Irish Children's Triage System: Skin Rash

Parameters

Findings

Category

respiratory distress

severe with stridor

1

moderate

3

mild

4

none

5

abnormal vital signs

category 1

1

category 2

2

category 3

3

shock

uncompensated

1

compensated

2

none

5

Glasgow coma scale

<= 12

1

13 or 14

2

15

5

type of rash

non-blanching rash

2

purpura or petechiae

2

widespread discharge

3

blistering

3

unexplained bruising

3

blanchinr rash

4

other

5

pain

severe (VAS >= 7)

2

moderate (VAS 4-6)

3

mild (1 to 3)

4

none

5

SaO2

>= 92 percent

5

90 to 91.9 percent

2

< 90%

1

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

signs of hypersensitivity

severe anaphylaxis

2

localized allergic reaction

4

none

5

Other Parameters

Category

airway compromise

1

respiratory failure/arrest

1

currently seizing

1

temperature > 40°C

2

temperature <= 35.5°C

2

central capillary refill time > 2 seconds

2

edema of the tongue

2

history of hematological problem

3