Paediatric Triage Assessment

Question 1

Airway ATS 1

Answer 1

Complete obstruction

Or

Partial obstruction with severe resp distress

Question 2

Breathing ATS 1

Answer 2

Absent Respiration 
or 
Hypoventalation
Or 
Sever Resp Distress: e.g. severe retraction, cynosis, severe use of accessory muscles

Question 3

Circulation ATS 1

Answer 3

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.

Question 4

S/S of dehydration

Answer 4

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.

Question 5

Disability ATS 1

Answer 5

GCS < 8

Question 6

Airway ATS 2

Answer 6

Patent or Partially obstructed with moderate resp distress

Question 7

Airway ATS 3

Answer 7

Patent or Partially obstructed woth mild resp distress

Question 8

Airway ATS 4

Answer 8

Patent

Question 9

Airway ATS 5

Answer 9

Patent

Question 10

Breathing ATS 2

Answer 10

Respiration present and moderate resp distress e.g. moderate use of accessory muscles, moderate retraction, skin pale

Question 11

Breathing ATS 3

Answer 11

Respiration present And Mild resp distress e.g. mild use of accessory muscles, mild retraction, skin pink.

Question 12

Breathing ATS 4

Answer 12

Respiration present and no resp distress e.g. no use of accessory muscles, no retraction.

Question 13

Breathing ATS 5

Answer 13

Respiration present and no resp distress e.g. no use of accessory muscles, no retraction.

Question 14

Circulation ATS 2

Answer 14

Circulation present. Moderate haemodynamic compromise e.g. weak/thready pulse, skin pale, cool, moderate tachycardia, cap refill 2-4secs, >6 s/s of dehydration.

Question 15

Circulation ATS 3

Answer 15

Circulation present. Mild Haemodynamic compromise e.g. palpable peripheral pulses, skin pale, warm, mild tachycardia, 3-6 s/s of dehydration.

Question 16

Circulation ATS 4

Answer 16

Circulation present, no haemodynamic compromise e.g. palpable peripheral pulses, skin pink, dry and warm, < 3 s/s dehydration.

Question 17

Circulation ATS 5

Answer 17

Circulation present. No haemodynamic compromise e.g. palpable peripheral pulses. Skin warm, pink and dry

Question 18

Disability ATS 2

Answer 18

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.

Question 19

Disability ATS 3

Answer 19

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.

Question 20

Disability ATS 4

Answer 20

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.

Question 21

Disability ATS 5

Answer 21

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

Question 22

Risk factors : Mechanism of injury

Answer 22

Penetrating injury
Fall > than 2x height 
MCA > 60kph
MBA/cyclist > 30kph
Pedistrian
Ejection/rollover
Prolonged extraction
Death in same car as occupant 
Explosion

Question 23

Risk factors: comorbities

Answer 23

Hx of prematurity
Cardiac, respiratory, renal disease
Carcinoma
Diabetes
Substance abuse
Immuno-compromised
Congenital disease
Complex medical history

Question 24

Risk factors:age

Answer 24

<3months and….
Febrile
Acute changes to feeding pattern
Or
Victoms of violence e.g 
Child at risk
Sexual assult
Neglect

Question 25

Risk factors: Historical variables (events preceding presentation)

Answer 25

Apnoeic/cynanotic episode
Seizure activity
Decreased intake
Decreased output 
Red current jelly stool 
Bile stained vomiting
Parental concern

Question 26

Risk factors: others

Answer 26

Rash
Actual/potential side effects from drugs/alcohol
Chemical exposure
Envenomation
Immersion
Alteration in body temp