The Canadian Association of Emergency Physicians L'Association canadienne des mdecins d'urgence

National Emergency Nurses Affiliation Inc. Laffiliation nationale des infirmiers/infirmires durgence incorpore

L ' A S S O C I AT I O N D'URGENCE DU

DES

MDECINS

QUBEC

The Canadian Paediatric E.D.Triage andAcuity Scale

Patients should have an initial triage assessment within 10 minutes of arrival

First Impression or EMS Assessment

Presenting Condition Assessment

see below PAEDIATRIC PRESENTING CONDITIONS

Appearance - Neurologic Respiratory Rate + Effort Heart Rate + Perfusion

Physiologic Assessment

TRIAGE LEVEL I

TRIAGE LEVEL II

TRIAGE LEVEL III

TRIAGE LEVEL IV

TRIAGE LEVEL V

RESUSCITATION
TIME TO REASSESSMENT OR MEDICAL CARE

EMERGENT

URGENT

LESS URGENT

NON URGENT

PHYSIOLOGIC ASSESSMENT
unresponsive

MINUTES**
altered conciousness lethargic RR <> NR +/- 1 SD marked stridor moderate distress HR <> NR +/- 1 SD capillary refill > 4 sec

MINUTES**
infant - unconsolable not feeding atypical behaviour RR outside NR for age stridor mild distress HR outside NR for age capillary refill > 2 sec

MINUTES**
infant - consolable history of atypical behaviour RR - normal for age

MINUTES**
no history of recent behaviour or vital sign change RR - normal for age

Respiratory Symptoms Cardiovascular

RR <> NR +/- 2 SD inadequate breathing severe distress HR <> NR +/- 2 SD cardiac arrest shock cyanosis (NR = Normal Range)

HR - normal for age

HR - normal for age

RESPIRATORY RATE (RR)

Age Birth - 3 months 3 months - 6 months 6 months - 1 year 1 year - 3 years 6 years 10 years +/- 2 SD 10 - 80 10 - 80 10 - 60 10 - 40 8 - 32 8 - 26 +/- 1 SD 20 - 70 20 - 70 17 - 55 15 - 35 12 - 28 10 - 24 Normal Range (NR) 30 - 60 30 - 60 25 - 45 20 - 30 16 - 24 14 - 20

HEART RATE (HR)

+/- 2 SD 40 - 230 40 - 210 40 - 180 40 - 165 40 - 140 30 - 120 +/- 1 SD 65 - 205 63 - 180 60 - 160 58 - 145 55 - 125 45 - 105 Normal Range (NR) 90 - 180 80 - 160 80 - 140 75 - 130 70 - 110 60 - 90

PAEDIATRIC PRESENTING CONDITIONS

Respiratory
airway compromise severe distress critical asthma chest trauma with respiratory distress marked stridor moderate distress severe asthma FB aspiration with respiratory distress inhalation of toxic substance stridor mild distress moderate asthma FB aspiration with no respiratory distress constant cough distressed minor head injury GCS 15 history of altered consciousness headache possible shunt dysfunction previous seizure tachycardia normal heart rate chest pain signs of dehydration uncontrollable minor haemorrhage well hydrated mild asthma possible FB aspiration with no distress minor chest injury no shortness of breath minor head injury no vomiting or altered consciousness chronic headache

Neurological CNS

major head injury GCS < 10 unresponsive actively seizuring

moderate head injury GCS 13 altered consciousness headache severe sudden onset ill - shunt dysfunction new neurologic findings

Cardiovascular Circulation

cardiac arrest shock hypotension exsanguinating haemorrhage

tachycardia ++ bradycardia severe dehydration uncontrollable major haemorrhage traumatic amputation - digit open fracture fracture with neuro- vascular deficit back pain with neurologic symptom avulsed 2 tooth

Musculo-skeletal

major trauma traumatic amputation -extremity hypothermia

fracture no neurovascular deficit tight cast joint pain with fever dental trauma burn < 10 % BSA frostbite cellulitis - ill / fever complex lacerations persistent or bilious vomiting acute vomiting/ diarrhea age < 2 ? appendicitis moderate testicular pain / swelling inguinal mass / pain

greenstick fracture

extremity swelling sprain/strain

Skin

burn, > 25 % BSA or airway involved

burn > 10 % BSA burn- face, hand, foot chemical /electrical purpuric rash acute bleeding vomitus or rectal abdominal pain with vomiting / diarrhea / abnormal vital signs severe testicular pain ? ectopic pregnancy urine retention >24 hr

minor burn minor cold injury local cellulitis simple laceration constipation / pain acute vomiting / diarrhea age > 2

superficial burn abrasion, contusion, local rash minor insect bite

Gastrointestinal

penetrating or blunt trauma with shock difficulty swallowing with airway compromise

vomiting or diarrhea no pain, no dehydration

Genitourinary Gynecologic

vaginal bleed - unstable

scrotal trauma possible UTI

urine retention > 8 hrs severe vaginal bleed paraphimosis vaginal bleeding foreign body nose epistaxis controlled puncture palate tonsillar pustules with difficulty swallowing hearing problem Post T& A bleed ear drainage earache sore throat mouth sores nasal congestion laryngitis

Ear/Nose/Throat

airway compromise

amputation ear uncontrolled epistaxis sore throat with drooling, stridor difficulty swallowing hoarseness after trauma

Eye Hematologic Immunologic Endocrine Psychiatry

diabetic- altered consciousness

chemical exposure penetrating injury orbital infection anaphylaxis bleeding disorder fever- neutropenic / sickle cell diabetic- ketoacidosis hypoglycemia toxic overdose high risk of harm to self / others violent behaviour

vision change periorbital infection sickle cell crisis moderate allergic reaction hyperglycemia ingestion requiring observation moderate risk of harm to self / others disruptive/distressed

tearing, discharge affecting function corneal FB

conjunctivitis

local allergic reaction

low risk of harm to self/ others

chronic symptoms with no change

depression irritable- consolable atypical behaviour Infant > 36 mon with temperature > 38.5 non toxic appearance signs / history of family violence Mild 1 - 3 / 10

Behaviour Change Infection Child Abuse Pain

unresponsive

lethargic child infant < 7 days old infant < 3 mon 36< temperature 38 toxic appearance - any age ongoing risk Severe 8 - 10 / 10

unconsolable infant infant not feeding infant 3-36 mon with temperature > 38.5 physical assault sexual abuse <48 hr Moderate 4 - 7 / 10

septic shock

unstable situation or conflict

*TIMES TO ASSESSMENT are operating objectives, not established standards of care. Facilities without onsite physician coverage may meet assessment objectives using delegated protocols and remote communication.

Health Canada

Sant Canada