Emergency Triage Assessment & ManagementETAT[1].pptx

Emergency Triage Assessment & Management in Malawi

1. ETAT Malawi: Pre-service Training

2. What is ETAT? Emergency Aim to identify sickest children and prevent death Triage Prioritising care of sick children according to need and resources available Assessment & Recognise ABCD emergency signs Treatment Provide systematic ABCD immediate care

3. What is ETAT? Developed by WHO and adapted for Malawi Part of your curriculum at Malawi College of Health Sciences and Malamulo College of Health Sciences Essential training for all healthcare workers who will help sick children Work hard and you will learn how to save lives! Be punctual Attend ALL sessions Turn off phones Complete all course reading

4. ETAT Malawi: Essential Signs

5. Essential Signs Children must be systematically assessed for signs of serious illness using the ABCD approach First, you must be able to recognise the signs of serious illness in children These essential signs will be used throughout the course in emergency triage, assessment and treatment

6. ABCD approach to assessment AIRWAY Does this child have an obstructed airway? Is there weak or absent breathing? BREATHING Does this child have cyanosis or severe respiratory distress? CIRCULATION Does this child have shock? COMA Does this child have signs of reduced conscious level? CONVULSION Is this child having a seizure? DEHYDRATION Does this child have severe dehydration?

7. AIRWAY Does this child have an obstructed airway? Is there weak or absent breathing? Look Is the chest wall rising? Listen Are there breath sounds? Is there noisy breathing? E.g. stridor, snoring Feel Can you feel breath against your cheek?

8. Stridor HARSH, LOW PITCH INSPIRATORY (can be both insp and exp if severe) Narrowing of LARGE airway Common causes of NEW(ACUTE) stridor Croup Foreign body Anaphylaxis Common causes of chronic stridor Laryngeal papilloma Laryngomalacia

9. Stridor - video

10. Obstructed breathing sounds Snoring Low pitched, inspiratory/expiratory Often a sign of airway obstructed by tongue in unconscious patient May improve with airway position or jaw thrust Secretions Bubbling noises May be visible secretions May improve with suction

11. BREATHING Does this child have cyanosis or severe respiratory distress? Cyanosis Signs of severe respiratory distress Very fast breathing Head nodding or accessory muscle use Grunting Severe Indrawing Acidotic/deep breathing Gasping (very worrying sign) Noisy breathing Wheeze (audible or heard with stethoscope) Crackles (usually only heard with stethoscope)

12. Cyanosis Cyanosis occurs when there is a very low level of oxygen in the blood Results in blue/purple discolouration of tongue, inside mouth and skin/nails Central cyanosis is best seen on the gums or tongue (lips unreliable) Not always obvious unless O 2 saturation very low (<80%) May be absent in severe anaemia

13. Respiratory Rate Should ideally be counted over 1 minute Accurate measurement needs timer or watch Normal range varies with age of child Fast Breathing < 12 months >50 breaths/ minute 12 months - 5 years >40 breaths/minute 5 years- 12 years >30 breaths/minute >12 years >20 breaths/minute

14. Head nodding or accessory muscle use Children working hard to breathe will use the muscles in the neck (accessory muscles) In young infants this causes nodding or bobbing movement of the head – this is a sign of severe respiratory distress In older children this can be seen by excess movement of the neck muscles at rest or tracheal tug (central indrawing just above the sternum)

15. Head nodding - video

16. Grunting Grunting is a sign of severe respiratory distress Short, repetitive, expiratory, grunting noise

17. Grunting - video

18. Indrawing Is there indrawing of the lower ribs? This may be mild, moderate or severe Is there indrawing of the sternum? This is a sign of severe respiratory distress

19. Indrawing - video

20. Acidotic/deep breathing Deep sighing breathing is a sign of severe illness in children Often due to acidosis rather than a problem with the lungs– this is a serious complication of shock, severe malaria or severe dehydration After starting oxygen these children should be assessed carefully for signs of shock, severe anaemia or severe dehydration

21. Acidotic breathing - video

22. Gasping Very seriously ill children may have very slow, deep, gasping breathing This type of breathing often occurs just before a respiratory arrest Children who are gasping must be urgently started on oxygen and assessed for other emergency signs such as shock Children with very slow gasping may need support with bag and mask ventilation

23. Gasping - video

24. Noisy breathing Wheeze High pitched expiratory noise May be audible or heard only with stethoscope If severe may be both inspiratory and expiratory Caused by narrowing of SMALL airways Common in young infants with bronchiolitis Common in older children with asthma Crackles (“crepitations”) Sign of lower respiratory tract infection or cardiac failure Usually heard only with a stethoscope It is very important to be able to tell the difference between WHEEZE and STRIDOR Likely underlying diagnoses and management are different

25. Wheeze- video

26. CIRCULATION Does this child have shock? Are the hands cold? Is the pulse weak and fast? Is the capillary refill time > 3 seconds? A child with ANY of these signs has impaired circulation (not an emergency sign) A child with ALL of these signs has SEVERELY IMPAIRED CIRCULATION (also known as SHOCK) which is an emergency sign

27. Capillary Refill Time Is the capillary refill time >3 seconds? Hold for 5 seconds over nailbed or sternum Count time taken for pink colour to return N.B. not reliable in severe anaemia.

28. COMA Does this child have signs of reduced conscious level? A –Is the child ALERT? If not, V –Does the child respond to Voice? If not, P –Does the child respond to Pain? U – Child who is Unresponsive to Voice and Pain Any child with a coma score of ‘P’ or ‘U’ needs emergency treatment for coma

29. How to assess conscious level Response to Voice (only if not alert) Without touching the child, say their name loudly Response to Pain (only if no response to voice) Provoke pain by either sternal rub or squeezing the trapezius First, make sure the child is awake. Do not mistake a sleeping child for a child who is not alert!

30. Coma - video

31. Assessment of coma: Blantyre Coma Scale Eye Movement 1: Watches or follows 0: Fails to watch or follow Best Motor Response 2: Localizes painful stimulus 1: Withdraws limb from painful stimulus 0: No response or inappropriate response Best Verbal Response 2: Cries appropriately with pain, or if verbal, speaks 1: Moan or abnormal cry with pain 0: No vocal response to pain BCS of 3 or less is an EMERGENCY sign

32. CONVULSIONS Is this child having a seizure? Look for abnormal, repetitive movements Uncontrolled jerky movements of limbs Incontinence Unresponsive Twitching or abnormal movements of face/eyes May be subtle, particularly in infants

33. Convulsions - video

34. DEHYDRATION (Severe) Does this child have severe dehydration? SEVERE DEHYDRATION (Emergency Sign) SOME DEHYDRATION (Not an emergency) Diarrhoea plus 2 or more of: Lethargy Sunken eyes Skin pinch ≥ 2secs Unable to drink Diarrhoea plus 2 or more of: Irritable/restless Sunken eyes Skin pinch 1- 2secs Drinks eagerly NO

35. Assessing for dehydration: General condition Is the child lethargic, unconscious or unable to drink/breastfeed? a sign of SEVERE dehydration Is the child restless/irritable? a sign of SOME dehydration

36. Sunken eyes If unsure if eyes are sunken, ask the mother

37. Skin Pinch Locate the area on the child’s abdomen halfway between the umbilicus and side of the abdomen Pinch the skin in a vertical (head to foot) direction and not across the child’s body You should pick up all the layers of the skin and tissue underneath Pinch for one second then release Goes back v.slowly (> 2secs) = SEVERE dehydration Goes back slowly (1-2secs) = SOME dehydration

38. Slow skin pinch - video

39. ABCD approach to assessment AIRWAY Does this child have an obstructed airway? Is there weak or absent breathing? BREATHING Does this child have cyanosis or severe respiratory distress? CIRCULATION Does this child have shock? COMA Does this child have signs of reduced conscious level? CONVULSION Is this child having a seizure? DEHYDRATION Does this child have severe dehydration?

40. ETAT Malawi: Triage

41. Triage Of all children who die in hospital >50% will die in the first 24 hours Some children die while waiting to be seen or due to delays in emergency treatment Triage prioritises care according to need and resources available

42. Triage Categories EMERGENCY PRIORITY NON-URGENT (QUEUE)

43. Who is most likely to die rapidly? Child A? Child B? BEWARE! Child B looks alert but could have signs you can’t see without assessment eg stridor, indrawing, oedema….

44. EMERGENCY SIGNS IRWAY REATHING IRCULATION ONSCIOUSNESS↓ /COMA ONVULSIONS EHYDRATION (SEVERE) A B C C C D

45. EMERGENCY: Airway and Breathing Airway & Breathing Obstructed breathing? Central cyanosis? Severe respiratory distress? Weak or absent breathing? TRIAGE AS EMERGENCY TREAT NOW! YES NO Move on to assess C signs

46. EMERGENCY: Circulation Circulation Cold hands AND Capillary refill >3 seconds AND weak, fast pulse? Slow (<60) or absent pulse? TRIAGE AS EMERGENCY TREAT NOW! YES NO Move on to assess C signs

47. EMERGENCY: Coma or Convulsion AVPU of P or U? BCS of 3 or less? Convulsing? TRIAGE AS EMERGENCY TREAT NOW! YES NO Move on to assess D signs Coma or Convulsion

48. EMERGENCY: Dehydration Severe Dehydration 2 or more of: Lethargy Sunken eyes Skin pinch > 2secs Unable to drink? TRIAGE AS EMERGENCY TREAT NOW! YES NO Not an emergency Move on to PRIORITY signs

49. Circulation Cold Hands AND capillary refill > 3 sec AND weak, fast pulse Slow (<60) or absent pulse Coma or Convulsion AVPU of P or U BCS of 3 or less Convulsing Dehydration 2 or more of: Lethargy, Sunken eyes, Skin pinch > 2 secs, Unable to drink Obstructed breathing Central cyanosis Severe respiratory distress Weak or absent breathing Airway & Breathing EMERGENCY TREAT NOW PRIORITY SIGNS? NO

50. PRIORITY Children with no emergency signs , but who: are more likely to become severely ill or develop complications or are in pain Need to be seen as soon as possible Go to front of queue Can have some treatments while waiting to be seen eg paracetamol

51. Priority signs – 3 TPR MOB Tiny baby: < 2 months old Temperature: very high >39.5 Trauma: major trauma Pallor: severe palmar pallor Poisoning: mother reports poisoning Pain: child in severe pain Restless/Irritable/floppy Respiratory distress Referral: has an urgent referral letter Malnutrition/ marasmus Oedema: of both feet Burns: severe burns Front of queue Clinician to see as soon as possible Weigh, baseline observations YES

52. NON-URGENT (QUEUE) No EMERGENCY signs (ABC 3 D) No PRIORITY signs (3TPR- MOB) NON-URGENT Wait turn in queue If condition changes RE-ASSESS from ABC 3 D

53. TRIAGE PROCESS NO

54. ETAT Malawi: Resuscitation

55. What are the most common causes of collapse/arrest in children? Respiratory Pneumonia Circulatory collapse Dehydration Severe Anaemia Septic Shock (Heart Failure )

56. How to manage the collapsed child CALL FOR HELP

57. Resuscitation: A is for AIRWAY In the unconscious patient the airway is at risk CLEAR the airway Visible obstruction? Sounds of obstruction? Use large bore suction under direct vision POSITION the airway

58. Airway position Use head tilt/chin lift BABY NEUTRAL (NOSE up) OLDER CHILD/ADULT “SNIFFING” (CHIN up)

59. If the airway is still obstructed after positioning….. Consider jaw thrust Consider guedel (oro-pharyngeal) airway You will be shown how to do this in the practical session

60. Resuscitation: A&B B is for BREATHING After airway positioning: LOOK Chest movement? LISTEN Stridor? Secretions? Noises of breathing? FEEL Air movement?

61. Resuscitation: A irway and B reathing LOOK, LISTEN, FEEL for BREATHING OPEN/ CLEAR AIRWAY CHILD IS GASPING or NOT BREATHING CHILD IS BREATHING PROCEED TO RESCUE BREATHS WITH BAG AND MASK CHECK RESPIRATORY EFFORT AND NEED FOR OXYGEN

62. Bag and Mask Ventilation Check bags in good working order regularly and before use Choose correct mask size Ensure good seal around mouth/nose and open airway (may need two people) Squeeze bag slowly and evenly Watch chest rise and allow to fall before giving next breath You will be shown how to do this in the practical session

63. Resuscitation B : Giving Rescue Breaths 5 RESCUE BREATHS WITH BAG AND MASK DEVICE 1 SECOND INSPIRATION, 1 SECOND EXPIRATION WATCH AND MAKE SURE THAT THE CHEST RISES (MUST RISE WELL AT LEAST TWICE) ATTACH OXYGEN TO THE BAG AND MASK DEVICE AS SOON AS POSSIBLE OPEN/ CLEAR AIRWAY LOOK, LISTEN, FEEL for BREATHING CHILD IS GASPING or NOT BREATHING

64. Resuscitation C : Check Large Pulse CHECK LARGE PULSE 5 RESCUE BREATHS WITH BAG AND MASK HEART RATE VERY SLOW (<60 BPM) OR ABSENT HEART RATE ABOUT 60 BPM OR MORE GET HELP PROCEED TO CHEST COMPRESSIONS CONTINUE B&M BREATHING 1-2 MINS WITH OXYGEN (20 BREATHS/MIN) REASSESS

65. Chest compressions Lower 1/3 of sternum Avoid xiphisternum In the MIDLINE Compress the chest by 1/3 its depth You will be shown how to do this in the practical session

66. Resuscitation C: Chest Compressions 5 RESCUE BREATHS WITH BAG AND MASK CHECK LARGE PULSE HEART RATE VERY SLOW (<60 BPM) OR ABSENT CHEST COMPRESSIONS 15 COMPRESSIONS TO EVERY 2 B+M BREATH AIM FOR 6-7 CYCLES OF 15:2 PER MINUTE

67. Resuscitation: Drugs? If cardiac arrest not responding to CPR get IV or IO access and give Adrenaline Take 1ml of Adrenaline 1/1000 solution, add 9 mls of water for injections (total volume 10mls) Give 0.1mls/kg of this solution (1/10,000) IV or IO Can repeat every 4 minutes REMEMBER – good CPR is much more likely to be effective than drugs. NEVER delay CPR to find drugs or get IV access D on’t E ver F orget G lucose – treat if glucose low Consider fluid bolus of saline or Ringers 10mls/kg

68. When to stop resuscitation The decision to stop resuscitation should be made by the most senior healthcare worker present in discussion with the team The decision must be based on Whether there is a likely reversible cause eg hypoxia, hypovolaemia, hypoglycaemia The child’s underlying diagnosis Whether there has been any response to resuscitation As a general rule, if there has been no response to good CPR after 10-15 minutes, resuscitation should stop Prolonged resuscitation is unlikely to result in a good outcome for the child Spending too much time with one child may put other children in the ward at risk, eg child does not get fluids because nurse busy

69. Summary: Resuscitation CALL FOR HELP! A Clear? Position? B Is BVM needed? C Are chest compressions needed? (DRUGS)

70. ETAT Malawi: Airway and Breathing

71. AIRWAY Does this child have an obstructed airway? Is there weak or absent breathing? Look Is the chest wall rising? Listen Are there breath sounds? Is there noisy breathing? E.g. stridor, snoring Feel Can you feel breath against your cheek?

72. Airway position Use head tilt/chin lift BABY NEUTRAL (NOSE up) OLDER CHILD/ADULT “SNIFFING” (CHIN up)

73. If the airway is still obstructed after positioning….. Consider jaw thrust Consider guedel (oro-pharyngeal) airway Consider suctioning You will be shown how to do this in the practical session

74. BREATHING Does this child have cyanosis or severe respiratory distress? Cyanosis Signs of severe respiratory distress Very fast breathing Head nodding or accessory muscle use Grunting Severe Indrawing Acidotic/deep breathing Gasping (very worrying sign) Noisy breathing Wheeze (audible or heard with stethoscope) Crackles (usually only heard with stethoscope)

75. Does this child need oxygen? ANY CHILD WITH: Central cyanosis Grunting Head bobbing/nodding Gasping/Deep/acidotic breathing GIVE OXYGEN ANY CHILD WHO IS NOT ALERT WITH: Very fast breathing Indrawing Wheeze GIVE OXYGEN

76. What if I have a saturation monitor? O2 saturation is useful in prioritising oxygen but think.... Will I be CONTINUOUSLY monitoring sats? If not, what if the child gets worse? Could this child be acidotic? In sepsis and malaria child may have normal sats but could still benefit from extra oxygen Could the sats monitor be wrong? Sats readings can be falsely high in anaemia If in doubt GIVE OXYGEN

77. Oxygen delivery Maximum flow 5l/min Maximum flow 15l/min Oxygen concentrator Oxygen cylinder Shared Oxygen Concentrator Maximum flow 0.5-2l/min

78. Is this a good place? Oxygen Delivery – Sharing Oxygen Use a splitter if available Regulator attaches to O2 concentrator Each port is labelled with the flow rate REMEMBER this is the MAXIMUM flow Turning up the flow on the concentrator will NOT increase oxygen to the child If there is no splitter O2 can still be shared by dividing nasal prongs or other tubing The child who breathes more strongly will get more O2 Not ideal but better than no O2 at all Turning up the flow rate on the concentrator WILL increase oxygen given Oxygen concentrators need: Regular maintenance To be kept free from dust –clean filter To be in a safe and stable place

79. Oxygen delivery Nasal prongs Keep clear, secure with tape Use correct size or cut to fit Gives 30-35% 0xygen Nasal catheter 6-8 FG tubing Insert to a distance= to nostril to inner eyebrow Should not be visible below uvula Avoid in pertussis or croup Gives 40-60% oxygen For both flow rate: 0.5-1l/min infants 1-2 l/min older child

80. Oxygen Delivery: Face Masks Simple face masks Need MINIMUM flow 5l/min (risk of CO2 toxicity if less) Oxygen 30-50% Only use if 1 patient/oxygen concentrator and flow is 5l/min Face mask with bag (rebreather) Need enough flow to fill bag to work (10-15l/min) Oxygen 70-100% Do not use with oxygen concentrator

81. Common oxygen mistakes Only giving oxygen if child blue or O2 saturation low Assuming face masks are always better Using face masks when only low flow 02 available Nasal prongs too small, too big or upside down Poorly maintained equipment ‘Turning up oxygen’ when a splitter is in the circuit (does not increase flow to child) Leaks and disconnects in ‘octopus’ 3-way tap oxygen sharing systems THINK! Am I delivering oxygen in the most efficient way possible with the equipment available?

82. What is the underlying cause of Respiratory Distress Lung/Airway Disease Pneumonia Asthma Croup Epiglottitis TB Systemic disease Malaria Severe Anaemia Sepsis Cardiac Failure Severe Dehydration

83. Assessment and Management of Pneumonia (WHO) Admit, Give O2 and IV antibiotics. Oral Amoxicillin for 5 days. Community care. Child with cough Severe respiratory distress or Cyanosis / O2 sats < 90% or Reduced conscious level or Shock Chest indrawing Fast Breathing Severe Pneumonia Pneumonia Fast Breathing < 12 months >50 12 months - 5 years >40 5 years- 12 years >30 >12 years >20 Yes Yes Yes No

84. MILD No respiratory distress Feeding well O2 sats > 92% MODERATE Respiratory distress Feeding well O2 sats > 92% SEVERE Severe respiratory distress Respiratory rate > 30 if > 5 yrs, > 50 if 2-5 years Too breathless to talk / feed O2 sats < 92 % IMMINENT ARREST Poor respiratory effort Altered conscious level Exhausted Cyanosis Silent chest ACUTE ASTHMA ATTACK: ASSESSMENT OF SEVERITY

85. Management of Acute Asthma ASSESS ABC and ASTHMA SEVERITY SEVERE ASTHMA IMMINENT ARREST OXYGEN SALBUTAMOL 2.5mg (under 5 years) or 5mg (over 5 years) x3 over 1 hour Or 8-10 puffs x 100mcg x3 via spacer over 1 hour STEROIDS (other drugs) MILD ASTHMA MODERATE ASTHMA CONSIDER OXYGEN SALBUTAMOL 2.5MG (under 5 years) or 5mg (over 5 years) Or 4-8 puffs via spacer once and reassess Can continue 1-4 hourly as required STEROIDS

86. Spacers Can be used at home Simple to make and maintain Do not need electricity Can stay on (nasal prong) oxygen during treatment Need to use correct technique Need to adapt for infants Bottle spacers are as effective as manufactured spacers Nebulisers Machines need maintenance Require electricity Air driven nebulisers mean patient off O2 for long period Useful for patient who is too young or too exhausted to use spacer correctly Useful if inhalers are in short supply If used correctly both deliver the same amount of salbutamol

87. Multi-dosing spacer technique Shake inhaler BEFORE EACH PUFF Allow 5-6 breaths for EACH PUFF Do not spray more than 1 puff at a time Ensure child is breathing through mouth Ensure good seal Usually takes 5 minutes for 10 puffs Keep spacer dry – only clean if very dirty! Consider spacer for all patients with asthma (even adults!)

88. Treat the underlying cause: Other causes- Lung / Airway Disease

89. Treat the underlying cause: Other causes- Systemic Causes

90. Summary There are many causes of respiratory distress More than one cause may be present in the same child It is not necessary to know the cause to start immediate treatment with OXYGEN Start with immediate assessment and emergency treatment of airway and breathing, then move on to assess C and D

91. ETAT Malawi: Fluid management in Impaired Circulation and Dehydration

92. CIRCULATION Does this child have shock? Are the hands cold? Is the pulse weak and fast? Is the capillary refill time > 3 seconds? A child with ANY of these signs has impaired circulation (not an emergency sign) A child with ALL 3 of these signs has SEVERELY IMPAIRED CIRCULATION (also known as SHOCK) which is an emergency sign

93. DEHYDRATION (Severe) Does this child have severe dehydration? SEVERE DEHYDRATION (Emergency Sign) SOME DEHYDRATION (Not an emergency) Diarrhoea plus 2 or more of: Lethargy Sunken eyes Skin pinch ≥ 2secs Unable to drink Diarrhoea plus 2 or more of: Sunken eyes Skin pinch 1- 2secs Irritable/restless Drinks eagerly NO

94. Deciding how to manage shock Before treating shock / severely impaired circulation or severe dehydration we must know: Is the child severely malnourished? Is the child anaemic? Is there severe infection? Is there severe trauma (is there acute blood loss)? WHY? Because treatment depends on knowing these

95. Fluid Guideline 1: Severe Malnutrition YES Does this child have severe malnutrition ? NO Fluid Guideline 2: Severe Dehydration (no malnutrition) YES Is there severe dehydration? Fluid Guideline 3: Shock with Severe Anaemia YES Is there severe anaemia ? NO Fluid Guideline 4: Shock due to Severe Infection YES Is there severe infection ? NO Fluid Guideline 5: Shock due to Severe Trauma YES Is there severe trauma ? NO Child with Shock or Severe Dehydration

96. IV Fluids Ringer’s Lactate Good for restoring circulation, correcting acidosis and replacing K+ First choice for SHOCK or SEVERE DEHYDRATION 0.9% Saline Good for restoring circulation Freely available, safe when given rapidly Can be used for SHOCK Blood First choice for SEVERE ANAEMIA and TRAUMA May be necessary if child has had >3 saline boluses with no improvement AVOID Low sodium fluids (eg ½ strength darrows) - unless there is severe malnutrition 5 or 10% dextrose only Ineffective and unsafe in management of impaired circulation as rapidly shifts out of intravascular space NEVER use for fluid resuscitation

97. FLUID MANAGEMENT IN SEVERE MALNUTRITION

98. Signs of Severe Malnutrition It is very important that severe malnutrition is recognised Severe malnutrition needs urgent nutritional management Children with severe malnutrition are also at high risk of death from other serious illnesses such as sepsis or diarrhoea Children with severe malnutrition with shock or dehydration need very different, and very careful fluid management

99. Visible severe wasting

100. Oedema (Kwashiorkor)

101. Fluid Management in Severe Malnutrition Why are malnourished children different? Low energy reserves High risk hypoglycaemia High risk hypothermia High risk of infection High risk of electrolyte abnormalities High risk of heart failure High risk of death Difficult to assess

102. Rehydration fluids in severe malnutrition Total body sodium is usually high and potassium and magnesium low Too much salt can make oedema/ heart failure worse PO / NGT fluids are best, if the child can tolerate them ReSoMal is recommended rather than ORS Half the sodium Twice the potassium A little more glucose Added magnesium Ringer’s Lactate with 5% dextrose is recommended for IV rehydration if they cannot tolerate oral / NG fluids ½ strength darrow’s with 5% dextrose is the ideal fluid, but is often unavailable.

103. What if I don’t have these fluids for a child with malnutrition? ReSoMal can be made from ORS

104. Is the child conscious and able to tolerate oral/NG feeds? YES YES Does the child have severely impaired circulation (shock)? Give 15mls/kg RL with 5% dextrose over 1 hour NO RR and HR↑ (gets worse) ?Septic shock? Fluid Guideline 1: Severe Malnutrition With Severe Dehydration or Severely Impaired Circulation (shock) Give ReSoMal PO/ NGT 5-10ml/kg/h for 4-10 h Aim to re-introduce F75 feeds after 4h (increase to full feeds by 12h) RR and HR↓ (improves) NO, but has Severe Dehydration NO IV FLUIDS Give ReSoMal PO/NGT 5mls/kg every 30 mins for first 2h Give blood 10mls/kg over 3 h Give maintenance fluids of 4mls/kg/h until blood arrives

105. FLUID MANAGEMENT IN DEHYDRATION

106. Fluid Guideline 2: SEVERE DEHYDRATION (no malnutrition) +/- Shock Severe Dehydration (+/- Signs of Impaired Circulation) Give 30mls/kg RL / NS Over 1 hour if <12m Over 30mins if >12m Give 70mls/kg RL / NS Over 5 hours ( if under 12m) Over 2.5 hours (if over 12m) REASSESS IMPROVING? “Plan C”

107. Ongoing management Once child is improving (usually after 1-2 hours in kids or 3-4 in infants) and able to drink encourage ORS/breastfeeding in addition to IV fluids On completion of deficit correction (100mls/kg over 3 or 6 hours) REASSESS Child not improved Think about ongoing losses Think about alternative diagnosis ?surgical ?DKA Repeat deficit correction Child improving If drinking well stop IV and continue ORS If not drinking/persistent vomiting continue IV maintenance but remember to add ongoing losses Maintenance should ideally be with high sodium fluids (with added dextrose)

108. Treatment of ‘Some dehydration’ Oral rehydration is equally effective (and may be safer) than IV rehydration Aim for 75mls/kg ORS over 4 hours If rate of drinking is not adequate ORS can be given via NG tube Use cup/ bottle or spoon measures to explain target volume to parents 300mls 300mls 200mls

109. Fluid Guideline 3: Shock with Severe Anaemia Give oxygen Get IV or IO access Order BLOOD urgently Give maintenance fluids while waiting for blood Give 10mls/kg Packed Red Cells or 20mls/kg Whole Blood over 4 hours

110. Fluid Guideline 4: Shock due to Severe Infection Child stable but signs of shock not improving Child getting worse THINK ?Fluid overload? ?Anaemia? Consider blood or slowing fluid down Consider CPAP Give Oxygen Get IV/IO access Give 10mls/kg RL / NS slowly over 1 hour Closely monitor HR, RR, CRT, BCS Child improves Maintenance Fluids RL / NS with 5% dextrose Repeat 10mls/kg RL / NS over 1 hour If still not improved after 4 x 10 ml/kg RL / NS give blood 20mls/kg over 1 h

111. In all children with signs of shock and infection Always treat any reversible cause Check blood glucose Give oxygen Give antibiotics Look for and treat severe malaria Think about uncommon causes of shock Cardiac tamponade (pericardial effusion) Cardiac failure from congenital heart disease Tension pneumothorax Diabetic Ketoacidosis

112. Fluid Guideline 5: Shock due to Trauma Stop any serious external bleeding Give oxygen Get IV or IO access Call for help (Anaesthetist+ Surgeon) Order BLOOD urgently Give 10mls/kg NS / RL over 20 minutes IMPROVING NOT IMPROVING Give maintenance fluids while waiting for urgent surgical review Repeat 10mls/kg NS / RL over 20 mins Give max 4 NS / RL boluses (40mls/kg) if no blood available As soon as blood arrives Give Blood 10mls/kg over 20mins Continue repeating until improved Not improved still NO blood

113. Fluid management of Impaired Circulation Children with some but not all of the circulation danger signs may have impaired circulation The FEAST trial showed that giving fluid boluses to these children was harmful Unless there are signs of severe dehydration, these children should be started on maintenance IV fluid (5% dextrose+ Normal saline / Ringers Lactate) determined by weight 100mls/kg/day (4mls/kg/hour) for the 1 st 10kg 50mls/kg/day (2mls/kg/hour) for the 2 nd 10kg 20mls/kg/day (1mls/kg/hour) for each kg after 6kg baby = 600ml/day, 24 mls/h 18kg baby = 1000+400= 1400ml/day, 40+16 = 56ml/h 25 kg child = 1000+500+100 = 1600 ml/day = 40+20+5 =65ml/h

114. THINK – What is best for this child? If the circulation signs (HR, CRT) are not improving think Is this child dehydrated? Do I need to give fluids faster? Is this child cold? Can I warm them? If the respiratory rate is worsening think Does this child have signs of pulmonary oedema? If so, slow fluids down and reassess If the Blantyre Coma Score is worsening think Check blood glucose again – correct if low Does this child have signs of raised intra-cranial pressure? Can I check the sodium? If concerns slow fluids down and reassess

115. Remember... Children with signs of shock have a high mortality and need careful management to survive Close monitoring is key Continue to monitor closely for minimum 48 hours after admission

116. ETAT Malawi: Coma and altered consciousness

117. COMA Does this child have signs of reduced conscious level? A –Is the child ALERT? If not, V –Does the child respond to Voice? If not, P –Does the child respond to Pain? U – Child who is Unresponsive to Voice and Pain Any child with a coma score of ‘P’ or ‘U’ needs emergency treatment for coma

118. Assessment of coma: Blantyre Coma Scale Eye Movement 1: Watches or follows 0: Fails to watch or follow Best Motor Response 2: Localizes painful stimulus 1: Withdraws limb from painful stimulus 0: No response or inappropriate response Best Verbal Response 2: Cries appropriately with pain, or if verbal, speaks 1: Moan or abnormal cry with pain 0: No vocal response to pain BCS of 3 or less is an EMERGENCY sign

119. Which score should I use? AVPU Simple Quick Broad categories, less useful in monitoring change over time Good for: Triage Blantyre Coma Scale More complicated Quick More detailed scoring, better for monitoring changes over time Good for: cerebral malaria, meningitis, head injury.

120. Management of Coma Manage the airway Position the child Recovery position Immobilise and log-roll if neck trauma Check blood sugar Give IV glucose Identify and treat cause

121. Don’t Ever Forget Glucose! Hypoglycaemia is common Present in 1 in 12 children admitted to hospital 7-30% children with severe malaria Hypoglycaemia is serious Associated with up to 5x increased risk of death Associated with long-term brain damage Hypoglycaemia is hard to spot clinically No consistently reliable symptoms Ideally should check glucose in all sick kids

122. Hypoglycaemia Treat blood glucose <2.5mmol/l (45 mg/dL) or <3mmol/l (54 mg/dL) in a malnourished child If child alert and able to drink treat with immediate high carbohydrate feed If child lethargic or convulsing treat IV Give 5mls/kg 10% dextrose Recheck glucose after 30 mins – if still low repeat Feed as soon as conscious If unable to feed give: Maintenance IV fluid containing 5-10% dextrose OR Milk or sugar solution via NG ( =4 tsp sugar in 1 cup water)

123. How to make 10% dextrose

124. How to make 10% dextrose

125. The febrile child with altered consciousness or neurological signs Cerebral Malaria Other Meningitis (viral, fungal, TB) Acute Bacterial Meningitis Encephalitis Cerebral Abscess Any severe illness causing respiratory or circulatory failure Tetanus

126. Should I do an LP? If you want to avoid deaths and disability from meningitis AND Avoid wasting antibiotics Consider LP in any child with fever and at least 1 of: Bulging fontanelle Seizures, especially if <6 months or > 6 years old Partial seizures Neck stiffness Altered consciousness AVPU <A

127. Remember.... 50% dextrose is no longer recommended Concerns about safety and rebound hypoglycaemia Always re-check the glucose to check bolus has been effective Bolus causes sudden rise, followed by fall (rebound hypoglycaemia) Always make sure child is encouraged to feed if able Consider nasogastric feeds or maintenance fluid with dextrose if child unable to feed

128. Summary: Management of altered consciousness Manage airway Place in appropriate position (recovery or log roll in neck trauma) Check blood glucose and treat hypoglycaemia Give maintenance dextrose once hypoglycaemia treated Identify and treat underlying cause ?bacterial meningitis – consider LP ?cerebral malaria - check blood film Other severe malaria or severe infection?

129. ETAT Malawi: Convulsions

130. CONVULSIONS Is this child having a seizure? Look for abnormal, repetitive movements Uncontrolled jerky movements of limbs Incontinence Unresponsive Twitching or abnormal movements of face/eyes May be subtle, particularly in infants

131. Managing the airway in seizures Can be difficult Move the child from danger eg away from walls If possible turn child’s head/body to side Be ready with suction for secretions/vomit Give oxygen After seizure stops put in recovery position and manage airway as for coma NEVER Put anything inside the child’s mouth Try to ‘hold’ the tongue Force the child’s head into a position against a spasm

132. SEIZURE (child >1 month) Diazepam* 0.3mg/kg IV Diazepam* 0.5mg/kg PR Diazepam 0.5mg/kg PR NO Check BLOOD GLUCOSE GIVE IV 10% Dextrose 5mls/kg LOW WAIT 10 MINUTES Phenobarbitone 20mg/kg IM (or IV over 20minutes) WAIT 10 MINUTES IV ACCESS? Diazepam 0.3mg/kg IV YES NORMAL *or Paraldehyde 0.4mls/kg PR

133. Anticonvulsants Both Diazepam and Phenobarbitone can cause respiratory depression–even at the correct dose Be very careful to give correct dose (by weight) Wait a MINIMUM 5 minutes between doses Be ready with bag and mask to support breathing NEVER GIVE DIAZEPAM IM Absorption is slow and unreliable Give PR if no IV access NEVER GIVE PHENOBARBITONE AS A FAST IV BOLUS Maximum IV infusion rate 1mg/kg/minute IM effective and safer NEVER GIVE PARALDEHYDE IV, ALWAYS GIVE PR Can be given IM but is painful and causes sterile abscesses Should be diluted in oil or saline Paraldehyde melts plastic! Give rapidly and store in glass vial

134. How to give rectal diazepam If dose <1ml can use 1ml syringe directly – insert almost all of barrel of syringe into the rectum For doses >1ml, or if no 1 ml syringes use a cut-off NG or butterfly tubing. Attach to syringe – remember to draw up extra drug to make up for space lost in tubing Flush tubing with drug – expel excess drug until amount in syringe is dose required Insert tubing into rectum and deliver drug Purpose-made rectal preparations with applicator available – but be careful of dose (only come in 5mg or 10mg)

135. Management of seizures Give oxygen and open/clear the airway DON’T EVER FORGET GLUCOSE Give diazepam 0.3mg/kg IV or 0.5mg/kg PR Repeat after 10 minutes if seizure continues (or give Paraldehyde 0.4mls/kg PR) If seizure continues >10 minutes after 2nd dose diazepam (or after Paraldehyde) Give Phenobarbitone 20mg/kg IM loading dose

136. ETAT Malawi: Trauma

137. Why is trauma important? 5.8 million injury deaths per year worldwide Common causes RTA, burns, falls, drowning For children aged 5-14 years, RTA is the second commonest cause of death, drowning is the 4 th most common In trauma for every 1 death there will be 4 permanent disabilities 100 temporary disabilities

138. Trauma in Malawi Malawi has the third highest number of RTA deaths/motor vehicles in Africa (193.2/10,000 vehicles) RTA are increasing High rates of burns due to open cooking fires

139. Children are NOT little adults…. Differ in: Size Shape Surface Area Skeleton Psychology Subsequent Growth

140. Why is trauma in children different? Size Force from a fall or RTA is more dispersed Large organs are close to each other Leads to MULTISYSTEM INJURY Shape Relative large heads, short limbs, small chest, large abdomen When hit by force usually tossed in the air Leads to ADDITIONAL INJURIES Surface Area Smaller child= greater surface area Leads to HEAT LOSS and THERMAL STRESS Skeleton Bones are more compliant – may bend but not break Can lead to severe underlying soft tissue injuries despite no obvious rib fracture High incidence of BONY INJURIES – look carefully at head, pelvis, limbs

141. Why is trauma in children different? Psychology Children do not understand why you are doing something (injections, stabilising the neck) May be frightened, think they have been naughty Even macho teenagers revert to child behaviour when in pain and frightened Be understanding. Explain. Talk to the child.

142. Why is trauma in children different? Subsequent sequelae Damage to growing bones may lead to permanent deformity Psychological harm may lead to fear and withdrawal Nasty scars, especially facial, cause adolescent anguish We must manage life threatening problems, but we must not neglect the lesser injuries

143. Structured approach to trauma Primary Survey Identifying life threatening conditions Resuscitation Dealing with life threatening conditions Post-Resuscitation Review pain, insert NGT, history Secondary Survey Thorough exam to make sure no injuries missed Definitive Care

144. Primary Survey: ABCD of Trauma A IRWAY Is the airway obstructed? Noisy breathing? Is there blood in the mouth/nose? B REATHING Is the chest moving? Both sides? Paradoxical? Is there cyanosis or respiratory distress? C IRCULATION Is there obvious bleeding? If so – stop by compression Are there signs of impaired circulation? D ISABILITY (neurological) AVPU? Convulsions? Lateralising signs (may suggest severe head injury): Pupils – equal and reactive? Posture – decerebrate/decorticate? Movement of all 4 limbs?

145. Trauma Resuscitation: A IRWAY In managing airway in trauma need to consider injury to cervical spine Stabilise C-Spine with hands or with collar or bags If suspected C-Spine injury, correct airway position is NEUTRAL with jaw thrust or guedel airway if necessary to maintain airway in unconscious patients Give high flow O2 Clear any secretions (vomit/blood) If airway completely obstructed even with positioning need anaesthetic/surgical support for consideration of intubation or cricothyroidotomy. These procedures should only be performed by skilled staff

146. Resuscitation: B reathing Give O2. Support breathing with bag and mask if shallow/slow If not improving consider life-threatening breathing problems Tension pneumothorax Haemopneumothorax Sucking chest wound Cardiac Tamponade Flail Chest Lung contusion/ Cardiac contusion

147. Life Threatening Breathing Problems Tension Pneumothorax No air entry on one side & same side is hyperresonant on percussion Place needle in 2 nd intercostal space, midclavicular line to release air Then place an underwater sealed chest drain in 5 th intercostal space, mid-axillary line. ALWAYS have an IV in situ first Haemopneumothorax Reduced movement and air entry on affected side Insert a chest drain. ALWAYS have an IV in situ first Likely to require urgent blood transfusion

148. Life Threatening Breathing Problems These problems are rare and require urgent expert care: Sucking wound (Open Pneumothorax) Cover with airtight dressing Insert chest drain Cardiac tamponade Quiet heart sounds, weak pulses, distended neck veins Needs pericardiocentesis Flail chest Fractured segment of chest moving against respiration Needs intubation and ventilation if possible

149. Resuscitation: C irculation (Fluid Guideline 5) Stop any serious external bleeding Give oxygen Get IV or IO access Call for help (Anaesthetist+ Surgeon) Order BLOOD urgently Give 10mls/kg NS / RL over 20 minutes IMPROVING NOT IMPROVING Give maintenance fluids while waiting for urgent surgical review Repeat 10mls/kg NS / RL over 20 mins Give max 4 NS / RL boluses (40mls/kg) if no blood available As soon as blood arrives Give Blood 10mls/kg over 20mins Continue repeating until improved Not improved still NO blood

150. Life Threatening Circulation Problems If circulation not improving consider hidden blood loss ?Splenic or liver rupture ?hollow viscus injury ?pelvic fracture Look for Signs of injury to trunk (tyre marks, bruises) Abdominal distension, tenderness, guarding Absent bowel sounds Haematuria

151. Resuscitation: D isability Identify life-threatening neurological problems Intracranial bleed Lateralising signs Severe brain injury – contusion/ axonal injury Treat pain and seizures adequately Treat shock then keep fluids at maintenance If possible nurse with head at 15 degrees Call for help from SURGICAL TEAM, consider REFERRAL to a centre with ITU/Neurosurgery

152. Post Resuscitation Is the child stable? If not reassess ABCD and resuscitate If stable Ensure good pain control Place an NGT on free drainage (stomach dilates after injury). Use OGT if suspect basal skull fracture Review brief history (AMPLE) Allergies – to drugs etc Medication – any chronic medication? Past medical history Last meal (may need theatre) Event (What happened?) Mechanism of injury, blood loss at scene, state of vehicle, any others injured?, treatment before arrival Involve and explain to family

153. Secondary Survey Top to toe examination including logroll Head Feel/look in hair for bleeding, depression, swelling Look in ears for bleeding/CSF leaks (basal skull#) Face Bleeding from nose/mouth CSF from nose/ears Missing/loose teeth Check mandible/midface/mouth for movement ?# Check eyes for movement/depression/protrusion Check pupils for size/reaction

154. Secondary Survey Top to toe examination including logroll Neck Signs of possible fracture Tenderness over the spine? Swelling/bruising of the neck? Abnormal position? If present keep spine immobilised, need lateral neck XR Subcutaneous emphysema (ruptured lung) Clavicles ?Tenderness ? Swelling on the bone (?#)

155. Secondary Survey Top to toe examination including logroll Chest Is there pain on “springing” the chest wall (?#ribs) Is there equal chest movement On auscultation is air entry good and equal? ?pneumothorax/haemothorax Are heart sound loud and clear? Cardiac tamponade? Abdomen Any external injuries? Any sign of internal injury? (Distension, tenderness, guarding, absent bowel sounds) Consider catherisation (unless bladder injury suspected)

156. Secondary Survey Top to toe examination including logroll Pelvis “Spring” the pelvis to look for # Limbs Careful exam for injury Swelling Crepitations Displacement Function Now do a log-roll to look for injuries to the back Order any x-rays needed

157. Definitive Care Call for help EARLY. Consider what skills/facilities available in your setting May require transfer once stabilised for definitive care If transferring, call the referral centre to let them know in advance Ensure good pain relief and stable before transfer Consider pain relief and medications/fluids required during transfer if journey will be long Ideally transfer with a trained healthcare worker who assess and treat any problems on the way

158. Burns Main problems Fluid loss Pain Infection Need to estimate severity by surface area affected using Rule of Nines Relative surface area changes with age but palm=1% ≥5% burns must be admitted Look for burnt hair or soot in nostrils. If admit and observe closely for inhalational burns which may compromise airway Rule of Nines in Children (slightly different from adults as legs are smaller)

159. Burns-severity

160. Burns: Fluid Management MILD <10% Give oral fluids ORS +++ MODERATE/SEVERE ≥10% Give IV fluids 3mls/kg x % SA burned +normal maintenance Give half in the first 8 hours, then the rest in the next 16 hours Use Ringer’s Lactate or normal saline with 5% dextrose. Avoid giving extra potassium Reassess, infants may need more fluids

161. Burns: Supportive Care Ensure good pain relief (regular paracetamol plus pethidine, oral morphine), particularly during dressing changes Dress partial/full thickness burns with clean, non adherent dressings. Specialist antimicrobial dressings may also be used Observe and treat (with Xpen and Gent) if any signs of infection. Do not give prophylactic antibiotics Give tetanus immunisation Weigh the patient on admission and ensure good nutrition Involve physiotherapy early if burns near joints Check Hb and PCV regularly

162. Structured approach to trauma Primary Survey Identifying life threatening conditions Resuscitation Dealing with life threatening conditions Post-Resuscitation Review pain, insert NGT, history Secondary Survey Thorough exam to make sure no injuries missed Definitive Care

163. ETAT Malawi: Pre-service Training