The Irish Children's Triage System is used to triage pediatric patient coming to the Emergency Department. Respiratory distress can be graded based on the patient's clinical manifestations.
Patient selection: respiratory distress
Shared Parameters:
(1) SaO2 in percent on room air
(2) accessory muscle use
(3) ability to talk
(4) mental status
(5) heart rate
(6) stridor
(7) nasal flaring
(8) increase in work of breathing
Parameter
Mild Distress
Moderate Distress
Severe Distress
SaO2
> 94%
92 to 94%
< 92%
accessory muscles
no or subtle
some use
moderate to marked
ability to talk
normal
some limitations
marked decrease, unable to speak a sentence
mental status
normal
normal
agitated, distressed
heart rate
normal
tachycardia
tachycardia
stridor
none
mild
at rest
nasal flaring
none
mild
marked
work of breathing
mild
moderate
marked
Additional findings in moderate distress:
(1) constant cough
(2) tracheal tug
(3) variable chest pain
Additional findings in severe distress:
(1) head bobbing in infant
(2) sighing/grunting respirations
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