Irish Children's Triage System: Major Trauma

Parameters

Findings

Category

hemorrhage

exsanguinating

1

severe

2

moderate uncontrolled

3

other

3

none

3

abnormal vital signs

category 1

1

category 2

2

category 3

3

other

3

shock

uncompensated

1

compensated

2

none

3

Glasgow coma scale

<= 12

1

13 or 14

2

15

3

concussion

unconsciousness >= 30 seconds

2

unconsciousness < 30 seconds

3

amnesia

3

none of these

3

penetrating trauma

to torso with signs of shock

1

other penetrating trauma

2

none

3

pain

severe (VAS >= 7)

2

moderate (VAS 4-6)

3

mild (1 to 3)

3

none

3

deformity

severe

2

limb deformity

3

no deformity

3

history or mechanism

significant

2

inconsistent with findings

3

consistent

3

Other Parameters

Category

airway compromise

1

respiratory failure/arrest

1

currently seizing

1

temperature <= 35.5°C

2

altered respiratory pattern

2

history of bleeding disorder

2

neurovascular compromise

2

potential spinal injury

2

persistent vomiting

2

blood or serous fluid in nose or ears

2

bruising around eyes

2

bruising behind ears

2

frank hematuria

2

blood in perineum

2

central capillary refill time > 2 seconds

2

open wound

3