Triage and ABCDE: a simulation session

Key messages to land

1. Triage first: the sickest are seen first, not the first to arrive.
2. ABCDE in order; treat each problem as you find it; reassess after every action.
3. Possible trauma: keep the neck still and use the jaw thrust.
4. Inadequate breathing: bag-valve-mask now; do not wait for oxygen.
5. Shock: stop bleeding, 1 litre for adults, smaller and slower for malnutrition, anaemia or heart problems.
6. Always check glucose in a confused or unconscious person.
7. Hand over by SBAR, with a written record.

Running the simulations

• Keep scenarios short and realistic. Reveal findings only when the team looks for them (for example, give the pulse only when someone feels for it).
• Make the patient respond to good care (for example, BP rises after fluid) and worsen if a key step is missed.
• Debrief kindly and specifically. Ask the team first what they would do differently.
• Rotate roles so everyone leads at least once if time allows.

Common misunderstandings

"Take a full history before treating"

Treat immediate threats in ABCDE order first; SAMPLE comes after.

"Wait for oxygen before ventilating"

Start bag-valve-mask ventilation straight away and add oxygen when ready.

"Big fluid boluses for every child in shock"

Use 10 to 20 mL/kg, and 10 to 15 mL/kg over 1 hour with malnutrition or severe anaemia, following your national protocol.

"Low BP is the first sign of shock"

Fast pulse, cool hands and slow capillary refill come earlier; low BP is late.

Adapting the session

Replace triage cards and scenarios with the cases your facility actually sees (for example snakebite, burns, postpartum bleeding). Use your national doses where they differ from the handout. For a shorter session, run two scenarios instead of four.

Case 1: Scenario 1: the wheezing woman

A 35-year-old woman is helped in, sitting forward, unable to finish sentences. Respiratory rate 32 per minute, wheeze on both sides, oxygen saturation 88%, pulse 120. She is alert.

1. What is her triage category and first treatment?
   Answer: Red. Airway is open (she is talking). Breathing: give oxygen and salbutamol (by spacer: 2 puffs every 2 minutes, or nebulised 5 mg), repeated as needed. Then C, D, E and a SAMPLE history.
2. What would make you think of anaphylaxis and change treatment?
   Answer: A trigger such as a sting, food or a medicine, with stridor, swelling of lips or tongue, or hives. Then give IM adrenaline 0.5 mg for an adult of 50 kg or more, repeated every 5 minutes as needed.

Case 2: Scenario 2: the motorcyclist

A 30-year-old man after a road crash. He groans when spoken to. Pulse 130, BP 80/50, capillary refill 4 seconds, cold hands. Bleeding from a deep cut on the forearm; swollen deformed thigh.

1. What are the key actions in order?
   Answer: Airway with the neck held still (jaw thrust if needed). Breathing: oxygen. Circulation: direct pressure on the forearm wound, two IV lines, 1 litre of normal saline or Ringer's lactate over less than 30 minutes, splint the thigh. Disability: AVPU (V) and glucose. Exposure: look for other injuries, log-roll, keep warm.
2. BP is still 82/50 after 2 litres. What next?
   Answer: Suspect ongoing internal bleeding; call for advanced help and transfer urgently to a facility that can operate and transfuse.

Case 3: Scenario 3: the unconscious man

A 50-year-old man is found unresponsive. Breathing 14 per minute with snoring, pulse 96, BP 140/90. No sign of injury. His family says he has diabetes. Glucose 2.2 mmol/L.

1. What do you do first?
   Answer: Open the airway (head-tilt and chin-lift, no trauma), consider an oral airway, and give 25 to 50 mL of 50% dextrose IV (or 125 to 250 mL of 10%). Recheck glucose and AVPU.
2. He wakes up. What next?
   Answer: Recovery position until fully alert, food when able to swallow, repeated glucose checks (lows on sulfonylureas recur), SAMPLE history, and review of his diabetes medicines.

Case 4: Scenario 4: the seizing pregnant woman

A woman 36 weeks pregnant is having a generalised seizure. BP 170/112. Her relatives say she has had a headache for two days.

1. What is the likely diagnosis and key medicine?
   Answer: Eclampsia. Protect her from injury, open the airway and turn her to the left side, give oxygen, and give magnesium sulfate per the obstetric protocol (BEC: 4 g IV over 5 minutes and 10 g IM, 5 g in each buttock), then transfer urgently.
2. How should she be positioned for transfer?
   Answer: Tilted onto her left side (pillows along the right of her back) to avoid compression of the large blood vessels by the uterus, with airway equipment ready and ABCDE reassessed at least every 15 minutes.

Read the questions aloud or print them. Participants choose one answer each. The answer key with reasons follows.

1. In triage, a red category means:
   1. Can wait
   2. Seen soon
   3. Seen immediately
2. What is the correct ABCDE order?
   1. Airway, Breathing, Circulation, Disability, Exposure
   2. Breathing, Airway, Circulation, Exposure, Disability
   3. Circulation, Airway, Breathing, Disability, Exposure
3. How do you open the airway of an unconscious injured patient?
   1. Head-tilt and chin-lift
   2. Jaw thrust with the neck held still
   3. Sit them up
4. A patient breathes too slowly and oxygen is not ready. You should:
   1. Wait for oxygen
   2. Start bag-valve-mask ventilation now
   3. Give salbutamol
5. Adult anaphylaxis: IM adrenaline dose (50 kg or more)?
   1. 0.05 mg
   2. 0.5 mg (0.5 mL of 1 mg/mL)
   3. 5 mg
6. First IV fluid bolus for an adult in shock (no overload, malnutrition or severe anaemia)?
   1. 250 mL over 2 hours
   2. 1 litre over less than 30 minutes
   3. 3 litres at once
7. Which is an early sign of shock?
   1. Capillary refill longer than 3 seconds and fast pulse
   2. High BP
   3. Warm pink hands
8. A confused patient's glucose cannot be tested. You should:
   1. Give glucose
   2. Give insulin
   3. Wait
9. A woman 34 weeks pregnant is seizing. Key medicine?
   1. Magnesium sulfate
   2. Naloxone
   3. Salbutamol
10. SBAR stands for:
    1. Situation, Background, Assessment, Recommendation
    2. Signs, Breathing, Airway, Response
    3. Sex, Bleeding, Age, Risk

Answer key

1. C. Red is high acuity: seen immediately.
2. A. Threats are addressed in the order they kill.
3. B. Possible spinal injury: jaw thrust, not head-tilt.
4. B. Do not delay ventilation while oxygen is prepared.
5. B. 0.5 mg IM, repeated every 5 minutes as needed.
6. B. 1 litre, then reassess.
7. A. Low BP is a late sign.
8. A. Give glucose if below 3.5 mmol/L or if it cannot be tested in altered mental status.
9. A. Seizure in pregnancy: magnesium sulfate and transfer.
10. A. The BEC handover method.