Paediatric Triage Assessment Flashcards
Airway ATS 1
Complete obstruction
Or
Partial obstruction with severe resp distress
Breathing ATS 1
Absent Respiration or Hypoventalation Or Sever Resp Distress: e.g. severe retraction, cynosis, severe use of accessory muscles
Circulation ATS 1
Absent Circulation, significant bradycardia e.g. HR< 60 in infant. And/or
Severe haemodynamic compromise e.g. pallor, cold, moist, motted skin, tachycardic, cap refill > 4secs,absent peripheral pulses, uncontrolled haemorrhage.
S/S of dehydration
Decreased LOC/activity, cap refill > 2 secs, dry mucousal membranes, sunken eyes, decreased tissue turgor, absent tears, deep respirations, thready/weak pulse, tachycardia, decreased urine output and fluid input.
Disability ATS 1
GCS < 8
Airway ATS 2
Patent or Partially obstructed with moderate resp distress
Airway ATS 3
Patent or Partially obstructed woth mild resp distress
Airway ATS 4
Patent
Airway ATS 5
Patent
Breathing ATS 2
Respiration present and moderate resp distress e.g. moderate use of accessory muscles, moderate retraction, skin pale
Breathing ATS 3
Respiration present And Mild resp distress e.g. mild use of accessory muscles, mild retraction, skin pink.
Breathing ATS 4
Respiration present and no resp distress e.g. no use of accessory muscles, no retraction.
Breathing ATS 5
Respiration present and no resp distress e.g. no use of accessory muscles, no retraction.
Circulation ATS 2
Circulation present. Moderate haemodynamic compromise e.g. weak/thready pulse, skin pale, cool, moderate tachycardia, cap refill 2-4secs, >6 s/s of dehydration.
Circulation ATS 3
Circulation present. Mild Haemodynamic compromise e.g. palpable peripheral pulses, skin pale, warm, mild tachycardia, 3-6 s/s of dehydration.
Circulation ATS 4
Circulation present, no haemodynamic compromise e.g. palpable peripheral pulses, skin pink, dry and warm, < 3 s/s dehydration.
Circulation ATS 5
Circulation present. No haemodynamic compromise e.g. palpable peripheral pulses. Skin warm, pink and dry
Disability ATS 2
GCS 9-12, severe decrease in activity, e.g. no eye conact, decreased muscle tone.
Or
Severe pain e.g. -pt and parents report moderate pain, skin pale and cool, alterations to vital signs, requests analgesia.
Or
Moderate neurovascular compromise e.g. pulseless, cool, nosensation movement and cap refill.
Disability ATS 3
GCS > 13, moderate decrease activity e.g. -lethargy - eye contact when disturbed.
Or
Moderate pain e.g. -pt and parents report moderate pain, skin pale and warm. alterations to vital signs, requests analgesia.
Or
Moderate neurovascular compromise e.g. pulse present, cool, decreased sensation movement and cap refill.
Disability ATS 4
GCS normal or no acute change from baseline. Mild decrease in activity, e.g. quiet but eye contact, interacts with parents.
Or
Mild pain e.g. -pt and parents report mild pain, skin pink, warm and perfused, no alterations to vital signs, requests analgesia.
Or
Mild neurovascular compromise e.g. pulse present, normal/decreased sensation movement and cap refill.
Disability ATS 5
Normal GCS or no acute change to usual GCS. No alteration to activity e.g. playing or smiling.
Or
No or Mild pin e.g pt or parents reports mild pain, no alterations in vital signs, declines analgesia.
Or
No neurovascular compromise
Risk factors : Mechanism of injury
Penetrating injury Fall > than 2x height MCA > 60kph MBA/cyclist > 30kph Pedistrian Ejection/rollover Prolonged extraction Death in same car as occupant Explosion
Risk factors: comorbities
Hx of prematurity Cardiac, respiratory, renal disease Carcinoma Diabetes Substance abuse Immuno-compromised Congenital disease Complex medical history
Risk factors:age
<3months and…. Febrile Acute changes to feeding pattern Or Victoms of violence e.g Child at risk Sexual assult Neglect
Risk factors: Historical variables (events preceding presentation)
Apnoeic/cynanotic episode Seizure activity Decreased intake Decreased output Red current jelly stool Bile stained vomiting Parental concern
Risk factors: others
Rash Actual/potential side effects from drugs/alcohol Chemical exposure Envenomation Immersion Alteration in body temp
