TABLE 6.1 HIGH-RISK PATIENTS • Hematology/oncology patient with fever • Shunt patient with headache, nausea/vomiting, and/or fever • Diabetic with altered mental status, ± nausea/vomiting • Bleeding disorder with significant trauma • Ocular exposure • Postoperative tonsillectomy and adenoidectomy bleed • Suicidal ideation or attempt • Gastrostomy tube or gastrojejunal tube out and unable to place Foley in stoma in triage • Smoke inhalation/carbon monoxide exposure • Open fracture or altered neurovascular status with deformity • Abdominal pain with peritoneal signs • Sickle cell patient with fever or pain • Cardiac patient with change in normal saturation and/or increased need for O2 • Infants ≤60 days with fever/hypothermia (temp ≤36°C or ≥38°C rectal by history or in ED) • Eye injury with significant pain • Scrotal pain • Apparent life-threatening event with history of cyanosis • Ingestions (excluding foreign body)— consult ED physician for non– foreign-body ingestions • Cervical spine immobilized and on backboard • Abdominal trauma with significant abdominal pain • Permanent tooth available for reimplantation TABLE 6.2 TRIAGE RESOURCES Aerosol treatments IV or IM medications Labs (blood, urine, cultures) X-rays ECG CT or ultrasound Specialty consultation IV fluids NG tube Simple procedure = (Laceration or Foley) Complex procedure = (sedation) PEDIATRIC TRIAGE CONSIDERATIONS The triage nurse needs a strong foundation of knowledge related to specific anatomic and physiologic issues that may put a child at risk, as well as agedependent “red flags” that must be considered during triage The nurse should also be comfortable interacting with children of all ages as well as their caregivers The following are key points when assessing a child: Children have a larger body surface area than adults This places them at risk for both heat and fluid loss Neonates have poor thermoregulation They should not be undressed for any extended length of time as this cold stress causes increased metabolic demands resulting in potential physiologic decompensation Critically ill neonates/children can present with subtle signs such as hypothermia, poor feeding, and irritability Cardiac output is heart rate dependent in neonates and young children Bradycardia or severe tachycardia can be very dangerous Hypotension is a late finding Weight in kilograms is important in order to safely administer medications to children Estimation of weights in critically ill children should be done utilizing validated tools and estimated guesses by providers and caregivers are discouraged Children are portable The most critically ill child may arrive being carried into your ED, you must be ready Caregivers’ perception of illness is key Providers must listen as caregivers know their children best and can explain when behavior is abnormal Triage nurses must be aware of risk factors for abuse Anything that stresses a family puts children at risk such as lower socioeconomic levels, history of substance abuse, history of mental illness, and single caregiver households Young children as well as children with chronic illness or disabilities are at increased risk The nurse’s knowledge of child development is very important when assessing injuries The nurse needs to assess if the injuries can be explained knowing the current developmental level of the child Mental health concerns, including suicidality, among children are on the rise Triage nurses must be cognizant of this risk no matter the presenting chief complaint Triage Process As previously described, triage is fundamental in determining the severity of illness and immediate needs of a patient who presents to the ED The pediatric triage process consists of a rapid initial assessment, primary survey, secondary survey, and triage decision Ideally, triage should take no more than to minutes Documentation of triage findings and interventions as well as reassessment of patients in the waiting room is also included in triage workflow Care of pediatric patients requires a core understanding of developmental stages and their associated risk factors, injury and illness patterns, and physiologic compensatory mechanisms As such, the triage process should be completed only by ED nurses experienced in caring for pediatric patients who demonstrate sound assessment, clinical judgment, and decision-making skills Should the triage provider’s assessment indicate the need for immediate lifesaving intervention, the triage process should end and the patient moved to a treatment area for care and further assessment Pediatric Assessment Triangle Once a child presents to the ED, an initial rapid assessment is conducted to determine “sick” or “not sick” utilizing the pediatric assessment triangle (PAT) This assessment should be completed during the first moments of interaction by any level healthcare provider and is separate from the primary survey Developed as a standardized tool for children of all ages, the PAT identifies overall general severity of illness or injury through focused, hands-off observation of three components of cardiopulmonary assessment: appearance, work of breathing, and circulation to the skin The triage provider should allow the child to remain with their caregiver, evaluating each parameter without touching the patient Examination can be completed within 30 seconds, allowing for prompt recognition of immediate physiologic needs and their associated level of urgency General Appearance General appearance is considered the most important factor in the assessment of a pediatric patient While a child may meet “alert” criteria on the AVPU (Awake, Verbal, Painful, Unresponsive) responsiveness scale, they can also display subtle signs of illness, injury, and deterioration through alterations in their general appearance The mnemonic “tickles” (TICLS) can be utilized to identify deviations from normal characteristics through evaluation of tone, interactiveness, consolability, look/gaze, and speech/cry ( Table 6.3 ) Work of Breathing In children, assessment of work of breathing provides accurate insight into the adequacy of oxygenation and ventilation through identification of abnormal findings and observation of compensatory mechanisms The triage provider should listen from a distance for abnormal sounds including snoring, grunting, wheezing, and changes in voice or speech Observation should include assessment of patient positioning, the presence and location of chest wall retractions, and nasal flaring TABLE 6.3 TICLS MNEMONIC Tone Interactivity Consolability Look/gaze Speech/cry Moves spontaneously, sits or stands as age appropriate Interacts with people, environment, objects Stops crying with comfort by caregiver Tracks objects, makes eye contact Age-appropriate speech or strong cry Adapted from APLS: The Pediatric Emergency Medicine Resource 5th ed American College of Emergency Physicians & Jones and Bartlett; 2012 TABLE 6.4 TRIAGE “RED FLAGS” Airway Breathing Circulation Disability Exposure Apnea, stridor, hoarse voice/cry, drooling, choking, gurgling, sniffing position, hypoxemia Increased work of breathing, retractions, grunting, nasal flaring, seesaw respirations, head bobbing, adventitious breath sounds, tripod positioning Tachycardia, bradycardia, hypotension, capillary refill >3 sec or 105.1°F, rash (petechial, purpura), signs of abuse Circulation to the Skin Assessment of circulation to the skin reflects the integrity of vital organ perfusion The child’s skin should be exposed by the parent in a warm environment and visual examination performed, evaluating for pallor, mottling, cyanosis, and visible active bleeding ... contact Age-appropriate speech or strong cry Adapted from APLS: The Pediatric Emergency Medicine Resource 5th ed American College of Emergency Physicians & Jones and Bartlett; 2012 TABLE 6.4 TRIAGE... further assessment Pediatric Assessment Triangle Once a child presents to the ED, an initial rapid assessment is conducted to determine “sick” or “not sick” utilizing the pediatric assessment... well as reassessment of patients in the waiting room is also included in triage workflow Care of pediatric patients requires a core understanding of developmental stages and their associated risk