Pediatric Triage

Dr C. Naveen Kumar

PG in Pediatrics

Dr Naveen Kumar CheriS.V. Medical College, Tirupati

What is Triage?

• French verb “trier”, means to separate or select.

• Triage is the process of rapid assessment of a patient with a view to define urgency of care & priorities in treatment.

• It helps in rational allocation of limited resources, when demand exceeds availability.

• Triage is the first step in the management of a sick child admitted to a hospital.


STEPS IN THE MANAGEMENT OF THE SICK CHILD ADMITTED TO HOSPITAL

TRIAGE

Check for emergency signs

Check for priority signs

Emergency treatment

Rapid assessment & treatment

Non-urgent cases & stabilized cases

• History and examination

• Laboratory and other investigations

• List and consider DIFFERENTIAL DIAGNOSES

• Select MAIN (WORKING) DIAGNOSIS and Secondary diagnoses

• Plan and begin INPATIENT TREATMENT (including supportive care)

YES

NO

NO

CO

UN

SELIN

G


STEPS IN THE MANAGEMENT OF THE SICK CHILD ADMITTED TO HOSPITAL(Contd.)

Monitor for

• Response to treatment

• Complications

INPATIENT TREATMENT

• Continue treatment

• Plan for discharge

• Revise treatment

• Treat complications

• Refer if not possible

IMPROVINGNOT IMPROVING OR

NEW PROBLEM

CO

UN

SELIN

G


When should Triage take place?

• As soon as the sick child arrives at hospital.

• Before any administrative procedure such as registration.

Where should Triaging be done?

• Can be carried out any where.

• At Emergency Room, at OP queue, at ICU or at ward.


Who should triage?

• All the staff working in a health care facility should be trained to carry out rapid assessment of sick child and triage.


Different Triage systems

•WHO – ETAT (Emergency Triage Assessment and Treatment) guidelines

Pediatric Triage according to F-IMNCI module: EPN (Emergency, Priority & Non-urgent) system

Triage of newborns according to FBNC module: EPN (Emergency, Priority & Non-urgent) system

• Emergency Severity Index

• Canadian Triage and Acuity Scale



• Rapid screening of the child to decide to which one of the following groups, the child belongs:

• Emergency treatmentEmergency cases

• Rapid assessment & actionPriority cases

• Can waitNon-urgent cases

Check for emergency signs

Check for priority signs

Emergency treatment

Rapid assessment & treatment

Non-urgent cases & stabilized cases

YES

NO

NO


Emergency signs (ABC3D)

Assessed & managed in the following five domains in sequential order:

• Airway & Breathing

• Circulation

• Coma

• Convulsions

• Severe Dehydration


Airway & Breathing - assessment

• Is the child breathing?

• Is there central cyanosis?

• Does the child have severe respiratory distress?

ABDr Naveen Kumar Cheri

S.V. Medical College, Tirupati


Is the child breathing?

• Look: If active, talking, or crying, the child is obviously

breathing. If none of these, look again to see whether the

chest is moving.

• Listen: Listen for any breath sounds.

• Feel: Feel the breath at the nose or mouth of the child.

Gasping is spasmodic open mouth breathing associated

with sudden contraction of diaphragm & retraction of hyoid

apparatus. It is a manifestation of brain hypoxia.




Is there central cyanosis?

• To assess for central cyanosis, look at the mouth and tongue.

• A bluish or purplish discoloration of the tongue and the inside of the mouth indicates central cyanosis.




Does the child have severe respiratory distress?

• Respiratory rate ≥ 70/min

• Severe lower chest in-drawing

• Head nodding

• Apneic spells

• Unable to feed due to respiratory problem

• Stridor (A harsh noise on breathing in is called stridor.)

• Grunting (A short noise when breathing out in young infants is called grunting.)



Airway & Breathing - management

Airway management

• If there is history of foreign body aspiration or if the child is choking with increasing respiratory distress, suspect foreign body.

• Clear any secretions in present.



Management of choking in young infant

Lay the infant on arm or thigh in a

head down position.

Give 5 blows to the infant’s back

with heel of hand. (Back slaps)

If obstruction persists, turn infant

over and give 5 chest thrusts with 2

fingers, one finger breadth below

nipple level in midline. (Chest

thursts)

If obstruction persists, check infant’s

mouth for any obstruction which can

be removed.

If necessary, repeat sequence with

back slaps again.



Management of choking in older child

Give 5 blows to the child’s back with

heel of hand with child sitting, kneeling

or lying. (Back slaps)

If the obstruction persists, go behind the

child and pass your arms around the

child’s body; form a fist with one hand

immediately below the child’s sternum;

place the other hand over the fist and

pull upwards into the abdomen; repeat

this Heimlich maneuver 5 times.

If the obstruction persists, check the

child’s mouth for any obstruction which

can be removed.

If necessary, repeat this sequence with

back slaps again.




Neck trauma – Suspect when there is history of trauma to head and neck region or history of fall or external injuries to head and neck region on examination.

• Keep the child lying on the

back on a flat surface.

• Tape the child’s forehead to

the sides of a firm board to

secure this position.

• Prevent the neck from moving

by supporting the child’s head.

• Place a strap over the chin.




Neck trauma

Jaw thurst is a way of opening the airway without moving

the head. Place two or three fingers under the angle of the

jaw on both sides, and lift the jaw upwards. (towards head

end)AB



Opening the airway in an infant & older child




•Manage airway

• Provide BLS - Basic Life Support

•Give Oxygen

•Make sure child is warm



Circulation - assessment

• Does the child have warm hands?

• If not, is the capillary refill time longer than 3 seconds?

• And is the pulse weak and fast?

C1



1. Does the child have warm hands?

• Take the child’s hand in your own. If it feels

warm, the child has no circulation problem

and you do not need to assess capillary refill

or pulse.

• If the child’s hands feel cold, you need to

assess the capillary refill time.

C1



2. Is capillary refill time longer than 3 seconds?

• Capillary refill is a simple test that assesses how

quickly blood returns to the skin after pressure is

applied.

• It is prolonged in shock because the body tries to

maintain blood flow to vital organs and reduces

the blood supply to less important parts of the

body like the skin (peripheral vasoconstriction).

The vessels open slowly because of low pulse

pressure.

C1



2. Is capillary refill time longer than 3 seconds?

• This sign is reliable except in cold

environment, as it can cause vasoconstriction

and a delayed capillary refill.

• In such a situation, check the pulses and

decide about shock.

C1


How to assess Capillary Refill Time?

• Apply pressure to the pink part of the nail bed of the

thumb or big toe in a child and over the sternum or

forehead in a young infant for 3 seconds.

• While applying pressure, count zero-zero-one-zero-zero-

two-zero-zero-three to make sure that it is 3 seconds.

And do the same while releasing pressure.

• The capillary refill time is the time from release of

pressure to complete return of the pink colour. It should

be less than 3 seconds.

• Lift the limb slightly above heart level to assess

arteriolar capillary refill and not venous stasis.

C1



3. Is the pulse weak and fast?

• In an infant (less than one year of age) the brachial

pulse may be palpated in the middle of upper arm. In

older children radial pulse can be palpated.

• If it is of normal volume and not obviously fast (Rate >

160/min in an infant and > 140/min in children above

1 year), the pulse is adequate and no further

assessment is needed.

• If peripheral pulses are of low volume, palpate central

pulses. If central pulses (femoral or carotid) are also

weak it is an ominous sign of shock.

C1


Circulation - management

• If the child has any bleeding, apply pressure to stop

the bleeding. Do not use a tourniquet

• Give Oxygen

• Make sure the child is warm

• Select an appropriate site for administration of fluids

• Establish IV or intraosseous access

• Rapidly assess if the child has severe acute

malnutrition.

• Begin giving appropriate fluids for shock.

C1


Check for severe malnutrition

Look for visible severe wasting

• A child with visible severe wasting

has a form of malnutrition called

marasmus.

• Look rapidly at the arms, legs &

chest for severe muscle wasting.

• Typically, the child appears to be

appears to be all skin and bone.

• The head may appear relatively

large because of wasting of the

body.Dr Naveen Kumar Cheri


Check for severe malnutrition

Check for oedema of both feet

• Oedema is a major sign of

kwashiorkor, a severe form of

longstanding malnutrition.

• Press the top of the foot gently

with your thumb for a few seconds.

• Oedema is present if a definite

dent is left in the tissues.

• Check if the other foot also has

oedema. Localized oedema can be

due to injury or infection.Dr Naveen Kumar Cheri


Circulation - summary

C1


Coma & Convulsion - assessment

• Is the child in coma?

• Is the child convulsing now?

C2,3



Is the child in coma?

• A child who is awake is obviously conscious and

you can move to the next component of the

assessment.

• If the child is asleep, ask the mother if the child is

just sleeping.

• If there is any doubt, you need to assess the level

of consciousness.

• Try to wake the child by talking to him/her, e.g.

call his/her name loudly.

C2,3



Is the child in coma?

• A child who does not respond to this should be

gently shaken (Little shake to the arm or leg).

• Don’t move the neck.

• If this is unsuccessful, apply a firm squeeze to the

nail bed, enough to cause some pain.

• A child who does not wake to voice or being

shaken or to pain is unconscious.

C2,3



Is the child convulsing now?

• Children who are actively convulsing should be

attended on an emergency basis.

• Children who have a history of convulsion, but are

alert during triage, need a complete clinical

history and investigation, but no emergency

treatment for convulsions.

C2,3



AVPU Scale

• A Is the child Alert? If not,

• V Is the child responding to Voice? If not,

• P Is the child responding to Pain?

• U The child who is Unresponsive to voice (or being shaken) AND to pain is Unconscious.

A child with a coma scale of “P” or “U” will receive emergency treatment for coma

C2,3


Coma & Convulsion - management

C2,3



Position the child

Unconscious child – No neck trauma

• Keep the child in recovery position.

• Turn the child on the side to reduce risk of aspiration.

• Keep the neck slightly extended and stabilize by placing the cheek on one hand.

• Bend one leg to stabilize the body position

• This position helps to reduce the risk of vomit entering the child’s lungs.

C2,3



C2,3

Recovery Position: Turn the child on the side. Keep the

neck slightly extended and stabilize by placing the cheek

on one hand. Bend one leg to stabilize the body position.Dr Naveen Kumar Cheri



Position the child

Unconscious child – Neck trauma suspected

• Stabilize the child while lying on the back.

• Use the “log roll” technique to turn the child on the side if the child is vomiting.

C2,3



C2,3

LOG ROLL: One person should stand at the head end of the

patient, hold the patient’s head, and place the fingers under

the angle of the mandible with the palm over the ears maintain

gentle traction to keep the neck straight and in line with the

body, while others are rotating the body.



Check blood sugar and correct hypoglycemia

C2,3

Age Blood glucose cut off Management

< 2 months < 45 mg/dL2 mL/Kg of 10%

Dextrose I.V

> 2 months < 54 mg/dL

5 mL/Kg of 10%

Dextrose I.V



C2,3


Severe Dehydration - assessment

Assess for severe dehydration if ABC3 assessments are normal.

If there is history of diarrhoea/vomiting look for presence of any two of the following signs:

• Is the child lethargic?

• Does the child have sunken eyes?

• Does the skin pinch take longer than 2 seconds to go back?

Also look if the child has severe malnutrition.

DDr Naveen Kumar Cheri



Is the child lethargic?

• Appears drowsy, may stare blankly and does not show interest in what is happening around him/her.

Does the child have sunken eyes?

• Look at the child’s eyes to determine if they appear unusually sunken in their sockets.

• Ask the mother if the child’s eyes are more sunken than usual, or if the skin around them appears darker than usual.




• Locate the area on the child’s abdomen

halfway between the umbilicus and the

side of the abdomen.

• Pinch the skin in a vertical (head to

foot) direction. Don't use finger tips.

• All the layers of the skin and the tissue

underneath should be picked up. Pinch

for one second and then release.

Does the skin pinch goes back very slowly

(> 2 sec?)



Severe Dehydration – management(In the absence of shock and severe malnutrition)

• Give the child a large quantity of fluids quickly according to Plan C.

• Fluid of choice: Ringer Lactate

• For infants:

o 30 ml/kg in the first hour

o 70 ml/kg in the next 5 hours

• For children > 1 year of age:

o 30 ml/kg in the first 30 minutes

o 70 ml/kg in the next 2.5 hours



Severe Dehydration – management(In the absence of shock and severe malnutrition)

• Assess the child every 1-2 hours

• If the signs of dehydration are not improving, give fluid more rapidly

• As soon as the child can drink:

o Give oral fluids in addition to the drip

o Give ORS 5 ml/kg every hour

oEncourage breast feeding

• If IV line couldn't be secured: Give 20 ml/kg/hour of Oral Rehydration Solution through nasogastric tube, for six hours.



Severe Dehydration – management(In severe malnutrition, in the absence of shock)

• Do not give IV fluids if possible.

• Give ReSoMal 5ml/kg every 30 minutes for the first 2 hours

• Then 5-10ml/kg/hour for the next 4-10 hours

• Give more ReSoMal if child wants more or large stool loss or vomiting

• Check blood glucose and treat hypoglycemia.



Severe Dehydration – management(In severe malnutrition, in the absence of shock)

ReSoMal (Rehydration Solution for Malnourished)

INGRADIENT QUANTITY

Water 2 Liters

ORS One 1 Liter sachet

Household sugar (Sucrose) 50 grams

Electrolyte / Mineral solution 40 ml



Priority signs (3TPR MOB)

• Tiny infant (< 2 months of age)

• Temperature (Fever)

• Severe Trauma or other urgent surgical condition

• Severe Pallor

• Poisoning & Envenomation

• Severe Pain

• Restless and Irritable or Lethargic

• Respiratory distress

• Urgent Referral

• Severe Malnutrition

• Oedema of both feet

•Major Burns


• Tiny infant (< 2 months of age)

Difficult to assess properly, more prone to get infections and are more likely to deteriorate quickly if ill.

So they should be attended on a priority basis.

• Temperature (Fever)

Children with high fever on touch need prompt treatment.

Check temperature with thermometer and give antipyretic while awaiting in the queue.


• Severe Trauma (or other urgent surgical condition)

Like acute abdomen, injuries and fractures.

• Severe Pallor

It is a sign of severe anemia,

Which might need urgent

transfusion. It can be detected

by comparing the child’s

Palms with your own.


• Poisoning / Envenomation

Children with a history of swallowing drugs or other dangerous substances or any bites need to be assessed immediately, as they can deteriorate rapidly and might need specific treatments.

• Severe Pain

If a child has severe pain and is in agony, she/he should be prioritized to receive pain relief and early full assessment.


• Lethargy or Irritable and Restless

AVPU scale - A lethargic child responds to voice but is drowsy and uninterested in surroundings.

Irritable or restless child is conscious but cries constantly and will not settle.


There may be signs present which are not severe, e.g. mild lower chest wall in-drawing , Respiratory rate < 70/min.

Such cases should be attended on priority.


• Severe wasting (Severe Malnutrition) & Oedemaof both feet

A child with visible severe wasting has a form of malnutrition called Marasmus.

Oedema of both feet is an important diagnostic feature of Kwashiorkor.

•Major Burns

Extremely painful and children who seem quite well can deteriorate rapidly.



EMERGENCY SIGNS

• Hypothermia (Temperature < 35.50 C)

• Apnea or gasping respiration

• Severe respiratory distress (rate > 70/min, severe retractions,

grunt)

• Central cyanosis

• Shock (cold periphery, CFT > 3 sec, weak & fast pulse)

• Coma, convulsions or encephalopathy

These neonates are at high risk.

Require urgent intervention and emergency measures.


PRIORITY SIGNS

• Tiny neonate (<1800 gms)

• Cold stress (Temperature 36.40C

– 35.50C)

• Respiratory distress (rate 60 –

70/min, no or minimal

retractions)

• Irritable/restless/jittery

• Refusal to feed

• Abdominal distension

• Severe pallor

• Severe jaundice (appears in <24

hrs / stains palms and soles /

lasts > 2weeks)

• Bleeding from any site

• Major congenital malformations

(Tracheoesophageal fistula,

Meningomyelocele, Anorectal

malformation)

• Large baby

The neonates with priority signs are sick and would need immediate

assessment.

They should be attended to on a priority basis. Dr Naveen Kumar CheriS.V. Medical College, Tirupati

NON - URGENT CASES

• Jaundice

• Transitional stools

• Developmental peculiarities

• Minor birth trauma

• Posseting

• Superficial infections

• Minor malformations

• All cases not categorized as Emergency/Priority


EMERGENCY SIGNS PRIORITY SIGNS NON URGENT CASES

• Hypothermia (temp<360

C)

• Apnea or gasping

respiration

• Severe respiratory distress

(rate>70, severe

retractions, grunt)

• Central cyanosis

• Shock (cold periphery,

CFT>3secs, weak & fast

pulse)

• Coma, convulsions or

encephalopathy

• Cold stress (temp 36.40C -

360C)


(rate>60, no retractions)

• Tiny neonate (<1800gms)

• Large baby

• Irritable/restless/jittery

• Refusal to feed

• Abdominal distension

• Severe jaundice

• Severe pallor

• Bleeding from any sites

• Major congenital

malformations

• Jaundice

• Transitional stools

• Developmental

peculiarities

• Minor birth trauma

• Posseting

• Superficial infections

• Minor malformations

• All cases not

categorized as

Emergency/Priority



Date post:	15-Jul-2015
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Pediatric Triage

Health & Medicine