Several assessment tools use these known markers of serious illness in infants and young children as the basis for triage decision-making. These include the Triage Observation Tool 91 and SAVE A CHILD. 92 The Yale Observation Scale is another tool that may be helpful in detecting occult bacteraemia in infants. 92-94 A brief summary of each of these tools is provided in the‘ Teaching resources’ section of this chapter.
Physiological approach to triage assessment and decision-making
General appearance
Clinical data to contribute to the assessment of urgency can be gained from observing the general appearance of a child presenting to the ED. This is particularly significant in cases in which examination is likely to upset the infant or young child, making further examination difficult.
Airway
Evaluation of the airway will concentrate on determining airway patency. Stridor is an indicator of airway obstruction, and therefore implies a high level of urgency.
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Evaluation of the extent of the airway obstruction in infants and young children should be made by assessing work of breathing.
Cervical spine management forms a component of airway evaluation where the presentation is the result of trauma.
Assessment and management of likely cervical injury in children is particularly challenging and may increase the relative urgency of the presentation.
Breathing
It is widely recognised that infants and young children tolerate respiratory distress poorly, and increased work of breathing has been shown to be an indicator of serious
82, 95 illness in infants.
Work of breathing and mental status are the most useful indicators of the severity of asthma. These parameters are also thought to be predictive of severity for most respiratory
96, 97 presentations in infants and young children.
Although the presence of elevated respiratory rate, retraction, nasal flaring and a range of other clinical signs are an indication of significant illness, their absence may not always be a
88, 98, 99 negative predictor of serious illness.
Triage nurses are encouraged to use a number of parameters to make a respiratory assessment.
Department of Health and Ageing – Emergency Triage Education Kit