Head Trauma Triage Levels, Boston Children’s Hospital | |
Level 1 (Most emergent) | Unresponsive or with depressed mental status after significant head trauma. Will need to go to OR or ICU immediately. |
Level 2 (Emergent) | Altered mental status (may have repetitive questioning or be slow to respond), lethargic, but able to respond verbally. |
Level 3 (Urgent) | Usually minor head trauma, may have vomiting and headache, but are awake and alert. |
Level 4 (Least urgent/Non-urgent) | Minor head trauma, appear normal with no headache or vomiting. Usually these patients present after falling while running or after running into an object. |
Head Trauma Triage Levels, Institute for Maternal and Child Health IRCCS Burlo Garofolo | |
Red (Emergent) | One or more of: Critical vital parameters, Fracture of the base/exposed fracture, Penetrating wound or scalp, Severe dynamica, Anisocory or pupils not reacting to light or gaze deviation, Coagulopathy, Infant with bulging fontanelle and weeping crying |
Yellow (Intermediate) | One or more of: Prostrate child, GCS 13 or less, Loss of consciousness, Amnesia/syncope/dizziness, Persistent vomiting > 2 h from the head trauma, Persistent headache > 2 h or worsening headache, Post-traumatic convulsion resolved, Newborn, Depressed fracture, Scalp or face tear, Irritability or incessant crying, Diplopia, Soft swelling of the head |
Green (Mild) | One or more of: 1–2 episodes of vomiting < 2 h from the head trauma, Headache at the impact point, GCS 14–15, Mild dynamica, Infant > 6 months with no symptoms, Cephalohematoma |
White (Trivial) | Head trauma with no signs or symptoms > 6 h |