Emergency Triage Education Kit | Page 58

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Table 8.2: Paediatric physiological discriminators 118

Category 5 – Non-urgent Within 120 minutes

Category 4 – Semi-urgent Within 60 minutes

Category 3 – Urgent Within 30 minutes

Category 1 – Immediate Category 2 – Emergency Within 10 minutes

Patent Patent Patent Patent Airway Obstructed

Partially obstructed with mild respiratory distress

Partially obstructed with moderate respiratory distress

Partially obstructed with severe respiratory distress

Respiration present Respiration present Respiration present Respiration present

Breathing Absent respiration or hypoventilation

No respiratory distress – no use accessory muscles – no retraction.

No respiratory distress – no use accessory muscles – no retraction.

Mild respiratory distress, e. g. – mild use accessory muscles – mild retraction – skin pink.

Moderate respiratory distress, e. g. – moderate use accessory muscles – moderate retraction – skin pale.

Severe respiratory distress, e. g. – severe use accessory muscles – severe retraction – acute cyanosis.

Circulation present Circulation present Circulation present Circulation present

Absent circulation Significant bradycardia, e. g. HR < 60 in an infant

Circulation s / s dehydration LOC / activity cap refill < 2 sec dry oral mucosa sunken eyes tissue turgor absent tears deep respirations thready / weak pulse tachycardia urine output

No haemodynamic compromise, e. g. – palpable peripheral pulses – skin pink, warm, dry.

No haemodynamic compromise, e. g. – palpable peripheral pulses – skin pink, warm, dry.

Mild haemodynamic compromise, e. g. – palpable peripheral pulses – skin pale, warm – mild tachycardia.

Moderate haemodynamic compromise, e. g. – weak / thready brachial pulse – skin pale, cool, – moderate tachycardia – capillary refill 2 – 4 secs.

Severe haemodynamic compromise, e. g. – absent peripheral pulses – skin pale, cold, moist, mottled – significant tachycardia – capillary refill > 4 secs.

Uncontrolled haemorrhage

Department of Health and Ageing – Emergency Triage Education Kit

> 6 s / s dehydration 3 – 6 s / s dehydration < 3 s / s dehydration No s / s dehydration

Normal GCS or no acute change to usual GCS. No alteration to activity, e. g. – playing – smiling.

Normal GCS or no acute change to usual GCS. Mild decrease in activity, e. g. – quiet but eye contact – interacts with parents.

GCS > 13 Moderate decrease in activity, e. g. – lethargic – eye contact when disturbed.