Irish Children's Triage System: Burns or Scalds

Parameters

Findings

Category

SaO2

>=94% on room air

5

91 to 93%

2

<= 90%

1

abnormal vital signs

category 1

1

category 2

2

category 3

3

none

5

shock

uncompensated

1

compensated

2

none

5

Glasgow coma scale

<= 12

1

13 or 14

2

15

5

burn extent

> =5% BSA full thickness

2

> =10% BSA partial thickness

2

< 5% BSA full thickness

3

< 10% BSA partial thickness

3

minor burn

4

other

5

pain

severe (VAS >= 7)

2

moderate (VAS 4-6)

3

mild (1 to 3)

4

none

5

duration

less than 48 hours (recent) or acute symptoms

4

> 48 hours without acute symptoms

5

history or mechanism

significant

2

inconsistent with findings

3

consistent

5

Other Parameters

Category

airway compromise

1

respiratory failure/arrest

1

temperature > 40°C

2

temperature <= 35.5°C

2

flame burn of face or neck or facial edema

2

burn of face, neck or perineum

2

circumferential burn of hand, foot or chest

2

other injuries

2

chemical or electrical burn

2

history of smoke inhalation or presence of dirt in mouth/nostrils

2

central capillary refill time> 2 seconds

2

delayed presentation

3

localised cold injury

3

local tenderness, infection or inflammation

4