Malaysian Triage Scale- Paediatric

9 month old girl is brought to you at primary triage by one of the parents with complaint of choking. There is no audible sound, she is in respiratory distress

• Level I - Resuscitation

• Level II- Emergency

• Level III- Urgent

• Level IV- Early care

A 6 year old boy arrives in ED with complaint of seizure. Clinically patient is conscious, no  

cyanosis, not in distress. Bp 100/60 HR 125 T 38 RR 25 breath spo2 98% on RA.

• Level I- Resuscitation

• Level II- Emergency

• Level III- Urgent

• Level IV- Early care

A 3 year old boy is brought into triage with complaint of difficulty breathing. His father says he                                                                                        

     has been unwell and coughing for three days. His BP 90/50 HR 150 T 38 RR 55 sp02 94%.

   

 

• Level I- Resuscitation

• Level II- Emergency

• Level III- Urgent

• Level IV- Early care

A 1 year old girl has a 2 days history of diarrhoea and vomiting. Her airway and breathing are   

     normal. Her hands are warm. Good pulse volume, Skin pinch lasts ≤2 seconds. Her eyes are not  

     sunken. BP 90/60 HR 120 T 37 Spo2 98%. She is on bottle feeding during assessment.

•  Level III- Urgent

• Level IV- Early care

• Level V- Routine

• Triage away

10 years old boy, presented with fever x 3 days associated with cough, RN. No covid contact.  

     Tolerated orally. No abdominal pain, vomiting and diarrhoea. No rashes. BP 110/70 HR 110 T

      37.5 spo2 100% RR 15

• Level III- Urgent

• Level IV- Early Care

• Level V- Routine

• Triage away

6 month old baby girl, brought in by parent with complaint of persistent vomiting and diarrhoea for   

    4 days. She had reduced oral intake for 1 days. Clinically she looks lethargic with weak cry. No tear

    seen during crying. Both eyes look sunken, CRT about 3 sec. BP 80/55 HR 160 T 36.7 Spo2 98%.

      

• Level I- Resuscitation

• Level II- Emergency

• Level III- Urgent

• Level IV- Early care

8 years old girl presented with epigastric pain and persistent vomiting for 1 days. Further history   

    he had fever x 5 days associated with headache and myalgia. He has no rashes or bleeding  

    tendency. He had taken Paracetamol prior to ED visit. BP 110/70 HR 110 T 37 Spo2 98% RR 18.

• Level I- Resuscitation

• Level II- Emergency

• Level III- Early care

• Level IV- Urgent

7 years old boy presented with rapid breathing associated with cough. No fever. Tolerated orally.

    He is on salbutamol inhaler for Bronchial asthma. On examination no wheeze. He speaks in full

    sentences. Mild SCR. On auscultation patient has generalized Ronchi. BP 110/80 HR 90 T 36.6 Spo2

    96 on RA RR 20.

•  Level III- Urgent

• Level IV- Early care

• Level V- Routine

• Asthma bay

11 years boy presented with right iliac fossa (RIF) pain for 2 days associated with diarrhoea x 3

    episode. He has Loss of appetite. No vomiting BP 120/80 HR 100 T 37.5 Spo2 100% RR 18 Pain

    score 7.

• Level I- Resuscitation

• Level II- Emergency

• Level III- Urgent

• Level IV- Early care

 2 month old baby girl brought to ED at 3 am in the morning with complaint of continuous crying for more than 2 hours. Otherwise, no other complaint. Upon review baby is sleeping in the mother arm. Baby not in distress. BP 90/55 HR 125 RR 35 Spo2 100%.

• Level I- Resuscitation

• Level II- Emergency

• Level III- Urgent

• Level IV- Early care