Triage of the Acutely Ill Child

Introduction to Triage of the Acutely Ill Child

Triage of the acutely ill child requires specialized knowledge of pediatric physiology and pathology. The approach must account for age-specific variations in normal parameters and disease presentations.

Core Principles of Pediatric Triage

Rapid assessment: Systematic evaluation of vital signs and general appearance within 60-90 seconds
Prioritization: Implementation of evidence-based triage scales (ESI, CTAS, MTS)
Continuous reassessment: Scheduled re-evaluation based on triage category
Age-appropriate approach: Recognition of age-specific vital signs and developmental markers

Triage Categories and Response Times

Level 1 (Immediate): Requires immediate life-saving intervention
Level 2 (Emergent): Requires evaluation within 15 minutes
Level 3 (Urgent): Requires evaluation within 30 minutes
Level 4 (Semi-urgent): Requires evaluation within 60 minutes
Level 5 (Non-urgent): Requires evaluation within 120 minutes

Red Flag Indicators

Altered mental status or abnormal behavior
Respiratory distress or cyanosis
Signs of shock or poor perfusion
Severe pain (pain score ≥7/10)
Age-specific vital sign abnormalities
Parental or healthcare provider concern

Primary Assessment

Pediatric Assessment Triangle (PAT)

The PAT provides rapid (30-60 second) identification of life-threatening conditions:

1. Appearance (TICLS)

Tone: Normal muscle tone vs. floppiness
Interactiveness: Response to environmental stimuli
Consolability: Ability to be comforted
Look/Gaze: Eye contact and tracking
Speech/Cry: Quality and strength of vocalization

2. Work of Breathing

Position: Tripod, sniffing, head bobbing
Respiratory rate: Age-specific norms
Retractions: Subcostal, intercostal, suprasternal
Nasal flaring and head bobbing
Audible breathing sounds: Stridor, wheezing, grunting

3. Circulation to Skin

Color: Central cyanosis, pallor, mottling
Temperature: Cool extremities
Capillary refill time: Normal <2 seconds

ABCDE Approach

A - Airway

Assess patency and protection
Look for foreign bodies, secretions
Evaluate for stridor or abnormal sounds
Position appropriately

B - Breathing

Count respiratory rate for full minute
Assess effort and pattern
Measure oxygen saturation
Auscultate breath sounds

C - Circulation

Heart rate and rhythm
Blood pressure (age-appropriate)
Peripheral and central pulses
Capillary refill time
Skin temperature gradient

D - Disability

AVPU Scale assessment
Glasgow Coma Scale (age-appropriate)
Pupillary response
Posture and tone
Blood glucose measurement

E - Exposure

Full body examination
Temperature measurement
Skin findings
Signs of trauma
Evidence of abuse

Secondary Assessment

Detailed History (SAMPLE)

Signs and Symptoms

Onset and progression
Associated symptoms
Severity and patterns
Aggravating/alleviating factors

Allergies

Medication allergies
Food allergies
Environmental allergies
Previous reactions

Medications

Current medications
Recent changes
Compliance
Over-the-counter medications

Past Medical History

Chronic conditions
Previous hospitalizations
Surgeries
Birth history
Immunization status

Physical Examination

Systems Review

Head and neck examination
Cardiopulmonary assessment
Abdominal examination
Neurological status
Musculoskeletal evaluation
Skin assessment

Vital Signs Assessment

Age	Heart Rate	Respiratory Rate	Systolic BP
0-3 months	100-150	30-60	65-85
3-6 months	90-120	30-45	70-90
6-12 months	80-120	24-40	80-100
1-3 years	70-110	20-30	90-105
3-6 years	65-110	20-25	95-110
6-12 years	60-95	14-22	100-120

Specific Conditions Requiring Urgent Attention

Respiratory Emergencies

Status Asthmaticus:
- Severe bronchospasm unresponsive to initial therapy
- Silent chest is an ominous sign
- Consider early PICU involvement
Bronchiolitis:
- Most severe in <6 months
- Risk of apnea in young infants
- Monitor work of breathing and feeding

Circulatory Emergencies

Septic Shock:
- Early recognition crucial
- Goal-directed therapy within first hour
- Fluid resuscitation and antibiotics
Cardiogenic Shock:
- Consider in infants with poor feeding
- Look for hepatomegaly
- Careful fluid management needed

Neurological Emergencies

Status Epilepticus:
- Time-sensitive management
- Staged medication approach
- Consider underlying causes
Raised Intracranial Pressure:
- Cushing's triad may be late
- Pupillary changes important
- Position head at 30 degrees

Management Principles

Initial Stabilization

Airway Management:
- Position appropriate for age
- Proper sizing of equipment
- Early recognition of difficult airway
Breathing Support:
- Oxygen delivery methods
- Non-invasive ventilation options
- Indications for intubation
Circulation Support:
- Vascular access options
- Fluid resuscitation protocols
- Inotrope considerations

Monitoring and Documentation

Vital signs frequency based on acuity
Response to interventions
Trending of clinical parameters
Clear communication with team

Family-Centered Care

Regular updates to family
Involvement in decision-making
Emotional support
Clear explanation of plans

Special Considerations

Age-Specific Considerations

Neonates (<28 days):
- Higher risk of sepsis
- Subtle presentation of illness
- Temperature instability
Infants (1-12 months):
- Limited respiratory reserve
- Risk of dehydration
- Non-specific symptoms
Toddlers (1-3 years):
- Separation anxiety
- Limited communication
- High metabolic demands

Communication Strategies

Age-appropriate language
Non-verbal assessment tools
Cultural considerations
Use of interpreters when needed

Diagnostic Approach

Initial Investigations

Point of Care Testing:
- Blood glucose
- Blood gas analysis
- Electrolytes
- Lactate
Laboratory Studies:
- Complete blood count
- Basic metabolic panel
- Coagulation profile
- Blood cultures
Imaging:
- Chest radiograph
- Point-of-care ultrasound
- CT when indicated

Monitoring Equipment

Basic Monitoring:
- Pulse oximetry - age-appropriate probes
- Cardiac monitoring - proper lead placement
- Blood pressure cuffs - correct sizing
- Temperature monitoring devices
- End-tidal CO2 monitoring when indicated
Advanced Monitoring:
- Central venous pressure monitoring
- Arterial line placement
- Intracranial pressure monitoring
- Continuous EEG monitoring

Documentation Requirements

Essential Elements:
- Time of arrival and triage
- Initial vital signs and assessments
- Interventions and responses
- Parental concerns and history
- Communications with healthcare team
Timing of Reassessments:
- Level 1: Continuous monitoring
- Level 2: Every 15 minutes
- Level 3: Every 30-60 minutes
- Level 4: Every 60-90 minutes
- Level 5: Every 120 minutes

Critical Procedures

Airway Management

Equipment Sizing:

Age	ETT Size	ETT Depth	Blade Size
Premature	2.5-3.0	6.5-7 cm	0
0-6 months	3.0-3.5	9-10 cm	1
6-18 months	3.5-4.0	10-11 cm	1
18m-3 years	4.0-4.5	12-13 cm	2
3-6 years	4.5-5.0	14-15 cm	2
6-8 years	5.0-5.5	16-17 cm	2-3
8-10 years	5.5-6.0	17-18 cm	3

Vascular Access

Peripheral IV Guidelines:
- First attempt: Hand/forearm
- Second attempt: Foot/ankle
- Consider IO after 2-3 failed attempts
- Use appropriate catheter sizes (24G-20G)
Intraosseous Access:
- Preferred sites by age
- Proper needle selection
- Confirmation of placement
- Maximum infusion times

Resuscitation Guidelines

Fluid Resuscitation:
- Initial bolus: 20mL/kg crystalloid
- Reassess after each bolus
- Maximum volume based on condition
- Consider blood products early in trauma
Medication Dosing:
- Use weight-based calculations
- Double-check high-risk medications
- Prepare common emergency drugs
- Use length-based tape when weight unknown

Quality Metrics

Time-Based Metrics:
- Door to triage time
- Triage to provider evaluation
- Time to critical interventions
- Length of stay by acuity level
Clinical Outcomes:
- Mortality rates
- Unplanned PICU admissions
- Return visits within 48 hours
- Adverse events during care