Irish Children's Triage System: Unwell Infant

Parameters

Findings

Category

blood glucose

< 2.8 mmol/L with neurological symptoms

1

< 2.8 mmol/L without

2

2.8 to 3.4 mmol/L

3

> 3.4 mmol/L

5

abnormal vital signs

category 1

1

category 2

2

category 3

3

category 4

4

other

5

shock

uncompensated

1

compensated

2

none

5

Glasgow coma scale

<= 12

1

13 or 14

2

15

5

SaO2 in percent

> 92%

5

90.1 to 92%

2

<= 90%

1

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

seizures

currently seizing

1

history of seizures

3

none

5

reaction to parents or guardian

unresponsive to

2

inconsolable

3

consolable

4

not in need of being consoled

5

Other Parameters

Category

airway compromise

1

respiratory failure/arrest

1

temperature > 40°C

2

temperature <= 35.5°C

2

abnormal cry

2

apnea > 20 seconds

2

bulging or sunken fontanelles

2

central capillary refill time > 2 seconds

2

history of cyanosis

2

irritable

2

lethargy, listless, floppy

2

meningismus

2

mottled or cold skin

2

new neurological symptoms

2

purpura or petechiae

2

age < 3 months

3

atypical behavior

3

drawing up legs

3

history of jittery episodes

3

jaundice

3

PEG or NG tube problem

3

projectile vomiting

3

prolonged crying

3

reduced feeding

3

reduced urine output, dry nappies

3

significant medical or surgical history

3