Triage

Question 1

Airway and Breathing management

Answer 1

Danger signs - not breathing, obstructed breathing, central cyanosis, severe respiratory distress
if any +
- manage airway
- give O2
- make sure child is warm
- check head/neck trauma before treating child to rule out - spinal cord injury

Question 2

Increased effort of breathing

Answer 2

tachypnoea 
nasal flaring 
inability to feed 
recession 
noisy breathing 
grunting 
gasping

Question 3

Airway management

Answer 3

assess for choking or foreign body aspiration
if present - back slaps/ Heimlich
open airway give O2
position child to improve airway
neutral position in infant - nose up
sniffing position in older child - chin up
if neck trauma - jaw thrust without head tilt and stabilise neck

Question 4

Circulatory Compromise

Answer 4

Cold hands
Capillary refill >/= 3 seconds
Weak and fast pulse

if any sign positive

• check for SAM
• Stop any bleeding
• Give O2
• Warm child
• Treat shock (based on nutritional assessment)

Question 5

Organ effects of impaired circulation

Answer 5

tachypnoea
cold, mottled skin
abnormal consciousness - agitated drowsy, unconscious
oliguria - < 2ml/kg/hr in infants and < 1ml/kg/hr in children

Question 6

Treat shock

Answer 6

check for SAM
stop any bleeding
give oxygen
warm child
select appropriate site fluid administration
establish IV or intraosseus access
take blood samples for emergency laboratory tests
begin giving fluids for shock - based on nutritional assessment

Question 7

SAM vs no SAM fluid administration

Answer 7

NO SAM - give fluids rapidly

• RL or NS 0.9%
• 20ml/kg bolus
• reassess
• 2-3 boluses

SAM

• assess oral/NGT fluids
• SOROL orally or NGT 5-10ml/kg/hour
• if cannot tolerate then only IV fluids
• 0.45% saline with 5% dextrose 15ml/kg over 1 hour
• reassess

Question 8

Coma or convulsing

Answer 8

if any positive

• manage airway
• if convulsing - give rectal diazepam (0.5mg/kg)
• position child - stabilise neck first if trauma suspected
• turn on side decrease aspiration risk
• check glucose - give IV glucose if low
• 3-5ml/kg IV 10% glucose solution

Question 9

AVPU

Answer 9

Alert
Voice response
Pain response only
Unresponsive to all stimuli

Question 10

DEFG

Answer 10

Don't Ever Forget Glucose 
No SAM 
- if shock - treat 
- no shock - 1/2 DD 5-10ml/kg/hour 
- as soon as child can drink oral or via NGT 
- ORS 5ml/kg/hr 
- encourage BF 
SAM 
- if shock - treat 
- no shock - no IV fluids 
- ORS 5-10ml/kg/hour orally or via NGT 
- check blood glucose --> treat if less than 3mmol/L

Question 11

Priority signs

Answer 11

Tiny baby < 3m 
Temperature very high or very low 
Trauma or other urgent surgical condition 
Pallor - severe
Poisoning - history of 
Pain - severe
Resp distress 
Restless, continuously irritable, lethargic 
Referral - urgent 
Malnutrition - visible severe wasting/SAM 
Oedema of both feet 
Burns - major