CTASPediatric Triage

Using the Canadian Triage and Acuity Scale

Samantha Chande, Clinical Nurse Educator, Sidra Medicine

• Identify key pediatric aspects of CTAS

• Describe differences in pediatric triage

• Define 1st and 2nd order modifiers to achieve a final CTAS level

Objectives

Pediatric CTASWhat is CTAS?

5 Level triage scale

Pediatric CTAS has a 3 step approach to assessment:

• Initial Assessment of illness/injury

• Evaluation of the presenting complaint

• Assessment of behavioral and age-related complaints

5 Levels

CTAS

Adult vs Peds CTAS

What’s the same?

Acuity process is the same:

• First Look (Pediatric Assessment Triangle)

• Infection Control

• Chief Complaint

• Modifiers

The five levels and definitions are the same

The use of presenting complaint, assessment

and modifiers are the same

Pediatric CTAS

Pediatric CTAS

Adult vs Peds CTAS

What’s different?

• In children the assessment techniques and

methods of interviewing are different

• Anatomical and physiologic differences

• Psychological and Social Differences

• History Gathering

Assessment

Quick or Full?• Level I & II undergo a quick

assessment

• Level III and below require a full

assessment to avoid missing a subtle

presentation in pediatrics

• CTAS IV & V must have normal vital

signs

Pediatric CTAS

Quick or Full Assessment?

Some Pediatric Considerations…

• Prematurity

• Congenital anomalies

• Metabolic disease

• Technology Dependent Children

• Developmentally Challenged Children

• Child Maltreatment

Pediatric CTAS

Anatomical Differences

• Proportionally big heads

• Smaller airways

• Breathing patterns vary by age

• Smaller size

• Weight dependent therapy

Pediatric CTAS

Pediatric Triage Assessment Tips

• Unwrap, assess, rewrap!

• This is the one time it’s ok to WAKE a sleeping baby!!

• Interview before hands on assessment

• Listen to parents/caregivers

• Do the most invasive examination last

• Explain, explain, explain

Pediatric CTAS

5 most common presentations to the ED

• Fever

• Respiratory difficulties

• Vomiting and/or diarrhea

• Injuries

• Change in behavior

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More modifiers…

Resources:

http://caep.ca/resources/ctas

https://www.cambridge.org/core/journals/canadian-journal-of-emergency-

medicine/article/revisions-to-the-canadian-emergency-department-triage-and-acuity-

scale-ctas-guidelines-2016/E2CB3E2063C54E11259313FA4FEAE4

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Questions?