Pediatric Cardiology Triage Guidelines for Nurses
Pediatric cardiology triage nurses should follow a structured approach based on symptom severity, cardiac physiology, and patient presentation when addressing common parent concerns, using standardized protocols to ensure timely intervention for potentially life-threatening conditions. 1
Emergency Triage Categories
Immediate Medical Attention (RED)
- Cyanosis - Especially in newborns or infants
- Differentiate cardiac from pulmonary causes
- Note if worsens with crying or improves with oxygen
- Hypercyanotic "tet spell" - Acute bluish discoloration with irritability
- Respiratory distress with cardiac symptoms
- Syncope or near-syncope with exertion
- Chest pain with:
- Exertion
- Radiation to back, jaw, or left arm
- Associated with palpitations or dizziness
- Palpitations with dizziness or altered consciousness
- Signs of heart failure:
- Poor feeding with diaphoresis in infants
- Respiratory distress
- Hepatomegaly
- Decreased urine output
Urgent Evaluation (YELLOW)
- Palpitations without other symptoms
- Non-exertional chest pain lasting >10 minutes
- Presyncope (dizziness without loss of consciousness)
- Fatigue with decreased exercise tolerance
- Feeding difficulties in infants with known cardiac disease
- Fever in patients with prosthetic valves or recent cardiac surgery
Routine Follow-up (GREEN)
- Innocent murmurs previously evaluated
- Mild chest pain - Brief, positional, reproducible with palpation
- Isolated palpitations - Brief, infrequent without other symptoms
- General questions about cardiac conditions
- Medication refill requests for stable patients
Key Assessment Questions for Triage
For Chest Pain
- Location and radiation pattern?
- Duration and frequency?
- Associated with exercise or rest?
- Relieved by rest or position change?
- Associated symptoms (shortness of breath, dizziness, palpitations)?
- Family history of sudden cardiac death or early heart disease?
For Palpitations
- Regular or irregular rhythm?
- Sustained or intermittent?
- Associated symptoms (dizziness, chest pain, syncope)?
- Triggers (exercise, caffeine, medications)?
- Duration of episodes?
For Syncope
- Circumstances (standing, exercise, emotional stress)?
- Prodromal symptoms?
- Duration of unconsciousness?
- Post-event symptoms?
- Family history of sudden death or arrhythmias?
For Cyanosis
- Central or peripheral?
- Continuous or episodic?
- Associated with feeding, crying, or activity?
- Present since birth or new onset?
- Response to oxygen administration?
Medication-Related Concerns
Common Cardiac Medications and Side Effects
- Prostaglandin E1 - Used for ductal-dependent lesions; monitor for apnea, hypotension 1
- Digoxin - Monitor for vomiting, arrhythmias, visual changes
- Diuretics (furosemide, chlorothiazide) - Monitor for dehydration, electrolyte imbalances
- ACE inhibitors - Monitor for hypotension, cough, hyperkalemia
- Beta-blockers - Monitor for bradycardia, hypotension, bronchospasm
- Antiarrhythmics - Drug-specific monitoring required
Condition-Specific Triage Guidelines
Single Ventricle Physiology
- Immediately evaluate for:
- Oxygen saturations <75%
- Signs of heart failure
- Respiratory distress
- Poor perfusion
- Urgent evaluation for:
- Feeding difficulties
- Weight loss or poor weight gain
- Increased work of breathing
Post-Operative Cardiac Patients
- Immediately evaluate for:
- Fever
- Wound drainage or redness
- Respiratory distress
- Decreased urine output
- New murmur
- Monitor for common complications:
- Catheter-related sepsis
- Pathological thrombosis
- Surgically-induced heart block 1
Arrhythmias
- Immediately evaluate:
- Symptomatic bradycardia or tachycardia
- Irregular rhythm with syncope
- Palpitations with dizziness
- Provide guidance on:
- When to obtain rhythm strips
- When to activate emergency services
- Use of home monitoring devices if prescribed
Parent Education Components
Red Flags Requiring Emergency Care
- Instruct parents to call 911 for:
- Syncope or near-syncope
- Chest pain with exertion
- Severe respiratory distress
- Cyanosis with irritability
- Altered mental status
Home Monitoring Guidelines
- Provide specific parameters for:
- Heart rate ranges by age
- Respiratory rate ranges by age
- Weight monitoring frequency
- Oxygen saturation targets (if home monitoring)
- Medication administration timing
Common Questions and Answers
- Create standardized responses for:
- Sports participation with cardiac conditions
- Vaccination recommendations for cardiac patients
- Travel considerations with cardiac disease
- Dental care and endocarditis prophylaxis
- Genetic counseling indications
Implementation Guidelines
- Train all triage nurses on cardiac-specific assessment techniques
- Develop standardized documentation templates
- Create clear escalation pathways for concerning symptoms
- Establish direct communication protocols with cardiology team
- Implement regular case review for quality improvement
- Provide reference materials for common cardiac medications and side effects 1
By following these structured guidelines, pediatric cardiology triage nurses can effectively prioritize patient concerns, ensure appropriate and timely interventions, and provide consistent education to families managing pediatric cardiac conditions.