Emergency Triage

Assessment and

Treatment - Plus

(ETAT+)

Modules For Participants

KENYA PAEDIATRIC ASSOCIATION

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Tel: +254 20 275309 / 272698

Emergency Triage Assessment and Treatment - Plus (ETAT+)

PREFACE ................................................................... ........... 11

INTRODUCTION .................................................................................... 13

MODULE OBJECTIVES: ........................................................................... 14

UNIT 1.1 THE CONCEPT OF ETAT+ .......................................................

UNIT 1.2 ESSENTIAL SIGNS AND SYMPTOMS OF SERIOUS

CHILDHOOD ILLNESSES......................................................................... 18

MODULE INTRODUCTION ..................................................................... 33

MODULE OBJECTIVES ............................................................................ 33

UNIT 1: TRIAGE OF SICK CHILDREN ...................................................... 34

..................

MODULE 1

MODULE 2

Unit Outline ................................................................. ...........14

1.1.1 Unit Introduction ................................................................................. 14

1.1.2 Unit Objectives ................................................................................... 14

1.1.3 ETAT+ Course Vision, Mission and Values ............................................ 15

1.1.4 Principles of ETAT+ ............................................................................. 15

1.1.5 Summary ............................................................................................16

1.1.6 Review questions ................................................................................. 17

1.1.7 References .......................................................................................... 17

Unit Outline ................................................................................................ 18

1.2.2 Unit Objectives ................................................................................... 18

1.2.3 Criteria of WHO Essential Signs and Symptoms .................................... 18

1.2.4 Essential symptoms of common childhood illnesses .............................. 19

1.2.5 Essential signs of childhood illnesses .................................................... 22

1.2.6 Summary ............................................................................................ 31

1.2.7 References .......................................................................................... 31

1.2.8 Review questions.................................................................................. 31

Unit Outline ................................................................................................ 34

2.1.1 Unit Introduction ................................................................................ 34

2.1.2 Unit Objectives.................................................................................... 34

2.1.3 The triage process .............................................................................. 35

.....................

TABLE OF CONTENTS

Emergency Triage Assessment and Treatment - Plus (ETAT+)

2.1.4 Summary ............................................................................... . 38

2.1.5 Review questions .......................................................................

Unit Outline ................................................................................................ 40

2.2.1 Unit Introduction ................................................................................. 40

2.2.2 Unit Objectives.................................................................................... 40

2.2.3 Definition and pathophysiology of cardiopulmonary collapse ................ 40

2.2.4 Important factors for success in resuscitation ........................................ 43

2.2.5 The equipment and resources required for resuscitation in paediatric

emergency units ................................................................................ 44

2.2.6 The structured ABC approach to the resuscitation of the collapsed child.. 45

2.2.7 Summary ........................................................................................... 53

2.2.8 Review questions ................................................................................ 54

2.2.9 References ......................................................................................... 54

Unit Outline ............................................................................................... 55

2.3.1 Unit Introduction ................................................................................ 55

2.3.2 Unit Objectives................................................................................... 55

23.3 Background and Rationale .................................................................. 55

2.3.4 Recognizing the Seriously Ill Child ...................................................... 57

2.3.5 Rapid Assessment of the seriously sick Non Collapsed Child ................. 64

2.3.6 Summary .......................................................................................... 67

2.3.7 Review questions ................................................................................ 67

2.3.8 References ......................................................................................... 67

Unit Outline ............................................................................................... 68

2.4.1 Unit Introduction ................................................................................ 68

2.4.2 Objectives ......................................................................................... 68

2.4.3 Importance of the Structured Forms for Medical Documentation............ 69

2.4.4 Symptoms included in the Paediatric Admission Record ........................ 69

2.4.5 Elements of the Paediatric Admission Record ....................................... 71

2.4.6 Strengths and Limitations of Structured Tools for Documentation............ 77

..........

........... 39

UNIT 2:ABC APPROACH TO THE MANAGEMENT OF THE

COLLAPSED CHILD................................................................................. 40

UNIT 3: ABCD APPROACH TO THE MANAGEMENT OF THE

CHILD WITH SIGNS OF LIFE (NON-COLLAPSED CHILD) ....................... 55

UNIT 4: STRUCTURED PAEDIATRIC ADMISSION RECORDS ................... 68

Emergency Triage Assessment and Treatment - Plus (ETAT+)

2.4.7 Summary ................................................................................ 79

2.4.8 Review questions ................................................................................. 80

2.4.9 References .......................................................................................... 80

............

MODULE 3

MODULE INTRODUCTION ..................................................................... 82

MODULE OBJECTIVES ............................................................................ 82

UNIT 3.1 MANAGING AN INFANT OR CHILD WITH RESPIRATORY

DISTRESS ............................................................................................... 83

MODULE 3: UNIT 2: ACUTE DIARRHOEA AND DEHYDRATION ............. 97

Unit Outline: ............................................................................................... 83

3.1.1 Unit Introduction ................................................................................. 83

3.1.2 Unit Objectives.................................................................................... 83

3.1.3 Causes of respiratory distress. ............................................................. 84

3.1.4 The ABCD approach to assessment of respiratory distress ..................... 84

3.1.5 Recognizing, classifying and managing a child with pneumonia who

is HIV negative. ....... 87

3.1.6 Recognizing, classifying and managing a child with wheeze or asthma... 89

3.1.7 Causes of treatment failure ................................................................. 95

3.1.8 Summary ........................................................................................... 95

3.1.9 Review questions ................................................................................ 96

3.1.10 References ....................................................................................... 96

Unit Outline ................................................................................................ 97

3.2.1 Unit Introduction ................................................................................. 97

3.2.2 Unit Objectives.................................................................................... 97

3.2.3 Definition of acute diarrhoea and dehydration ..................................... 98

3.2.4 Classification of the level of dehydration .............................................. 98

3.2.5 Choice of fluid therapy in dehydration: ................................................ 102

3.2.6 Treatment of different levels of dehydration: ......................................... 105

3.2.7 Use of zinc in diarrhoea ...................................................................... 109

3.2.8 Treatment of dysentery ........................................................................ 110

3.2.9 Summary ........................................................................................... 111

3.2.10 Review Questions: ............................................................................ 111

3.2.11 References ........................................................................................ 112

.........................................................................

MODULE 4:

INTRODUCTION ................................................................................... 114

MODULE OBJECTIVES ........................................................................... 114

UNIT 4.1: MANAGEMENT OF THE CHILD WITH HYPOGLYCEMIA .......... 115

UNIT 4.2 MANAGING CONVULSIONS IN CHILDREN ........................... 122

UNIT 4.3 MANAGEMENT OF THE CHILD WITH MENINGITIS ................. 133

Unit Outline ............................................................................................... 115

4.1.1 Introduction ...................................................................................... 115

4.1.2 Unit Objectives.................................................................................. 115

4.1.3 Definition of Hypoglycaemia ............................................................. 115

4.1.4 Clinical signs associated with hypoglycaemia...................................... 116

4.1.5 Treatment of hypoglycaemia............................................................... 117

4.1.6 Summary .......................................................................................... 121

4.1.7 Review questions ............................................................................... 121

4.1.8 References and Further Reading ......................................................... 121

Unit Outline ................................................................................................ 122

4.2.1 Introduction ....................................................................................... 122

4.2.2 Unit Objectives................................................................................... 122

4.2.3 ABCD approach of managing a child with convulsions ......................... 122

4.2.4 Rational use of anticonvulsants in a convulsing child ............................ 125

4.2.5 Properties of commonly available anticonvulsant drugs – diazepam

and phenobarbitone

4.2.6 Summary ........................................................................................... 131

4.2.7 Review Questions .............................................................................. 131

4.2.8 References ........................................................................................ 132

4.3.1 Unit Introduction ................................................................................. 133

4.3.2 Objectives .......................................................................................... 133

4.3.3 Aetiology of acute bacterial meningitis in children ................................. 133

4.3.4 Clinical signs of acute bacterial meningitis............................................ 134

4.3.5 Indications for lumbar puncture (LP) and interpretation of LP results........ 135

4.3.6 Management of acute bacterial meningitis in children older than

one month.....

4.3.7 Summary ........................................................................................... 139

4.3.8 Review Questions ............................................................................... 139

4.3.9 References .......................................................................................... 140

.......................................................................... 127

................................................................................... 138

Emergency Triage Assessment and Treatment - Plus (ETAT+)

UNIT 4.4 MANAGEMENT OF THE CHILD WITH SEVERE MALARIA ......... 141

INTRODUCTION .................................................................................... 149

UNIT OBJECTIVES ................................................................................. 149

UNIT 5.1: NEWBORN RESUSCITATION .................................................. 150

UNIT 5.2: NEONATAL SEPSIS AND COMMONLY USED DRUGS

Unit Outline ................................................................................................ 141

4.4.1 Unit Introduction ................................................................................ 141

4.4.2 Unit Objectives................................................................................... 141

4.4.3 Epidemiology of malaria .................................................................... 142

4.4.4: Other forms of severe malaria ........................................................... 142

4.4.5 Management of severe malaria .......................................................... 145

4.4.6 Summary ........................................................................................... 147

4.4.7 Review Questions .............................................................................. 147

4.4.8 References ......................................................................................... 147

Unit Outline ................................................................................................ 150

5.1.1 Introduction ....................................................................................... 150

5.1.2 Objectives........................................................................................... 150

5.1.3 Background to newborn resuscitation .................................................. 150

5.1.4 Newborns and warmth. ...................................................................... 151

5.1.5 Newborn Resuscitation Equipment ....................................................... 151

5.1.6 Structured approach to newborn resuscitation ...................................... 154

5.1.7 Meconium in newborn resuscitation ..................................................... 157

5.1.8 Summary ............................................................................................ 159

5.1.9 Review questions.................................................................................. 160

5.1.10 References and Material for Further Reading ....................................... 160

................ 161

Unit Outline ................................................................................................ 161

5.2.1 Introduction ........................................................................................ 161

5.2.2 Objectives........................................................................................... 161

5.2.3 Signs and symptoms of neonatal sepsis ............................................... 161

5.2.4 Antibiotic treatment of neonatal sepsis ................................................. 163

5.2.5 Other commonly used drugs................................................................ 166

5.2.6 Summary ........................................................................................... 167

5.2.7 Review questions ................................................................................. 168

5.2.8 References .......................................................................................... 168

MODULE 5

Emergency Triage Assessment and Treatment - Plus (ETAT+)

UNIT 5.3: NEONATAL JAUNDICE ......................................................... 169

UNIT 5.4: MANAGEMENT OF LOW BIRTH WEIGHT INFANTS ................ 174

MODULE INTRODUCTION .................................................................... 187

MODULE OBJECTIVES ........................................................................... 187

UNIT 6.1: RECOGNITION OF SEVERE ACUTE MALNUTRITION .............

Unit Outline ............................................................................................... 169

5.3.1 Introduction ....................................................................................... 169

5.3.2 Objectives.......................................................................................... 169

5.3.3 Indications for treating neonatal jaundice ........................................... 169

5.3.4 Phototherapy ..................................................................................... 171

5.3.5 Summary .......................................................................................... 173

5.3.6 Review questions................................................................................ 173

5.3.7 References and Material for Further Reading ....................................... 173

Unit Outline ................................................................................................. 174

5.4.1 Introduction ........................................................................................ 174

5.4.2 Objectives........................................................................................... 174

5.4.3 Standards of care ............................................................................... 174

5.4.4 Warmth .............................................................................................. 175

5.4.5 Kangaroo mother care ........................................................................ 176

5.4.6 Feeding and fluids .............................................................................. 177

5.4.7 Summary ............................................................................................ 185

5.4.8 Review questions ................................................................................. 185

5.4.9 References .......................................................................................... 185

MODULE 6

188

Unit Outline ............................................................................................... 188

6.1.1 Introduction........................................................................................ 188

6.1.2 Unit Objectives .................................................................................. 188

6.1.3 Definition of severe acute malnutrition ................................................ 188

6.1.4 Clinical diagnosis .............................................................................. 196

6.1.5 Summary .......................................................................................... 201

6.1.6 Review question ................................................................................ 201

6.1.7 References ........................................................................................ 202

Emergency Triage Assessment and Treatment - Plus (ETAT+)

UNIT 2: INITIAL MANAGEMENT OF A CHILD WITH SEVERE ACUTE

MALNUTRITION......

UNIT 3 NUTRITIONAL TREATMENT OF A SEVERELY MALNOURISHED

CHILD..213

MODULE INTRODUCTION ................................................................... 222

MODULE OBJECTIVES ........................................................................... 222

UNIT 7.1: THE RIGHTS OF THE CHILD .................................................. 223

............................................................................... 203

Unit Outline ................................................................................................ 203

6.2.1. Introduction....................................................................................... 203

6.2.2 Unit objectives ................................................................................... 203

6.2.3 The altered physiology of the child with severe acute malnutrition.......... 203

6.2.4 The (10) step approach to management of severe acute malnutrition

(SAM).. 205

6.2.5 Summary ........................................................................................... 211

6.2.6 Review questions ................................................................................ 211

6.2.7 References ......................................................................................... 212

Unit Outline ................................................................................................ 213

6.3.1 Introduction........................................................................................ 213

6.3.2 Unit Objectives .................................................................................. 213

6.3.3 Starting the initial feeds –F75 .............................................................. 213

6.3.4 Catch up Growth (Recovery Phase) ...................................................... 215

6.3.5 Rehabilitation and Monitoring ............................................................. 217

6.3.6 When to discharge ............................................................................. 219

6.3.7 Summary ........................................................................................... 220

6.3.8 Review question .................................................................................. 220

6.3.9 Reference ........................................................................................... 220

...............................................................................................

MODULE 7

Unit Outline ............................................................................................... 223

7.1.1 Introduction ....................................................................................... 223

7.1.2 Objectives.......................................................................................... 223

7.1.3 Legislative Framework for the Rights of Children .................................. 223

7.1.4 Summary ........................................................................................... 228

7.1.5 Review questions................................................................................. 228

7.1.6 References ......................................................................................... 228

Emergency Triage Assessment and Treatment - Plus (ETAT+)

UNIT 7.2: STANDARDS OF CARE FOR CHILDREN ................................... 229

Unit Outline ................................................................................................. 229

7.2.1 Introduction ........................................................................................ 229

7.2.2 Objectives........................................................................................... 229

7.2.3 The Standards of Care for Children ..................................................... 229

7.2.4 When to Admit and Discharge Children ............................................... 237

7.2.5 Summary ........................................................................................... 239

7.2.6 Review questions ................................................................................ 239

7.2.7 References ......................................................................................... 239

Emergency Triage Assessment and Treatment - Plus (ETAT+)

Preface

ETAT+ is an acronym for Emergency Triage Assessment and Treatment plus admission care of

new-borns and children in the first 48 hours.

The ETAT+ is modified from the World Health Organisation's ETAT programme. The ETAT+

modification was done by Kenyan experts in collaboration with the Ministry of Health,

KEMRI- Welcome Trust, University of Nairobi, MTRH and the Kenya Paediatric Association

and first launched in 2005.

This is a course aimed at giving all health workers (nurses, clinical officers, doctors – and even

nutritionists, laboratory technicians and pharmacists for part of it) the appropriate skills and

knowledge in providing healthcare for sick children in a low to middle income resource setting.

The ETAT+ course covers the following areas:

1. Outpatient triage for sick young infants and children.

2. Emergency care including technologically appropriate life support for infants,

children and the newborn.

3. Evidence-based, immediate and admission care for children with hypoglycaemia,

convulsions, dehydration, malaria, severe anaemia, meningitis, pneumonia, asthma,

4. severe malnutrition, neonatal sepsis and care of the preterm infant

The ETAT+ programme is adapted from the World Health Organisation publication on Hospital

Care for Children: Pocket book of Hospital Care for Children: Guidelines for management of

common illnesses. In Kenya, these guidelines have been adopted by the Ministry of Health, and

summarised in the pocket book dubbed; Basic Paediatric Protocols

ETAT+ will enable you provide quality care to sick children based on best practices adapted by

WHO and Government of Kenya, Ministry of Health guidelines. The ETAT Plus guidelines are

based on the best evidence available and not on expert opinion. It focuses on basic, effective

care for common problems, things that all facility-based health workers should be able to

manage. It is not a comprehensive course for paediatrics or neonatal care. Health workers

should always be on the lookout for important but less common problems. As soon as possible

they should seek the best available advice on managing a severely ill child or new-born.

Introduction to Emergency

Triage Assessment

and Treatment Plus Admission Care of

The Severely Ill Child and

Newborn (ETAT+)

MODULE 1

MODULE INTRODUCTION

MODULE OBJECTIVES:

In this module, we will discuss how and why ETAT+ training was developed and the use of

essential signs and symptoms as defined by World Health Organization (WHO).

This module is covered in two units as follows:

Unit 1.1: Concept of ETAT+

Unit 1.2: Essential signs and symptoms of serious common childhood illnesses

Lets' go through the objectives of the module

By the end of the module you should be able to:

i. Describe the Concept of ETAT+.

ii. Discuss the essential signs and symptoms in common

childhood illnesses.

Emergency Triage Assessment and Treatment - Plus (ETAT+)

UNIT 1.1: THE CONCEPT OF ETAT+

Unit Outline

1.1.1 Unit Introduction

1.1.2 Unit Objectives

1.1.1 Unit Introduction

1.1.2 Unit Objectives

1.1.3 Vision, mission and values of ETAT+

1.1.4 Principles of ETAT+

1.1.5 Summary

1.1.6 Review questions

1.1.6 References

Timely identification and management of common childhood emergencies and illnesses such

as respiratory infections, diarrheal illnesses, malaria, meningitis, and acute malnutrition is

often seen as a challenge to many health care workers.

This unit will cover the definition of ETAT+ and direct you to the source of the materials used.

We will also outline the vision, mission and values of ETAT+ and the principles of ETAT+ using

the ABC approach to management of childhood illnesses.

Let us start by going through the objectives of this unit,

By the end of the unit you should be able to:

1. Outline the vision, mission and values of ETAT+.

2. Outline the principles of ETAT+.

Take note 1.1.1

You have been provided with:

1. Pocket book of Hospital Care for Children: Guidelines for

management of common illnesses.

2. MOH, Republic of Kenya; Basic Paediatric Protocols.

M O D U L E 1

Emergency Triage Assessment and Treatment - Plus (ETAT+)

Figure 1.1.1: The WHO pocket guide and Basic Paediatric Protocols

To improve new-born and child survival in resource-limited settings

To improve survival of newborns and children through the delivery of quality care through

evidence based best clinical practice in resource limited settings.

Commitment to continuous efforts to provide high quality care through:

i. Evidence based clinical practice

ii. Optimising the organisation and delivery of care

iii. Teamwork based on mutual respect

iv. Continuous learning

v. Leadership and mentorship

The ETAT+ programme is about more than identifying and treating sick newborns and children.

It recognises that facilities, health workers and even patients and carers will often need to work

1.1.3 ETAT+ Course Vision, Mission and Values

1.1.4 Principles of ETAT+

Vision

Mission

Values

The image of the two refrence materials is presented in Figure 1.1.1

M O D U L E 1

Emergency Triage Assessment and Treatment - Plus (ETAT+)

together so that they organise themselves as best they can with the resources they have to

optimise the care they provide. Care only improves when new knowledge is turned into

effective action – and this will require effort, teamwork and a willingness to develop local

solutions. At its core, the ETAT+ programme gives a structure for a rapid and comprehensive

approach to initial assessment and intervention based on the acronym “ABC” This systematic

approach to assessing a sick infant or child aims to promote recognition and management of

conditions that are acutely life threatening.

In this course, we will discuss the triage and treatment of childhood illnesses based on the four

“ABC” approaches outlined below.

i. The ABCD approach to triage.

ii. The ABC approach to basic life support (BLS) of a collapsed infant or child.

iii. The ABCD approach to provision of emergency care when there are signs of life in a

neonate, infant or child.

iv. The ABC approach for newborn resuscitation.

It is important that by the end of the course you will understand and be skilled in applying all

four approaches. You will also go through management of specific common childhood and

neonatal illnesses throughout this course and use simplified algorithms and job aids to make

focused decisions on diagnosis, and management of these illnesses.

A time has been set aside during the 2 day practical sessions for you to practice these skills,

under the guidance of your ETAT+ facilitators.

1.1.5 Summary

In this unit we have learnt:

Ÿ The vision, mission and values of ETAT plus programme.

Ÿ We have learnt that the ETAT plus programme providers

learners with an evidence based structured approach of

offering acute care for sick neonates, infants and children. It

emphasises the use of evidence based clinical practice

guidelines, team work and intergrated approach of

common childhood illnesses. The guidelines used are part

of the Ministry of Health –Kenya Basic paediatric

protocols adapted from the WHO guidelines.

Ÿ We have also seen that ETAT plus enables facilities, health

workers, patients and carers to work together and organise

the available resources to optimise the care provided to

children.

Emergency Triage Assessment and Treatment - Plus (ETAT+)

SUMMARY

M O D U L E 1

1. Describe what you now understand by the concept of ETAT+.

2. List the approach to 4 ABC approaches you will use in ETAT+.

1.1.6 Review questions

1. World health Organization; 2013 Hospital Care for Children;

Guidelines for management of common illnesses with limited

resources.

2. Ministry of Health-Kenya; 2013; Basic Paediatric Protocols.

1.7 References

M O D U L E 1

Emergency Triage Assessment and Treatment - Plus (ETAT+)

UNIT 1.2: ESSENTIAL SIGNS AND SYMPTOMS OF SERIOUS CHILDHOOD

ILLNESSES

Unit Outline

1.2.1 Unit Introduction

1.2.2 Unit Objectives

1.1.1 Unit Introduction

1.2.2 Unit Objectives

1.2.3 Criteria of WHO essential signs and symptoms

1.2.4 Essential symptoms of common childhood illnesses.

1.2.5 Summary

1.2.6 Review questions

1.2.7 References

In this unit, we will focus on the most reliable symptoms and signs used in the recognition of

severely ill infants and children; later in the course you will apply this knowledge in managing

various common childhood illnesses. The core clinical symptoms and signs described

represent the best, minimum set required to assess newborns and children. Carefully

documenting a complete history and examination including other relevant symptoms and signs

to the best of one's ability is a critical part of good clinical practice but one that cannot be

covered in this course.

By the end of the unit you should be able to:

i. Outline the criteria of WHO essential signs and symptoms.

ii Describe the essential symptoms of common childhood and

neonatal illnesses.

Let us outline the criteria of essential signs as described by the World Health Organization

(WHO).

The WHO describes essential signs and symptoms as the most reliable ones that meet the

following criteria:

Ÿ Observed commonly in serious common childhood illnesses.

Ÿ Used in assessment of the nature and the severity of illnesses to indicate risk of death,

monitor clinical progress and differentiate diseases.

Ÿ Easy for everyone to observe and learn and use reliably.

1.2.3 Criteria of WHO Essential Signs and Symptoms

Emergency Triage Assessment and Treatment - Plus (ETAT+)

M O D U L E 1

1.2.4 Essential symptoms of common childhood illnesses

You may have noticed in your clinical practice that sick neonates, infants or children present

with various symptoms and signs. Some of these are considered more reliable than others in the

recognition, classification and management of various illnesses.

Let us start off by defining symptoms (presenting complaints) of common illnesses in infants

and children but before we proceed, carry out activity 1.2.1.

Activity 1.2.1

Enumerate symptoms that you would consider important when managing

a seriously sick infant or child.

Think about the illnesses that most commonly cause admission to hospital

and death to help you with this.

Good try, we will describe the World Health Organization (WHO) essential symptoms, at the

end of this section, compare your list of symptoms with the list discussed and take note of the

ones you may have missed.

Cough: If the child has history of cough it is necessary to ask the duration of the cough. Why is

that so?

Well done! A history of cough for more than 2 weeks may indicate presence of other illnesses

besides upper respiratory tract infections or acute pneumonia. This will be discussed further in

module 3 of this course.

Difficulty breathing: May or may not accompany a cough, do you know what it indicates?

Good! Difficulty breathing usually indicates respiratory distress, which may inform you that

the infant or child could be severely ill.

Would you be worried if a mother told you that her little one has not been feeding well?

Difficulty feeding is an essential symptom that indicates that the infant or child is too sick to

feed; this includes asking about the ability to breastfeed for neonates and infants. Note though

that this is slightly different from the complaint of 'poor appetite', it is focussed more on

difficulty actually taking feeds because of problems such as breathlessness, lethargy or even

weakness, irritability or even altered consciousness.

Diarrhoea: Any time you manage an infant or children always establish the presence or

absence of diarrhoea, the frequency (number of times) per day, and duration (number of days)

M O D U L E 1

Emergency Triage Assessment and Treatment - Plus (ETAT+)

of the illness. What is diarrhoea? A diarrhoea stool is defined as a stool that is liquid enough that

if it was poured into a cup or bowl it would take the shape of the container and have a flat surface

– like very thin porridge! We say a child has true diarrhoea if they have 3 or more of such

diarrhoeal stools in 24 hours. It is actually important to write down the number of such stools in

24 hours as whether this is going up or down is a way to check progress.

Presence of diarrhoea for more than 14 days may not be a simple infection and will require a

different approach to treatment – this is called persistent diarrhoea.

In text Question 1.2.1

i. Is a history of bloody diarrhoea significant?

Prove reasons for your answer in (i) above

Good try!

Presence of blood in the stool is a significant finding that would change your approach to

treatment; you should treat with antibiotics for dysentery (a specific bacterial infection – non-

bloody diarrhoea can be caused by bacteria but these do not need an antibiotic). If there is blood

in the stool you also need to think of other diagnoses such as intussusceptions in infants and

younger children!

Vomiting everything: When attending to sick infants or children reported to be vomiting,

always establish if they are vomiting everything.

This means that every feed ingested is vomited and not a single episode of large amounts of

vomitus. In other words if the child is vomiting each time they feed, this is considered more

significant than vomiting a large amount after feeding several times

History of convulsions or sudden jerky body movements, worrisome to the caregiver (and I am

sure to you too!). What should you try to find out about them?

Convulsions and partial or focal convulsions (fits): Should be investigated in detail. It is

important to ask the caregiver to describe or demonstrate the observed movements to establish

that a true convulsion occurred and to determine the type of convulsion i.e. generalized or

partial, and how often they occur.

Generalized convulsions involve the whole body and are always associated with loss of

consciousness during the convulsion. Commonly in children (but not infants aged less than 6

months) these are associated with an acute febrile illness. Remember though that these 'febrile

convulsions' are typically short (less than 5 minutes) and that the child should regain full

Emergency Triage Assessment and Treatment - Plus (ETAT+)

M O D U L E 1

consciousness within one hour. If the convulsions are long or full consciousness does not return

do not dismiss these as 'simple febrile convulsions'.

Partial or focal fits are convulsions that involve only part of the body for example one side of the

body, an arm, a leg, or one side of the face. If the convulsion starts in one part of the body and

then spreads to the whole body with loss of consciousness this is a generalised convulsion not a

partial convulsion.

Take note 1.2.1

For now, the emphasis is that you must establish the presence or absence,

frequency and type of convulsion.

We will revisit convulsions in infants and children in module 4 and

discuss it in further detail.

You may have noticed that small babies behave differently when they are sick. It is with this

regard that some additional essential symptoms should be used to recognize severe illness in

infants who are less than 2 months old.

Ÿ Essential symptoms in infants aged less than 2 months

Abnormal movements: This is mainly the mother's assessment that strength or frequency of

movements of some body parts are reduced increased or have an odd pattern of movement e.g.

Arching of the back (opisthotonus), smacking of lips, and jerky movements of legs, arms or

eyes.

High pitched cry: This is an abnormal cry to the mother and is usually associated with

irritability.

Apnoea: This is the cessation of breathing for more than 10 seconds that requires stimulation to

re-establish breathing – it is especially relevant in the first days of life.

Pus and cellulitis at the umbilicus: The umbilicus may be dirty but evidence of inflammation

of the skin (redness and warmth) around the cord stump and discharge of pus may signify

serious infection.

Before we proceed to discuss essential signs of childhood illnesses, carry out activity 1.2.1

again and compare to your first list.

M O D U L E 1

Emergency Triage Assessment and Treatment - Plus (ETAT+)

Activity 1.2.1

Enumerate symptoms that you would consider important when

managing a sick infant or child.

1.2.5 Essential signs of childhood illnesses

Having defined the essential symptoms, we will now concentrate on the essential signs that

you would look for when examining a sick child.

The sick child should be examined systematically using the ABCD approach.

In text Question 1.2.2

Do you know what ABCD stands for in managing sick infants

or children?

Well done!

It stands for: Airway, Breathing, Circulation and Disability.

Let us go through the essential signs assessed based on the ABCD approach.

When examining a sick infant or child you must establish that the airway is patent i.e. the nose

and mouth are clear of any object and secretions and are in the optimal position for gas

exchange.

If the patient is not alert, the patient's airway may be at risk of obstruction and may need to be

maintained in a position that keeps it clear (patent). Methods of ensuring airway

opening/patency will be described in greater detail in module 2.

Stridor is an important inspiratory sound that may be heard when the upper airway is

obstructed.

In a child with altered consciousness the airway can sometimes be at risk because the infant or

child does not clear the secretions by coughing or swallowing. This can result in hearing a

crackling or bubbling sound as the child breathes.

i. Airway (A):

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M O D U L E 1

Once you are sure that the airway is patent, you can now assess the breathing.

In an emergency we only try and get a quick estimate of the rate of breathing by observing the

respiratory rate in about 10 seconds to determine is it very slow, very fast or not remarkable.

To make a proper assessment of breathing in a child who does not need emergency care or after

the emergency is dealt with then it is very important to measure the respiratory rate (RR)

accurately. This will help you tell if the rate of breathing is normal, too fast or too slow. To do

this you must now count it for 1 minute. Neonates and infants tend to have a faster respiratory

rate and so the normal rate changes with the age of the child.

The following are the upper limits of respiratory rate in different age groups.

RR of more than or equal to 60/min in an infant less than 2 months old.

RR of more than or equal to 50/min in an infant 2-11 months old.

RR of more than or equal to 40/min in a child 12 months – 59months

ii. Breathing (B):

Activity 1.2.1

List 6 signs you would use to assess the adequacy of

breathing.

Good try!

Did you mention the following?

Central cyanosis: which is the blue discolouration of mucus membranes e.g. the gums and the

tongue. Cyanosis is an indication of very severe pneumonia (or rarely Congenital Heart Disease

or other problem).

Grunting: This is an abnormal expiratory sound that may occur in severe chest disease. It is

much more common in sick infants than older children.

Lower chest wall in-drawing: which is the inward movement of the bony structure of the

lower chest wall (rib margin) with inspiration- the area where the diaphragm is attached to the

ribs.

You will notice that throughout this course we will use lower chest wall in-drawing as an

essential sign because it is more specific than “Inter-costal in-drawing (or recession).” This

literally means that the soft tissue between the ribs without involvement of the bony structure of

the chest wall may be sucked in when breathing in.

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Acidotic (or deep) breathing: This is the type of breathing seen in a patient with diabetic

ketoacidosis or the type of breathing you would have after completing a 400 meters race! It can

be described as deep breathing and apparent with every breath. This is not the same as the

occasional deep sighing that is sometimes observed in an unconscious patient.

At this point your stethoscope will come in handy to identify the next two essential signs and

these are:

Wheeze: This is musical note which can be heard as the child breathes out and on auscultation

are described as rhonchi – although we will use the simpler term wheeze for both.

Crackles: These are also known as crepitations and are best heard using a stethoscope as the

child breathes in. If possible re-assess immediately after a child has coughed if they disappear,

it means that they were not significant.

Although not a clinical sign a key part of examining breathing in sick infants and children now

is assessment using pulse oximetry. This should now be offered to all those sick enough to be

admitted to hospital.

Pulse oximetry: Using a carefully applied pulse oximeter (also known as an oxygen saturation

monitor) the percentage oxygen saturation of the blood (or haemoglobin) can be directly and

painlessly measured in a few minutes. Normal oxygen saturations are usually 95% to 99%; we

are definitely concerned if the measurement is less than 90% and the lower the reading the

greater the worry – although check the reading is accurate!

Let as now shift our attention to essential signs in assessing the circulation.

The pulse is the first thing you should assess in circulation. Just like in the assessment of

breathing, in the emergency setting you must assess for a normal, fast or slow pulse rate (PR)

for the first 5 to 10 seconds by checking a large pulse (brachial, carotid or femoral).

In this course, a pulse rate of 60 and below is considered too slow and chest compressions will

be required if the infant / child is not alert.

To make a proper assessment of pulse and heart rate in a child who does not need emergency

care or after the emergency is dealt with then it is very important to measure the pulse or heart

rate (HR) accurately. To do this, you must then continue to count it for 1 minute.

iii. Circulation (C):

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M O D U L E 1

The peripheral pulse (radial) should also be assessed because a weak (hard to feel) or even

absent pulse is an emergency sign as you will see in module 3.

Capillary refilling: This is a sign that can easily be done by anyone and involves pressing a

finger/toe pulp gently for 5 seconds to empty the capillaries of blood (make the skin being

pressed pale or white). When the pressure is released the time in seconds it takes for a normal

pink colour to return is observed and recorded. A normal capillary refill time (CRT) is < 3

seconds. Figure 1.2.1 illustrates how to assess for capillary refill time.

Release and count the time in second for the normal pink colour to

Press for 5 seconds

Figure: 1.2.1. Assessing capillary refill time

Pallor: Pallor is commonly due to anaemia and may range from mild to severe pallor in severe

anaemia. You can compare colour of the palm with yours or the mother's palm. It should be

classified as obviously severe (+++); mild or moderate (+) or not present (-).

Notice that we avoid using (++) as it is most important to make a decision on whether the pallor

is an urgent concern or a concern to be managed but not as an emergency.

If you found severe anaemia (+++) it would mean that you would need to act now and act fast!

Figure 1.2.2 (a) and (b) illustrates assessment of palms for pallor.

a) b)

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Figure 1.2.2: Assessing palmar pallor

Let us now look at signs that would help you assess for dehydration. We include signs for

dehydration as part of the 'C' or circulation assessment because the loss of fluid in dehydration

causes circulatory problems.

Sunken eyes: The eyes of a dehydrated child may look sunken. Some children have eyes that

look like they are sunken normally. If in doubt, ask the caregiver of the child if the eyes look

more sunken that usual or not. Figure 1.2.3 shows a child with sunken eyes.

Figure 1.2.3: Sunken eyes

Skin pinch (Skin turgor): Pinch up a fold of skin of the abdomen (halfway between the

umbilicus and flank) for one second to create a large fold/tent, then release and observe the fold

disappear until the skin is completely back to its normal shape while counting seconds. Normal

skin return is rapid – often so rapid it is hard to count to one. If the fold/tent of skin returns more

slowly the record the number of seconds it takes. We classify the time for the skin to return to

normal as 'immediate', 1 to 2 seconds or 2 or more 2 seconds. Figure 1.2.4 shows how assess

skin pinch.

Figure 1.2.4: Demonstrating skin pinch.

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M O D U L E 1

In text Question 1.2.3

In which conditions are sunken eyes and prolonged skin turgor not

used reliably to assess for dehydration

Well done! Severe acute malnutrition where the infant or child is severely wasted would make

it difficult to assess dehydration using sunken eyes and skin turgor.

When we assess disability, it means we are assessing for a change in the level of consciousness.

In this course we will use the AVPU scale for assessment of disability. AVPU stands for; Alert,

Verbal, Pain and Unresponsive. Let us now describe this in details.

A = Alert and responsive. This score is given to an infant or child aware of the surrounding

environment. The easiest way to confirm this is to check the infant/child can make eye contact –

clearly look at you or its carer and often track any movements.

iv. Disability (D):

Figure 1.2.5: Alert infant

V = (response to) voice or verbal instructions or sound. This score is given to a child who is not

alert but responds to Voice or Verbal instructions, e.g. turns head to mother's call.

P = (response to pain) this score is given to a child who is not alert, not responding appropriately

to voice but responds to Pain appropriately. It is important to assess the response to pain

carefully. The way ETAT+ teaches is to gradually increase the pressure, using a knuckle of a

finger, on the bony part of the infant/child sternum (breastbone). A child who can respond

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Emergency Triage Assessment and Treatment - Plus (ETAT+)

appropriately to pain should reach across with their hand and try and push your finger/hand

away. You are testing they know where the pain is (localising the pain) and that they can

deliberately try and remove it. Just bending the arms without purpose is NOT an appropriate

response. This appropriate localizing and motor response to a painful stimulus would be scored

as P.

U = failure of an infant or child to elicit any of the responses described above is deemed as

Unresponsive or Unconscious and scored as U.

Take a look a figure 1.2.6. Can you tell the level of consciousness of this infant?

Figure 1.2.6: Altered consciousness

Good try! You must use the AVPU scale to score the infant.

In text Question 1.2.4

Is the AVPU scale a reliable method of assessing conscious level in

infants?

The AVPU scale is harder to use in infants. It is known that infants aged less than 9 months of

age may not reliably localise a painful stimulus – they may simply decide to cry vigorously and

move their arms and legs without a real effort to push the cause of the pain away! If an infant

younger than 9 months makes this vigorous response to pain you should score them at P.

Unfortunately in very young infants and especially the newborn it is even harder to assess

conscious level whatever the scale being used. In these cases signs that go beyond the teaching

in the ETAT+ course can be useful.

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Signs that are useful for a more general assessment of disability in infants and children include:

Ability to drink or feed/ Inability to suck: You should actually observe the infant or child

trying to feed by offering a cup of fluid or observe ability to breastfeed or presence of the rooting

reflex in neonates.

Bulging fontanelle: The fullness of the fontanelle should be examined with the infant lying

down at rest (i.e. not crying). A full or bulging fontanel indicates raised intracranial pressure.

This may be seen in infants with meningitis.

Stiff neck: if a child is conscious and alert, ask the child to flex the neck, which should move

freely. If the child is semi-conscious or unconscious, lay the child in supine position and gently

flex the neck brining the head onto the chest. Resistance to this movement occurs if the neck is

stiff.

Signs that are useful for a more general assessment of disability in young infants (< 2months)

include:

Reduced tone / movement (Floppy): This can be checked by carefully observing whether the

young infant makes any spontaneous movements or the strength of movements in response to

any stimulation (such as being placed on a bed). More specifically this can be checked by

looking for 'head lag'.

Head lag – after laying an infant on its back on a clean, flat surface, raise the chest of

the baby by lifting the shoulders. As you raise the shoulders observe whether the baby

is able to raise its head to keep it 'in line' with the chest. Baby's whose head remains

touching the table/bed as you lift the shoulders with no effort at raising the head have

'head lag' and reduced tone

Apart from signs that can be used to assess ABCD, other essential signs include the following.

Finally, let us look at some signs that are seen in the general condition of the child.

Jaundice: yellow colouration of eyes and mucous membranes. – In neonates classify as severe

(+++) if the sole of the foot is obviously yellow when observed after slight pressure has been

used to blanch the skin.

Mid Upper Arm Circumference (MUAC): MUAC is measured using a tape around the left

upper arm. MUAC is the best quick way to assess for severe acute malnutrition. It will be

discussed more Module 6.

General condition / nutrition essential signs:

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Visible severe wasting: It is better to use MUAC to assess severe acute malnutrition but in an

emergency examine the large groups of muscles such as buttocks, shoulders, arms and legs to

look for wasting. Figure1.2.7 shows a child with severe wasting.

Oedema – and oedema of Kwashiorkor: To check for oedema the best place to look is over

the top of the foot or over the lower shin. Check for any mild oedema – that may not be

immediately obvious – by pressing the skin down firmly over the bony part of the top of the foot

for 5 seconds and then releasing the pressure. If a dip or pit remains in the skin and tissues where

you had pressed skin that slowly resolves this is a sign of oedema. Check how extensive the

oedema is – does it go above the knee? Does it include a puffy face? In Kwashiorkor there are

usually changes to the hair (thin, brittle and loss of curl / colour) and flaky 'paint' skin.

Figure 1.2.7 severe wasting

We have described the essential signs and symptoms as defined by WHO that you can use when

assessing for common childhood illnesses. You will repeatedly come across these symptoms

and signs as you go through the course and these will guide you in recognizing illnesses and

classifying the severity of the illnesses based on their presence or absence.

Take note 1.2.2

Other clinical signs and symptoms are important in making a clinical

diagnosis and a full history and examination should always be carefully

documented.

Here, we have focused on observing essential signs and symptoms that

you would need to respond rapidly to a potential cause of severe disease

or even death.

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M O D U L E 1

Now let us see how we can effectively use some of these essential signs and symptoms to

answer the questions in scenario 1.2.1.

Scenario 1.2.1

A 4 year old child presents at your health facility with history of cough,

very high fever and poor feeding for 3 days.

a. what more would you like to know about the cough?

b. what other symptoms would you be interested in.

c. List down 6 signs you would assess if this child was alert but had a

Respiratory Rate of 65 breaths per minute.

1.2.6 Summary

In this unit we have

Ÿ Outlined the criteria of the WHO essential signs and symptoms

which are reliable, easy to observe, common in serious

childhood illnesses. They can be used to assess the nature and the

severity of illnesses. These signs and symptoms were further

described and grouped as common childhood and neonatal

illnesses used in ETAT+

1.2.8 References

1. WHO guidelines 2010; maternal, new-born, child and adolescent

health http://www.who.int/maternal_child_adolescent/en/

2. Kenya Clinical Guidelines, 2013; http://www.idoc-africa.org

3. World health Organization; 2013; Hospital Care for Children;

Guidelines for management of common illnesses with limited

resources

4. Ministry of Health-Kenya; 2013; Basic Paediatric Protocols.

1. Write down the WHO criteria used to describe essential signs and

symptoms.

2. List essential symptoms you would use in assessing infants aged less

than 2 months.

3. What essential signs are used to assess circulation?

SUMMARY

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Emergency Triage Assessment and Treatment - Plus (ETAT+)

1.2.7 Review Questions

Emergency Triage Assessment and Treatment - Plus (ETAT+)

MODULE 2

Triage and Emergency Care

MODULE INTRODUCTION

Greetings! Welcome to Module 2.

This module will introduce you to the concepts of using structured approaches to quickly

identify and stabilize sick children presenting to your hospital. We will consider the use of these

'A-B-C Approaches' in triage, resuscitating the child who has suffered cardiopulmonary

collapse and in managing the sick child with signs of life. We will also consider how we can use

Standard Admission Record Forms to document essential clinical findings.

The module is divided into the following units:

UNIT 2.1: Triage of Sick Children

UNIT 2.2: ABC approach to the management of the Collapse Child

UNIT 2.3: ABC approach to the management of the Non Collapsed Child

UNIT 2.4: Use of Standard Admission Records

MODULE OBJECTIVES

By the end of the module you will be able to,

i. Describe the process of Triage of Sick Children

ii. Describe the structured approach to the management of the Child

with Cardiopulmonary Collapse (the Collapsed Child)

iii. Describe the structured approach to the management of the Child

with signs of life (the Non- Collapsed Child)

iv. Illustrate the use of Standard Admission Record

M O D U L E 2

Emergency Triage Assessment and Treatment - Plus (ETAT+)

UNIT 1: TRIAGE OF SICK CHILDREN

Unit Outline

2.1.1 Unit Introduction

2.2.1 Unit Introduction

2.2.2 Unit Objectives

2.2.3 The Triage process

2.2.4 Summary

2.2.5 Review questions

2.2.6 References

This unit will cover the definition of triage and describe the triage process.

2.1.2 Unit Objectives

By the end of the Unit you should be able to;

i. Define triage

ii. Describe the /process of triage of sick children.

If you work in a busy health facility, sometimes you may have many sick children waiting for

care in the waiting bay/area. The very sick ones may die or worsen if they are kept waiting for

long hours without being recognized and offered emergency care. Research has shown that of

all the paediatric deaths in our hospitals, over 50% will occur in the first 24 hours of admission.

This indicates that many children arrive when they are already very ill – they need rapid

attention.

The term 'triage' simply means “sorting out”. Triage is the process of rapidly screening sick

children upon arrival at the hospital according to the severity of their condition.

While doing triage, all sick children should be rapidly classified either as:

i. Having an emergency sign(s) which requires immediate emergency treatment;

ii. Having a priority sign(s) which requires placement in front of the queue for prompt

assessment and treatment;

iii. Or as a non-urgent case, which can wait for assessment and treatment later while in the

queue.

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M O D U L E 2

Take note 2.1.1

Why triage is important:

• Some children can die while waiting to be seen

• Of all the children dying in hospital >50% will die within 24 hours.

• Some children can only be saved if treatment starts immediately on

arrival to a hospital.

Anyone with some basic training can do triage as it is only sorting out and NOT treating. You

quickly look for some signs that will help you classify the patient as shown in figure 2.1.1.

All facilities attending to sick children should have a triage system in place.

The signs used in doing triage are shown in Figure 2.1.1. The person doing triage should use

the ABCD of triage and correctly classify the patient as emergency, priority or non-urgent. The

very sick children with emergency signs as shown in Figure 2.1.1 are at higher risk of dying and

should be attended urgently. The triage person identifies them and sends them to the emergency

care area. The clinician should stop everything else and attend to the emergency patient.

The children with priority signs may worsen and they should be put in front of the queue for the

clinician to attend to. They should not be made to wait for long. The children with no emergency

or priority signs are non-urgent and can wait in a queue. The priority signs in figure 2.1.1 form a

mnemonic 3TPRMOB. If the waiting time is too long, the triage person should repeatedly look

through the queue to check if any of them is worsening.

This sorting out of the patients can be done by the hospital staff who handles patients on arrival.

In some places, this person may be the security guard, registration clerk or the nurse doing vital

signs observations. The parents and other caregivers should be informed of the triage system

and its importance.

The person doing triage should just direct the patient correctly as an emergency or priority or

non-urgent. They are not involved in the treatment of these patients. The person doing the

treatment should do their independent assessment and give the needed treatment.

Emergency Signs: Rapidly screen all sick children when they arrive at the hospital using

ABCD approach. Note, here, and only in Triage, we use 'D' to refer to dehydration and

disability.

2.1.3 The triage process

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Emergency Triage Assessment and Treatment - Plus (ETAT+)

Airway &

Breathing

Weak / absent breathing

Immediate transfer to

emergency area:

Start Life support procedures

Give oxygen

Circulation

Coma / convulsing / confusion: AVPU = ‘P or U’ or Convulsions

If the patient has no emergency signs then screen for Priority Signs

(3TPRMOB)

Front of the Queue -

Clinical

review as soon as possible:

Weigh

Baseline

observations

Non-urgent – Children with none of the above emergency or priority signs.

Figure 2.1.1: The steps for doing triage for all sick children

Diarrhoea with sunken eyes → assessment / treatment for severe dehydration

Emergency Triage Assessment and Treatment - Plus (ETAT+)

M O D U L E 2

Before you proceed, examine figure 2.1.1 again. Then use the information to complete the

activity 2.1.1 and activity 2.1.2:

Well done! Now compare your answers with the correct answers provided below:

A. Proceed to check circulation

B. Proceed to check other “C's”

C. Emergency - Immediate transfer for attention.

What actions would you take at the boxes labelled A, B, and C?

Activity 2.1.1

6. A child of about 3 years comes to you at the triage area of the hospital

casualty

What Action would

you take?

When you

Check

The Finding is:

Airway &

Breathing

No stridor

No cyanosis

No severe respiratory distress

Breathing regularly

Circulation 1 Warm Hands

Child looks abnormally

sleepy and is very weak

Coma /

Convulsions /

Confusion

What Action would

you take?

When you

Check

The Finding is:

Airway &

Breathing

No stridor

No cyanosis

No severe respiratory distress

Breathing regularly

Circulation 1 Warm Hands

Coma /

Convulsions /

Confusion

Activity 2.1.2

Write down the actions you would take at the boxes labelled A,B,C,D and E.

Diarrhoea/dehydration No sunken eyes D

No convulsions

Looking at the mother

Not obviously confused

Tiny

Temperature

Trauma

2 years

Slightly hot, not very hot

Right forearm fracture

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Emergency Triage Assessment and Treatment - Plus (ETAT+)

Well done! I hope your responses compare favourably with the answers below:

A. Proceed to check circulation

B. Proceed to check other ''c's”

C. Proceed to check for diarrhoea/dehydration

D. Proceed to check for priority signs

E. Priority Case – front of the queue to be seen as soon as possible (check

weight and vital signs)

So far we have described the process of triage and attempted two activities to help you master

the skill. Now you need to find out how triage is practiced in your emergency unit. Please kindly

take some time to carry out assignment 2.1.1

Assignment 2.1.1

Take time to visit your paediatric emergency unit and look at how

triage is done.

1. How is the triage system organised?

2. Is there someone with a duty to do triage?

3. Is the person doing triage using the same signs/symptoms as

outlined in figure 2.1.1?

4. How can triage be improved in your emergency unit? Please

discuss this with the team working here.

Thank you for completing the assignment. I hope you made useful observations and

suggestions to help improve the process of triage in your unit. We will now summarize what we

have learnt in this unit so far.

2.1.4 Summary

In this unit we have learnt that triage is sorting out only.

Upon arrival at the hospital all sick children should be rapidly

screened. Those who are seriously sick should be offered emergency

care. Those with priority signs should be put in front of the queue to

receive prompt attention while those who are non-urgent can wait for

treatment.

Emergency Triage Assessment and Treatment - Plus (ETAT+)

SUMMARY

M O D U L E 2

2.1.5 Review questions

1. Briefly describe how you would improve the process of triage in your hospital.

2. Using the ABCD approach list down the signs and symptoms that you would use to triage a

patient as:

i. Emergency.

ii. Priority?

iii. Non-urgent?

3. What does 3TPR MOB stand for in priority signs?

2.1.6 References

1. WHO guidelines 2010 Maternal, new-born, child and adolescent

health;http://www.who.int/maternal_child_adolescent/en/

2. Kenya Clinical Guidelines, 2013; http://www.idoc-africa.org

3. World health Organization, 2013; Hospital Care for Children;

Guidelines for management of common illnesses with limited resources

4. Ministry of Health-Kenya; 2013; Basic Paediatric Protocols

M O D U L E 2

Emergency Triage Assessment and Treatment - Plus (ETAT+)

UNIT 2: ABC APPROACH TO THE MANAGEMENT OF THE

COLLAPSED CHILD

Unit Outline

2.2.1 Unit Introduction

2.2.2 Unit Objectives

2.2.3 Definition and pathophysiology of cardiopulmonary collapse

2.2.4 Important factors for success in Resuscitation

2.2.5 The equipment and resources required for resuscitation in paediatric emergency units

2.2.6 Structured ABC Approach to the Resuscitation of the collapsed Child

2.2.7 Summary

2.2.8 Review Questions

2.2.9 References and Further Reading

This unit will deal with the definition and pathophysiology of cardiopulmonary collapse and

discuss the important factors to consider when preparing our hospitals for paediatric

emergencies. We will also consider how we can use a structured ABCD approach to resuscitate

a collapsed child.

Let us get started by outlining the unit objectives.

2.2.2 Unit Objectives

By the end of this unit, you will be able to:

i. Explain the pathophysiology of cardiopulmonary collapse

ii. Explain the important factors for success in resuscitation

iii. List the equipment and resources required for resuscitation in the

area in which you deal with paediatric emergencies

iv. Describe the steps in the structured approach to the resuscitation

of the collapsed child

I hope you will find this unit to be very useful in your day- to- day practice. First, we will begin

by looking at the definition and pathophysiology of cardiopulmonary collapse.

Cardiopulmonary collapse refers to a pre-terminal state where a child is either not breathing

(apnoeic) or breathing inadequately and where the child's heart rate is less than 60 beats per

2.2.3 Definition and pathophysiology of cardiopulmonary collapse

Emergency Triage Assessment and Treatment - Plus (ETAT+)

M O D U L E 2

minute or absent. Children with gasping respirations are also treated as having developed

cardiopulmonary collapse. More commonly, their cardiopulmonary compromise results from a

gradual decline in respiratory and/or circulatory function. This results into inadequate or lack of

oxygen delivery and blood flow to the vital organs. Without adequate oxygen supply and blood

flow to these body organs, they may stop functioning well and the patient may eventually die.

This therefore means that urgent treatment should be commenced to immediately restore

delivery of oxygen to the lungs and blood and to improve blood flow to these vital body organs.

Now let us see how it is specific for children.

Sick children rarely undergo sudden cardiopulmonary collapse. Unlike adults, children

collapse because of lack of oxygen to vital organs or lack of blood flow to vital organs. Heart

attacks in children are incredibly rare unless they have a pre-existing heart condition.

Initially, the body may compensate for the decline in oxygen delivery or blood flow to the vital

organs by working extra hard to increase both the respiratory and heart rates. This temporary

mechanism is referred to as compensated respiratory and/or circulatory failure, respectively.

Eventually, however, these compensatory mechanisms may be overwhelmed as the condition

further deteriorates, especially if immediate treatment is not commenced. The child may then

progress to a state of decompensated cardiac or pulmonary failure when the supply of oxygen to

the body is less than is needed for the organs to function. Again if there is no urgent intervention

the child often rapidly progresses to cardiopulmonary arrest and may die.

This pathophysiology of cardiopulmonary collapse is summarized in figure 2.2.1.

Compensated

Circulatory Failure

Decompensated

Circulatory Failure

Decompensated

Respiratory Failure

Cardiopulmonary

Failure

Cardiopulmonary

Arrest

Compensated

Respiratory Failure

M O D U L E 2

Emergency Triage Assessment and Treatment - Plus (ETAT+)

Figure 2.2.1: Progressive Deterioration to Cardiopulmonary Arrest

As we shift our attention to the causes of respiratory and cardiac failure, complete activity 2.2.1.

Activity 2.2.1

List three common conditions that could potentially lead to respiratory

failure

Well done! Now, review the following information regarding the causes of respiratory failure.

Respiratory failure often results from severe illnesses affecting the respiratory system. These

include severe pneumonia, asthma and bronchiolitis. These children often present to hospital

with worsening respiratory distress. Occasionally, children may undergo respiratory failure

from hypoventilation (breathing too slowly) in neurological illnesses (like meningitis) or

following the use of sedative medications. Rarely respiratory failure is caused by a severe

blockage of the airway. This can be caused by some illnesses or an inhaled foreign body.

Managing a critically impaired airway requires great skill and is not covered in the ETAT+

course – always look for the best help possible if faced with this situation.

Having looked at the causes of respiratory failure, please attempt activity 2.2.2

Causes of Respiratory Failure

Activity 2.2.2

List three common conditions that could potentially lead to circulatory

failure in sick children

Good! Now compare your answer with the following information regarding the causes of

circulatory failure.

Circulatory failure may result from severe anaemia, dehydration and septic severely impaired

circulation (shock). These problems are tackled in ETAT+. Other causes of circulatory failure

include severe haemorrhage (often with trauma), severe burns, or anaphylaxis. Children with

acquired or congenital heart diseases may also develop circulatory failure from their heart

failure. These conditions are not covered in the ETAT+ course.

These children should be prioritized to receive care to avoid deterioration to the point of

collapse.

Having looked at the causes of cardiorespiratory collapse, we will now turn our attention to the

important factors that may ensure that our resuscitation efforts are successful.

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M O D U L E 2

2.2.4 Important factors for success in resuscitation

As you begin, kindly take time to answer the following question

Question 2.2.1

Explain why adequate preparation and prompt treatment is necessary in

emergency situations?

Thank you for your effort. It is important to keep in mind that once cardiopulmonary

compromise occurs, even with adequate resuscitation. Mortality is high in most cases.

Research has shown that more than 90% of children who present to the emergency units in our

hospitals with cardiopulmonary failure cannot be resuscitated successfully because they either

present too late or the units are not adequately prepared and equipped to handle such

emergencies promptly. Even amongst the children who may be successfully resuscitated, many

of them have been shown to develop significant disabilities thereafter.

It is therefore very important to put in place adequate measures for prompt recognition and

early intervention for all sick children to prevent them from progressing to cardiovascular

collapse.

Please answer the following question before you proceed

Question 2.2.2

What measures can we put in place to ensure that children who suffer

cardiopulmonary collapse receive prompt and adequate resuscitation?

Well done!

The key to successful resuscitation is adequate preparation and early recognition of the

seriously sick child. The staff should be knowledgeable in resuscitation. The appropriate

equipment and resources must be available. The environment or setting must also be conducive

and safe.

There must be a structured and effective system for handling paediatric emergencies that the

staff is familiar with. This system should comprise the following important aspects:

i. Clearly identified team members and a system of coordinating their activities

ii. A conducive and safe environment or area for resuscitation

iii. Appropriate and adequate resuscitation equipment and resources.

M O D U L E 2

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In addition, it is also important for doctors, nurses and clinical officers to have the knowledge

and skills to promptly recognize children with emergency signs and intervene appropriately

before they deteriorate to cardiopulmonary arrest. Having looked at the measures that can help

improve resuscitation outcomes, let us now enumerate the equipment required in emergency

units.

As we prepare to talk about the equipment and resources required for resuscitation, please take

some time to complete the following assignment.

2.2.5 The equipment and resources required for resuscitation in paediatric

emergency units

Assignment 2.2.1

Take some time to visit your paediatric emergency unit and identify and

list the equipment and resources available for resuscitation of children in

your unit. Remember, children come in a variety of sizes! Is your unit

organised and equipped to deal with a 5 kg infant, a 15kg child and others?

Thank you for making an effort to visit your department to collect that important information.

You may now compare your list with the one provided on table 2.2.1 and see what equipment or

resources you may be missing and possibly bring it to the attention of the unit in-charge.

Table 2.2.1 Equipment and resources required for resuscitation

Domain

Equipment/ resources required

Airway

Suction tubes/catheters

–

should be rigid, large bore suction devices (Yankauer type)

and FG 14 or larger flexible suction tubes

Gguedel airways – these should be a full range of sizes (are there guidelines on how

to choose the correct size?)

Breathing

Bag

Valve Mask (BVM)

devices ,500 ml, 1750 ml

that are in working order with

different face masks (sizes 0,1,2,3);

oxygen source and delivery

high flow oxygen 10

L /min

system, nasal catheters/prongs, , oxygen face -masks (with and without

reservoir bags), salbutamol nebuliser or MDI with mask/spacer, stethoscope

Circulation

IV giving sets, syringes (including 20 cc), paediatric cannulae, intraosseous needles,

IV fluids

(Ringer’s lactate), adrenaline, sample bottles

Disability

10% dextrose

Others

Resuscitation table/resuscitaire, warming devices for babies getting emergency care,

NG tubes (FG 6,8,10,12), weighing scales, gloves , sharps containers, alcohol hand

rub (or soap and water)

Easily accessible guidelines, walls charts

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M O D U L E 2

So far we have looked at the definition and pathophysiology of cardiopulmonary collapse, the

important considerations for success in resuscitation and the required equipment and resources.

We will now discuss the structured ABC approach to the resuscitation of a collapsed child.

The resuscitation of the collapsed child follows a structured approach as shown in the simple

algorithm in figure 2.2.2

2.2.6 The structured ABC approach to the resuscitation of the collapsed child

Figure 2.2.2: The ABC approach to the collapsed child

We will now discuss each of the above steps individually. Usually either you have observed a

patient collapse or have been called to see a patient who has collapsed as the entry point to using

this ABC.

First, it is important to ensure safety. To adequately assess this, you should ask yourself:

Am I safe? Personal safety includes wearing gloves and ensuring that you are protected

from sharps and potentially infective body fluids

Is the patient safe? Patient Safety involves transferring the patient to an appropriate

setting, a clean firm flat surface for resuscitation, free from contamination or sharp

objects.

The next consideration is providing stimulation. Here, you should ask yourself:

Is the patient responsive to stimulation? To establish this, try to rouse the patient by

calling out their name (vocal stimulation) and/or gently tapping them on the shoulders

(tactile stimulation)

If the child does not respond to your stimulation, you should then shout for help from your

colleagues or other health care workers because you will need their assistance during

resuscitation

After considering safety, stimulation and the need to shout for help, you can now progress to

manage the Airway, Breathing and Circulation in that order.

1. Safety, Stimulate and Shout for Help:

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We will begin by focussing on the assessment and management of the Airway.

When doing assessment of the airway you should ask yourself:

Is the airway clear or obstructed?

Is it correctly positioned?

To answer the first question, begin by looking in the child's mouth to see whether there is any

removable foreign body or secretions.

If you find a foreign body, go ahead and remove it gently. If there are secretions these should be

cleared with an appropriate suction device.

2. Airway Assessment and Management

Take note 2.2.1

Deep or blind Suctioning is unnecessary and even dangerous. It could

cause additional airway trauma and reduce the heart rate.

To answer the second question, you need to correctly position the airway using the head tilt chin

lift manoeuvre to either the neutral or sniffing position, depending on the age of the patient. For

infants younger than one year, this manoeuvre should be used to position their airway into a

neutral position where the nose and mouth are at a plane parallel to the resuscitation table. The

correct neutral position is illustrated in Figure 2.2.3

Figure 2.2.3 Head Tilt Chin Lift Manoeuvre to Neutral Position

In children older than one year, this manoeuvre should be used to position the airway into a

sniffing position; with the chin being raised above the nose. The correct sniffing position is

illustrated in Figure 2.2.3.

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M O D U L E 2

Figure 2.2.4: Head Tilt Chin Lift Manoeuvre to Sniffing Position

Both the neutral and sniffing positions will be demonstrated when you do your practical later

for a better understanding. We will now turn our attention to the assessment of breathing and its

management.

To assess for breathing, we need to ask, 'Is the child breathing?'

To adequately assess for breathing, we need to look, listen and feel for breathing for 5-10

seconds.

i. Look for the rise and fall of the chest with each breath

ii. Listen for the presence of the breath sounds

iii. Feel for the presence of the warmth of the child's breath on your cheek

This assessment can be performed by closely listening at the child's nose and mouth, while

feeling for air movement, as we look at their chest. The correct position for assessment is

illustrated in Figure 2.2.5.

3. Assessment and Management of the Breathing

Figure 2.2.5: Look, Listen and Feel for Breathing

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If the child is not breathing or only taking a few breaths a minute, it is important to ventilate the

child using a functioning self- inflating BVM device and a correctly fitting face mask.

Take note 2.2.2

Gasping is NOT adequate breathing and the child needs to be ventilated

using a BVM device.

To check whether the BVM device is working properly, block off the patient's connection with

your thumb and compress the bag attempting to push the air out of the bag to see whether it

empties easily. A functional bag will not empty easily, but would retain the air with gentle

compression. If the air empties too easily, then the bag is probably leaking. Bag mask devices

with pressure valves are designed to release air at the valves if pressed too hard.

The correct mask should then be identified and attached to the BVM Device. An ideal mask for

resuscitation should be a clear mask that covers both the nose and mouth. It should not go below

the chin or have the mask rim across or above the level of the eyes. Using a mask that is either

too large or too small makes it difficult to achieve an adequate seal to deliver the ventilation

breaths. The correct mask size is illustrated in Figure 2.2.6.

Figure 2.2.6: Correct Sizing of the Masks for Ventilation

Once you have chosen the correct mask size, then go ahead and administer 5 rescue breaths,

with each breath lasting 1 – 2 seconds. Learning how to hold the bag valve mask device to

maintain a seal is very important. This will be taught in the practical classes but if you have a

chance to practice on a manikin in your facility then do so. Delivering the breaths at the

appropriate speed ensures adequate pressure to inflate the chest and prevents stomach

distension. It is very important that you see the chest rise as you give the ventilations. The

rescue breaths should be delivered in the position illustrated in Figure 2.2.7 and you will notice

the 'C' (or 'E') grip being used.

Emergency Triage Assessment and Treatment - Plus (ETAT+)

M O D U L E 2

Figure 2.2.7: Ventilating a Baby with a Self Inflating Bag Valve Mask Device

Once, the rescue breaths have been administered, you need to assess and manage the

circulation.

The first step involves assessing the child for the presence and character of a large pulse. This is

assessed in different areas according to the child's age.

In children, aged below 1 year, the large pulse is assessed at the brachial pulse. This is found on

the inner aspect of the arm, slightly above the elbow joint as illustrated in Figure 2.2.8

4. Assessment and Management of the Circulation:

Figure 2.2.8: Assessing the Brachial Pulse

In children, older than 1 year, the carotid pulse is assessed by palpating below the angle of the

jaw, in the ridge between the larynx and the sternocleidomastoid muscle.

The large pulse should be palpated for 5 – 10 seconds to determine its presence. If the pulse is

absent or estimated to be less than 60 beats per minute (1 per second), then you need to

administer chest compressions.

The correct position for chest compressions is in the midline one finger breath above the

xiphisternum, as illustrated in Figure 2.2.9.

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Emergency Triage Assessment and Treatment - Plus (ETAT+)

Figure 2.2.9: Chest Compressions administered by a Single Rescuer

Once the landmark is identified, cardiopulmonary resuscitation (CPR) should be commenced

at the rate of 15 chest compressions to 2 ventilation breaths, for a total of 6-7- cycles in a minute.

The patient should be reassessed every 2-3 minutes to see if there is any improvement or if

management should be changed.

Figure 2.2.10: Optimal Site for Chest Compressions by two Rescuers

After going through the CPR for 2 -3 min, we will now reassess the child. The steps of

reassessment are as follows.

1. Look into the airway again, for the presence of Secretions or Foreign Material. If present,

these should be removed by gentle suction

5. Reassessment

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M O D U L E 2

2. Look, Listen and Feel for Breathing while also palpating for the Large Pulse.

a. If child is breathing regularly and the pulse is more than 60 beats per minute then

start the child on oxygen

b. If the child's breathing is inadequate (weak and slow with rate 15-20 or less

depending on age, or intermittent gasping), but the circulation is normal (heart rate

is more than 60/min) you continue to only ventilate the baby (without chest

compressions) at 30 breaths per minute.

c. If the child's breathing is inadequate (weak and slow with rate 15-20 or less

depending on age, or intermittent gasping) and the circulation is also inadequate

(heart rate is less than 60/min) then you must continue to offer CPR with

reassessments every 2-3 minutes.

The ABC Approach is summarized in the following algorithm.

Take note 2.3

Keep calling for help – providing effective ventilation and compressions

is much better done with two people. Adrenaline may be considered at the

dose of 0.1ml/kg of 1 in 10000 solution. Adrenaline should only be

administered if you have at least 3 rescuers – then one can focus on

preparing and giving the adrenaline without disturbing the CPR.

Additionally, IV bolus fluid therapy may be given to correct

hypovoleamic shock caused by dehydration; and 10% dextrose at 5

mls/kg for Hypoglycaemia

M O D U L E 2

Emergency Triage Assessment and Treatment - Plus (ETAT+)

Figure 2.2.11 – ABC Algorithm for the Collapsed Child

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M O D U L E 2

Congratulations, for completing this unit. Now take some time to complete the

following review exercise

Scenario 2.2.1

Consider the following case study and answer the questions that follow:

A one-year old boy named Jack is carried into the outpatient department in his mother's arms.

He is reported to have had cough and fast laboured breathing over the last 3 days. The mother

also reports that Jack was unable to breastfeed owing to his breathlessness the previous day.

Today, his mother says he has been drowsy and could not be aroused for the last 2 hours. She

also reports that she noted that the child was not breathing on arrival to hospital. The child is

brought in to emergency room for resuscitation care.

1. What signs and symptoms point to cardiopulmonary collapse in this child?

2. List 3 possible causes of cardiorespiratory failure in this child?

3. List the equipment and resources that you will require in the resuscitation of this

child?

4. What sequential steps will you take to assess and resuscitate this child?

We have come to the end of the unit, now go through the summary

2.2.7 Summary

This unit, we have learned that;

1. Cardiopulmonary collapse is often the final result of the gradual

decline in respiratory and circulatory function.

2. To increase the effectiveness in managing sick children, we must try

to prevent children from collapsing by intervening before the

collapse and be adequately prepared to resuscitate them

3. All paediatric care settings must have the necessary equipment to

resuscitate the children under their care

4. Following a stepwise ABC approach to the resuscitation of the

collapsed child with frequent reassessments every 2 -3 minutes may

increase your chances of success.

SUMMARY

M O D U L E 2

Emergency Triage Assessment and Treatment - Plus (ETAT+)

2.2.8 Review questions

1. Define and explain the pathophysiology of cardiopulmonary collapse.

2. List the factors that can predispose to cardiopulmonary collapse?

3. Briefly explain why it is important for hospitals to be adequately prepared for paediatric

emergencies

4. List the equipment and resources required for resuscitation?

5. Describe the structured approach for resuscitating a collapsed child?

2.2.9 References

1. World Health Organization (2013). Pocket book of hospital care for

children. Guidelines for the management of common illnesses with

limited resources. WHO.

2. Ministry of Health (2013). Basic Paediatric Protocols – Revised

Protocols. Ministry of Health: Kenya.

3. World Health Organization (2005). Emergency Triage Assessment

and Treatment – Manual for Participants. WHO.

Emergency Triage Assessment and Treatment - Plus (ETAT+)

M O D U L E 2

UNIT 3: ABCD APPROACH TO THE MANAGEMENT OF

THE CHILD WITH SIGNS OF LIFE (NON-COLLAPSED

CHILD)

Unit Outline

2.3.1 Unit Introduction

2.3.1 Introduction

2.3.2 Unit Objectives

2.3.3 Background and Rationale

2.3.4 Recognizing the Seriously Ill Child

2.3.5 Rapid Assessment of the Seriously Sick Non Collapsed Child

2.3.6 Summary

2.3.7 Review Questions

2.3.8 References and further reading

Greetings!

Welcome to Unit 3 of this module. This unit will help you to learn a simplified and structured

ABCD approach to assessing and instituting lifesaving treatment in a child with signs of life.

2.3.2 Unit Objectives

By the end of this unit, you will be able to:

i. Explain the rationale of having a rapid assessment for every sick

child on presentation to hospital

ii. Recognize the seriously ill child using simple signs and

symptoms.

iii. Describe the sequence of assessment and the required

interventions in the structured ABCD approach of the non-

collapsed child.

2.3.3 Background and Rationale

Before we start take some time to answer the following question:

Question 2.3.1

How do sick children progressively develop cardiopulmonary collapse

and arrest?

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Emergency Triage Assessment and Treatment - Plus (ETAT+)

Well Done!

As we discussed in Unit 2.2 children suffer cardiopulmonary collapse following a gradual

decline in either cardiac or pulmonary function when the particular causes such as severe

dehydration, severe pneumonia or severe infection are not recognized early and treated

immediately. By the time a child collapses, only emergency resuscitative measures may help

save their lives. However, if these emergency measures are instituted late when the child's

condition has severely deteriorated, then these may not be successful and the child may die.

Therefore, much effort should be directed at prevention or early identification and treatment of

the causes of cardiopulmonary compromise in order to prevent these children from progressing

to cardiopulmonary failure or arrest.

In addition, it is widely recognized that majority of the deaths that occur amongst children

presenting to hospitals in Africa, occur within the first 24 hours of arrival to the hospital.

Fortunately, most of these deaths result from preventable causes. This means that if the

appropriate treatment is given in the first few minutes of a child's arrival to the hospital then it is

possible to prevent death and reduce the mortality rates of children in our hospitals.

Could you please take some time to answer the following question before we proceed?

Question 2.3.2

What is the most important factor for saving lives amongst critically

ill children presenting to our hospitals as was discussed in Module 2,

unit 2?

Well done! Prevention of further deterioration of the critically sick child through immediate

recognition and intervention is the most important factor if we are to reduce deaths from

common childhood illnesses.

This can be done if we follow a structured approach to assessment and intervention in these

children. We manage this by using the ABCD approach.

The main aim of the ABCD assessment of a child with signs of life is to make the child as stable

as possible by intervening appropriately, before taking a full history and clinical examination.

The ABCD assessment is therefore conducted to recognize and immediately correct emergency

signs which are a threat to life.

Since the assessment comprises a series of simple steps it can be performed by any healthcare

worker with basic training in resuscitation. This increases the chances that sick children will

receive lifesaving emergency treatment early enough to prevent them from deteriorating and

dying.

Emergency Triage Assessment and Treatment - Plus (ETAT+)

M O D U L E 2

Let us now consider how we recognize a sick child who requires urgent treatment using the

structured ABCD approach to the Non-Collapsed Child.

To be able to recognize the seriously ill child you need to identify the emergency signs which

point to problems either in the Airway, Breathing, Circulation and/or Disability (Level of

Consciousness).

Before we start using the ABCD approach in these children, however, we need to check:

i. Are we prepared to provide emergency care – always check where you are working

that the right equipment and resources are available

ii. Has the child collapsed or are there clear signs of life – you may need to observe and

stimulate to check for clear signs of life

iii. Do you need help?

iv. Have you considered your safety and that of the child

If you identify clear signs of life and are adequately prepared then start the ABCD. The ABCD

aimed at the severely ill child with clear signs of life can be used for infants / children who are

still alert while they remain seated with their mother / carer if this will keep them most calm and

minimise distress. If they are not alert then transfer the child to an examination bed / couch.

First we will consider signs related to the airway. However, before, we continue, please carry

out activity 2.3.2

2.3.4 Recognizing the Seriously Ill Child

1. Signs that point to Airway Problems

Activity 2.3.2

List down at least two signs that point to a problem with the airway

Well done! You can now look at the following information and compare it with your answer:

The main sign that points to a problem with the airway in the child with signs of life is the

presence of noisy breathing. Assessment of the airway should therefore involve listening to

sounds such as stridor and/or bubbling/crackling (gargling) sounds (sounds of excessive

secretions at the back of the throat). Remember this should not take more than 10 seconds.

In the child who is alert and sitting with the carer then to check the airway simply stand with

your head close to the child's and listen carefully – do not try to force the mouth open to look

inside. If there is severe stridor or sounds of obstruction you may need to call for expert help

M O D U L E 2

Emergency Triage Assessment and Treatment - Plus (ETAT+)

while enquiring about possible inhalation. It is not appropriate to try suction in a child who is

alert.

The child who is unresponsive or has reduced level of consciousness should be placed on a

resuscitation table/couch for further assessment and treatment. The mouth should be opened

gently and examined for the presence of secretions or foreign body. Presence of these signs

requires urgent intervention to clear the airway. The airway may also need to be positioned

either in a neutral (infants below one year) or sniffing (children above one year) position to

make sure if remains clear.

Additionally, the maintenance of the airway may involve the use of the oropharyngeal (Guedel)

Airways that prevent the tongue from falling back and obstructing the airway in the

unconscious child. Figure 2.3.1 shows the different sizes of oropharyngeal airways. These

should only be used where there is reduced consciousness.

Figure 2.3.1: Oropharyngeal Airways (Guedel Airways)

Before using the oropharyngeal airway, it is important to choose the correct

size.

To get the right size, use the device itself as a measure. When you place it on the patient's cheek

with the flange parallel to his front teeth, the tip of the oropharyngeal airway should reach no

further than the angle of the jaw. If the airway is too long, it could obstruct breathing by

displacing the tongue against the oropharynx. If it's too short, it won't be able to hold the tongue

away from the pharynx, and patency won't be restored. Figure 2.3.2 shows the correct sizing of

the oropharyngeal airway

Emergency Triage Assessment and Treatment - Plus (ETAT+)

Figure 2.3.2: Sizing the Oropharyngeal Airway for Placement

M O D U L E 2

2. Signs that point to Inadequate Breathing

Next, let us consider the signs that point to breathing problems. Before we proceed, kindly

complete activity 2.3.3.

Activity 2.3.3

List five signs that point to breathing problems or indicate respiratory

distress

Well Done, The following signs point to inadequate respiration:

• Central Cyanosis

• Respiratory rate:

– Very Fast or Very Slow Respiratory rates for age

• Increased respiratory Effort

– Grunting?

– Head nodding / bobbing?

– Lower chest wall indrawing?

– Deep / acidotic breathing?

– Symmetrical movement?

• Wheezing or crackles

– Oxygen Saturation Pulse oximetry reading of < 90%

Amongst these, some signs indicate severe respiratory distress and may be signs of impending

respiratory failure. These include central cyanosis, deep acidotic breathing, grunting and head

nodding.

Additionally, if any of the signs is accompanied by a reduction in the child's level of

consciousness or a reduction in the child's ability to feed, then the respiratory distress is

considered to be severe.

Presence of one or a combination of any of these signs indicates that the child may be

hypoxemic and therefore needs treatment with oxygen. Using pulse oximetry will actually

allow you to measure the blood oxygen saturation and is the best way to make decisions on

using oxygen as well as monitor whether the treatment is effective.

Immediate bronchodilator therapy may also be required when wheezing is noted when it is

accompanied by respiratory distress.

M O D U L E 2

Emergency Triage Assessment and Treatment - Plus (ETAT+)

Having mentioned the signs of inadequate breathing, let us now highlight the signs of

inadequate circulation

Simple clinical signs can be very helpful in rapidly assessing the circulatory system. One

should look out for the following signs that indicate an inadequate circulation:

Cold hands and feet (taking into account environmental or ambient temperatures) The

temperature gradient of the extremities (how far the coldness of the upper limbs and

lower limbs extends upward to the elbow/knee or shoulder/hip)

The presence / absence and character of the central pulse (brachial or carotid pulse)

The presence and strength of the peripheral pulse should also be assessed to determine

if it is weak, absent or strong.

Pulse rate- to determine if it is too fast (>180/min in a child less than 1 year, and

>160/min in a child more than one year) or too slow (<60 /minute).

Capillary refill time to determine if the refilling is prolonged >3 sec when the child is in

a warm environment. Note it is best to count and record the actual refilling time in

seconds as this can help you see if a child is getting better or worse.

Blood pressure should also be measured – although this is not commonly done in many

of our facilities in children it should be done, and done accurately in seriously ill

children. In the ETAT+ guidelines and practical we do not refer to blood pressure – but

this is for practical reasons not because it is unimportant!

Presence of any one of these signs suggests an inadequate circulation. If any one of these signs

is present, remember to also assess for:

a) Skin turgor to determine if it takes longer than 2 seconds.

b) Ability to drink (should be demonstrated as a sign by the health care worker - involves

actually visualizing the child drinking or breastfeeding)

c) Sunken eyes (Are the eyes sunken according to the mother?)

3. Signs of Inadequate Circulation:

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M O D U L E 2

Take note 2.3.1

The environment and the ambient temperature can affect both the

temperature of the hands as well as the return of capillary refill. It is

therefore an important consideration in assessing the adequacy of the

circulation.

In addition, presence of these signs in combination may point to serious and potentially life

threatening circulatory problems.

Before we proceed please complete activity 2.3.4

Column B:

Severe Pallor in a Child with

respiratory distress

Cold hands plus a weak/ absent

pulse and capillary refill more

than 3 seconds and AVPU < A

(all four signs) without diarrhea

or signs of dehydration

Unable to drink or AVPU< A

plus: sunken eyes and return of

skin pinch =2secs

Column A:

Severely impaired

circulation with no

diarrhoea / dehydration

Severe Dehydration

Severe Anaemia

Activity 2.3.4 Match the diagnosis in column A with the group of

symptoms in column B

Good

You can now compare your answers with the following explanations

1. Severely impaired circulation without diarrhoea / dehydration, usually in a child with

a severe febrile illness– this is diagnosed when a child is noted to have cold hands plus

a weak / absent pulse and Capillary refill > 3 secs and AVPU < A (all four signs) but

there is no evidence of diarrhea / dehydration. It is important to recognize this group as

their fluid management is not the same as those who have these signs together with

diarrhea/dehydration. Those with diarrhea/dehydration who have these signs are

M O D U L E 2

Emergency Triage Assessment and Treatment - Plus (ETAT+)

treated for hypovolaemic shock. This management will be covered in later modules.

2. Severe Dehydration – A child who is unable to drink or AVPU < A plus: sunken eyes

and return of skin pinch =2 secs with a history of diarrhea. Often these children may

have some signs of an impaired circulation (eg a slow capillary refilling) but they do

not have all four signs described above that would indicate a severely impaired

circulation.

3. Severe Anaemia: Severe palmar pallor with or without respiratory distress

If a severely impaired circulation is identified because a child has all four critical signs then

specific fluid therapy is indicated. If there is diarrhoea/dehydration (presence of the signs

sunken eyes and skin pinch of 2 or more seconds) then urgent intravenous fluid therapy is

required. If there is a severely impaired circulation but no diarrhoea/dehydration then fluids are

given more slowly. For severe anaemia in the presence of respiratory distress (especially

characterised by acidotic breathing) indicates the need for an urgent blood transfusion.

We will now continue to disability and use of the AVPU Scale.

In order to determine neurological disability in relation to the child's illness, use of a simplified

scale to assess the level of consciousness is recommended.

Take time to answer question 2.3.3

Disability and the AVPU Scale

Activity 2.3.3

Name three examples of scales which are used to assess the level

consciousness in sick children.

Good answer!

There are various scales which have been used to assess the level of consciousness in children

including:

i. Paediatric Glasgow Coma Scale

ii. Blantyre Scale

iii. AVPU Scale

Emergency Triage Assessment and Treatment - Plus (ETAT+)

M O D U L E 2

In this unit, we will discuss the use of the AVPU scale in assessing the level of consciousness of

sick children by looking at its various components: