Irish Children's Triage System: Unwell Child

Parameters

Findings

Category

blood glucose

< 2.8 mmol/L

2

2.8 to 3.4 mmol/L

3

> 3.4 mmol/L

5

abnormal vital signs

category 1

1

category 2

2

category 3

3

shock

uncompensated

1

compensated

2

none

5

Glasgow coma scale

<= 12

1

13 or 14

2

15

5

SaO2 in percent

> 92%

5

90.1 to 92%

2

<= 90%

1

pain

severe (VAS >= 7)

2

moderate (VAS 4-6)

3

mild (1 to 3)

4

none

5

breathing difficulty

severe increase in work of breathing

2

moderate increase in work

3

other

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

seizures

currently seizing

1

history of seizures

3

none

5

reaction to parents or guardian

unresponsive to

2

inconsolable

3

consolable

5

Other Parameters

Category

airway compromise

1

respiratory failure/arrest

1

temperature > 40°C

2

temperature <= 35.5°C

2

lethargy, listless, floppy

2

central capillary refill time > 2 seconds

2

new neurological symptoms

2

purpura or petechiae

2

meningismus

2

hallucinations

3

syncope or rigors

3

oliguria

3

PEG tube problem

3

jaundice

3

reduced feeding with dehydration

3

significant medical or surgical history

3

"off form"

4