Assessment of Critically Ill Child - Triaging Flashcards
Who is a critically ill child?
A child who requires or potentially requires high dependency or intensive care
When do most deaths of children admitted to the hospital occur? How could they be prevented?
Within 24 hours of admission.
Some of these deaths could be prevented if very sick children are identified early and treated immediately
How does triaging prevent deaths in children?
Facilitates rapid assessment and triage for all children presenting to hospital to identify those needing immediate emergency care
Steps in Management of the Sick Child
Triage (SATS)
Primary assessment (ABCDE approach)
Secondary assessment (SAMPLE history - in community settings/detailed history and physical examination)
Tertiary Assessment (Lab and Radiology Investigations)
Treatment (Definitive)
What is Triage?
The process of rapid assessment of a patient with a view to define urgency of care and priorities in treatment.
From the french word trier - to separate/sort.
First step in management of a sick child reporting to a health facility
What does Triage help in?
It helps in the rational allocation of limited resources, when demand exceeds availability in low resourced settings.
Expedites delivery of time critical treatment for patients with life threatening condition.
Improve patient’s satisfaction and decrease patients overall length of stay - ‘cause of less complications leading to faster recovery.
What is the purpose of Triage?
Identify sick patients before they become too sick and to prevent cardiac or respiratory arrests and/or ICU admissions. (Outcomes for children who develop cardio-pulmonary arrest are poor).
Most triaging systems seek to identify
Potential respiratory failure
Potential circulatory failure
Potential neurological failure & institute management preventing arrest.
Examples of conditions requiring immediate treatment to prevent death or disability
Respiratory distress / failure
Shock
Altered Sensorium/Coma
Anaphylaxis
Non-trauma surgical emergencies
Trauma
When should Triage take place?
As soon as the sick child arrives at the hospital, before any administrative procedures such as registration
Who should Triage?
All staff working in a health care facility should be trained on how to carry out rapid assessment of sick children and triage
Example of Triage systems
South African Triage Scale (SATS)
WHO-ETAT (Emergency Triage Assessment and Treatment)
Canadian Triage and Acuity Scale
Paediatric Triage according to F-IMNCI module: EPN (Emergency, Priority and Non-Urgent) system
Emergency Severity Index
Describe the South African Triage Scale (SATS)
+2 part tool
*TEWS (Triage Early Warning Score)- detect very urgent & urgent signs, measure vital signs (each given a score)
*Discriminators - Based on presence of emergency signs/senior health officer discretion, TEWS not needed - straight to resuscitation.
+2 versions
Adult (>12) and Paediatric (<12) version
+5 colours – Red, Orange, Yellow, Green and Blue (Based on priority level)
SATS Five Step Approach
Step 1 (Red): Look for emergency signs (if present, don’t continue steps but resuscitate) and ask for presenting complaint
Step 2(Orange & Yellow): Look for very urgent (if present, skip to step 3) then urgent signs (if no emergency signs present)
Step 3(Grey): Measure the vital signs and calculate the TEWS (If 7/more, resuscitate
Step 4(Blue): Check key additional investigations (can change TEWS - if 7/more resuscitate)
Step 5: Assign final triage priority level
What are the Triage Scores?
Very Urgent (Orange): TEWS 5 or 6
Urgent (Yellow): TEWS 3 or 4
Routine (Green): TEWS 0, 1 or 2
Deceased (blue)
Senior Healthcare professionals discretion
Approach to SATS Emergency Signs
ABC-c-c-DO approach: Airway-Breathing-Circulation/Coma/Convulsion-Dehydration-Others
Patient with any emergency signs should be sent directly to the resuscitation area; not necessary to calculate TEWS
SATS Emergency Signs - Airway and Breathing
Not Breathing or reported apnoea
Obstructed Breathing
Central Cyanosis or SpO2 less than 92%
Severe Respiratory Distress
To assess for AB: Is patient active talking/crying? Inspect movement of chest + abdomen, listen for breathing sounds, feel for air coming out of nose and mouth, listen for breathing (normal?)
Obstructed breathing
SATS Emergency Signs - Circulation & Coma
Circulation - Cold hands + 2 or more of the following:
Pulse weak and fast, Capillary refill time 3 sec or more, Lethargic
Uncontrolled bleeding (not nosebleed)
Coma - AVPU: Responds only to pain (P) OR Unresponsive (U)
Confusion
SATS Emergency Signs - Convulsions, Dehydration
Convulsions - Convulsing or immediately post-ictal and not alert
Dehydration - Diarrhea or vomiting + 2 or more of the following:
Lethargy/Floppy infant
Very sunken eyes
Skin pinch very slow - 2 sec or more
Other SATS Emergency Signs
Facial/Inhalation Burn
Hypoglycemia recorded at any time - glucose less than 3mmol/L
Purpuric rash
Signs of Airway Obstruction and Severe Respiratory Distress
Obstructed breathing - noisy. Grunting/Wheezing/Stridor
Respiratory Distress - Tachypnea, Use of accessory muscles of respiration, severe lower chest wall indrawing, head nodding/bobbing, inability to feed because of respiratory problems, grunting and flaring
SATS Very Urgent Signs
Tiny baby - younger than 2 months
Inconsolable crying/Severe pain
PC - More sleepy than normal
Poisoning or overdose
Focal neurology acute
Severe mechanism of injury
Burns (circumferential, electrical, chemical, 10% or more)
Eye injury
Fracture - open or threatened limb
Dislocation of larger joint (not finger or toe)
SATS Urgent Signs
*Some Respiratory distress
*Some dehydration - Diarrhea or Diarrhea and vomiting + 1 or more of the following: sunken eyes, restless/irritable, thirsty/decreased urine output, dry mouth, crying without tears, skin pinch slow - less than 2 sec.
*Some dehydration - Unable to drink/feed OR vomits everything + 1 or more of signs above (dehydration signs)
*Malnutrition (visible severe wasting)
*Malnutrition oedema (pitting edema of both feet)
*Unwell child with known diabetes
*Any other burn less than 10%
*Closed fracture
*Dislocation of finger or toe
What are the additional investigations and why are they done?
*May be indicated to identify potentially serious complications of their presenting conditions
*Additional investigations may change the triage priority level
*Investigations include Oxygen saturation and Capillary Blood glucose tests
SATS Priority Levels and Target
Priority Color Target Time Management
Red->Immediate->Take to resusc. for emergency management (emergency signs or High TEWS)
Orange - <10 mins - Refer to majors for very urgent management
Yellow - <1 hour - Refer to majors for urgent management
Green - <4 hours - Refer to designated area for non urgent cases
Blue - <2 hours - Brought in dead - Refer to Doctor for Certification
SATS Additional Tasks
PROBLEM -> IMMEDIATE TASKS
1. Poisoning OR overdose -> Refer to Senior Healthcare Professional (SHCP)
2. Child in pain OR inconsolable crying -> Check with SHCP for analgesia initiation
3. Child with a burn -> Check with SHCP for analgesia initiation
If burn occurred within 3 hours, cool the burnt area
Cover burn in clingwrap or clean dry sheet
4. Temperature 38.5 ° or more -> Remove excessive clothing & discuss with SHCP
5. Temperature 35 ° or less -> Warm the child with blankets if available. Refer to SHCP
6. Diarrhoea -> Take to ORT corner and advise caregiver to give ORT by cup
and spoon
7. Vomiting without diarrhoea but with dehydration -> Refer to SHCP for assessment
8. Presenting complaint - abdominal pain ->younger child - urine bag / older child - urine container
9. Closed fracture -> Check with SHCP for analgesia initiation
Immobilize affected limb with a simple padded splint or
triagular bandage
10. Active ongoing bleeding -> Apply pressure to the site of trauma
Perform finger prick haemoglobin to obtain a baseline
Refer to SHCP
11. History of recent bleeding ->Perform finger prick haemoglobin
If less than 8 g/dl then refer to SHCP
