5. Paediatric Considerations

Canadian Paediatric Triage and Acuity Scale:
Implementation Guidelines for Emergency Departments

It is particularly difficult to meet the needs of children and the expectations of their parents or caregivers in an ED that treats both children and adults. Children are less likely to have life-threatening conditions. On the other hand, the signs and symptoms of serious problems may be subtle or develop quickly. Frequent reassessment of patients is especially important to ensure the safety of children and address the concerns of parents or caregivers.

The initial impression of the severity of illness from a quick assessment of alertness, respiratory effort, or perfusion can often define a need for immediate attention. Level I or Level II categorization requires immediate transfer of the child into the ED for further physiologic assessment and detailed history of the presenting complaint by the attending nurse or physician.

Assessment of presenting complaint is often complicated by children's inability to communicate their difficulties and the health care team's reliance on perceptions of caregivers. Many conditions are categorized differently in the paediatric population, and there are a number of paediatric specific entities (e.g., neonatal jaundice) that have their own unique investigations and care plans. Many problems may be categorized within multiple triage levels, depending on the physiologic response of the child to his or her condition.

A specific physiologic assessment will assist triage in the less severe Levels III, IV and V:

1. assessment of level of alertness and interactivity
2. respiratory rate and effort
3. heart rate and perfusion.

Triage assignment

The following descriptions are not all inclusive; they are guides to supplement the information in Sections 4 and 9. Physiologic variables, heart and respiratory rate have been adapted from standardized tables for ease of use and efficiency of assessment. Pain scale assessment is often difficult in children and may not be possible in a timely interval. If pain is believed to be severe, the triage decisions should be made as if the rating was 8­10/10.

Level  I

Initial impression
Conditions that are a threat to life or limb (or imminent risk of deterioration) requiring immediate aggressive interventions.

• Child or infant in respiratory failure, shock, coma or cardiopulmonary arrest.
• Any child or infant who requires continuous assessment and intervention to maintain physiological stability.

Presenting conditions
Examples: status epilepticus, severe respiratory distress, unconsciousness, major burns, trauma, significant bleeding and cardiopulmonary arrest.

Physiologic assessment

• Unresponsive.
• Respiratory rate greater than or less than 2 standard deviations from normal range.
• Severe respiratory distress or inadequate breathing.
• Heart rate greater than or less than 2 standard deviations from normal range.
• Cardiac arrest or shock or cyanosis.

Level II

Initial impression
Conditions that are a potential threat to life, limb or function requiring rapid medical intervention or delegated medical acts.

• Any physiologically unstable child with moderate respiratory distress, altered level of consciousness, dehydration.
• Fever (<36°C or >=38.0°C ) in patients <3 months. Temperature is not always a reliable indicator of the severity of illness, any child who appears toxic.
• Infants <7 days can have serious problems even though the signs and symptoms may be subtle.

Presenting conditions
Examples: sepsis, toxic ingestion, severe asthma, DKA, ongoing risk of child abuse, purpuric rash (a rash that does not blanch with pressure, such as petechiae), open fractures, violent patients, testicular pain, lacerations or orthopedic injuries with neurovascular compromise, dental injury with avulsed permanent tooth, patients receiving chemotherapy or immunosuppressed patients with fever.

Physiologic assessment

• Altered consciousness or lethargic.
• Respiratory rate greater than or less than 1 standard deviation from normal range.
• Moderate respiratory distress or marked stridor.
• Heart rate greater than or less than 1 standard deviation from normal range.
• Capillary refill >4 seconds.

Level III

Initial impression
Conditions that could potentially progress to a serious problem requiring emergency intervention. May be associated with significant discomfort or ability to function.

• Child or infant who is alert, with minor behavioural or vital signs alterations from normal.
• Febrile child 3­36 months with a T >38.5°C.

Presenting conditions
Examples: Simple burns, fractures, moderate asthma, pneumonia without distress, history of seizure, suicide ideation, ingestions requiring observation only, head trauma (alert, with vomiting), moderate dehydration, physical assault, alleged sexual abuse.

Physiologic assessment

• Infant -- inconsolable, not feeding; child -- atypical behaviour.
• Respiratory rate at the limits of normal range.
• Mild respiratory distress or stridor.
• Heart rate at the limits of normal range.
• Capillary refill >2 seconds.

Level IV

Initial impression
Conditions related to patient age, distress, or potential for deterioration or complication that would benefit from intervention or reassurance.

No history suggestive of potential for immediate deterioration.

Presenting conditions
Examples: mild asthma, vomiting or diarrhea with no dehydration, minor trauma, otitis media

Physiologic assessment

• Consolable, appropriate behaviour, but history of atypical behaviour.
• Respiratory rate within normal range for age.
• Heart rate within than normal range for age.

Level V

Initial impression
Conditions that may be acute but non urgent, and conditions that may be part of a chronic problem with or without evidence of deterioration. Investigations and interventions for some of these illnesses or injuries could be delayed or referred to other health care resources.

Presenting conditions
Examples: nasal congestion, lice, suture removal

Physiologic assessment (Table 4)

• No history of atypical behaviour.
• Respiratory rate within normal range for age.
• Heart rate within normal range for age.

CJEM has been unable to obtain permission from the original publisher of Table 4 to republish the table online. Table 4 is available in the print version of CJEM (Can J Emerg Med, Oct. 2001, 3(4) S19)

Tertiary paediatric centres

As a result of referral patterns and population density, paediatric EDs in urban areas see a different case mix than EDs that see patients of all age groups. The availability of experienced paediatric triage personnel combined with the use of assessment and treatment protocols may lead to variance in the triage process in a general ED. Since it is "access to appropriate care," not simply "access to physician assessment," the time from triage to see a physician is not a strict requirement or objective, and it may change, based on the introduction of delegated care plans or verbal review with physicians.