II SEMI-CRITICAL NON-CRITICAL

No CHIEF CRITICAL 1 CRITICAL II SEMI-CRITICAL NON-CRITICAL

No CHIEF CRITICAL 1 CRITICAL II SEMI-CRITICAL NON-CRITICAL

No CHIEF CRITICAL 1 CRITICAL II SEMI-CRITICAL NON-CRITICAL

Specific discriminator Explanation

Specific discriminator Explanation

Specific discriminator Explanation

Specific discriminator Explanation

Signs of meningism Stiff neck with headache and photophobia

Specific discriminator Explanation

4.2 DISABILITY ASSESSMENT IN PAEDIATRICS TRAUMA18

3. BEHAVIOURAL SCALE – FLACC (Face/ Legs/ Activity/ Cry / Consolability)12

CLINICAL PRESENTATION POSSIBLE LIFE THREATING CAUSES / EMERGENCIES

CLINICAL PRESENTATION POSSIBLE LIFE THREATING CAUSES / EMERGENCIES

CLINICAL PRESENTATION POSSIBLE LIFE THREATING CAUSES / EMERGENCIES

CLINICAL PRESENTATION POSSIBLE LIFE THREATING CAUSES / EMERGENCIES

CLINICAL PRESENTATION POSSIBLE LIFE THREATING CAUSES / EMERGENCIES

CLINICAL PRESENTATION POSSIBLE LIFE THREATING CAUSES / EMERGENCIES

CLINICAL PRESENTATION POSSIBLE LIFE THREATING CAUSES / EMERGENCIES

• Abdominal pain (≥20w pregnancy)

CLINICAL PRESENTATION POSSIBLE LIFE THREATING CAUSES / EMERGENCIES

CLINICAL PRESENTATION POSSIBLE LIFE THREATING CAUSES / EMERGENCIES

CLINICAL PRESENTATION POSSIBLE LIFE THREATING CAUSES / EMERGENCIES

INDEX FOR PRESENTING COMPLAINT

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