ISSUES IN PAEDIATRIC TRIAGE

Cathy Almond

RN, Grad Cert Paeds, Grad Dip Vocational Ed and

Training, ENPC Instructor
Sydney Childrens Hospital
Abstract

Recognising the unwell child at triage is a difficult

process. Vital signs, particularly in paediatrics, can be
an unreliable basis for making a triage decision.
Common signs obtained at triage include temperature,
heart and respiratory rates, oxygen saturations and
blood pressure but the only vital signs that may be

they cannot swallow saliva or fluids without drooling

(babies around 6-9 months normally drool - ask the
caregiver if this is normal);

the child has difficulty breathing both asleep and awake.

Consider whether the child is sitting upright, being held or

able to lie flat. The 'tripod' position describes the child who
attempts to maximise air entry by sitting forward, hands on
knees with their neck extended. It is often seen with an upper
airway obstruction, eg epiglottitis, where the child is struggling
to maintain a patent airway.
Breathing

considered necessary are the heart and respiratory rates.

Triage nurses need to increase utilisation of their

Assessment of the breathing is ascertained by looking at the

excellent observational skills in order to enhance the

child's respiratory rate and pattern. Looking at the chest you

process of triage.

can ascertain whether the child's rate is too fast or too slow.
It is important to know normal age ranges and therefore

Initial assessment of the child presenting to emergency

recognise abnormal.

is via an 'across the room' assessment# This, arguably, is

the single, most important observational tool that is

You will also note signs of respiratory distress, e.g. tracheal tug,

utilised for children. With experience, it quickly

intercostal/subcostal recession, nasal flaring. It then becomes

becomes obvious whether the child has a problem with

obvious the child has an increased respiratory effort; pulse

airway, breathing or circulation and whether

oximetry or a respiratory rate will not change your triage

intervention is necessary. Taking the child's

decision.

temperature, blood pressure or measuring pulse

Consider any audible respiratory noises that the child may be

oximetry are useful adjuncts but given the time and

making. Wheezing is generally expiratory, indicative of a lower

nature of triage, unnecessary. The benefit of taking vital

airway obstruction and is commonly associated with asthma,

signs at triage can be questioned based on well-

bronchiolitis or foreign body obstruction. A stridor is a low,

documented evidence.

harsh sound, usually inspiratory and indicative of an upper

airway obstruction, eg croup (laryngotracheobronchitis).

Look at the child

Grunting occurs because the child attempts to create their own

Instead of relying on vital signs, we need to develop our

PEEP (positive end expiratory pressure), to prevent alveoli

observational assessment skills. A n 'across the room

collapsing at the end of expiration. It is a sign of severe

assessment' that occurs when the patient arrives 8 can

respiratory distress observed most frequently in children with

communicate vital information. This assessment can be

pneumonia. These are easily identifiable signs that indicate the

considered an observational primary assessment in that airway,

child needs priority treatment, without having touched or

breathing, circulation and disability are simultaneously

talked to the child or parents.

assessed. In doing this, the question of whether the child 'looks

well', 'looks unwell' or whether the nurse is uncertain is

Circulation

decided. This will help triage category allocation; if the child

Circulation is evaluated by looking firstly at the child's colour.

looks well, they are at the lower end of the scale. An unwell

A child with a compromised circulating blood volume may be

child is probably a 1 or 2 and uncertainty may indicate the

pale, mottled, flushed, or grey looking. Cyanosis in children is a

need for further assessment.

late sign compared to adults. Children are relatively anaemic

by comparison and up to 50% of a child's haemaglobin may be

Airway

desaturated before cyanosis will be clinically obvious#

Airway patency is obvious from looking at the child, taking

Evaluation of the child's capillary refill, skin temperature and

into account the position necessary to maintain a patent

turgot will give a good indication of the adequacy of circulating

airway. A significant airway problem in a child may be

blood volume. The capillary refill should be less than two

suspected if:

seconds; skin turgor can be evaluated by gently pinching the

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they are unable to vocalise normally eg cry, babble, talk;

AENJ VOLUME 3 NO. 1 APRIL 2000

arm or abdomen of the child. The skin should return to a

normal state immediately. When the skin is lifted and remains

in that position for a prolonged period it is known as tenting.

We should consider the education we give parents regarding

It is a sign of severe dehydration.

the recognition and treatment of a fever as perhaps a more

important role at triage. Caregivers - and health personnel -

Disability

need to refocus our concerns. How the child looks is a much

When a child arrives at the triage desk, their activity level,

better indicator of how well or unwell they are, rather than the

response to their environment and level of consciousness is an

height of the fever. We need to explain t O parents that it is the

excellent indicator of their neurological status? The brain is

cause of the fever that will determine the child's outcome, not

one of the most sensitive organs to hypoxia, hence changes in

the fever itself. A fever is a symptom of the underlying

the child's mental status are a good indication of this. Consider

problem, not the problem.

how the child responds to the environment they are in and to

their parents/caregivers. Most children in a different

What was the pulse oximetry?

environment will be curious; looking around at the people and

Pulse oximetry functions by emitting light through the skin via

equipment.

a sensor, with the aim of measuring oxyhaemoglobin; that is,

In pre-verbal children, listen to their cry and response to

comfort measures. Parents can distinguish their child's cry from
one of hunger/dirty/in pain or wind; they recognise a normal
cry for their child. Children who cry inconsolably or have a
high pitched, almost cat like wail are of concern, as are
children who do not respond to comfort measures.

the amount of haemoglobin saturated with oxygen. 1 It is a

widely used, non-invasive tool for monitoring oxygen
saturation, as an indicator of hypoxia. Pulse oximetry is
difficult to obtain in children with even slight motion, where
abnormal haemoglobin exists (e.g. carboxyhaemoglobin
poisoning), or with poor perfusion. External light sources can
result in a false reading, as can nail polish as it interferes with

From around six weeks of age a neonate is able to maintain eye

the light transmission. 2 A n anaemic child may have normal

contact and starts to recognise primary caregivers. A child who

oxygen saturation because the total haemoglobin present is

is disinterested in the environment, does not recognise his

fully saturated, although this may be insufficient to meet the

caregivers or is difficult to rouse should alert the nurse to an

body's requirements. The hypoxic child can be clinically

unwell child. Paradoxical irritability is the term used for a child

recognised, as discussed, by looking at the mental status,

who is quiet and listless, often falling asleep when left alone,

respiratory status, colour and capillary refill.

and restless and irritable when disturbed. It is an indicator of a

neurological problem (eg meningitis). A decreased response to
pain in a child of any age is abnormal.
M y child has a fever!

You haven't done a blood pressure.

Children can lose up to 25% of their circulating blood volume

before a decrease in blood pressure is evident. 8 A hypovolaemic
child is clinically evident. A widening pulse pressure (the

Fever is a common presenting problem and often creates great

difference between the systolic and diastolic pressure) may be

anxiety amongst parents. The anxiety is mainly associated with

an indicator of raised intracranial pressure, however an altered

the possibility of a seizure or brain damage. A common

mental state and tachycardia would be earlier signs. Identifying

perception is that "...infection is bad, infection causes fever,

a trend in blood pressure measurement is more significant than

and that therefore fever is bad. ''7 Literature suggests that giving

one single blood pressure reading.

paracetamol will not prevent a febrile convulsion. Fever,

h9wever, has some beneficial effects. It improves the body's
immune response, is associated with an increased survival rate
and has been shown tobe a protective mechanism to prolong
survival. 5 It is also an indication that an infection exists.

Assessing blood pressure in children is not always easy; the

automated sphygmomanometer, which is routinely used in
many emergency departments, inflates the cuff well above
expected normal systolic blood pressure for children and can be
painful. Excessive movement will affect the accuracy of the

Treatment of fever is considered appropriate for patient

reading, and few young children will remain still long enough

comfort. Generally children will be irritable and miserable

for this to be completed. The cuff should cover at least two-

when febrile, and a reduction in temperature can be very

thirds of the child's upper arm or leg; a variety of sizes are not

comforting. Children have higher oxygen demands than adults

always readily available at triage. The time taken to attend to

due to higher metabolic needs. A child with a pre-existing

this and the clinical significance means it is unlikely to alter

medical condition (eg asthma, cardiac structural anomaly) may

your triage decision, therefore is an unnecessary initial

mean the body is less tolerant of the increased metabolic

intervention.

demands that a fever produces. 5 As long as the infection is

present, the fever will often remain - regardless of the amount
of antipyretic administered.
AENJ VOLUME 3 NO. | APRIL 2 0 0 0

13

The 'essential' vital signs

It may prove useful to obtain some baseline vital signs in a
child at rest, ie, when the child is settled. As cardiac output
increases to meet the body's increased oxygen demands, an
elevated heart and respiratory rates are early signs of
compromise in a child. This elevation may be due to a variety
of causes, but it is important that it is recognised, k resting
pulse and respiratory rate is a good indicator of how well or

difficult. We need to consider whether attending vital signs

will change the triage decision. A n unwell child is clinically
evident based on observation, therefore blood pressure, pulse
oximetry and temperature are useful adjuncts but not essential
components of paediatric triage.
References
1. Cowan, T 1997 'Pulse oximeters' in Professional Nurse 12(10) pp744-750

unwell the child is.

2. Durren, M 1992 'Clinical Notebook Getting the most from pulse oximetry' in
Journal of Emergency Nursing 18(4) pp 340-342

Fear, anxiety, shock, hypoxia, hypovolaemia, crying or fever

3. Henker, R 1999 'Evidence-based practice: fever-related interventions' in

American Journal of Critical Care 8 (1) pp 481-487

will all cause an elevation of a child's heart and respiratory

rates which should be acknowledged at triage when
observations are recorded. It is important not to attribute,
however, an elevation in vital signs because the child is crying.
Always attempt to obtain resting vital signs at some stage.

4. Keddington, R.K. 1998 A triage vital sign policy for a children's hospital
emergency deparunent in Journal of Emergency Nursing 24 pg 189-192
5. LetiziaM and Janusek L 1994 'The self-defense mechanism of fever' in MedSurg
Nursing 3(5) pp 373-377
6. Nelson D 1998 'Pediatric Update Emergency treatment of fever phobia' in Journal
of Emergency Nursing 24(4) pp 83 84
7. Shan, F 1995 'Paracetamol: use in children' in Australian Prescriber 18(2)
pp 33-34

Development
There is very little time at triage to develop a rapport with
children. Having an understanding of basic growth and
development will enhance knowledge of expected normal
behaviour and therefore simplify the triage process. Neonates'

8. Soud TE & Rogers JS 1998 Manual of Pediatric Emergency Nursing Mosby,

St Louis
9. Travers, D 1999 'Triage: how long does it take? How long should it take? in
Journal of Emergency Nursing 25(3) pp 238-240
10. Walsh, P 1996 'Febrile convulsions' in The Aus~alian Paediatric Review 6(3)
pp 1-2

posture is predominantly one of flexion; they lie with arms and

legs slightly drawn up and into their body. They are able to
maintain eye contact from around six weeks of age. Infants
from around 7-9 months develop an awareness of their
caregivers as significant others and may become distressed at
being separated from them. Toddlers, although desiring
independence, have a strong awareness of 'stranger danger' and
will often protest strongly and loudly at the absence of their
main caregiver. Preschoolers are curious about their
environment. School age children will often put on a brave
face for their peers. Adolescents desire independence and
privacy. From this basic overview, it is easy to understand why
knowledge of normal development can guide triage assessment.
This understanding will make it easier to recognise normal and
abnormal behaviour.

Conclusion
Nurses attend to vital signs in paediatrics because they are
afraid of 'missing something'. Those new to triage require
objective reassurance that they allocated the appropriate triage
category. I believe we need to change our thinking and update
triage training programs. We need to rely less on machines and
more on observation. A sick child is often observable. Placing a
hand on the child's head is sufficient to tell whether the child
is hot or not. "Vital signs are not infallible indicators. ''4
The triage process - from the initial assessment to the triage
decision - should take no longer than five minutes. 9 The time
taken to gain a child's trust and co-operation means
ascertaining baseline vital signs within this time frame can be

14

AENJ V O L U M E 3 N O . 1 APRIL 2 0 0 0

EXTRICATION COLLARS~ WHEN

ARE THEY REMOVED?
Pat Barnwell
RN, BA, Grad Cert Research, ICU Neuro Cert, TNCC,
ENPC and CATN Instructor
Westmead Hospital
The use of extrication collars for injured patients has
limited the incidence of further injury due to
insufficient stabilisation of the cervical spine.
Extrication collars are removed when the neck is cleared
of injury or definitive treatment is commenced. The
problem I have identified is that clearing the cervical
spine may be delayed many hours due to various factors
and the hard collar stays on causing the patient
increasing discomfit and possible pressure areas.
This survey asks you, as nurses, to identify a benchmark
time for the replacement of the extrication collar with a
treatment type, irrespective of the presence or absence of
injury. The trauma guidelines tend to suggest 24 hours;
the patient would seem to suggest a much shorter time.

Responses to the survey can be emailed to the

Association at enainc@ozemail.com.auor posted to the
Association address (PO Box 141 Toongabbie, 2146)
marked attention Pat. The results will be published in
the Journal at a later date. Thank you for considering
the survey: our patients thank you for your advocacy.