Pediatric Triage 🔥

Goals of Pediatric Triage

• Triage, originating from the French word for "sorting," is the process of rapid assessment of patients presenting to the emergency room (ER) to define the urgency of care and priorities in management.
• In an overcrowded ER, a structured triage system ensures that seriously ill patients receive immediate attention irrespective of their sequence of arrival, contrasting with outpatient departments that operate on a first-come, first-served basis.
• The triage assessment is typically conducted by a junior resident trained in Advanced Life Support (ALS) and supervised by an on-duty senior resident.
• The overarching philosophy of triage is defined by the rule of "Rights": Getting the right patient to the right provider, in the right moment of time, to receive the right care, to achieve the right outcome.
• The primary goals of the pediatric triage system include rapidly assessing and identifying children with life-threatening illnesses, determining the appropriate initial cause, and initiating first aid, necessary investigations, and procedures.
• Continuous and ongoing assessments are a critical goal, as pediatric patients can deteriorate rapidly in the ER setting.
• Furthermore, an organized triage system ensures safe and quality care while judicially allocating limited resources in settings where patient demand frequently exceeds availability.
• Because examination in the acute setting is often compromised by non-cooperative children, anxious parents, and overworked staff, a systematic, stepwise approach is imperative to promptly identify physiological impairment.

Stepwise Approach to Pediatric Triage

• The stepwise approach to a sick child begins with a critical first look, followed by objective hands-on primary and secondary assessments to identify the physiological abnormality and stabilize the patient accordingly.

Step 1: The Critical Look (Pediatric Assessment Triangle - PAT)

• The "critical look" is the initial visual and auditory assessment of the child as soon as they enter the ER.
• This assessment utilizes the Pediatric Assessment Triangle (PAT), which evaluates three core parameters: Appearance, Breathing, and Color.
• Appearance: This parameter provides crucial clues regarding the child's overall physiological status and brain perfusion. It is rapidly assessed using the "TICLS" mnemonic:
  • Tone: Evaluates the general posture (e.g., normal, flaccid, sniffing position, or tripoding).
  • Interactiveness: Assesses if the child is responsive, lethargic, or entirely unresponsive.
  • Consolability: Notes whether the child is unusually irritable, inconsolable, or calm.
  • Look/Gaze: Checks for a normal gaze directed at the caretaker versus a vacant, glassy stare.
  • Speech/Cry: Determines if the speech or cry is strong and age-appropriate, weak, or hoarse.
  • An abnormal appearance strongly denotes a seriously ill child, potentially indicating severe infection, poisoning, hypoxemia, hypoglycemia, brain injury, or poor cerebral perfusion.
• Breathing: This involves an auditory and visual check of the respiratory rate and the work of breathing (WOB). Healthcare providers must look for nasal flaring, lower chest retractions, and abnormal breath sounds like wheezing, grunting, or stridor, which point to impaired respiratory physiology.
• Color: Skin color acts as a surrogate marker for the adequacy of circulation. Abnormal skin colors—such as pallor, mottling, or cyanosis—indicate circulatory compromise, with pallor and mottling often serving as the earliest signs of shock.
• Categorization based on PAT: At the end of the critical look, the child is classified as either "stable" or "unstable". A child is deemed unstable if any one of the three PAT parameters is abnormal.
• Unstable children presenting with life-threatening conditions—such as cardiorespiratory failure, cardiac arrest, deep coma, severe stridor, or decompensated shock—require immediate, aggressive resuscitation before the provider moves on to the primary assessment.

Step 2: Primary Assessment (The ABCDE Pentagon)

• Once the child is on the path to stabilization, the primary assessment is performed; this objective, hands-on evaluation takes roughly 1 to 3 minutes.
• The primary assessment is guided by the assessment pentagon: Airway (A), Breathing (B), Circulation (C), Disability (D), and Exposure (E).
• Airway (A): The provider assesses whether the airway is open, maintainable, or compromised.
• Breathing (B): This involves evaluating the work of breathing, checking for retractions and accessory muscle use, noting the adequacy and synchrony of chest rise, auscultating for differential air entry or adventitious sounds, and checking pulse oximetry (normal oxygenation is denoted by SpO2 > 94% in room air).
• Circulation (C): Providers assess heart rate and rhythm, looking for age-specific tachycardia or bradycardia. Palpation of both central and peripheral pulses is critical; in shock, peripheral pulses weaken first, followed by a fall in blood pressure, and lastly a decrease in central pulses. Capillary refill time (CRT) is evaluated, with 2-3 seconds considered normal. Blood pressure must be measured using an appropriately sized cuff to define hypotensive shock (e.g., <60 mmHg for term neonates, <70 mmHg up to 1 year, and <90 mmHg for children over 10 years).
• Disability (D): Cortical function is assessed using the AVPU scale (Alert, Voice, Pain, Unresponsive) or the Glasgow Coma Scale (GCS). Brainstem function is evaluated via pupillary size and reaction. A critical step in the disability assessment is checking blood glucose (dextrostix) in any child presenting with altered consciousness, seizures, or persistent vomiting, as hypoglycemia is a reversible and easily treatable cause of encephalopathy. Based on this, brain dysfunction is categorized as primary (e.g., meningitis, intracranial bleed) or secondary (due to hypoxia or shock).
• Exposure (E): The child is fully exposed to look for surface findings such as petechiae, purpura, trauma, or features of dehydration (like a slow skin pinch), and core temperature is recorded to detect hypothermia or fever.
• At the conclusion of the PAT and ABCDE assessments, the child is assigned a final physiological classification, such as stable, respiratory distress/failure, compensated/hypotensive shock, primary/secondary brain dysfunction, or cardiorespiratory failure/arrest.

Step 3: Triage Acuity Classification

• Depending on the final physiological classification obtained from the initial and primary assessments, the child is assigned to one of five triage acuity levels to dictate the required response time.
• Level 1 - Resuscitation: This involves patients with immediately life-threatening conditions who require treatment within 1 to 5 minutes. Examples include cardiorespiratory failure or arrest, hypotensive shock, seizures, major burns, severe trauma, or a GCS < 10.
• Level 2 - Emergent: This level includes children with serious conditions that could rapidly become life-threatening or disabling, requiring treatment within 15 minutes. Clinical examples include severe respiratory distress, severe dehydration, acute bleeding, toxic ingestions, GCS 10-13, and fever in any child under 3 months of age.
• Level 3 - Urgent: This classification is for significant health problems that are not immediately life-threatening or disabling, requiring medical attention within 30 minutes. Examples include minor alterations in vital signs, GCS 14-15, and fever in children older than 3 months.
• Level 4 - Less Urgent: This includes stable conditions that need evaluation in the emergency department within 1 hour, such as acute diarrhea without clinical dehydration or conditions causing moderate pain.
• Level 5 - Non Urgent: This level encompasses highly stable conditions that can safely be evaluated in the ER or an outpatient department (OPD) within 2 hours. These children are alert, afebrile, well-hydrated, and have entirely normal vital signs.