Triage

TRIAGE
TRIAGE
◦ Triage refers to assessment of a patient in the emergency room
◦ with a view to define urgency of care and priorities in management
◦ Thus helping in the rational allocation of limited resources when the demand exceeds the
availability.
Goals of Triage System
◦ To rapidly assess and identify children with life-threatening illness
• To determine appropriate cause and initiate timely interventions
• Order immediate investigations and procedures as per the need
• To provide safe and quality care to patients
• To utilize the limited resources in an efficient manner.
PEDIATRIC TRIAGE
1. The pediatric triage assessment is a rapid 3–5 min clinical evaluation of a child with an aim to
determine the severity of illness
2. It is particularly important to triage each child according to the age, symptomatology and acuity of
illness.
Triage Assessment
Triage evaluation can be completed in an organized and systematic manner using the general assessment,
i.e., Pediatric Assessment Triangle (PAT) and primary assessment (ABCDE approach).
General Assessment
rapid and hardly takes 30–40s
Appearance:Muscle tone, interaction,

consolability, look/gaze or speech/cry are assessed.
Work of breathing: Increased work of breathing

(nasal flaring, retractions), decreased or absent
efforts or abnormal sounds (wheeze, grunt, and
stridor).
Circulation: Abnormal skin color (pale or

cyanosed) or bleeding.
Based on PAT assessment, patient’s illness is categorized as either
stable or unstable. The unstable ones are further classified into life-
threatening and non-life-threatening.
Primary Assessment
Involves a more detailed physical

examination/assessment of airway (A),
breathing (B), circulation (C), neurologic
abnormalities (D) and head-to-toe examination
(Exposure).
Primary assessment should be completed in 1–3

minutes
Airway
The anatomical part of respiratory tract which acts as a conduit for carrying atmospheric air to lungs but
does not participate in gas exchange is called the airway
The goal is to determine the patency of airway which can be determined by look, listen and feel
maneuvers.
Look: for chest rise.
Listen: for breath sounds and air movement.
Feel: the movement of air at the nose and mouth.
Signs that suggest airway obstruction are inability to speak, a silent cough, breathing difficulty, poor
chest rise, gurgling noises, pooling of secretions or paradoxical chest movements.
Stabilization
1. Simple maneuvers such as positioning (chin-lift head-tilt) or suction

2. Adjuncts such as oropharyngeal airway, endotracheal tubes or laryngeal mask airway
Breathing
The assessment of breathing includes an evaluation of the respiratory rate and effort, lung sounds, and
pulse oximetry.
Normal respiratory rates are age dependent and hence respiratory rates more or slower than normal for age
are defined as tachypnea and bradypnea, respectively.
Apnea is defined as a complete cessation of breathing for 20 sec or more.
Increased work of breathing (WOB) manifests in the form of nasal flaring, retractions, accessory muscle
use, or irregular respirations
The adequacy of tidal ventilation is determined by the chest wall excursion, and auscultation of air
movement. Abnormal lung sounds include stridor, grunting, gurgling, wheezing, and crackles
Status classification.
1. Respiratory distress
2. Respiratory failure.
◦ Retractions + stridor = Upper airway obstruction

◦ Retractions + wheeze = Lower airway obstruction
◦ Retraction + Grunt/labored breathing + crepitations = Parenchymal disease
◦ Increased rates without recessions = Acidosis or neurogenic hyperventilation
◦ Paradoxical breathing/see-saw breathing = Neuromuscular weakness
Stabilization
O2 saturations less than 92% qualifies for hypoxemia and warrant oxygen
support through nasal prongs, facemask, partial re-breathing or non-rebreathing
mask provided, the patient is breathing spontaneously.
Patients having hypoxemia with poor respiratory efforts, require assisted
breathing with bag and mask or bag and tube immediately.
Circulation
Assessment of Direct parameters which include heart rate and rhythm,
peripheral and central pulses, blood pressure, and capillary refill
time and indirect parameters which indicate adequacy of end
organ perfusion such as skin color and temperature, urine output
and level of consciousness.

◦ Hypotension is defined as BP below the fifth percentile for age. In children who are not hypotensive, an
observed fall of 10 mm Hg in systemic blood pressure from baseline should prompt careful evaluations
Status classification.
1.Compensated shock (poor perfusion with maintained BP)
2. Hypotensive shock (poor perfusion with less than 5 th centile BP).
Disability
Involves a quick evaluation of cortical and brainstem
functions.
Standard evaluation includes the level of consciousness using an AVPU scale

(Awake, Voice, Pain, Unresponsive), or Glasgow Coma Score (GCS), muscle
tone, pupillary response to light, motor activity and symmetry/asymmetry of
movements.
Exposure
Examine for evidence of trauma, unusual markings of abuse, rashes,
bleeds and core temperature.
At the end of the primary assessment, patient’s physiological status
is classified as; stable, respiratory distress or respiratory failure,
shock compensated or hypotensive, primary brain/systemic
dysfunction, cardiorespiratory failure or cardiorespiratory arrest and
further triaged into 5 levels.
REFERENCE
◦ Piyush Gupta
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Triage

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TRIAGE

Appearance:Muscle tone, interaction,

Work of breathing: Increased work of breathing

Circulation: Abnormal skin color (pale or

Involves a more detailed physical

Primary assessment should be completed in 1–3

1. Simple maneuvers such as positioning (chin-lift head-tilt) or suction

Apnea is defined as a complete cessation of breathing for 20 sec or more.

◦ Retractions + stridor = Upper airway obstruction

Assessment of Direct parameters which include heart rate and rhythm,

peripheral and central pulses, blood pressure, and capillary refill

time and indirect parameters which indicate adequacy of end

organ perfusion such as skin color and temperature, urine output

and level of consciousness.

Standard evaluation includes the level of consciousness using an AVPU scale

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