Irish Children's Triage System: Head-Related Problem

Parameters

Findings

Category

abnormal vital signs

category 1

1

category 2

2

category 3

3

Glasgow coma scale

<= 12

1

13 or 14

2

15

5

unconsciousness

> 30 seconds

2

<= 30 seconds or amnesia

3

head injury without

4

no head injury

5

pain

severe (VAS >= 7)

2

moderate (VAS 4-6)

3

mild (1 to 3)

4

none

5

seizures

currently seizing

1

history of

2

neither

5

duration

less than 48 hours (recent) or acute symptoms

4

> 48 hours without acute symptoms

5

history or mechanism

significant

2

inconsistent with findings

3

consistent

5

Other Parameters

Category

airway compromise

1

respiratory failure/arrest

1

penetrating head injury

1

history of bleeding disorder

2

ventriculo-peritoneal shunt

2

new neurological symptoms

2

persistent vomiting

2

blood or serous fluid in ears or nose

2

bruising around eyes

2

bruising behind ears

2

history of blurred vision

2

large scalp laceration with pulsatile bleeding

2

boggy temporal, occipital or parietal swelling

2

age < 1 years

3