The Emergency Severity Index Version 4* (available free for download) has a chapter, chapter 6, specifically on triage of the pediatric patient.
It turns out that 25% of all emergency department patients are pediatric patients and seriously ill pediatric patients can present with very subtle symptoms. Examples include a two week old newborn who is difficult to wake up at feeding time. Another example would be a six month old who looks “out of it” meaning he is not looking around and not interested in his surroundings.
It is critical in pediatric patients, especially newborns and infants, that they not become hypothermic. Although the doctor must examine the patient’s skin, it should be done serially, and the part examined re-covered when that part of the exam is finished. Never leave pediatric patients exposed as they can quickly become dangerously hypothermic.
The Handbook recommends a six step approach to pediatric triage and they are:
1. First, use the Pediatric Assessment Triangle from the Pediatric Advanced Life Support Course. Quickly assess the patient’s appearance (“tone, interactiveness, consolability, look/gaze, and speech/cry”), work of breathing (“the nature of airway sounds, positioning, retractions, and flaring”), and circulation (“pallor, mottling, or cyanosis”).
A significant abnormality in any of the above indicates that the pediatric patient is ESI Level 1 and requires immediate treatment.
2. If the patient appears stable on the initial Pediatric Assessment Triangle, then proceed to the Airway/Breathing/Circulation/Disability/Exposure/Environmental Control (ABCDE).
“This assessment must be done in order and includes assessing for airway patency, respiratory rate and quality, heart rate, skin temperature and capillary refill time, blood pressure (where clinically appropriate, such as a child with cardiac or renal disease), and an assessment for disability or neurological status. A child’s neurological status can be obtained by assessing appearance, level of consciousness, and pupillary reaction. Exposure involves undressing the patient to assess for injury or illness, …”
3. If no high risk situations requiring immediate treatment are found above, then a brief history is taken.
One memory aid is SAMPLE (Signs and Symptoms, Allergies, Medications, Past Medical Problems, Last Food or Liquid, and Events Leading to Injury/Illness).
4. Take the vital signs. The blood pressure is measured at the triage nurse’s discretion as blood pressure is not necessary to assign an ESI level. Measurement of oxygen saturation by oximetry is needed for any pediatric patient with respiratory symptoms or with respiratory distress.
5. Take the pediatric patient’s temperature. Newborns (babies in the first 28 days of life) with a temperature of 100.4F or 38.0C or greater are assinged Level 2 because they may have a serious infection. Infants with that level of fever who are from 1 to 3 months are assigned to Level 2 based on their individual institutional policies.
6. Every pediatric patient needs an assessment of pain. There are two scales in common use, the FLACC pain scale and the FACES pain scale.
The FLACC Pain Scale is validated in patients age 2 months to seven years but is not valid for patients with developmental delay. It is available at https://www.sjhlex.org/documents/Nursing/FLACC.pdf.
A four page pediatric pain assessment tool is available from the Texas Tech University Health Sciences Center which includes the FACES Pain Scale, the Visual Analog Scale, Pain Assessment of Infants, Nonverbal Pain Assessment and is available at https://www.ttuhsc.edu/som/clinic/forms/ACForm3.02.A.pd.
*Gilboy N, Tanabe T, Travers D, Rosenau AM. Emergency Severity Index (ESI): A Triage
Tool for Emergency Department Care, Version 4. Implementation Handbook 2012 Edition.
AHRQ Publication No. 12-0014. Rockville, MD. Agency for Healthcare Research and Quality. November 2011. available at https://www.ahrq.gov/research/esi/esihandbk.pdf