Irish Children's Triage System: Wound or Signs of Local Inflammation

Parameters

Findings

Category

hemorrhage

exsanguinating

1

severe

2

moderate uncontrolled

3

other

4

none

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

needle stick

with known blood-borne pathogen

3

without known pathogen

4

none

5

pain

severe (VAS >= 7)

2

moderate (VAS 4-6)

3

mild (1 to 3)

4

none

5

wound

traumatic amputation => 50%

2

de-gloving injury

2

partial amputation < 50%

3

deep wound

4

lesser or none

5

infection and inflammation

inflammation with tracking

3

local infection/inflammation

4

none

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

distal neurovascular compromise

2

delayed presentation

3

age < 3 months

3

foreign body

4

suspicion of bite injury

4