Irish Children's Triage System: Vomiting or Diarrhea

Parameters

Findings

Category

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

pain

severe (VAS >= 7)

2

moderate (VAS 4-6)

3

mild (1 to 3)

4

none

5

dehydration

severe

2

moderate

3

mild

4

none

5

blood glucose

< 2.8 mmol/L

2

2.8 to 3.4 mmol/L

3

> 3.4 mmol/L

5

urine output

anuria

2

oliguria

3

normal

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

currently seizing

1

temperature > 40°C

2

temperature <= 35.5°C

2

abnormal cry

2

central capillary refill time > 2 seconds

2

acute hematemesis

2

melena

2

not responding to parents

2

petechia or purpura

2

meningismus

2

lethargic, listless or floppy

2

irritable

2

bulging or sunken fontanelles

2

sunken eyes

2

metabolic illness

2

persistent vomiting

3

persistent diarrhea

3

reduced skin turgor

3

decreased oral intake

4