Emergency Department Triage Manual

Emergency Department Triage Manual

ED Triage Manual

Emergency Department Vital Sign Table

Age Group Respiratory Rate Heart Rate Systolic Blood Pressure  Diastolic Blood Pressure Weight in Kilos Consider Higher Acuity without
Presence of Fever
Newborn 30–50 120–160 50–70 30–60 2–3 > 180 HR
Infant
(1–12 mos)		 30–40 80–140 70–100 53–66 4–10 > 180 HR
Toddler
(1–3 yrs)		 20–30 80–130 80–110 53–66 10–14 > 140 HR
Preschooler
(3–5 yrs)		 20–30 80–120 80–110 55–69 14–18 > 140 HR
School Age
(6–12 yrs)		 20–30 70–110 80–120 57–71 20–42 > 130 HR
Adolescent
(13+ yrs)		 12–20 55–105 110–120 66–80 > 50 > 110 HR

Emergency Severity Index Handbook — Fifth Edition

Key Points to Remember

  • Every degree Celsius rise in temperature should only show a ten percent rise in heart rate
  • If one vital sign parameter is abnormal, then a full set of vital signs should be attempted
    • Exception: unable to obtain an accurate blood pressure on a crying and kicking child
  • Reset triage blood pressure machines between each patient
  • If the heart rate is low normal or high normal, assess further

For further information, reference Vital Sign Range Guidelines for Emergency Department, Primary, Speciality Care, and Inpatient Job Aid