EMERGENCY TRIAGE ASSESMENT

& TREATMENT plus admission

ETAT+

Dr. Edel Karau

Introduction to ETAT+
Evidence based care in the first 24
hours for sick children needing
admission to hospital
Why do we need this
training?
Would you give this
child a High Protein
Diet?

Would you resuscitate this baby with

oxygen immediately?
 Clinical Medicine Changes
Many old
practices are
wrong
Many health
workers have
only 10 weeks
of paediatric
There are 100,000s of
training new medical research
findings every year.
Quality Care?
Training designed to introduce most up
to date approaches to providing high
quality care
Improve safety - Drug errors, some life-
threatening, are still common
Even simple resources, used correctly,
can save lives
Where did the training come
from?
The best research evidence
GoK, KEMRI, Universities, Kenya
Paediatric Association
2010 Child Health Evidence Week
2013 Guideline Panels
2014 Guideline Panel
2015 Guideline Panels
World Health Organisation
Evidence Based Pocketbook of
Hospital Care
This Course serves as an
Inpatient IMCI
Guidelines consistent
with OP IMNCI and
EmONC etc
Up to date
Concentrate on
management of the
very sick / referred
child & newborn
Used in Kenya,
Uganda, and
Rwanda, Somaliland
Zimbabwe, Sierra
Leone, Myanmar
Job Aides
Your ABCDs
We will teach FOUR ABCs in this
course
An ABCD for triage
An ABC for infant / child life
support
An ABCD to guide the provision of
emergency care when there are
signs of life
An ABC for newborn
resuscitation
Essential Clinical
Symptoms and Signs
The Most Useful Symptoms
and Signs
Observed commonly in common
illnesses
Help assessment of nature and severity
of illness
Indicate risk of death
Useful for monitoring progress
Differentiate diseases
Easy for everyone to observe and learn
Symptoms 1 Why is it important
to document the
5 duration of fever?
3
of cough?

5
Cough for more than
TWO weeks is not acute
pneumonia

Why is history of contact

with TB /chronic cough
important.
What does contact mean?
Why last 12 months?
Symptoms 2
Why do we need to ask
whether there is diarrhoea
>14 days or whether it is
bloody?

Vomiting everything
means no oral
medicines and is a
danger sign

Convulsion >1 or
Partial convulsions
2 suggest meningitis a
danger sign. Requires
LP
Airway and Breathing Signs
Airway
Stridor (inspiratory)
Noisy/Gurgling Breathing

Breathing adequacy
Respiratory Rate Counted for 1 minute in a calm
child!
Oxygen saturation (pulse oximetry)
Central cyanosis
Head nodding
Grunting
Indrawing
Acidotic / deep breathing
Wheeze / crackles
Central Cyanosis
Gums / Tongue
NOT fingers
Lips unreliable
Problem detecting
cyanosis if the child
has severe anaemia
Lower Chest Wall Indrawing
Deep/Acidotic
Breathing
Pulse Oxymetry
Saturati
on <90%
give
oxygen
Signs 2 Circulation and Dehydration

Pulse
Weak (or absent)
Rate
Capillary Refill Time
Capillary Refill in Immediate Newborn Period

Assess centrally over sternum

Normal range 1 to 3 secs
Abnormal begins at 4 secs and longer
Palor
Sunken Eyes
Skin Pinch
Disability
AVPU Scale
A = Alert
V = Responds to a voice / sound
appropriately
P = Responds appropriately to pain
U = Unresponsive / Unconscious
Alert?
Responds to Voice?
Responds to Pain?
Ability to Drink / Breastfeed?
Bulging Fontanelle and Stiff neck

Fontanelle should be examined with the infant lying

down at rest (i.e. not crying)
Bulging Fontanelle and Stiff neck
Fontanelle should be examined with the infant lying
down at rest (i.e. not crying)
General Condition and
Nutrition
Jaundice
Oedema
Mid Upper Arm Circumference
MUAC is the recommended
measure for assessing nutritional
status in children
aged 6 59 months
MUAC is a single linear
measurement that does not
require arithmetic, table look-up
or plotting data on growth charts
A colour-coded tape is used to
determine the level of severity of
malnutrition
Length Measurement
Children up to 87
cm (or <2 years)
are measured
while lying down
Classification of
nutritional status
based on WHZ
score is used in
infants <6 months
Definitions of Malnutrition
MUAC cm WHZ
(6-59 months) (<6months)

None >13.5 >-1

At Risk 12.5 to 13.4 -2 to -1

Moderate 11.5 to 12.4 -3 to -2

<11.5 <-3
Severe
Oedema of severe malnutrition
 Simple symptoms and signs will
help guide basic treatment in 80-
90% of children admitted.
A common approach to interpreting
clinical signs helps clinical
communication.
Always be on the look out for
additional important signs
Triage
Why Triage?
Why Triage
Some children will
die waiting to be
seen

Of all the children

dying in hospital
>50% will die
within
24 hours.
Who is likely to die most
rapidly?

A B
Triage
Needs Emergency Care
Airway
Breathing (Oxygen)
Circulation
Consciousness reduced
Convulsions
Dehydration - severe
Triage
Emergency Care

TPR
3 Ts
3 Ps
3 Rs
MOB
Triage

Emergency Care

Priority Care

Non-urgent - Queue
Who can do triage?
Who can do triage?

Anyone
Doctor
Nurse
Cleaner
Askari
Records Clerk
Simple tool - Used in Malawi
and deaths of children were
reduced.
Emergency Signs - ABCD
Emergency Signs - ABCD

TRIAGE ACTION
Immediate Action
Take to
emergency area
Clinician / Nurse
sees NOW
Priority Signs 3TPR-MOB

TRIAGE
ACTION
Take the Vitals
Weigh the
Infant
Position at the
front of the
Queue
Triage
 Triage is sorting ONLY
Diagnosis or Treatment are not the
responsibility of the person doing
triage
In a busy department it is a
continuous / frequent process
Departments need to be organised
so that emergencies and priorities
can be appropriately handled
Life Support in
Infants and Children
Objective

To describe the structured approach of life

support for infants and children
Emergency care in Hospital.

What is the most important factor in success?

Being prepared.
Who is responsible?
Who comprises the team? Specific roles?
How are they alerted?
Where will Life Support take place?
Special area or Bedside?
Equipment?
Responsibility?
Knowledge & Skills/Competence (guidelines)?
Training and Orientation?
Provision of emergency care in Hospital.

What is the most important factor in

saving lives?
Prevention early recognition of very
severe illness and appropriate timely
action so that children do not collapse.
What are the most common causes of
collapse / arrest in children?

Respiratory failure
Pneumonia
Circulatory failure
Severe anaemia
Dehydration
Septic shock.
(Pump failure adults and children with
CHD)
The collapsed child - A structured approach

Safe, Stimulate, Shout, Setting

Airway
Breathing
Circulation
Resuscitation A - Airway
Is the airway clear
and safe?
At risk?
Obstructed?
Look in the mouth
Vomit?
Secretions?
Position the airway

The picture shows the neutral position in an

infant
If there is an airway problem
ACT!
Call for help
Suction?
Airway opening
manoeuvres?
Oropharyngeal
airways?
Resuscitation A & B is there any breathing?

After
positioning
Look
Chest
movement?
Listen
Stridor?
Secretions?
Noises of
breathing?
Feel
Air movement?
Resuscitation Step 1 Airway and Breathing

Open / Clear the AIRWAY:

Look / Listen / Feel for
BREATHING
Child is breathing

Check adequacy of breathing

and need for oxygen.

Proceed to rescue breaths with

bag and mask
Choosing the right size of Bag and
Mask
Resuscitation B Giving Rescue
Breaths
Open / Clear the AIRWAY:
Look / Listen / Feel for
BREATHING
Child IS NOT breathing Or only
gasping
5 rescue breaths with Bag and Mask device
1 second inspiration, 1 second expiration
Watch and make sure the chest rises
Attach oxygen to BVM device as soon as possible

The chest must rise well at least twice.

 Resuscitation C Check for signs
of life
5 Rescue breaths with Bag and Mask
device

Check for Signs of Life PLUS Large Pulse

Heart Heart Rate about 60 bpm

Rate or more
very Continue with B & M Ventilation for
slow, < (using oxygen), rate of 20
60 bpm breaths/min.

Help is Chest Must rise with each

needed ventilation
Re-assess after 1-2 minutes!
Use your help to check
Resuscitation C Give Chest
Compressions

5 Inflation breaths with Bag and Mask

device

Check for Signs of Life and the Large

Pulse
No Signs of Life and Absent
pulse or Heart Rate, < 60 bpm

Chest compressions
15 compressions to every two B & M breaths
Aim for 6 7 cycles of 15:2 per minute
Giving Effective CPR
Lower of sternum, one finger breadth
above xiphisternum
Compress the chest by 1/3rd its depth &
allow for chest recoil
Aim at a rate of 100-120 chest
compressions/min
Give 15 chest compressions:2breaths for I
minute
Reassess ABC after one minute
Chest Compressions in an Infant

2-finger technique 2-thumb encircling

(1 rescuer) technique (2
rescuers)
Chest Compressions in an Older
Child

Onehand Twohands
technique technique
 Drugs in Resuscitation
Consider IO/IV line insertion when a 3rd
helper arrives

Get samples for random blood sugar

Consider IO/IV Adrenaline (0.1ml/kg

1:10,000) as rapid push plus a flush of 2-
5mls normal saline

Manage hypoglycemia with IO/IV

10%dextrose
 Post-Resuscitation Care
Frequent reassessment of ABC after
every 1-2 minutes

Appropriate supplemental oxygen (based

on clinical assessment)

Decide on admission care

Summary The Collapsed Infant
Safe, stimulate, shout for help
A
Clear? Position?
B
Is BVM needed? (add oxygen to bag)
C
Are chest compressions needed (no signs of life)
Reassess ABC after every one minute
Questions?