Session 1: Emergency

Triage, Assessment and

Treatment (ETAT)
Hailemariam Mekonnen
M.Sc., Ass't Professor of Pediatrcs Health Nursing
Bahir Dar University, Bahir Dar Ethiopia.
Learning Objectives

 By the end of this session, students are expected to be able to:

 Explain the meaning of triage and its importance
 Describe emergency signs that are assessed in triage
 Describe the priority signs assessed in triage
 Describe the management of a child with emergency signs
 Describe the management of a child with priority signs
 Describe the management of a child with non-emergency and non-priority signs
Meaning and Importance of Triage
Definition of terms

 Triage: The sorting of patients into priority groups according to their needs and
the resources available
 In paediatrics, triage is the process of rapidly examining all sick children when
they first arrive, in order to place them in one of the following categories:
 Those with emergency signs who require immediate emergency treatment
 Those with priority signs, indicating that they should be given priority while waiting in
the queue so that they can rapidly be assessed and treated without delay
 Those who are not urgent (no emergency or priority signs), these children can wait their
turn in the queue for assessment and treatment
 Triage is an on-going process
 Organization of triage and emergency treatment should be carried out in the
place where the sick child presents before any administrative procedures such as
registration
Importance of Triage

o Helps to identify children who are very sick and need immediate attention
o Helps to reduce deaths which, in paediatrics, mostly occur within 24 hours of
admission
o Simplifies the work at a health facility
o Motivates parents to bring their children to the health facility for management
o Triage of patients involves looking for signs of serious illness/disease or injury
Emergency Signs Assessment

 The assessment is based on

o o A – Airway
o o B – Breathing
o o C – Circulation, Coma, Convulsion
o o D – Dehydration (severe)

 The above signs should be assessed in every child, and when a sign is found,
immediately give the appropriate emergency treatment
 Ask and look for any head/neck trauma before positioning the child or moving the
head/neck
•

If emergency signs are found, take the following 2

steps:

 Call an experienced health professional and others to help, but do not delay
starting treatment
 Carry out emergency investigations- blood glucose, blood smear, haemoglobin,
send blood for grouping and cross-matching (at hospital level) if the child is in
shock, or appears to be severely anaemic, or is bleeding significantly
Management of Emergency Signs

 Management of Airway and Breathing (A)

 To assess airway and breathing, you need to know:
o Is the airway obstructed?
o Is the child breathing?
 ƒObstructed breathing can be due to blockage of airway by the tongue, foreign body or
severe croup

o Is the child cyanosed?

 ƒBluish/purplish discolouration of the tongue and the inside of the mouth
o Are there signs of severe respiratory distress? ƒ
o Is the child having trouble breathing so that it is difficult to talk, eat or breastfeed?
o ƒDoes the child’s breathing appear very laboured? ƒ
o Is the child tiring?

o If the patient is not breathing:

o o Open the airway by correctly positioning the head in the ‘sniffing position’
o o Remove any foreign bodies or objects
o o Ventilate with bag and mask
 Give oxygen in all cases of airway or breathing problems:
o o 0.5 to 1 litre/minute (if less than 1 year old)
o o 1 to 2 litres /minute (older children)
Management of Circulation (c)

 Does the child have warm hands?

 o Is the capillary refill time equal or more than 3 seconds? ƒ
 To test, apply pressure to whiten the nail of the thumb or big toe for 3 seconds, determine
capillary refill time from the moment of release until total recovery of the pink colour

 Is the pulse fast and weak?

 If the child is shocked and is not severely malnourished:
o Stop any bleeding
o Give oxygen o Keep the child warm
o Give IV fluids rapidly

 If the child is shocked and is severely malnourished

o Stop any bleeding
o Give oxygen o Keep the child warm
o Assess if the child can drink oral or be given nasogastric (NGT) fluids
o Give IV fluids if the child is unable to tolerate oral or NGT fluids
Management of Coma and Convulsions (or other
abnormal mental status)

 Coma
 Is the child in coma? ƒ
o The level of consciousness can be assessed rapidly by the Glasgow (AVPU) scale
o A- Allert
o V- Voice
o P- Pain
o U- Unresponsive
 If the child is unconscious you should: ƒ
 Manage the airway and breathing ƒ
 Position the child (if there is history of trauma, stabilize neck first) ƒ
 Ensure circulation ƒ
 Check the blood sugar ƒGive IV glucose
 Convulsions
 Is the child convulsing?
 Are there spasmodic repeated movements in the unresponsive child?
 If the child is convulsing now, you must: ƒ
 Manage the airway and breathing ƒ
 Position the child (if there is history of trauma, stabilize neck first) ƒ
 Ensure circulation ƒCheck the blood sugar ƒ
 Give IV glucose ƒGive anticonvulsant (e.g. diazepam or lorazepam)
Management of Severe Dehydration

 To assess if the child is severely dehydrated, you need to know:

 Is the capillary refill time equal or more than 3 seconds? ƒ
 To test, apply pressure to whiten the nail of the thumb or big toe for 3 seconds, determine
capillary refill time from the moment of release until total recovery of the pink colour

 Is the child lethargic? ƒ

o Does the child appear drowsy and show no interest in what is happening? o Does the child
have sunken eyes?

 Does a skin pinch take longer than 2 seconds to go back? ƒ

o To test, pinch the skin of the abdomen halfway between the umbilicus and the side, pinch for
1 sec, then release and observe
If the child is severely dehydrated, but no signs of
shock, and the child is not severely malnourished:

 Give the child a large quantity intravenous (IV) fluid quickly, the fluids will replace the
body’s large fluid loss ƒ
 This is Treatment Plan C for diarrhoea
 The first portion of the IV fluid (30 ml/kg) is given very rapidly (over 30 to 60
minutes) ƒ
 This will restore the blood volume and prevent death from shock
 Then 70 ml/kg is given more slowly (2 ½ to 5 hours) to complete the rehydration
 In all cases the fluid of choice is Ringer’s lactate or Normal Saline
 Reassess the child every hour
 As soon as the child can drink, you should give oral fluids in addition to the drip
 Use oral rehydration solution (ORS) and give 5 ml/kg every hour
Severe Dehydration with Severe Malnutrition

 Do NOT give IV fluids (unless the child is in shock and is lethargic or has lost
consciousness)
 Give Rehydration Solution for Malnutrition (ReSoMal) which can be made (see
Figure 1 for recipe below) or is commercially available
 The ReSoMal should be given orally or by nasogastric tube, much more slowly
than you would when rehydrating a well-nourished child
 When assessing the blood sugar in a malnourished child, remember that a low
blood sugar level is between 2 and 4 mmol/l
 It is better to give 10% glucose to a child whose sugar is borderline than to
withhold it
 As these children have no energy stores, they cannot, unlike well-nourished
children, maintain their blood sugar in a crisis
“ Priority Signs Assessed During
Triage
”
1. Any sick young infant (<2 months old)
o If the child appears very young (or tiny), ask the mother his/her age ƒIf the child is obviously
young infant, you do not need to ask this question
o Small infants are more difficult to assess properly, more prone to getting infections (from other
patients), and more likely to deteriorate quickly if unwell o All young infants should therefore be
seen as a priority

2. Temperature (fever or high temperature)

o A child that feels very hot may have high fever
o Children with high fever on touch need prompt treatment
o Take the waiting child to the front of the queue and take locally adopted action, like having the
temperature checked by thermometer, giving an antipyretic, or doing investigations like a blood
film for malaria
3. Severe trauma or injuries (or other urgent surgical condition)
• Usually this is an obvious case, but one needs to think of acute abdomen, fractures and head
injuries in this category

4. Severe palmar pallor

• Pallor is unusual paleness of the skin, and severe pallor is a sign of severe anaemia which might
need urgent blood transfusion
• It can be detected by comparing the child’s palms with your own
• ƒIf the palms are very pale (almost paper-white), the child is severely anaemic
5. Poisoning
• A child with a history of swallowing drugs or other dangerous substances needs to be
assessed immediately, as he/she can deteriorate rapidly and might need specific
treatments depending on the substance taken
• Parent will tell you if she/he has brought the child because of possible intoxication

6. Severe Pain
• If a child has severe pain and is in agony, she/he should be prioritized to receive early
full assessment and pain relief
• Severe pain may be due to severe conditions such as acute abdomen, meningitis, etc
7. Lethargy, drowsiness
 Recall from your assessment of coma with the AVPU scale whether the child was
lethargic
 ƒA lethargic child responds to voice but is drowsy and uninterested

8. Continually irritable and restless

 o The child is conscious but cries constantly and will not settle
9. Respiratory distress
 When you assessed the airway and breathing, did you observe any respiratory distress?
 If the child has severe respiratory distress, it is an emergency
 There may be signs present that you do not think are severe (e.g. lower chest wall
indrawing or difficulty in breathing) ƒ
• In this case, the child does not require emergency treatment but will need urgent assessment

 Decisions on the severity of respiratory distress come with practice, but if you have any
doubts, have the child seen and treated immediately
10. Urgent Referral
o The child may have been sent from another clinic
o Ask the mother if she was referred from another facility and for any note that may
been given to her
o Read the note carefully and determine if the child has an urgent problem
11. Visible severe wasting
o A child with visible severe wasting has a form of severe malnutrition called marasmus
o To assess for this sign, look rapidly at severe wasting of the muscles of the shoulders,
arms, buttocks and thighs or visible rib outlines
12. Oedema of both feet
o Oedema is an important diagnostic feature of kwashiorkor, another form of severe
malnutrition
o Look for other signs of kwashiorkor such as apathy, skin and hair changes

13. Major burns

o Burns are extremely painful and children who seem quite well can deteriorate rapidly
o If the burn occurred recently, it is still worthwhile to cool the burnt area with water (e.g. by
sitting the child in a bathtub with cool water)
o Any child with a major burn, trauma or other surgical condition needs to be seen quickly
o Get surgical help or follow surgical guidelines
 These children need prompt assessment to determine what further treatment is
needed, they should not be asked to wait in the queue
 If a child has trauma or other surgical problems, get surgical help (refer)
General Treatment for Priority Signs

 Priority signs lead to quicker assessment of the child by moving the child to the
front of the queue
 While waiting, some supportive treatment may be given
o For example give antipyretic such as paracetamol to a child found to have a hot body
 If a child has no emergency signs or priority signs, she/he may return to the
queue
 If no emergency or priority signs are found, assess and treat the child who will
follow the regular queue of non-urgent patients
Key Points

 Triage is a continuous process of sorting of patients into priority groups

according to their need.
 Triage should be carried out quickly and all children should undergo triage.
 Triage helps to reduce deaths which, in pediatrics, mostly occur within 24 hours
of admission.
 The main steps in triage are looking for emergency signs, treat emergency signs
and call a senior health worker, look for priority signs, place priority patients at
the front of the queue, and move onto the next patient.
ASSIGNMENT

1. Define triage.
2. What do the letters A, B, C and D in ‘ABCD’ stand for?
3. List the priority signs assessed during triage.
4. Which fluid would you give to a child in shock with signs of severe malnutrition?
“
THANK YOU