Irish Children's Triage System: Airway or Breathing Difficulty

Parameters

Findings

Category

SaO2 in percent (room air)

<= 90%

1

91%

2

92 to 94%

3

> 94%

5

Glasgow coma scale

<= 12

1

13 or 14

2

15

5

respiratory distress

severe with marked stridor

1

severe

2

moderate

3

mild

4

none

5

vital signs

class 1

1

class 2

2

class 3

3

other

5

hemoptysis

uncontrollable

1

coughing fresh blood

2

history of hemoptysis

3

none

5

pain

7 to 10 out of 10

2

4 to 6 out of 10

3

1 to 3 out of 10

4

none

5

time since onset

< 48 hours

4

> 48 hours

5

Other Parameters

Category

airway compromise

1

respiratory failure

1

"tripod" positioning

1

compensated shock

2

history of floppiness with pallor or cyanosis

2

history of apnea >= 20 seconds

2

history of smoke inhalation

2

history of submersion

2

central capillary refill > 2 seconds

2

history of significant respiratory problem in the past

3

history of inhalation or ingestion of foreign body

3

inhalation of sharp foreign body

3

cough without distress

4