Paediatric Emergency Triage Tools
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Direct answer
Triage tools exist because children compensate brilliantly and then collapse: a child maintains blood pressure until a third of circulating volume is lost, so triage must read physiology, not vital-sign thresholds. The WHO's Emergency Triage Assessment and Treatment (ETAT) is the backbone of resource-limited and Indian emergency practice — a rapid look for emergency signs (obstructed breathing, severe distress, central cyanosis, shock, coma or convulsions now, severe dehydration, severe malnutrition) that routes the child to immediate treatment, with priority signs next and non-urgent cases last. In advanced settings, the Paediatric Assessment Triangle — appearance, work of breathing and circulation to skin — is the 30-second bedside equivalent, Paediatric Early Warning Scores track ward deterioration, and JumpSTART adapts mass-casualty triage to children. Mastering one system deeply beats knowing three superficially, and ETAT is the one Indian postgraduates are examined on.
What you must remember
- ETAT emergency (red) signs: obstructed breathing, severe respiratory distress, central cyanosis, signs of shock (cold hands, weak fast pulse, capillary refill longer than 3 seconds), coma, convulsions occurring now, severe dehydration (lethargy, sunken eyes, very slow skin pinch), and severe visible wasting or oedema of both feet — any one means treatment before registration.
- ETAT priority (yellow) signs: tiny infant under 2 months, temperature problem, trauma or burn, poisoning, severe pain, respiratory distress short of emergency, or restless irritability — seen ahead of the queue but after reds.
- Paediatric Assessment Triangle (PAT): Appearance (tone, interactiveness, consolability, gaze, speech — the TICLS mnemonic), Work of breathing (retractions, stridor, grunting, position), and Circulation to skin (pallor, mottling, cyanosis) — any abnormal side predicts the need for intervention before a vital sign is taken; ETAT's emergency signs likewise trigger treatment — airway positioning, oxygen, cause-directed therapy at the triage desk itself.
- Physiology of compensation: heart rate and systemic vascular resistance rise first; hypotension is a late, pre-arrest sign — a normotensive child with tachycardia and prolonged capillary refill is already in compensated shock.
- JumpSTART for mass casualties: modifies adult START — children who cannot walk are assessed by breathing after five rescue breaths for apnoeic children with a pulse (a paediatric-specific step), respiratory rate over or under 15, perfusion and mentation sort into immediate, delayed, minimal or expectant categories; Paediatric Early Warning Scores do the equivalent work on wards, aggregating behaviour and cardiorespiratory parameters to trigger review before collapse.
- Indian programme reality: ETAT is embedded in the Facility-Based Newborn and Child Care packages under the National Health Mission and underpins triage desks at District Hospitals and Medical Colleges; auxiliary nurse midwives and Anganwadi workers use simplified IMNCI danger-sign referral (fast breathing, chest indrawing, unable to feed, convulsions).
Reading the triage desk in practice
A busy evening triage: five children arrive near-simultaneously. The five-month-old grunting with chest indrawing and cyanosed lips satisfies "central cyanosis plus severe respiratory distress" — straight to the resuscitation bay. The two-year-old with watery diarrhoea who is irritable and drinking eagerly is priority-yellow (some dehydration, ORS Plan B), while her lethargic, pinch-very-slow twin goes red for severe dehydration. The ten-day-old tiny infant feeding poorly is yellow purely for age under 2 months. The eight-year-old with a forearm deformity and severe pain is yellow for analgesia. Total decision time under two minutes — that is ETAT functioning as designed.
The same desk at night runs the PAT on a feverish two-year-old: listless with a weak cry (abnormal appearance), mild subcostal recession (abnormal work of breathing), mottled knees (abnormal circulation) — all three sides broken, no vital signs yet taken, and she is already being carried to the bay, where compensated septic shock is found because the triangle forced early action.
How the exam frames it
Two question families recur. The first is category assignment: a stem describes a child and the options are emergency, priority or queue — the discriminators tested are convulsing now (not a past seizure), coma (not mere irritability), skin pinch speed, and the under-2-months rule. The second is the PAT composition — appearance, work of breathing, circulation to skin — often disguised as "which parameter is not part of the triangle" (blood pressure is the classic distractor, since the PAT needs no equipment). The viva favourite is physiological: why hypotension is a late sign in paediatric shock — tachycardia, vasoconstriction, then decompensation.
Frequently asked questions
What are the emergency signs in WHO ETAT?
Obstructed breathing, severe respiratory distress, central cyanosis, signs of shock, coma, current convulsions, severe dehydration, and severe visible malnutrition or oedema of both feet.
What are the three sides of the Paediatric Assessment Triangle?
Appearance, work of breathing, and circulation to the skin — a hands-free, equipment-free 30-second assessment that predicts decompensation.
Why is hypotension a late finding in paediatric shock?
Children defend blood pressure with tachycardia and vasoconstriction until reserves are nearly exhausted, so a normal pressure with tachycardia and prolonged capillary refill already signifies compensated shock.
How does JumpSTART differ from adult START triage?
It adds five rescue breaths for apnoeic children who still have a pulse, and applies paediatric respiratory-rate and perfusion thresholds, recognising that paediatric apnoea is often respiratory, not cardiac, in origin.
Which children are triaged as priority (yellow) in ETAT?
Infants under 2 months, temperature abnormalities, trauma, burns, poisoning, severe pain, respiratory distress without emergency signs, and abnormal restlessness or irritability, among others.