Etat

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: Emergency signs - require immediate emergency treatment Priority signs - should be given priority while waiting in the queue so that they can rapidly be assessed & treated without delay 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 Helps to identify children who are very sick & need immediate attention Helps to reduce deaths which, in pediatrics, mostly occur within 24 hours of admission Simplifies the work at a health facility Motivates parents to bring their children to the health facility for management

6. Goals Of Triage Rapidly identify patients with urgent, life threatening conditions Assess/determine the severity & acuity of the presenting problem Direct patients to appropriate treatment areas 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) YES NO NO C O U N S E L I N G

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 C O U N S E L I N G

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 R eSoMal at 10mls/kg/hr Then: introduce first feed with F75 and alternate R eSoMal / 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. Ensure safe and check ABC. Start oxygen . Treat both fit and hypoglycaemia : Give iv diazepam 0.3mg/kg slowly over 1 minute, OR rectal diazepam 0.5mg/kg. Check glucose / give 5mls/kg 10% Dext Check ABC when fit stopped Investigate cause if having 3 rd convulsion

27. EMERGENCY SIGNS PRIORITY SIGNS NON URGENT CASES Hypothermia (temp<36 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 36.4 C - 36 C) 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 D e v e lopm e n t al peculiarities Minor birth trauma Posseting Superficial infections Minor malformations All cases not categorized as E m e r g e nc y /Priority

28. Priority Signs (3TPR MOB) T iny infant; any sick child ages <2 months T emperature: child is very hot/cold T rauma or other urgent surgical condition P allor (severe) P oisoning (history of) P ain (severe)

29. Priority Signs Cont … R espiratory distress R estless, continuously irritable or lethargic R eferral(urgent) M alnutrition: visible severe wasting O dema of both feet B urns (major)

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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 .