5. Additional Pediatric Considerations
Canadian Emergency Department Triage and Acuity Scale Implementation Guidelines
Meeting the needs of children and the expectations of parents is particularly difficult in an ED that sees children and adults. Children are much less likely to have life threatening conditions but on the other hand the signs and symptoms of serious problems may be subtle or develop quickly. Frequent reassessment of patients is especially important for the safety of the child and the concerns of parents or caregivers. The conditions described in the previous section apply to children and adults.
Use of presenting complaints to assign triage in pediatrics is frequently complicated by the fact that they are often based on caregiver perceptions. This often means that there will be expanded use of physiological assessment early in the triage process to determine urgency. There are many problems that are the same (or similar) in all age groups but the signs, symptoms and treatment may have some age related variability.
Tertiary pediatric centres
As a result of referral patterns and population density, pediatric emergency departments in urban areas see a different case mix than EDs seeing patients of all age groups. The availability of experienced pediatric triage personnel combined with the use of assessment and treatment protocols may lead to some variance in the triage process used in a general emergency department. Since it is access to appropriate care not simply physician assessment, the time from triage to see a physician is not a strict requirement or objective and may change based on the introduction of delegated care plans or verbal review with physicians.
| Age | Weight (kg) | Heart rate (average /min) |
Respiratory rate | Blood pressure (mean ± 2 SD) |
ET tube | Chest tube (Fr) | Laryngoscopy blade | |||
|---|---|---|---|---|---|---|---|---|---|---|
| Systolic | Diastolic* | ID† (mm) | Length (cm) | Suction catheter (Fr) | ||||||
| Premature | 1 | 145 | <40 | 42 ± 10 | 2 ± 18 | 2.5 | 10 | 6 | 10 | 0 st |
| Newborn | 1–2 | 135 | 50 ± 10 | 28 ± 8 | 3 | 11 | 6–8 | 10–12 | 1 st | |
| Newborn | 2–3 | 125 | 60 ± 10 | 37 ± 8 | 3 | 12 | ||||
| 1 mon | 4 | 120 | 24–35 | 80±16 | 46±16 | 3.5 | 13 | 8 | ||
| 6 mon | 7 | 130 | 89±29 | 60±10 | 3.5 | 14 | ||||
| 1 yr | 10 | 125 | 20–30 | 96±30 | 66±25 | 4 | 15 | 8–10 | 16–20 | 1 st |
| 2–3 yr | 12–14 | 115 | 99±25 | 64±25 | 4.5 | 16 | 10 | 20–24 | ||
| 4–5 yr | 16–18 | 100 | 99±20 | 65±20 | 5.0–6.0 | 17 | 20–28 | 2 | ||
| 6–8 yr | 20–26 | 100 | 12–25 | 99±20 | 65±20 | 6.0–6.5 | 18 | |||
| 10–12 yr | 32–42 | 75 | 105±20 | 65±20 | 7 | 20 | 12 | 28–32 | 2–3 | |
| >14 yr | >50 | 70 | 12–18 | 115±20 | 70±20 | 7.5–8.5 | 24 | 32–42 | 3 | |
| Reprinted, with permission, from Appendix C-2 in Emergency Pediatrics: a Guide to Ambulatory Care, 3rd ed. R.M. Barkin, P. Rosen (eds). St. Louis: C.V. Mosby; 1990. p. 701. Note: Data for this table are taken from a table in Nadas A. Pediatric Cardiology, 3rd ed. Philadelphia; WB Saunders, 1976 and a table from Vesmond HT, et al. Pediatrics 1981;67:607. *Point of muffling (Nadas). †Variability of 0./5 mm is common. Estimate: 16 + age (yr)/4 | ||||||||||
Triage assignment
The following descriptions are not all-inclusive but are meant as guides to supplement information contained in the information contained in section 4. Pain scales may not be possible and if pain is believed to be severe the triage decisions should be made as if the rating was 8–10/10.
Level I
- Child/infant in respiratory failure, shock, coma or cardiopulmonary arrest.
- Any child or infant who requires continuous assessment and intervention to maintain physiological stability.
E.g., coma/seizures, moderate to severe respiratory distress, unconscious, major burns, trauma, significant bleeding and cardiopulmonary arrest.
Level II
- Any physiologically unstable child with moderate to severe respiratory distress, altered level of consciousness, dehydration. Dehydration is difficult to accurately assess. Any suspicion (or evidence) should cause concern.
- Any child/infant who requires comprehensive assessment and multiple interventions to prevent further deterioration.
- Fever — age <3 months ≥38.0°C. Temperature is not always a reliable indicator of the severity of illness.
- Younger patients can have serious problems even though the signs and symptoms may be subtle.
E.g., sepsis, altered level of consciousness, toxic ingestion, asthma, seizure (postictal), DKA, child abuse, purpuric rash (a rash that does not blanch with pressure, like petechiae), fever, open fractures, ingestion/overdose, violent patients, testicular pain, lacerations or orthopedic injuries with neurovascular compromise, dental injury with avulsed permanent tooth.
Level III
- Child/infant who is alert, oriented, well hydrated, minor alterations in vital signs.
- Interventions include assessment and simple procedures.
- Febrile child >3 months with a T >38.5°C
- Mild respiratory distress
- Infant <1 month
E.g., Simple burns, fractures, dental injuries, pneumonia without distress, history of seizure, suicide ideation, ingestion requiring observation only, head trauma — alert/vomiting.
Level IV
- Patient with vomiting/diarrhea and no dehydration age >2.
- Simple lacerations/sprain/strains.
- Alert child with fever and simple complaints such as ear pain, sore throat or nasal congestion.
- Head trauma — no symptoms.
Level V
- Child/infant who is afebrile, alert oriented, well hydrated with normal vital signs.
- Interventions not usually required other than assessment/discharge instruction.
- Vomiting alone or diarrhea alone with no suspicion or signs of dehydration.
