The Irish Children's Triage System is used to triage pediatric patient coming to the Emergency Department.
Patient selection: psychosocial problem and/or self-harm
Shared parameters:
(1) abnormal age-related vital signs
(2) Glasgow coma scale
(3) violent behavior
(4) self-destructive behavior
(5) shock
(6) agitation
(7) risk of absconding
|
Parameters |
Findings |
Category |
|
abnormal vital signs |
category 1 |
1 |
|
|
category 2 |
2 |
|
|
category 3 |
3 |
|
|
other |
4 |
|
Glasgow coma scale |
<= 12 |
1 |
|
|
13 or 14 |
2 |
|
|
15 |
4 |
|
violent behavior |
immediate risk to self or others |
1 |
|
|
probable risk to self or others |
2 |
|
|
threat of harm |
3 |
|
|
recent assault |
3 |
|
|
other |
4 |
|
self-destructive behavior |
requires restraint |
1 |
|
|
attempted |
2 |
|
|
acts of deliberate self-harm |
2 |
|
|
expressing suicidal ideation |
2 |
|
|
none |
4 |
|
shock |
uncompensated |
1 |
|
|
compensated |
2 |
|
|
none |
4 |
|
agitation |
extreme with aggressive behavior |
2 |
|
|
restless with intrusive behavior |
3 |
|
|
other |
4 |
|
risk of absconding |
high |
2 |
|
|
moderate |
3 |
|
|
other |
4 |
|
Other Parameters |
Category |
|
airway compromise |
1 |
|
respiratory failure/arrest |
1 |
|
currently seizing |
1 |
|
confused unable to cooperate |
2 |
|
auditory or visual hallucinations |
2 |
|
disclosure of abuse |
3 |
|
significant behavior change |
3 |
|
bizarre or disorganized behavior |
3 |
|
withdrawn, uncommunicating |
3 |
|
ambivalent about treatment |
3 |
|
psychotic symptoms of affective disorder (depression, elated) |
3 |
|
eating disorder with normal vital signs |
4 |
The final triage category is MIN(triage category for all of the parameters)
The patient should not be triaged to Category 5.
If ingestion of a toxic substance is suspected then assess for overdose or poisoning.
Specialty: Pedatrics
