children triage

1. The Emergency Triage Assessment
And Treatment (ETAT) In
Pediatrics
AIC Litein Mission Hospital CME
DR. MATE SHILULI

2. Introduction
• Most deaths in hospital often occur within 24 hours of admission
• Many of these deaths could be prevented if very sick children are
identified soon after their arrival in the health facility & treatment
is started immediately.
• ETAT helps:
• Triage all sick children when they arrive at a health facility, into
those with emergency signs, with priority signs, or non-urgent
• Provide emergency treatment for life-threatening conditions

3. Definition of terms
• Triage: Sorting of patients into priority groups according to their needs &
the resources available
• In pediatrics, triage is the process of rapidly examining all sick children
when they first arrive/daily assessment in the ward, in order to place them
in one of the following categories:
i. Emergency signs - require immediate emergency treatment
ii. Priority signs - should be given priority while waiting in the queue
so that they can rapidly be assessed & treated without delay
iii. Not urgent (no emergency or priority signs) - can wait their turn in
the queue for assessment and treatment

4. Definition Of Terms Cont.…
• Triage is an on-going process
• Organization of triage & emergency treatment should be
carried out in the place where the sick child presents
before any administrative procedures such as registration
• Triage of patients involves looking for signs of serious
illness/disease or injury

5. Importance of Triage
i. Helps to identify children who are very sick &
need immediate attention
ii. Helps to reduce deaths which, in pediatrics,
mostly occur within 24 hours of admission
iii. Simplifies the work at a health facility
iv. Motivates parents to bring their children to the
health facility for management

6. Goals Of Triage
a) Rapidly identify patients with urgent, life
threatening conditions
b) Assess/determine the severity & acuity of the
presenting problem
c) Direct patients to appropriate treatment areas
d) Reevaluate the patients awaiting treatment

7. Who Should Triage?
All clinical staff involved in the care of sick children should be
prepared to triage
• Doctor/Clinical officer
• Nurse
• Cleaner
• Gateman
• Records clerk
• Anyone

8. Triaging Process
• Should not take too much time
• Health workers should learn how to assess several
signs at the same time e.g. a child who is smiling or
crying does not have severe respiratory distress shock
or coma
• Examine the child for emergency and priority signs
e.g. severe malnutrition and non urgent cases

9. When To Triage
• Triage should be carried out as soon as the sick child
arrives in the hospital, before any administrative
procedure
• Can be carried out in different locations e.g. in
outpatient queue or emergency room
• Daily in the wards

10. Steps In The Management Of The Sick Child
TRIAGE
Check for emergency signs
Check for priority signs
Emergency treatment
Rapid assessment & treatment
Non-urgent cases & stabilized cases
• History and examination
• Laboratory and other investigations
• List and consider DIFFERENTIAL DIAGNOSES
• Select MAIN (WORKING) DIAGNOSIS and Secondary diagnoses
• Plan and begin INPATIENT TREATMENT (including supportive care)
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NO
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11. Steps In The Management Of The Sick Child
Monitor for
• Response to treatment
• Complications
INPATIENT TREATMENT
• Continue treatment
• Plan for discharge
• Revise treatment
• Treat complications
• Refer if not possible
IMPROVING
NOT IMPROVING
OR NEW PROBLEM
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12. Emergency Signs Assessment
• Based on:
• A – Airway
• B – Breathing
• C – Circulation, Coma, Convulsion
• D – Dehydration (severe)
• The above signs should be assessed in every child, when a
sign is found, immediately give the appropriate emergency
treatment

13. 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, complete blood count (Hb), send blood
for grouping and cross-matching (at hospital level) if
the child is in shock, or appears to be severely
anemic, or is bleeding significantly

14. A- Airway & Breathing
• To assess airway & breathing, you need to know:
• Is the airway obstructed? Is the child breathing? Is the child
blue? (centrally cyanosed)
• Does the child have severe respiratory distress?(head nodding
,grunting, chest in drawing ,wheeze, nasal flaring, use of
accessory muscles for breathing), Is the child having difficult
to talk, eat or breastfeed? Does the child’s breathing appear
very labored? Is the child tiring?

15. A- Airway & Breathing cont…
• Ask about head & neck trauma
• The most common problem of breathing problems in
children during emergencies is pneumonia.
• Other causes can be anemia, sepsis, shock and
exposure to smoke (inhalational burns)

16. Management of Airway and
Breathing cont.…
• If the child has obstructed airway or is not breathing:
• Open the airway by correctly positioning the head in the ‘sniffing position’
• Remove any foreign bodies or objects/suction (secretions, vomitus…)
• Ventilate with bag & mask
• Oral pharyngeal airways
• Give oxygen in all cases of airway or breathing problems:
• 0.5 to 1 liter/minute (if less than 1 year old)
• 1 to 2 liters /minute (older children)

17. Correct positioning

18. Resuscitation – Step 1 – Airway and
Breathing

19. Effective Bag and Mask Ventilation

20. Circulation
• Does the child have
– cold hands?
– Cap refill >3 seconds
– Present weak/fast pulse or absent
– Pulse slow(<60 beats/min or absent)
• A rapid assessment of conscious level can be done by
AVPU scale
• Quickly evaluate for shock & treat

21. Management of Circulation
• Two large bore IV lines access.
• Start fluid resuscitation and take samples for
investigations
• If the child is shocked & is not severely malnourished:
• Stop any bleeding
• Give oxygen
• Keep the child warm
• Give IV fluids rapidly (20mls/kg bolus RL)

22. Circulation cont…
• If the child is shocked and is severely malnourished:
• Stop any bleeding
• Give oxygen
• Keep the child warm
• Assess if the child can drink oral or be given nasogastric (NGT)
fluids
• Give IV fluids if the child is unable to tolerate oral or NGT fluids
• Give 10mls/kg packed cells or 20mls/kg whole blood. Start urgently,
transfuse over 3-4hrs if severely pale/anaemic

23. .
If not shocked/ after treating shock
• If unable to give oral/NGT fluid- cont. with fluids at
maintenance regimen of 4mls/kg/hr
• If able to introduce oral or NGT fluids:
For 2hrs: give ReSoMal at 10mls/kg/hr
Then: introduce first feed with F75 and alternate ReSoMal
/ F75 each hour at 7.5mls/kg/hr for 10hrs- can increase or
decrease as tolerated btwn 5-10mls/kg/hr
• At 12hrs switch to 3hrly oral/NGT feeds with F75.

24. Use of intra-osseous lines
• Site -Middle of the antero-
medial (flat)
surface of tibia at junction
of upper and
middle thirds
• Use IO or bone marrow
needle 15-18G if available
or 16-21G hypodermic
needle if not available.

25. Management of Coma and Convulsions
(or other abnormal mental status):
• Coma:
• Is the child in coma?
• The level of consciousness can be assessed rapidly by the Glasgow (AVPU)
scale A- Alert, V- Voice, P- Pain, U- Unresponsive
• If the child is unconscious you should:
– Manage the airway & breathing
– Position the child (if there is history of trauma, stabilize neck first)
– Ensure circulation
– Check the blood sugar - Give IV glucose

26. Treatment Of Convulsions
• First 1 month of life - treated with Phenobarbitone 20mg/kg stat, & a further 5-
10mg/kg given within 24 hours.
• If children have up to 2 fits lasting <5 mins they do not require emergency drug
treatment
• Age > 1 month & child convulsing for more than 5 minutes.
1. Ensure safe and check ABC.
2. Start oxygen.
3. Treat both fit and hypoglycaemia:
4. Give iv diazepam 0.3mg/kg slowly over 1
minute, OR rectal diazepam 0.5mg/kg.
5. Check glucose / give 5mls/kg 10% Dext
6. Check ABC when fit stopped
7. Investigate cause if having 3rd convulsion

27. EMERGENCY SIGNS PRIORITY SIGNS NON URGENT
CASES
• Hypothermia (temp<360
C)
• Apnea or gasping
respiration
• Severe respiratory distress
(rate>70, severe retractions,
grunt)
• Central cyanosis
• Shock (cold periphery,
CFT>3secs, weak & fast
pulse)
• Coma, convulsions or
encephalopathy
• Cold stress (temp 36.40C -
360C)
• Respiratory distress
(rate>60, no retractions)
• Tiny neonate (<1800gms)
• Large baby
• Irritable/restless/jittery
• Refusal to feed
• Abdominal distension
• Severe jaundice
• Severe pallor
• Bleeding from any sites
• Major congenital
malformations
• Jaundice
• Transitional stools
• Developmental
peculiarities
• Minor birth trauma
• Posseting
• Superficial infections
• Minor malformations
• All cases not
categorized as
Emergency/Priority

28. Priority Signs (3TPR MOB)
• Tiny infant; any sick child ages <2 months
• Temperature: child is very hot/cold
• Trauma or other urgent surgical condition
• Pallor (severe)
• Poisoning (history of)
• Pain (severe)

29. Priority Signs Cont…
• Respiratory distress
• Restless, continuously irritable or lethargic
• Referral(urgent)
• Malnutrition: visible severe wasting
• Odema of both feet
• Burns (major)

30. .

31. References
• WHO manual of Emergency Triage Assessment
and Treatment (Manual for
participants)
• MOH Basic Paediatric Protocols for ages up to 5
years-Revised 2016 Edition
• www.idocAfrica.org

32. END
thank you
.