Triage

Revised March 2011
Triage
Definition
Triage is the process of rapidly screening sick children soon after their arrival in hospital in
order to identify:
 those with emergency signs, who require immediate emergency treatment;
 those with priority signs, who should be given priority while waiting in the queue so
that they can be assessed and treated without delay;
 non-urgent cases, who have neither emergency nor priority signs.
In our department this is done in A&E by the triage nurse at the desk in front of room 1. The
health passport is stamped E (emergency) P (priority) or Q (queue).
Emergency signs include:
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obstructed breathing
severe respiratory distress
central cyanosis
signs of shock (cold hands plus capillary refill longer than 3 seconds plus weak, fast
pulse)
coma
convulsions
signs of severe dehydration in a child with diarrhoea (lethargy, sunken eyes, very
slow return after pinching the skin—any two of these).
Children with emergency signs require immediate treatment to avert death – see the
diagram on the following page. In A&E they should go immediately to the resuscitation room.
Priority signs include (abbreviated to 3TPR MOB):
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Tiny baby: any sick child aged under 2 months
Temperature: child is very hot
Trauma or other urgent surgical condition
Pallor (severe)
Poisoning
Pain (severe)
Respiratory distress
Restless, continuously irritable, or lethargic
Referral (urgent)
Malnutrition: visible severe wasting
Oedema of both feet
Burns (major)
The priority signs identify children who are at higher risk of dying. These children should be
assessed without unnecessary delay and wait on the priority bench immediately outside
room 1.
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Revised March 2011
Reference:
WHO Pocket book of Hospital Care for Children
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Revised March 2011
Airway Obstruction
Causes (common causes in bold)
Airway swelling
Infective
 Viral croup
(laryngotracheobronchitis)
 Bacterial tracheitis
 Retropharyngeal abscess
 Epiglottitis
 Diphtheria
 URTI in an infant
 Severe tonsillitis
Non infective
 Recurrent croup
 Anaphylaxis
 Adenoidal hypertrophy
 Laryngeal burns e.g. due to hot
gases in fire
Airway obstruction
Congenital
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Laryngomalacia
Choanal atresia
Subglottic stenosis
Laryngeal web
Acquired
 Foreign body
 Tumour e.g. vocal cord
papillomas, mediastinal
tumour
 Extrinsic haematoma
causing airway
compression e.g. post thyroidectomy
Airway collapse
 Depressed
conscious level
 Drug intoxication
Opiates
Benzodiazepines
Chlorpromazine
 Organophosphate
poisoning
 Bulbar palsy
 Myopathy
Important points in history
 Length of history of stridor (Stridor since birth suggests a congenital anomaly)
 Is it present all the time or only when upset / feeding / lying down?
 Coryzal symptoms , fever
 Barking cough, hoarse voice (suggests croup)
 Rapid deterioration or sudden onset when playing (suggests foreign body)
 History of choking episode (suggests foreign body inhalation)
 Recurring episodes (? recurrent croup or papillomas)
 Pain on swallowing (? Retropharyngeal abscess)
 Ingestion of drug or food possibly allergy
 Immunization history (? Haemophilis influenza B in epiglottitis)
 HIV status (Kaposi‘s sarcoma or laryngeal papillomas)
Important points in examination
 Toxic (? Epiglottitis), shock, temperature
 Hoarse voice, barking cough (Croup)
 Severity of respiratory distress / central cyanosis
 Agitation / drowsiness
 Respiratory rate / heart rate
 Drooling (? Epiglottitis, retropharyngeal abscess)
 Posture - e.g. sitting up, leaning forward.
 Unilateral hyperexpansion or wheeze (? Foreign body)
 Bull neck appearance, blood stained nasal discharge, grey pharyngeal membrane
(suggest diphtheria)
 Associated urticaria or lip swelling (? Anaphylaxis)
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Revised March 2011
Croup v Epiglottitis
Feature
Onset
Preceding coryza
Cough
Able to drink
Drooling saliva
Appearance
Fever
Stridor
Voice muffled
Need for intubation
Croup
Over days
Yes
Severe, barking
Yes
No
Unwell
<38.5 C
Harsh, rasping
Hoarse
1%
Epiglottitis
Over hours
No
Absent or slight
No
Yes
Toxic, very ill
>38.5 C
Soft
Reluctant to speak
80%
Severity of upper airway obstruction
Remember! The loudness of the stridor does not
reflect the severity of the airway obstruction!
Upper airway
noise
Work of
breathing
Mild
 Hoarse voice
 Barking
cough
 Mild or loud
stridor
Mild intercostal
recession and
tracheal tug
Efficacy of
breathing
 Alert
 Not distressed
Cardiovascular
effects
 Mild increase in
heart rate
Moderate
 More severe
stridor
Severe
 Stridor may reduce
as exhaustion occurs.
Moderate increase in
effort:
 Nasal flare
 Tracheal tug
 Accessory
muscles
 Alert
 Distressed
 ↓O2 sats
Huge increase in work
of breathing:
 Severe distress
 Exhaustion
 Respiratory arrest
 Moderate rise in
heart rate
 Reduced conscious
level
 Cyanosis
 Severe tachycardia
 Bradycardia if
exhausted
Investigations
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If ?croup/epiglottitis- O2 saturations if able, nil else
If ?foreign body / tumour / retropharyngeal abscess – CXR, lat neck X-ray
If ?toxic - blood culture ONLY once airway stable.
Avoid painful or frightening procedures (including PCV and MPS)
until you are sure the airway is stable or secure
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Revised March 2011
X-rays:
CXR – May see foreign body if radio-opaque
Unilateral hyper-expansion suggests FB in main bronchus with air-trapping
If a coin seen above the carina:
 Seen as a circle – likely in the oesophagus
 Seen as a straight line – likely between the vocal chords
Lateral neck – Retropharyngeal abscess – distance between the anterior vertebral body
wall and the air column in the pharynx is increased. (At C3 this distance should be no more
than ½ of the vertebral body diameter)
Indications for admission
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All but the mildest case of croup will need to be admitted.
If severe upper airway obstruction d/w senior/ anaesthetist re admitting to ICU.
Treatment
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TRY AND KEEP CHILD CALM - let child sit on parent‘s knee
If severe obstruction give nebulised adrenaline 1-2ml of 1 in 1000 in 2mls of
saline/water while calling for senior help and anaesthetist. Repeat 2 hourly as
necessary
Severe airway obstruction: call ENT (Dr W Mulwafa) and anaesthetist on call
Croup stay calm, O2, prednisolone 1mg/kg.
Bacterial infection (tracheitis, retropharyngeal abscess): ceftriaxone
Foreign body: if acutely compromised try backslaps etc, call for help- anaesthetist
and senior colleagues and surgeon. If not acutely ill, organise bronchoscopy (ENT,
surgeons)
Epiglottitis stay calm, O2, call for help as above. DO NOT EXAMINE THROAT, OR
PUT IN AN IV, OR DO ANY BLOOD TESTS.Transfer to ICU for intubation.
Anaphylaxis: see anaphylaxis protocol
Laryngomalacia usually resolves as child gets older
Supportive care
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Ensure adequate analgesia, fluid and nutritional intake.
Monitoring
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Keep patient in high dependency area of Special Care
If transferred from ICU monitor closely for deterioration.
When to discharge
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When child fully recovered and no longer has respiratory distress.
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Revised March 2011
Oxygen Therapy in Children
Oxygen therapy should be guided as far as possible by pulse oximetry. Oxygen should be
given to children with SaO2 <90%, and oxygen increased to achieve a SaO2 >90%.
If pulse oximeters are not available or not working it may be necessary for Oxygen therapy
to be guided by clinical signs – however these are less reliable.
Where the oxygen supply is limited and need for oxygen concentrators is greater than the
number available it may be necessary to prioritise certain children. DO check to see whether
there are any concentrators available in any other wards first.
Priority should be given to children with very severe pneumonia, bronchiolitis, asthma and
congestive cardiac failure who:
 have central cyanosis, or
 are unable to drink (where this is due to respiratory distress).
When oxygen concentrators are available, oxygen should be given to children with any of
the following
 severe lower chest wall indrawing
 respiratory rate of 70/min or above
 grunting with every breath (in young infants)
 head nodding
Oxygen delivery
Three methods are recommended for the delivery of oxygen: nasal prongs, nasal catheter
and nasopharyngeal catheter. Nasal prongs or a nasal catheter are preferred in most
circumstances. Nasal prongs are the best method for delivering oxygen to young infants and
children with severe croup or pertussis. Use of a nasopharyngeal catheter calls for close
monitoring and prompt action, in case the catheter enters the oesophagus or other serious
complications develop. Face masks can be considered to supplement Oxygen delivery if
enough concentrators are available – this will provide an additional 2-5 litres.
Nasal prongs. These are short tubes inserted into the nostrils. Place
them just inside the nostrils and secure with a piece of tape on the
cheeks near the nose. Care should be taken to keep the nostrils clear
of mucus, which could block the flow of oxygen.
 Set a flow rate of 1–2 litres/min (0.5 litre/min in young infants)
to deliver an inspired oxygen concentration of 30–35%.
Humidification is not required with nasal prongs.
Nasal catheter. This is a 6 or 8FG catheter which is passed to the
back of the nasal cavity. Place the catheter at a distance from the
side of the nostril to the inner margin of the eyebrow.
 Set a flow rate of 1–2 litres/min. Humidification is not
required with a nasal catheter.
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Revised March 2011
Nasopharyngeal catheter. This is a 6 or 8FG catheter which is passed to the pharynx just
below the level of the uvula. Place the catheter at a distance equal to that from the side of
the nostril to the front of the ear. If it is placed too far down, gagging and vomiting and,
rarely, gastric distension can occur.
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Set a flow rate of 1–2 litres/min, which delivers an inspired oxygen concentration of
45–60%. It is important that this flow rate is not exceeded because of the risk of
gastric distension. Humidification is required.
Monitoring
Nursing and medical staff should know how to place and secure the nasal prongs or catheter
correctly. Equipment should be checked regularly to ensure it is working properly. The
prongs or catheter should be removed and cleaned at least twice a day.
All children receiving Oxygen therapy need regular observations. They should preferably be
monitored at least every 3 hours to identify and correct any problems, including:
• SaO2 by pulse oximeter
• nasal catheter or prongs out of position
• leaks in the oxygen delivery system
• oxygen flow rate not correct
• airway obstructed by mucus (clear the nose with a moist wick or by gentle
suction)
• gastric distension (check the catheter‘s position and correct it, if necessary).
Duration of oxygen therapy
Continue giving oxygen continuously until the child is able to maintain a SaO2
>90% in room air. When the child is stable and improving, take the child off oxygen for a few
minutes. If the SaO2 remains above 90%, discontinue oxygen, but check again 1/2 hour
later, and 3 hourly thereafter on the first day off oxygen to ensure the child is stable. Where
pulse oximetry is not available, the duration of oxygen therapy is guided by clinical signs
(see above), which are less reliable.
Care of Oxygen concentrators
Oxygen concentrators need looking after if they are to continue to work for a long time.
There are a few simple things that will help:
 If a concentrator is not being used for a patient turn it off
 Try to minimize moving concentrators
 Don‘t push the back of concentrators against a wall – this will damage the flex
 Get someone to show you how to clean the filter – this should be done regularly
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Revised March 2011
Anaphylaxis
Anaphylaxis is potentially life threatening and can present with or progress to:
 Shock with acute vasodilatation and capillary leak
 Upper and lower airway obstruction
Anaphylaxis is immunologically mediated. Most common causes are reactions to:
 Allergy to Penicillin and other beta-lactam antibiotics
 Certain foods: eg Nuts
 Radiographic contrast media etc
Prodromal symptoms:
 Flushing, itching, facial swelling, urticaria
 Abdominal pain, diarrhea
 Wheeze/ stridor might precede shock
Patients might NOT have had a previous reaction to the same allergen
Severity:
Mild allergic reaction
Itching, nausea, abdominal pain
Urticarial rash, angio-oedema, conjunctivitis
Moderate reaction
Cough, wheeze, tachycardia, sweating, loose stools
Severe reaction
Severe bronchospasm or upper airway obstruction
Shock
Management:
IF POSSIBLE REMOVE ALLERGEN
Call for HELP!!!
Airway
 Assess and manage airway
 O2 via face mask, max. flow available
 10 micrograms/kg of Adrenaline IM – do NOT give IV adrenaline in anaphylaxis
 Nebulised Adrenaline
 Consider intubation (experienced paediatrician or anaesthesist)
o A surgical airway might be needed in some situations
Breathing
 In case of insufficient respiratory effort – start bag mask ventilation + consider intubation
 Wheeze/bronchospasm
o Adrenaline IM
o Nebulised Salbutamol
o Hydrocortisone IV
o Consider Aminophylline infusion
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Revised March 2011
Circulation
 If no pulse – CPR
 Shock
o IM Adrenaline
o IV/IO access – 20ml/kg Normal Saline/Ringer Lactate – bolus
o Re-assess
 Consider further IM Adrenaline + fluid bolus
 Consider Adrenaline infusion
o IV Hydrocortisone
Further Management
 Monitor on HDU
 Chlorpheniramine TDS for 48 hours
 Check blood sugar, MPS, PCV
Drug doses in Anaphylaxis
 Adrenaline IM (NOT IV!)
o 0.01ml/kg of 1:1000 Adrenaline (1mg/ml)
o Or 0.1ml/kg of 1:10.000 Adrenaline (1mg diluted in 10ml Normal Saline)
 Doses of Adrenaline might have to be repeated
o Adrenaline infusion in life-threatening shock, when IM Adrenaline is insufficient:
 0.3mg/kg in 50ml Saline or Dextrose 5%
 1ml/hr = 0.1 microgr/kg/min
 Dose = 0.05 – 2 microgr/kg/min
 Use syringe driver
 Ideally via central line, temporary via peripheral line – then use
quarter strength
 Adrenaline Nebulised
o 500 micrograms/kg Adrenaline (0.5ml of 1:1000) - max. 5mg
 Hydrocortisone IV
o 4mg/kg, then 2-4mg/kg 6 hourly
 Salbutamol nebuliser
o < 5years: 2.5mg dilute in 2-3 ml Normal saline
o > 5years: 5mg
 Chlorpheniramine
o > 12 years: 10-20mg
o 6- 12 years: 5-10mg
o 1-5 years: 2.5 – 5mg
o 1 month- 1 year: 250 microgr/kg
 Aminophylline
o 25 mg/kg in 500ml of Normal Saline (or 5mg/kg in 100ml via paediatric
burette)
o 10ml/hour = 0.5mg/kg/hour
o Dose range: 0,3- 1mg/kg/hour use (use lower dose - 0.5mg/kg/hour in
older children > 12 years)
o Consider loading dose of 5mg/kg over 20 -30 min
o Or 25mg/kg in 50ml N-Saline via syringe driver: 1ml/hour = 0.5mg/kg/hour
Always re-check drug doses!
Source:
APLS Manual 4th edition
PICU Standard Infusion Guidelines- Birmingham Children Hospital, UK
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Revised March 2011
Shock
Shock is an emergency. There are many potential causes (see below), with some being
more common than others. The key to managing shock is:
Prompt recognition
Prompt initiation of emergency treatment
Prompt management of the underlying cause
Recognition of shock
All children seen in hospital should be screened for the presence of shock:
1)When first presenting to hospital as part of Triage
2)Each time they are reviewed by medical or nursing staff
A child is in shock if s/he has all three of:
Cold Hands
Capillary Refill time >3seconds
Fast weak pulse
Emergency Treatment of Shock
When a child is found to be shocked do the following:
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Manage shock in Resus room or HDU
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First ensure adequate Airway and Breathing
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Give Oxygen
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If the child has any bleeding apply pressure to stop the bleeding
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Make sure the child is warm
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Select an appropriate site for administration of fluids
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Establish IV or intraosseous access
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Before giving IV fluids check for severe malnutrition (visible severe wasting or
oedema of both feet)
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Begin giving fluids for shock (as below)
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Whilst giving IV fluids consider the cause (see below)
If the child has NO severe malnutrition proceed as follows
 Insert an intravenous line (check blood glucose).
 Attach Ringer‘s lactate or normal saline - make sure the infusion is running well.
 Infuse 20 ml/kg as rapidly as possible (consider using 20ml or 50ml syringes).
 The circulation should be reassessed as described before.
Improvement: warmer hands, pulse slows and capillary refill faster.
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Revised March 2011
If there is NO improvement:
 Give another 20 ml/kg of Ringer‘s lactate or normal saline as quickly as possible.
 Reassess the circulation again
If there is still NO improvement.
 Give another 20 ml/kg of Ringer‘s lactate or normal saline, as quickly as possible.
 The circulation should be assessed again.
If there is still NO improvement – Call for senior help
 Give 20 ml/kg of blood over 30 minutes unless there is profuse watery diarrhoea. In this
case, repeat Ringer's lactate.
 The circulation should be assessed again.
If the child HAS severe malnutrition AND can tolerate oral/NG fluids
 Avoid IV if possible, find out if the child can drink or use a nasogastric tube (NGT).
 Weigh the child.
 Insert an intravenous line (check blood glucose)
 Give ReSoMal rehydration fluid orally or by NGT:
o 5 ml/kg every 30 min for 2 hours, then
o 5-10 ml/kg/hour for 4-10 hours
If the child HAS severe malnutrition but CANNOT tolerate oral/NG fluids
If the child is lethargic or unconscious or unable to tolerate oral/NG fluids
 give 15ml/kg half strength Darrows with 5% glucose
(or R/L with added glucose)
 give over 1 hour
 Observe the child and check the pulse and breathing rate every 5-10 minutes.
 Discontinue the intravenous infusion if either of these increase (pulse by 15, respiratory
rate by 5/min).
 Reassess the circulation again, and
If there IS improvement:
(pulse and breathing rate fall)
If there is NO improvement:
 Call senior help.
 Repeat 15ml/kg over 1 hour.
 Give maintenance IV fluid
4ml/kg/hour while waiting for blood.
 Switch to oral or NGT rehydration
with ReSoMal 10ml/kg/hour.
 Transfuse whole blood at
10ml/kg/hour slowly over 3 hours
(use packed cells if in cardiac failure).
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Revised March 2011
Further Treatment of the underlying cause of shock
Gastroenteritis
Intussusception,
volvulus, peritonitis
Burns
Septicaemia
Anaphylaxis
Pressure to site of bleeding
Involve surgeons early
Urgent X-match
Once shock treated manage as per acute
gastroenteritis protocol
Contact Surgeons
If shock within few hours of burn consider
other cause for shock
Give fluids according to extent of burn
IV antibiotics
IM Adrenaline
See Anaphylaxis protocol
Contact orthopaedic surgeons
Give resuscitation fluid cautiously
Discuss with senior
Tension pneumothorax
Haemothorax
Flail chest
Cardiac Tamponade
Needle thoracocentesis
then chest drain
Chest drain
Consider advanced ventilatory support
Emergency needle pericardiocentesis
Profound Anaemia
Urgent blood transfusion
Cardiogenic
Heart Failure
Cardiomyopathy
Valvular disease
Duct-dependent congenital
Heart disease
Obstructive
Spinal Cord Injury
Specific management in addition
management described above.
Dissociative
Distributive
Hypovolaemic
Causes of Shock
T
y
Haemorrhage
Unlikely to survive in this setting
All children in shock or treated for shock should be initially admitted to an HDU.
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Revised March 2011
Convulsions (epilepsy)
Management of Status Epilepticus
ABCD-
Airway: airway adjuncts/ recovery position
Breathing: support if necessary with oxygen, bag and mask
Circulation: check adequacy, treat if required
Don‘t Ever Forget Glucose!
(correct hypoglycaeia with 1ml/ kg 50% dextrose i.v.)
If the fit(s) has been going on more than 5 minutes:
Paraldehyde
0.2ml/kg i.m. or 0.4ml/kg p.r
Fit still ongoing after 10 minutes or has recurred:
Paraldehyde
0.2ml/kg i.m. or 0.4ml/kg p.r
Fit still ongoing after 10 minutes or has recurred:
Diazepam
0.5mg/kg p.r.
or
0.25mg/ kg i.v./ i.o.
(not i.m.)
or
Paraldehyde
0.2ml/kg i.m.
or
0.4ml/kg p.r
Fit still ongoing after further 10 minutes or has recurred:
Phenobarbitone
15mg/kg im/ slow iv STAT
If fit still ongoing after another 10 minutes:
Inform seniors +/- anaesthetist
D/W research ward or ICU regarding admission for
administration of phenytoin infusion or other therapies
****Once seizure has stopped, investigate and treat underlying cause****
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Revised March 2011
Causes of seizures
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Febrile convulsion with intercurrent illness e.g. malaria, viral or bacterial infection
(febrile convulsions only occur in children 6 months – 6 years)
Cerebral malaria
Intracranial infections: Meningitis, Cerebral Abscess, Encephalitis
Hypoxia of any cause
Hypoglycaemia of any cause
Other electrolyte or metabolic disturbances
Cerebrovascular accidents
Head Injury
Seizure disorder (Epilepsy)
Hypertensive encephalopathy
Poisoning e.g. alcohol, tricyclic antidepressants, OPP poisoning
Differential diagnosis of seizure-like episodes
 Reflex-Anoxic seizure / Breath-holding attack leading to seizure
 ‗Pseudo-seizures‘
 Rigors
 Tetanus (muscle spasms)
 Rabies (agitation and spasms)
Important points in the history
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Preceding symptoms of illness, fever.
Recent new neurological deficit or history of headaches
Preceding significant head injury
Ingestion of any medication; drug history; compliance with anticonvulsants
PMH: seizures/ neurological illness/ disability/ developmental delay /
immunosuppression/ TB
Family history of seizures
Contact with source of infection e.g. meningitis case, herpes simplex
Get an exact description of the seizure and document it
 Full description of ‗fit‘ by an eyewitness, especially:
o What was child doing immediately before the fit?
o Did child detect a prodrome to fit? (remember it ‗coming on‘)
o Nature of seizure- what was seen and sequence, movements of which limbs,
mouth, face etc.
o WAS IT FOCAL OR GENERALISED? (may be important if epilepsy)
o Colour of the child
o Was the child responsive during the episode?
o Duration
o Incontinence/ tongue biting/ injuries sustained
o Recovery period - ?post ictal
 Has full recovery been made?
 Ongoing symptoms e.g. Fever, headache, neck stiffness, rash, altered behaviour
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Revised March 2011
Important points in examination
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Adequacy of: Airway, Breathing, Circulation
Blantyre Coma Score/ AVPU and behaviour (irritable, lethargic, confused?)
Evidence of ongoing seizure activity?
Temperature
Neck stiffness, Kernig‘s sign, rash, Fontanelle
Blood pressure
Abnormal neurology e.g. focal signs, papilloedema, asymmetrical pupils
Evidence of head injury
Any child with reduced conscious level or focal neurology following a seizure should
be re-examined after an interval (e.g. 1 hour) to ascertain which (if any) features are
„post-ictal‟, and to check for signs of deterioration.
Relevant Investigations
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Blood sugar (BM stix)- ALWAYS if actively fitting/ reduced consciousness/ abnormal
behaviour
Blood film for malaria parasites
Lumbar puncture- if meningitis cannot be confidently excluded, and no
contraindications exist
Blood culture if toxic-looking child or febrile infant
U&E‘s if appropriate (e.g. seizures in dehydrated child)
Indications for admission
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Most children should be admitted when there is a history of a convulsion.
Consider short-stay ward and same-day discharge for children who are known to
have febrile convulsions WITH a clear focus such as URTI or uncomplicated malaria
AND who are well when seen in admissions
Known epileptics may be discharged to the care of a competent guardian if child has
recovered and no concerns about ongoing management. Ensure follow-up date given
in general or neurology clinic
NB The Convulsing Neonate (< 2 months old)
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Treat ABC, check glucose etc
Give phenobarbitone 15mg/kg (Better than paraldehyde and diazepam in this age
group).
If the baby is still fitting after 20 minutes the dose can be repeated.
Adjunctive treatments
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Fever: exposure, tepid sponging, paracetamol
Diagnosis or suspicion of cerebral malaria, meningitis, encephalitis, hypertensive
encephalopathy- see relevant protocol
Head Injury: urgent neurosurgical opinion and consider neuroimaging
Supportive Care
 Consider research ward if BCS < 3
 Prevent recurrent hypoglycaemia if at risk (eg. unable to take adequate feeds).
 Consider iv fluids with added dextrose, or NGT feeding if airway is safe.
 Consider maintenance dose of phenobarbitone 5mg/kg/day if further seizures occur
or if a high risk of further seizures is thought to exist.
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Revised March 2011
Monitoring
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Nurses to be specifically informed of patients causing concern
If reduced conscious level or at risk of deterioration- regular review
Guardians to be asked to alert nurses or medical staff if further fits occur
Guardian Advice
Guardians are likely to be frightened, and need appropriate reassurance and education
 about the cause of the fits
 risk of recurrence and any measures they can take to prevent further seizures (eg.
avoiding prolonged fasting periods)
 actions to take in the event of a further fit (protection from injury etc)
 Advise NOT to insert anything into mouth of convulsing child
Is it epilepsy?
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Recurrent seizures without fever suggests epilepsy as a cause
If a seizure disorder is suspected and frequency of fits is interfering with quality of
life, the child may need to take a regular anticonvulsant- refer to a senior for decision
Sodium valproate and carbamazepine (when available) are better first line choice
drugs than phenobarbitone
When to discharge


Depends largely on cause of fit, and completion of cause-specific treatments (for
example, infection adequately treated)
Child must be clinically stable, fully conscious, behaving normally (unless a chronic
neurological disability remains), and not at high immediate risk of further fits as far as
can be predicted.
Follow up



If epilepsy, give date for general clinic (1.30 pm Wednesday)
Consider neurology clinic if ‗complicated‘ epilepsy – discuss with Dr Mallewa
If ongoing disability, consider what supports might be available to the child and family
e.g. Chesire Homes or SOS Machinjiri for physiotherapy, mobility aids
Guardians should be adequately informed about risk of further fits
and what to do if they occur
28
Revised March 2011
Coma
Common Causes
Hypoxia / shock
Infections
Any cause
Malaria, Meningitis, Encephalitis,
Cerebral abscess
Overt / subclinical seizures, post ictal
Head Injury, Non-accidental injury
(shaken baby)
Hypoglycaemia, Hyperglycaemia,
electrolyte imbalance, Renal failure,
liver failure
Opiates, salicylates,
organophosphates, benzodiazepines,
alcohol
Seizures
Trauma
Metabolic
Poisoning
Tumours
Vascular
Haemorrhage, Thrombosis,
Hypertension, Vasculitis
Important Points in History










Timing of onset of coma
Symptoms of deterioration or recovery
Infants – hx of poor or reduced feeding
History of convulsions, either recently or in the past
History of trauma, which may or may not be significant
History or possibility of dog bite
Availability of medications at home, belonging to the child, or another family member.
Possibility of local mankhwala.
Availability of potential poisons, e.g. organophosphates due to rat infestation
Past Medical History, e.g. diabetes, including drug history
Relevant family history, e.g. diabetes, bleeding diatheses
Associated symptom
Cough, vomiting, fever, rash
Dog bite, unusual behaviour, fluctuating coma
Profuse D+V
Cough, dyspnoea
Poor feeding, malaria (especially infant)
Polyuria, polydypsia, vomiting
Oliguria, haematuria, oedema
Jaundice, bleeding, fever, vomiting
29
May indicate diagnosis of…
Encephalitis,meningitis
Rabies
Dehydration, electrolyte
imbalance
Hypoxia
Hypoglycemia
Hyperglycemia
Renal failure
Liver failure
Revised March 2011
Important Points Initial Examination
AB
Respiratory Pattern may be irregular due to brainstem lesion or raised intracranial
pressure. May be rapid due to acidosis or drug ingestion
C
Pulse Bradycardia suggests raised intracranial pressure, or OPP poisoning
Blood Pressure hypertension suggests raised ICP
D
Coma Score
(Blantyre, AVPU)
Pupil size and reactivity may reveal signs of drug ingestion (see poisoning
protocol). May be unequal/unreactive due to raised intracranial pressure
Posture – floppy, extensor posturing, decorticate, decerebrate
Coma Scores – AVPU, Blantyre
A
V
P
U
Alert
responds to voice
responds to pain
unresponsive
BCS Motor:
BCS Verbal:
BCS Eye:
localises (2)
withdraws (1)
None (0)
Appropriate cry (2) Inappropriate (1)
None (0)
Follows (1)
Does not follow (0)
Secondary examination







Fundi may show papilloedema, retinal haemorrhages
Examine for signs of dehydration or malnutrition
Skin rashes may indicate infections e.g. meningococcal disease
Breath Odour may indicate diabetic ketoacidosis, alcohol ingestion, inborn errors of
metabolism
Full Neurological examination to establish a baseline, identify focal deficits (space
occupying lesions), lateralising signs (hemiplegia), neck stiffness (meningitis)
Respiratory examination paying careful attention to breathing pattern (as above)
and signs of respiratory disease
Gastrointestinal examination particularly splenomegaly (malaria) and
hepatomegaly (metabolic disorders)
Relevant Investigations







Blood glucose
in all patients
MPS and PCV
Lumbar Puncture if MPS negative
o or MPS positive but clinical picture does not fit with malaria
o and child well enough to tolerate the flexed position
o and cardiovascularly stable, with no signs of bleeding
o and no features of raised intracranial pressure
ALWAYS FOLLOW UP CSF RESULTS.
DO NOT ASSUME IT IS OK BECAUSE IT IS ‗CLEAR‘
Blood culture if pyrexial
Serum electrolytes
Neuroimaging
as dictated by individual cases and availability
EEG
d/w senior if unsure
30
Revised March 2011
Indications for Admission



All comatose children should be admitted
If the child has proven meningitis OR has a BCS of 2 or less from any cause, admit
to the research ward
Otherwise admit to PSCW/PN
Treatment
Call for help whenever uncertain. The earlier the better.
 A
Position the airway (using head tilt, jaw thrust, chin lift)
Consider use of Guedel airway
 B
Apply oxygen
 C
Support circulation in order to maintain normal cerebral perfusion
pressure. Treat shock
 Don‟t ever forget glucose
o If hypoglycaemic, give the child 1ml/kg of 50% dextrose, and follow up with
regular feeds, or an infusion containing dextrose (see below)
o If no blood sugar test available, assume hypoglycaemia, give 1ml/kg of 50%
dextrose
Seizures
Treat if present (see seizures protocol).
Fluids
Maintain appropriate fluid balance.
 Consider giving 2/3 of the normal total maintenance requirements (to reduce cerebral
oedema), providing no circulatory compromise. See fluid protocol. In order of
preference use:
o Half strength darrows with 5% dextrose
o Normal Saline with added 50% dextrose to make 10% solution
Antimalarials
 Unless there is an obvious cause for the coma (e.g. cloudy CSF indicating
meningitis) all comatose children should be given quinine
Antibiotics
 If proven meningitis (cloudy CSF or elevated white cell count on CSF microscopy),
give 100mg/kg Ceftriaxone IV/IM daily, and refer to the research ward.
 When meningitis is strongly suspected clinically, but either the child is too sick for an
LP, or the cell count is not available (e.g. at night), commence Ceftriaxone at above
dose, or Chloramphenicol 25mg/kg tds IV/IM and Benzylenicillin 100,000U/kg qds
IV/IM
 If doubt remains about the diagnosis (e.g. MPS and CSF negative), ensure a blood
culture has been taken and start Chloramphenicol 25mg/kg tds IV/IM and Gentamicin
6mg/kg OD IV/IM.
Other definitive management
 Other treatment will be guided by the history and clinical findings, e.g.
o Aciclovir if suspicion of encephalitis
o Hydralazine if hypertensive encephalopathy
o Atropine if OP Poisoning (refer to poisoning protocol)
o Surgical review if trauma suspected (refer to trauma protocol)
31
Revised March 2011
Supportive Care
Nutritional Support
 The child should be encouraged to feed where this is possible.
 However it must be stressed to mothers that unconscious children are often not able
to feed, and under NO CIRCUMSTANCES should they be forced
 If the child is not able to eat for more than 2 days, an NGT should be inserted. Give
F100 from Moyo
Other Supportive Care
 Regulate temperature
 Prevent bedsores by turning the patient. Use the recovery position where possible
 Maintain oral hygiene with mouth washes
 Encourage physiotherapy of chest to avoid hypostatic pneumonia, and of limbs to
prevent joint contractions
Monitoring


A Comatose child should be monitored at least 4 hourly by a nurse and twice a day
by a doctor.
o Pulse
o Respiratory rate
o Temperature
o Blantyre Coma Score
Blood pressure should be checked if it were previously abnormal or the child has
deteriorated
Complications
Acute Complications
 Aspiration Pneumonia
 Electrolyte imbalance
 Seizures
 Hypostatic pneumonia
 Joint contractures
 Secondary septicaemia
Chronic complications
 Cerebral Palsy
 Deafness / Visual problems
 Behavioural and learning difficulties
When to Discharge


When the child has made a full recovery
OR the child remains static, and after discussion with seniors it is thought unlikely
that the child will benefit from any additional inpatient care, and is unlikely to recover
further. Arrange support from Cheshire homes/ physiotherapy/ hospital clinics/
palliative care
32
Revised March 2011
Trauma
Resuscitation - ABCDE - Call for HELP!
Airway & Cervical Spine Protection
Breathing: O2 and support of ventilation
Circulation: correction of shock and haemorrhage control
Disability
Exposure
Secondary survey
Stabilisation - Monitor & Reassess
Involve A&E, Paediatric, Surgical & / or Anaesthetic Consultants EARLY!!!
Triage and emergency management



Treat children with severe trauma immediately in the resuscitation room
In a conscious child, a reassuring and kind manner will reduce stress
As far as possible keep the child covered and warm
Airway management & Cervical Spine Protection


Check if the airway is patent
In case of a compromised airway:
o Jaw thrust – avoid ―head tilt‖ in case of cervical spine injuries
o Suction/Removal of foreign body under direct vision (eg loose teeth)
o Oxygen via face mask – maximum flow available
o Consider oro-pharyngeal airways (Guedel airway)
o If indicated: intubation & ventilation (see below)

Cervical spine protection
o Assume a spinal injury in any significant trauma (RTA, fall etc.)
o Cervical spine protection is required until it can be ―cleared –see below‖
o In an uncooperative/combative child too rigid C-spine protection might not be
beneficial.
o
o
o
o
Place the child on a spinal board or a trolley with a firm surface.
Immobilisation initially by ―in-line immobilisation‖ then:
hard collar (if available), blocks (or Fluid bags) and straps
Any case of position change: ―log-roll‖ the child keeping the spine ―in-line‖
Intubation with a hard collar can be difficult – in this case the collar might be
taken off. Manual ―in-line immobilisation‖ is maintained.
33
Revised March 2011
Breathing









O2 mask at highest flow rate available. Monitor O2 saturation if possible
If respiratory effort is inadequate – start Bag Mask Ventilation
This child might need intubation + ventilation – Call for HELP!!!
Check trachea position
Check chest expansion and check for signs of thoracic injuries
o Pneumothorax/ haematothorax
o Rib fractures/‖flail chest‖
o Open thoracic injury (eg ―sucking chest wound‖)
In case of suspected pneumothorax
o Needle thoracocentesis: 2nd intercostal space, mid-clavicular line, above the rib
o Chest drain insertion will be needed subsequently. Call for HELP!!! While this is
being arranged continue with ABC assessment + management
In case of haematothorax or haemo-pneumothorax
o Fluid resuscitation/transfusion
o Chest drain
Consider the possibility of cardiac tamponade
o Urgent Echo
o Pericardiocentesis if indicated
Consider other mediastinal injuries, disruption of great vessels, diaphragmatic
rupture etc.
In case of stab or shot gun wounds – small entry lesions can be associated with
significant ―internal trauma‖.
Indication for intubation and ventilation:
 Persistent airway obstruction
 Predicted airway obstruction (eg inhalational burn, severe facial trauma)
 Loss or airway reflexes/loss of consciousness
 Inadequate respiratory effort or increasing fatigue
 Disrupted ventilator mechanism eg flail chest
 Persistent hypoxia despite O2 administration
 Severe traumatic brain injury
Resources for mechanical ventilation are limited!
A pragmatic approach to intubation + ventilation is needed!
Call for HELP!!! – Experienced paediatrician and/or anaesthesist!!!
Note on the usage of drugs: In our scenario we use ketamine as an induction agent. In
traumatic brain injury (TBI) the theoretical risk of increasing intra- cranial pressure is outweighed by the relative haemodynamic stability compared with the use of other induction
agents.
34
Revised March 2011
Circulation: Management of shock and control of haemorrhage








Establish vascular access
o Two ―large‖ peripheral IV cannulas
o In the event of failure – consider rapidly other options – Call for HELP
 Intra-osseous cannulation of tibia – avoid injured limb (eg femur fracture etc.)
 External jugular vein, central line (femoral vein etc.)
 Cut down – cephalic vein (elbow) or long saphenous vein (ankle)
o Sample for Cross-match, blood sugar, MPS & PCV
Assses: HR, central/peripheral pulses, CRT, temperature gradient +/- pallor,
BP- hypotension is a very late sign of severe shock
Direct pressure to any obvious visible external site of bleeding
In case of signs of shock/impaired perfusion
o 10ml/kg Ringer Lacate or Normal Saline - bolus
o Reassess and repeat fluid boluses
o If 40ml/kg crystalloids have been administered – use blood transfusion if
further fluid boluses are needed.
o Consider type specific or O-negative blood in extreme emergencies
o Contact surgical team early – especially if 20ml/kg do not stabilise the CVS
Consider thoracic (pneumothorax/haematothorax), abdominal or pelvic trauma
Consider bed-side ultrasound scan – FAST scan
In case of stab wounds or shot gun wounds – a relatively small entry wound can be
associated with significant internal injuries
Blood loss in case of femur fractures can be massive – alignment and traction
needed
Disability




Assess level of consciousness
o AVPU-scale: Alert, responds to Voice, Pain or Unresponsive
or use BCS/GCS
Record pupil size and reactivity to light
Urgently contact senior surgeon in case of suspected intracranial haemorrhage (eg
extradural haematoma)
o Discuss if MRI/CT should be done before potential intervention
Basic management of traumatic brain injury (TBI) in order to prevent secondary
brain injury:
o Adequate oxygenation
o Control of CO2 tension – (Intubation& ventilation might be needed)
o Maintenance of adequate cerebral perfusion pressure (CPP):
 URGENT correction of shock –inotropes might be needed (currently
only possible on ICU)
 CPP= Mean arterial pressure (MAP)- Central venous pressure (CVP)
– intracranial pressure (ICP)
o Control of potentially raised ICP
 Consider Mannitol: 250mg to 500mg/kg (1.25 -2,5ml of 20% Mannitol)
IV –over approx. 30mi
 Or 2-3 ml/kg of 3% NaCL as a short infusion
o Control of hypoglycaemia, convulsions
o Head –up position - around 30 degrees
o Avoid aspiration - insert OGT , aspirate and keep on free drainage
o Avoid electrolyte imbalance (especially hyponatremia)
 Isotonic fluids or blood for fluid resuscitation
 Use Ringer Lactate or Normal Saline + added Glucose as
maintenance fluids
35
Revised March 2011
Exposure



Examine all parts of the body
Straighten fractured limbs +/- traction in case of a fractured femur
Provisional dressings of wounds/lacerations
Other procedures + imaging





Emergency imaging if indicated:
o Bed-side ultrasound – FAST scan
o XR‘s: Skull, C-spine (all 7 cervical vertebrae should be visible on XR‘s),
Thorax, pelvis, limbs
 In our setting no portable XR is available
 The patient needs to be stabilised before being transferred to the
radiology department
o MRI scan brain +/- spine – discuss with consultant.
Analgesia, keep the child warm
Avoid opiates in the non-intubated head injured patient.
Consider femoral nerve block in femur fractures (only by trained colleague)!
In case of open wounds/open fractures: Tetanus toxoid and antibiotics
Secondary survey after management of ABCDE
 If ABCDE was stabilised during primary survey , perform secondary survey
 Careful and quick ―head to toe examination‖
Take a more detailed HISTORY:
Age, name
Time, date, location, mechanism of injury
Condition after accident – pre-hospital care
Last meal
PMH, SH, FH
Allergies, immunisations, regular medication
Is there any suspicion of non accidental injury -NAI?
Secondary survey - some specific points:
 Reassess ABC + re-examine: thorax, abdomen, pelvis
 Quick neurological exam:
o Level of consciousness, pupils, movements, tone, reflexes
o Fundoscopy if possible
o Assess spine: In case of suspected acute spinal cord injury – high dose
Steroids should be started within 8 hours of the injury
 If a MRI/CT scan head is requested in case of TBI –ask radiologist to scan the Cspine as well!!!
 Check for injuries
o Face & skull - including maxillar/mandibular, dental injuries, check ears,
nose, mastoid
 Examine the back of the child. In case of potential spinal injury – the child needs
to be “log-rolled”
o Check for injuries/wounds: skull, neck, thorax, lumbar area, pelvis
o Check spine
 Examination of limbs - Signs of fractures?
o In case of severely angulated fractures - alignment and splinting +/- traction
o Any signs of open fractures?
36
Revised March 2011


 In this case TT and IV antibiotics needed
 Any deep wound within vicinity of a fracture could communicate with
fracture
Any signs of compartment syndrome? - Monitor perfusion and pulses
Any signs of vascular injury?
Guidelines for clearing a cervical spine
Remember- despite normal XR‘s the child can have a spinal cord injury without
radiological abnormalities (eg haematomas, ligament injuries) - SCIWORA
The child should be cooperative and alert:
 No midline cervical tenderness on direct palpation
 No focal neurological deficit
 No painful distracting injuries
Transfer & further management
 Reassess ABCDE regularly
 Children with significant trauma need to be observed on ICU or PSCW/HDU
 Transfer to PSCW, theatre, ICU, radiology department
o Critically ill children need to be accompanied by nurse +/- doctor
o Take resuscitation equipment/box + with you
o Use O2 cylinder for transfer of sick children
o Hand-over to receiving team
 Regular monitoring on HDU, including ―neuro-obs‖ in severely injured child
 Signs of raised ICP due to cerebral oedema or intracranial haematomas (eg
extradural) can present even hours after initial presentation
 Encourage parents to alert nurses or medical team in case of any concern
Reference: APLS manual 4th edition
37
Revised March 2011
Poisoning (including snake bite)
Causes


Organophosphates (carbamate)
Local medicines
Other causes





Petroleum compounds: paraffin
Carbon monoxide
Plants (‗magic mushrooms‘)
Bleach
Snake bite
Important points in history
*Remember there may not be a clear history!
 Sudden unexplained illness in previously healthy child
 Unusual behaviour
 Try to establish the potential poison that the patient may have had exposure to
 Enquire about quantity exposed to / taken
 Earliest possible exposure time
 Ask if container or sample of poison available
 Other children involved? If so, what symptoms do they have?
 Ask about access to ―poisons‖
Important points in examination














Drowsiness / coma/ BCS
Convulsions (OPP)
Shock
Diarrhoea (OPP) {if a child is dehydrated but salivating ++ consider OPP confirm with
pin point pupils}
Hypersecretions (noisy wet breathing) (OPP)
Pupillary abnormalities - (pin-point: - consider OPP, sometimes mushooms : dilated
pupils consider barbiturates
Ataxia
Tachypnoea / tachycardia or flushing / bradycardia (in OPP)
Wheezing (paraffin inhalation)
Cardiac arrhythmia or hypotension
Presence of burns within the mouth ( consider bleach or acid with oesophageal
injury)
Stridor (suggests laryngeal damage)
Abdominal distension (local medicine intoxication)
Acidotic?
Investigations

Mainly depend on the presentation and specific poison exposure
38
Revised March 2011
Indications for admission




Exposure to potentially fatal poison
Ill / haemodynamically unstable patient
Deliberate poisoning
Consider observation in Short Stay if well otherwise
Management











Primary assessment (A B C D) to recognize life-threatening emergencies
Resuscitate / stabilize the patient if necessary
Assess potential lethality of the overdose
Definitive management of specific condition once stabilized
Reassess ABCD at frequent intervals to assess progress / detect deterioration
Test for hypoglycaemia, if present treat with 1ml/kg 50% glucose IV or PO
Treat convulsions (see p25)
Give maintenance IV fluids
Use antidote for specific poison if available (see below)
Use activated charcoal (1g/kg), except for heavy metals, if available
Gastric lavage (used occasionally for ferrous sulphate poisoning) only if:
o a potentially fatal dose has been taken
o the airway is protected
o Avoid if reduced level of consciousness, and in hydrocarbons or corrosives
DO NOT Induce vomiting
When to Discharge


When the patient is stable
Needs to be followed up with psychiatric assessment if deliberate
Treatment of specific poisons
A: Organophosphate compounds
 Get rid of poison
o Eyes (irrigation)
o Skin (remove clothing) and bathe

Specific Rx
o Atropine 20ug/kg IV or IM every 15 min until secretions have stopped the
chest is dry

Monitor regularly (respiratory rate, coma score, heart rate, secretions) e.g. every 15
minutes initially then every 30 minutes
Assisted ventilation if necessary

B: Local medicines
Usually taken for diarrhoea and vomiting
May lead to acidosis, respiratory distress, paralytic ileus


Rehydration i.e. give IV fluids and glucose
Pass an NGT and leave on free drainage
39
Revised March 2011
C: Petroleum compounds (Paraffin)
May cause pneumonitis
CXR if symptomatic



Do not induce vomiting
Give oxygen if necessary
Antibiotic therapy may be needed for secondary chest infections
D: Carbon monoxide poisoning
Toxic effects are due to hypoxia
Carboxyhaemoglobin estimation is useful (sometimes available in ICU). Oxygen
saturations can be misleading.

Give 100% oxygen
E: Poisonous plants
Usually only small quantities are ingested

Treatment mainly supportive + activate charcoal if available
F: Bleach
 Treatment: liberal fluids and milk
 Do not induce vomiting
G:Snake bite






Check for fang marks, note if scarifications present or not.
Look for evidence of use of a tourniquet
Ask about time of bite
Check bitten limb for swelling, pulses, colour and viability
Check for systemic evidence of envenoming – fever, altered coma score, shock,
anaemia.
Mark with a pen, the level of swelling on a limb so that further swelling can be
assessed.
Management





ABC
Do FBC and diff, blood culture and blood clotting time (see how long it takes for
blood to clot in a plain tube)
Group and cross match and hold blood unless anaemic.
Place an IV infusion of normal saline
Check that Tetanus toxid immnisation is up to date; if not give it
If local swelling is marked or there is evidence of systemic envenoming:

Inform senior. Anti snake venom will be required

Give 40mls in 200mls of normal saline IV over 1hr but have adenaline standing by:
anaphylactic reactions are not uncommon.

If circulation is threatened inform the surgical team on call as compartment syndrome
may need fasciotomy.
Treat pain appropriately – morphine may be needed
40