Irish Children's Triage System: Ear or Nasal Problem

Parameters

Findings

Category

hemorrhage

exsanguinating

1

uncontrollable major

2

minor hemorrhage

3

none

5

abnormal vital signs

category 1

1

category 2

2

category 3

3

other

5

shock

uncompensated

1

compensated

2

none

5

Glasgow coma scale

<= 12

1

13 or 14

2

15

5

changes around ear

bruising or swelling behind ear over mastoid process

2

any swelling behind ear

3

swelling, deformity or hematoma of external ear

4

none

5

pain

severe (VAS >= 7)

2

moderate (VAS 4-6)

3

mild (1 to 3)

4

none

5

discharge from ear or nose

clear fluid from nose or ear with trauma history

2

other discharge from ear or nose

4

none of these

5

duration

less than 48 hours (recent) or acute symptoms

4

> 48 hours without acute symptoms

5

history of bleeding disorder

with bleeding

2

without current bleeding

3

none

5

history or mechanism

significant

2

inconsistent with findings

3

consistent

5

Other Parameters

Category

airway compromise

1

respiratory failure/arrest

1

marked stridor with severe respiratory distress

1

cyanosis

1

temperature > 40°C

2

temperature <= 35.5°C

2

capillary refill time > 2 seconds

2

difficulty swallowing

2

nasal foreign body

3

history of recent head injury

3

foreign body in ear

5