Paediatric Triage Poster

National Emergency Nurses Affiliation Inc.

The Canadian Association of Emergency Physicians L'Association canadienne des médecins d'urgence

L’affiliation nationale des infirmiers/infirmières d’urgence incorporée

L ' A S S O C I AT I O N

DES

D'URGENCE

QUÉBEC

DU

MÉDECINS

The Canadian Paediatric E.D. Triage andAcuity Scale Patients should have an initial triage assessment within 10 minutes of arrival

First Impression or EMS Assessment

Presenting Condition Assessment

Physiologic Assessment

see below PAEDIATRIC PRESENTING CONDITIONS

Appearance - Neurologic Respiratory Rate + Effort Heart Rate + Perfusion

TRIAGE LEVEL I

TRIAGE LEVEL II

TRIAGE LEVEL III

TRIAGE LEVEL IV

TRIAGE LEVEL V

RESUSCITATION

EMERGENT

URGENT

LESS URGENT

NON URGENT

MINUTES**

MINUTES**

TIME TO REASSESSMENT OR MEDICAL CARE

MINUTES**

PHYSIOLOGIC ASSESSMENT

MINUTES**

unresponsive

altered conciousness lethargic

infant - unconsolable not feeding atypical behaviour

infant - consolable history of atypical behaviour

no history of recent behaviour or vital sign change

Respiratory Symptoms

RR NR +/- 2 SD inadequate breathing severe distress

RR NR +/- 1 SD marked stridor moderate distress

RR outside NR for age stridor mild distress

RR - normal for age

RR - normal for age

Cardiovascular

HR NR +/- 2 SD cardiac arrest shock cyanosis

HR NR +/- 1 SD capillary refill > 4 sec

HR outside NR for age capillary refill > 2 sec

HR - normal for age

HR - normal for age

(NR = Normal Range)

RESPIRATORY RATE (RR) Age

+/- 2 SD

+/- 1 SD

Birth - 3 months 3 months - 6 months 6 months - 1 year 1 year - 3 years 6 years 10 years

10 - 80 10 - 80 10 - 60 10 - 40 8 - 32 8 - 26

20 - 70 20 - 70 17 - 55 15 - 35 12 - 28 10 - 24

HEART RATE (HR) Normal Range (NR) 30 - 60 30 - 60 25 - 45 20 - 30 16 - 24 14 - 20

+/- 2 SD

+/- 1 SD

40 - 230 40 - 210 40 - 180 40 - 165 40 - 140 30 - 120

65 - 205 63 - 180 60 - 160 58 - 145 55 - 125 45 - 105

Normal Range (NR) 90 - 180 80 - 160 80 - 140 75 - 130 70 - 110 60 - 90

PAEDIATRIC PRESENTING CONDITIONS Respiratory

airway compromise

marked stridor

stridor

severe distress

moderate distress

mild distress

critical asthma

severe asthma

moderate asthma

mild asthma

chest trauma with respiratory distress

FB aspiration with respiratory distress

FB aspiration with no respiratory distress

possible FB aspiration with no distress

inhalation of toxic substance

constant cough distressed

minor chest injury no shortness of breath

Neurological

major head injury GCS < 10

moderate head injury GCS ≤ 13

minor head injury GCS ≤ 15

minor head injury

CNS

unresponsive

altered consciousness

history of altered consciousness

no vomiting or altered consciousness

actively seizuring

headache severe sudden onset

headache

chronic headache

ill - shunt dysfunction

possible shunt dysfunction

new neurologic findings

previous seizure tachycardia

Cardiovascular

cardiac arrest

tachycardia ++

Circulation

shock

bradycardia

hypotension

severe dehydration

signs of dehydration

exsanguinating haemorrhage

uncontrollable major haemorrhage

uncontrollable minor haemorrhage

major trauma

traumatic amputation - digit

traumatic amputation -extremity

open fracture fracture with neuro- vascular deficit

fracture no neurovascular deficit tight cast

greenstick fracture

back pain with neurologic symptom

joint pain with fever

extremity swelling sprain/strain

avulsed 2˚ tooth

dental trauma

Musculo-skeletal

normal heart rate

well hydrated

chest pain

hypothermia

Skin

burn, > 25 % BSA or airway involved

burn > 10 % BSA burn- face, hand, foot chemical /electrical purpuric rash

burn < 10 % BSA frostbite cellulitis - ill / fever complex lacerations

minor burn minor cold injury local cellulitis simple laceration

Gastrointestinal

penetrating or blunt trauma with shock

acute bleeding vomitus or rectal

persistent or bilious vomiting acute vomiting/ diarrhea age < 2

constipation / pain

difficulty swallowing with airway compromise

abdominal pain with vomiting / diarrhea / abnormal vital signs

? appendicitis

vaginal bleed - unstable

severe testicular pain

moderate testicular pain / swelling

Genitourinary Gynecologic

? ectopic pregnancy

acute vomiting / diarrhea age > 2

superficial burn abrasion, contusion, local rash minor insect bite

vomiting or diarrhea no pain, no dehydration

scrotal trauma possible UTI

inguinal mass / pain urine retention >24 hr urine retention > 8 hrs severe vaginal bleed paraphimosis

Ear/Nose/Throat

airway compromise

amputation ear

vaginal bleeding

uncontrolled epistaxis

foreign body nose epistaxis controlled puncture palate

sore throat with drooling, stridor

tonsillar pustules with difficulty swallowing

difficulty swallowing hoarseness after trauma

hearing problem

ear drainage earache

sore throat mouth sores nasal congestion laryngitis

tearing, discharge affecting function corneal FB

conjunctivitis

Post T& A bleed

Eye Hematologic

anaphylaxis

Immunologic Endocrine

diabetic- altered consciousness

Psychiatry

chemical exposure penetrating injury orbital infection

vision change periorbital infection

bleeding disorder

sickle cell crisis

fever- neutropenic / sickle cell

moderate allergic reaction

diabetic- ketoacidosis hypoglycemia

hyperglycemia

toxic overdose

ingestion requiring observation

high risk of harm to self / others

local allergic reaction

low risk of harm to self/ others

chronic symptoms with no change

moderate risk of harm to self / others

violent behaviour disruptive/distressed

depression

Behaviour Change

unresponsive

lethargic child infant < 7 days old

unconsolable infant infant not feeding

irritable- consolable atypical behaviour

Infection

septic shock

infant < 3 mon 36< temperature ≥ 38 toxic appearance - any age

infant 3-36 mon with temperature > 38.5

Infant > 36 mon with temperature > 38.5 non toxic appearance

Child Abuse

unstable situation or conflict

ongoing risk

physical assault sexual abuse