Table 8.2: Paediatric physiological discriminators 118( cont)
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
No or mild pain, e. g.
– patient / parents report mild pain
– skin, pink, warm – no alteration in vital signs – declines analgesia.
Mild pain, e. g. – patient / parents report mild pain
– skin, pink, warm – no alteration in vital signs – requests analgesia.
Moderate pain, e. g.
– patient / parents report moderate pain
– skin, pale, warm – alteration in vital signs – requests analgesia.
Severe pain, e. g. – patient / parents report severe pain – skin, pale, cool – alteration in vital signs – requests analgesia.
No neurovascular compromise
Mild neurovascular compromise, e. g. – pulse present – normal / sensation – normal / movement – normal capillary refill.
Moderate neurovascular compromise, e. g. – pulse present – cool – sensation – movement – capillary refill.
Severe neurovascular compromise, e. g. – pulseless – cold – nil sensation – nil movement – capillary refill.
Risk factors for serious illness or injury
These should be considered in the light of history of events and physiological data. Multiple risk factors = increased risk of serious injury. The presence of one or more risk factors may result in allocation of triage category of higher acuity.
Mechanism of injury, e. g.
Other, e. g.
• rash
• actual / potential effects of drugs / alcohol
• chemical exposure
• envenomation
• immersion
• alteration in body temperature.
Historical variables, e. g. events preceding presentation to ED
• apnoeic / cyanotic episode
• seizure activity
• decreased intake
• decreased output
• red current jelly stool
• bile stained vomiting. Parental concern
Age < 3 months and
• febrile
• acute change to feeding pattern
• acute change to sleeping pattern Victims of violence, e. g.
• child at risk
• sexual assault
• neglect.
Co morbidities, e. g. Hx prematurity
• respiratory disease
• cardiovascular disease
• renal disease
• carcinoma
• diabetes
• substance abuse
• immuno-compromised
• congenital disease
• complex medical Hx.
• penetrating injury
• fall > 2 – height
• MCA > 60 kph
• MBA / cyclist > 30 kph
• pedestrian
• ejection / rollover
• prolonged extrication(> 30 minutes)
• death same car occupant
• explosion.
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Department of Health and Ageing – Emergency Triage Education Kit