Tool | Tool components | ||||||
1st step | 2nd step | 3rd step | 4th step | 5th step | 6th step | 7th step | |
Paediatric Triage Tape (PTT)6 | <10 kg: alert and moving all limbs 11–18 kg: alert and moving all limbs or walking >19 kg: walking | Breathing (open airway if required) | RR: <10 kg: <20 or >50 11–18 kg: <15 or >45 >19 kg: <10 or >30 | Capillary refill: <2 s | HR: <10 kg: <90 or >180 11–18 kg: <80 or >160 >19 kg: <70 or >140 | ||
JumpSTART7 | Walking? | Breathing (open airway if required) | If apnoeic, assess for pulse. If present, give 5 rescue breaths. | RR: <15 or >45 | Palpable pulse? | Conscious level assessment (AVPU)§ | |
Sheffield Paediatric Triage Tool (SPTT) | Catastrophic haemorrhage? | Walking? | Breathing (open airway if required) | If apnoeic, assess for pulse. If present, give 5 rescue breaths. | Responds to voice? | Age-appropriate RR?* | Age-appropriate HR† |
Careflight14 | Walking? | Obeys commands? | Palpable radial pulse? OR Breathes with open airway? | – | – | – | – |
Major Incident Medical Management and Support (MIMMS) Triage Sieve1 | Walking? | Breathing (open airway if required) | RR: <10 or ≥30 | HR: >120 | – | – | – |
Modified Physiological Triage Tool 24 (MPTT-24)‡9 10 17 | Catastrophic haemorrhage? | Walking? | Breathing? Open airway if required. | Responds to voice? | RR: <12 or ≥24 | HR: ≥100 | – |
Modified Simple Triage and Rapid Treatment19 | Walking? | Spontaneous breathing | RR: >30 | Radial pulse absent | Obeys commands | – | – |
National Ambulance Service Medical Directors (NASMeD) Triage Sieve18 | Catastrophic haemorrhage | Are they injured? | Walking? | Breathing? Openairway if required | Unconscious | RR: <10 or ≥30 | Pulse >120 or capillary refill >2 s |
Rapid Assessment of Mentation and Pulse (RAMP)20 | Casualty without signs of obvious death | Casualty follows commands | Radial pulse present? | – | – | – | – |
*RR: <1: 30–40, 1–2: 25–25, 2–5: 25–30, 5–12: 20–25, >12: 15–20.
†HR: <1: 110–160, 1–2: 100–150, 2–5: 95–140, 5–12: 80–120, >12: 60–100.
‡MPTT-24 was updated in 2018 following consultation with NHS England to explicitly include the ‘open airway’ step as part of the breathing assessment.17 This current version is currently in use in both UK military and civilian in-hospital practice (within the NHS Clinical Guidelines for Major Incidents).10
§AVPU: Alert, responds to Voice, responds to Pain, Unconscious.