the south african triage scale - emssa · hard work in developing paediatric triage based on two...

Department of Health

PO Box 2060, Cape Town, 8000

Mobile:

For more information contact: Michele Twomey (SATS Implementation Advisor)

+27 850 3281 email: [email protected]

The South AfricanTriage Scale

(SATS)

Training manual 2012

Departmental Website: www.health.gov.za

Provincial Website: www.westerncape.gov.za

ISATS TRAINING MANUAL 2012

Table of Contents

TABLE OF COnTEnTs

Table of Contents IAcknowledgements II1. Introduction 1 1.1 ThebenefitsofimplementingSATS 1 1.2 Triagerequirements 2 1.3 Whoshouldbethetriageprovider? 2 1.4 Terminologyandkeyconcepts 3 AssessmentQuestions 5

2. TheSATSprocessflowchart 6 2.1 Thefivestepapproach 6 2.2 TheSATSprocessflowchart 6 2.3 SATSprioritylevels 6 2.4 Terminologyandkeyconcepts 7 AssessmentQuestions 7 AdultSATSChart 8 PaediatricSATSChart 10

3. Adult Clinical signs 12 3.1 Emergency signs 12 3.2 Very urgent signs 12 3.3 Urgent signs 13 AssessmentQuestions 13

4. Paediatric Clinical signs 14 4.1 Emergency signs: the abc-c-c-do approach 14 4.1.1 Abairwayandbreathingareusuallyassessedtogether 14 4.1.2 Ccirculationassessment 16 4.1.3 C-ccomaandconvulsionsassessment 16 4.1.4 Dseveredehydrationassessment 17 4.1.5 Ootheremergencysigns 18 4.2 Very urgent signs 18 4.3 Urgent signs 21 AssessmentQuestions 24

5. Triage Early Warning score TEWs 25 5.1Observationsattriage 26 5.2Terminologyandkeyconcepts 26 AssessmentQuestions 27

6. AdditionalInvestigations 28 AssessmentQuestions 29

7. Additional Tasks 30 AssessmentQuestions 32

8. Triage in Context 33 8.1 Pre-Hospital 33 8.2 Patientstreaming 33 8.3 Infrastructure 33 8.4 Alignmentofstafftotemporalflowofpatients 33

9. summary 3410. References 34

1SATS TRAINING MANUAL 2012II SATS TRAINING MANUAL 2012

Introduction

InTRODUCTIOn

LearningObjectives:

• UnderstandthepurposeoftriageandthebenefitsofimplementingtheSATS• Befamiliarwiththerequirementsforstandardisedtriageimplementation• Understandtheterminologyandkeyconceptsaroundtriage

Anine-montholdbabyboyiscarriedintothechildren’ssectionoftheoutpatientdepartmentinhismother’sarms.Heappearstobeasleep.Atthetriagedeskheisseenbyanurseandfoundtohavelipsandtonguethataregrey/blueincolour,andheistakenstraightintotheresuscitationroomasanemergency.Intheresuscitationroomheisgivenoxygenat15litres/minutebyfacemaskwithanon-rebreatherreservoirbag.Heisnotedtobegruntingandbreathingveryfast.Hishandsarecoldtotouchandthecapillaryrefilltimeisprolongedtofourseconds.Anintravenouscannulaisplaced.Abloodsampleistakenatthesametimeforbloodglucose,fullbloodcountandbloodculture.Anintravenousinfusionofnormalsalineiscommencedat20ml/kgtorunasfastasitcango.Othertreatmentsaregiven,dependingontheresultoftheinvestigationsandtheresponsetothetreatmenthereceives.Itisnow18minutessincethebabycamethroughtheoutpatientdepartment’sdoor,andhissituationisstable.Itisnowtimetotakeafullhistoryandcarryoutafullexaminationtomakeadefinitivediagnosis.Heisdiagnosedashavingveryseverepneumonia,andreceivesspecifictreatmentforthis.However,beforecomingtothisdiagnosis,notimewaswasted,hisstatuswasstabilized,basedonafewleadingsignsandsymptoms,evenwhenthemedicalstaffdidnotknowexactlywhatwaswrongwithhim.Thiswasgoodtriageandemergencymanagement.Wouldithavehappenedlikethisinyourhospital?Inthistrainingcourse,youaregoingtoacquirethenecessaryknowledgeforthecorrecttriageofsickchildrenandadults.Manydeathsinhospitaloccurwithin24hoursofadmission.Someofthesedeathscanbepreventedifverysickpatients(especiallychildren)arequicklyidentifiedontheirarrivalandtreatmentisstartedwithoutdelay.Inmanyhospitalsaroundtheworld,childrenarenotcheckedbeforeaseniorhealthworkerexaminesthem;asaresult,someseriouslyillpatientshavetowaitaverylongtimebeforetheyareseenandtreated.Childrenareknowntohavediedofatreatableconditionwhenwaitinginthequeuefortheirturn.Theideaoftriageistopreventthisfromhappening.Thepurposeoftriageistoprioritisepatientsbasedonmedicalurgencyincontextswherethereisamismatchbetweendemandandcapacity(i.e.patientloadoverwhelmstheavailableresources).

1.1ThebenefitsofimplementingSATS1. expeditethedeliveryoftime-criticaltreatmentforpatientswithlife-threateningconditions.2. ensurethatallpatientsareappropriatelyprioritisedaccordingtotheirmedicalurgency.3. improvepatientflow.4. improvepatientsatisfaction.5. decreasethepatient’soveralllengthofstay.6. facilitatestreamingoflessurgentpatients.7. provideauser-friendlytoolforalllevelsofhealthcareprofessionals.

ByintroducingtheSATSatapublicurbanhospitalinCapeTown,meanwaitingtimeswerereducedsignificantlyforallprioritylevelsexceptthenon-urgentgreencategory.Themostdramaticreductioninwaitingtimeswasseeninpatientscodedasred(82%).1

1

Acknowledgements

ACKnOWLEDGEMEnTs

TheSouthAfricanTriageGroup(SATG)wouldliketothankthePaediatricTriageWorkingGroup(PTWG)oftheWesternCapeGovernment(WCG)ofSouthAfrica(SA)(undertheauspicesofthePaediatricProvincialCo-ordinatingCommittee&theEmergencyMedicineProvincialCo-ordinatingCommittee)fortheireffortsandhardworkindevelopingpaediatrictriagebasedontwoexistingtriagetools:theEmergencyTriageAssessmentandTreatment(ETAT)oftheWorldHealthOrganization(WHO)andtheSouthAfricanTriageScale(SATS).

TheSATGandPTWGwishestoacknowledgetheWHODepartmentofChildandAdolescentHealthandDevelopmentandProfessorElizabethMolyneux,whodevelopedtheETATtrainingcourseonwhichthesecoursematerialsarebased.WearealsogratefultotheETAT-SouthAfrica(ETAT-SA)workinggroupforalltheireffortsandhardworkinadaptinganddevelopingthegenericETATmaterialsintotheETAT-SAmaterialsspecificallyfortheSouthAfricansetting.

AllreasonableprecautionshavebeentakenbythePTWG,theETAT-SAworkinggroup,WHOandSATSgrouptoverifytheinformationcontainedinthispublication.However,thepublishedmaterialisbeingdistributedwithoutwarrantyofanykind,eitherexpressorimplied.Theresponsibilityfortheinterpretationanduseofthemateriallieswiththereader.InnoeventshallthePTWG,theETAT-SAworkinggroup,WHOortheSATGbeliablefordamagesarisingfromitsuse.

Dr Baljit Cheema and Dr Michèle Twomey

On behalf of the Paediatric Triage Working Groupand thesouth African Triage Group

Paediatric TriageWorking Group AnthonyWestwoodBaljitCheemaHeloiseBuysJeanAugustynHeatherTuffinMichaelLeeAndrewArgentShaheemdeVriesLeeWallisZaneleNxumaloLouiseCookePeterLeschMajedahIsmailLieslStraussAngeladeSáJacoSlabbertWendyRosenthalMichèleTwomey

ETAT-sAWorking Group

LesleyBamfordGerryBoonHeloiseBuysBaljitCheemaSueHarrisMarkPatrickCindyStephenChrisSutton

3SATS TRAINING MANUAL 20122 SATS TRAINING MANUAL 2012

1.4 Terminology and key concepts1. Triage,fromtheFrenchword“trier”,literallymeans:“tosort”.Theaimistobring“thegreatest

goodtothegreatestnumberofpeople”–thisisachievedthroughprioritisinglimitedresourcestoachievethegreatestpossiblebenefit.Patientsaresortedwithascientifictriagescaleinorderofurgency-theendresultisthatthepatientwiththegreatestneedishelpedfirst.

2. Patient to triage:forthehospitalorcliniccontextthisreferstoapatientthatappearsrelativelystableandisabletomobilisehim/herselftothedesignatedtriagearea.Thiswillbethetypeoftriageusedformosthospitalandcliniccases.

3. Triage to patient:herethepatientisusuallyunstable.Thepatientisunabletomobilisehim/herselftothedesignatedtriageareaandwillneedtobetriagedwheretheyarefound.Theymayneedtobereferreddirectlytotheresuscitation(resus)areaiftheyareatahealthfacility.Triagemayalsobeperformedatthebedsideanddocumentedinretrospect.Thistypeoftriagewillbeusedlessofteninthehospitalcontextandpredominantlyinthepre-hospitalcontext.

4. Physiology(i.e.vitalsigns):referstothenormalfunctioningofthedifferentbodysystems.Someofthephysiologycanbereadilymeasured(e.g.pulse,bloodpressure,respiratoryrate,temperature).

5. TEWs: Triage Early Warning score.Thisisacompositescoreofthepatient’sphysiology.Thescoreisderivedbyassigninganumberbetween0and2foreachofthepatient’svitalsigns.Thehigherthescorethegreatertheurgency.

6. streaming:theuseofdedicatedhealthcareresourcesforeachprioritygroupofpatients.Forgreenpatients,thismaybeadoctorornursepractitioner:thispersonneedstheirownspacetoseethesepatients.

7. Pain:Severepainisunbearable,theworstpainthepatienthaseverfelt.Itmaybeassociatedwithsweatiness,paleness,andalteredlevelofconsciousness.Moderatepainisintense,butbearable.Mildpainisanyotherpain.Remembertodoapainassessmentoneverypatientthatyousee.

8.

!AdditionalInvestigation:Youwillfindthisexclamationiconinlaterchapters. Itrepresentsanadditionalinvestigationwhichmayleadtoachangeinthepatient’striageprioritylevel.Checkingthebloodglucoseconcentrationormeasuringtheoxygensaturationlevelareexamplesofadditionalinvestigations.Sectionsixoutlinesallkeyadditionalinvestigationsimportantattriage.TheycanalsobefoundontheSATScharts.

9. Warning: Thelightbulbiconindicatesawarningthatusuallyfollowsimmediatelyafteranadditionalinvestigation,implyingthatsomeimmediateactionisrequired(e.g.achildwhoseoxygensaturationlevelsarefoundtobe80%requiresoxygenadministrationandshouldbetakentotheresuscitationarea).

10. Additional tasks: Theiconwitharedcrossrepresentsadditionaltasksthatarebeneficialtothepatientifinitiatedattriage.Theseadditionaltasksdonotchangethepatient’striageprioritylevel.Examplesincludestartingoralrehydrationtherapyforachildthatisdehydrated,coolingaburnthatoccurredwithin3hoursorapplyingdirectpressuretoanuncontrolledhaemorrhage.

1.2 Triage requirements Triageissimpletodo,butinordertostandardisetheprocessandcomprehensivelyimplementtheSATSasavalidatedtoolcertainrequirementsneedtobemet.Table1showstheequipmentneededfortheprocessandAppendixAonpage4includesadetailedchecklistofrequirements.

Location Equipment Additional equipment

Privacy:Screen,partitionorseparateroom.

Gloves,facemasks&otherbarrierprotectivedevices

Pulseoximeterwithpaediatricprobes

Safety:Security/protected Wallclock ECG

Sizeofarea:pushchairs,wheelchairs,stretchers

Lowreadingelectronic/mercurythermometer

Fingerprickmachine,haemoglobinandglucometermeasurement

Accessibility VitalsignsmonitorORbauma-nometerwithpaediatriccuffs

Urinecollectioncontainers,urinedipsticks&urinepregnancytests

Baby-changingfacilities Drydressings/bandages

Table 1: Requirements for adequate / efficient triage

1.3Whoshouldbethetriageprovider?Nurse-basedtriagehasbeensuccessfullyimplementedworldwideinthecountriesofNorthAmerica,Europe,theMiddleEastandAustralasiasincethedevelopmentofEmergencyMedicineasaspecialityabout30yearsago.Table2showsthenumberofmedicalpractitionersandnursesperunitofpopulationinSouthAfrica,comparedtosome“developed”countries.Giventhesignificantlylowerdoctor:nurseratioinSouthAfricacomparedtocountrieswherenursetriageiswidelypracticed,itisapparentthatthedevelopmentofnurse-basedtriageshouldbeapriorityinoursetting.

Country Rate per 100,000 population/ year

Doctors nurses Doctor: nurse ratio

SouthAfrica 56.3 471.2 1:8.0

Canada 229 897 1:4.0

Australia 240 830 1:3.4

Israel 385 613 1:1.6

UK 164 479 1:3.0

Table 2: Doctor and nurse rates per 100,000 population per annum for selected countries

NursesarethefirstmedicalcontactforthepatientsattendingtheEmergencyCentreinmostinstances.InSouthAfricanstudies,adequatelytrainedEnrolledNursingAssistants(ENAs)havebeenshowntobeaccuratetoadegreecomparablewithinternationalstandardsofnursingtriage.2 3 TheSouthAfricanTriageScaleshouldbeknownandappliedbyallhealthcareprofessionalsinvolvedintheEmergencyCentre.Thetriageprovidercanbethemedicalofficer,theregisterednurse,enrollednurseortheENA.Thepurposeofthistrainingprogramistoempowertheindividualwhoparticipateswiththeknowledgetotriage.Itwillonlybethroughpracticeandrepetitionthataproviderwillbecomeskilledwithtriage.Successfulprovidersarethereforeencouragedtoparticipateintriagingasfrequentlyaspossibleinordertostayinpracticeanduptodate.

IntroductionIntroduction


APPEnDIX A: Checklist of triage emergency centre requirements

structural Requirements

Doesthetriageareameetthefollowingcriteria: Yes No

1 Isthetriageareaadedicatedspace?

2 Isthetriageareawellsigned?

3 Isthetriageareasecure(i.e.behindthesecuritygate,orineasyviewofsecuritystaff)?

4 Isthetriageareaatleast10squaremetersinsize(i.e.shouldbeabletoaccommodateanurse,patientinawheelchairandrelativeorcarer)?

Checklist of triage Infrastructure Requirements

Content Requirements

Doesthetriageareacontainthefollowing: Yes No

1 Adeskandchair?

2 Triagepaperworkforadult,childrenandinfants?

3 Awallclockwithasecondhand?

4 Astethoscope?

5 Alowreadingthermometer?

6 Drydressingsandbandages?

7 Gloves?

8 Sphygmomanometer(manual,digitalorelectronic)?

9 Bloodglucosemonitor?

10 AmeasuringtapeORmarksdisplayedonwallintriageareatomeasurechildren(i.eonemarkat95cmandoneat150cm)?

11 2xdifferentSATSpostersprominentlydisplayedintriagearea?

12 SATSmanualreadilyavailablefortriageofficeasasourceofinfo?

13 SATSpatientinfoleafletprominentlydisplayedinthewaitingarea?

14 Triageregisterorcomputerwithregister?

15 Whiteboardtotrackandcommunicatetootherstaffacuityofthosetriaged?

Assessment QuestionsClearlyindicatewhetherthefollowingstatementsaretrueorfalse:

1. Thepurposeoftriageistopreventdeteriorationordeathofapatientwhilewaitinginthequeuefortheirturn.

True False

2. Thetriagemethodshouldbeknownandappliedbyclinicalnursepractitionersonly.

True False

3. Streamingistheprocessofgettingpatientstowaitforaslongaspossible.

True False

Choosethecorrectanswer:4. Thebenefitsoftriageare: (a) Tofacilitatestreamingofgreenpatients (b) Todecreasethewaitingtimeoflife-threateningconditions (c) Toensurethatpatientsareappropriatelyprioritizedbyurgency (d) Topreventchildrenfromdyinginthewaitingroom (e) Alloftheabove

5. TEWSisshortfor: (a) TriageEarlyWarningSystem (b) TraumaEarlyWarningScale (c) TriageEmergencyWarningSystem (d) TriageEarlyWarningScore (e) TraumaEmergencyWaitingScore

IntroductionIntroduction


TheSATSprocessflowchart

ThE sATs PROCEss FLOWChART

LearningObjectives:

• UnderstandthefivestepapproachandSATSprocessflowchart• BefamiliarwiththetwoversionsoftheSATSchart• BefamiliarwiththeprioritylevelsofSATS

2.1Thefivestepapproachstep 1: Look for emergency signs and ask for the presenting complaintStep2: LookforveryurgentORurgentsignsStep3: MeasurethevitalsignsandcalculatetheTEWSStep4: CheckkeyadditionalinvestigationsStep5: Assignfinaltriageprioritylevel

Figure 1: SATS five step approach

Theprocessoftriagestartswithaquestiontothemother/carer/patientastothereasonforcomingtotheemergencycentre.AsthisquestionisbeingaskedandansweredthetriageprocessalreadycommenceswiththetriagepractitionerrapidlyassessingthepatientforanyEmergency clinical signs.TheAirway,Breathing,Circulation,Coma,Convulsion,Dehydration,Other(ABC-c-c-DO)approachisusedforpaediatricpatients.Ifemergencyclinicalsignsarefound,thepatientisassignedaRedprioritylevelandtakenstraighttotheresuscitationareawithoutdelay.IfnoEmergencyclinicalsignsarepresentthencheckforanyVery Urgent or Urgentclinicalsigns.Whetherthesearepresentornot,vitalsignsaremeasured,theTEWSiscalculated,keyadditionalinvestigationsarecheckedandthetriagepriorityadjustedasshowninFigure2.ItisimportanttonotethatifapatienthasanyemergencysignsthenaTEWSdoesNOTneedtobecalculatedattriage.Thereshouldbenodelayintakingthepatienttotheresuscitationarea.Finallytheseniorhealthcareprofessional’s(SHCP)discretionasseeninFigure2,allowstheclinicalnursepractitionerorseniordoctortooverridethefinaltriagepriorityassigned.

2.2TheSATSprocessflowchartTherearetwoversionsoftheSATSchartasseeninFigure4and5.ThepaediatricversionoftheSATSchartisusedtotriageallpatientsyoungerthan12yearsandsmallerthan150cm.TheadultversionoftheSATSchartisusedtotriagepatientsolderthan12yearsortallerthan150cm.BothagespecificversionshavetheexactsameSATSprocessflowchartasdepictedinFigure2.ThefivestepsinFigure1areintegratedintothisprocessflowchart.ThedifferencesarefoundintheirrespectiveclinicalsignsandtheirageappropriateTEWS.Thenexttwosectionsdescribeindetailtheadultandpaediatricclinicalsignsrespectively.

2.3SATSprioritylevelsTheSouthAfricanTriageScalehasfourprioritylevelsasshowninTable3.Eachprioritylevelshouldideallybemanagedwithinthetargettimetotreatment.

2

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Figure 2: The SATS process flowchart

TheSATSprocessflowchart

2.4 Terminology and key concepts1. RedvsResus:PatientsmaybetriagedRedonthebasisoftheirpresentation,butnot

necessarilybeafullresuscitationcase.Conversely,ifapatientpresentstoyouasaresusyoudonotneedatriagetooltotellyouthattheyareaRedcase.Forthosepatientswhopresentlikethis(e.gCardiacarrest),triagebeforetreatmentisnotnecessary–ifapatientisaresus,theyareRedbydefinition.

2. MajorsvsMinors:Themajorsareainahospitalisstaffedbyappropriatelytrainedpersonnelandadvancedequipmenttodealwithemergency,veryurgentandurgentpatients.Theminorsareaisstaffedbyappropriatelytrainedpersonnelandtherespectiveequipmentandresourcestodealwithroutineornon-urgentpatients.

Priority COLOUR Target time Management

RED IMMEDIATE Taketotheresuscitationroomforemergencymanagement

ORAnGE < 10 mins Refertomajorsforveryurgentmanagement

YELLOW < 1 hour Refertomajorsforurgentmanagement

GREEn < 4 hours Refertodesignatedareafornon-urgentcases

BLUE < 2 hours Refertodoctorforcertification

Table 3: SATS priority levels and target times to be seen with-in


1. TherearetwoSATScharts–oneforpaediatricpatientsandoneforadultpatients.

True False

2. Ifanemergencysignisidentifiedinthefirststep,thepatientistakentotheresuscitationareaimmediately.

True False

3. Ifnoemergencysignsareidentifiedinstepone,butanurgentsignisidentifiedinsteptwo,thepatientisimmediatelytriagedyellowandaskedtowait.

True False

Choosethecorrectanswer:4. TheSATSprioritylevelOrangeisdefinedas: (a)Emergencyrequiringimmediateintervention (b) VeryUrgentrequiringinterventionwithin10minutes (c) Urgentrequiresinterventionwithin60minutes (d) Routinerequiringinterventionwithin240minutes (e) Lifethreateningbutnotrequiringanyintervention

5. Theseniorhealthcareprofessional’sdiscretionrefersto: (a) Thejuniornurseoverridingthefinaltriagedecision (b) Theclinicalnursepractitioneroverridingthefinaltriagedecision (c) Themedicalstudentoverridingthefinaltriagedecision (d) Themedicalofficeroverridingthefinaltriagedecision (e) banddabove


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AdultClinicalSigns

3

It is important to note that if a patient has any emergency signs then a TEWs does nOT need to be calculated to categorise them as RED. There should be no delay in taking the patient to the resuscitation area. Thefirstsetofvitalsmaybeobtainedintheresuscitation area or in the ambulance.

ADULT CLInICAL sIGns

LearningObjectives:

• Befamiliarwiththeadultemergencysigns• Befamiliarwiththeadultveryurgentandurgentsigns

3.1 EMERGEnCY sIGns

EMERGEnCYObstructed airway – not breathing

seizures - current

Burn – facial /inhalationhypoglycaemia – glucose less than 3 mmol/L

Cardiac arrest

Burn - facial inhalationAnypatientinwhomtheairwayhaspotentiallybeenexposedtoheat(e.g.trappedinahousefire,hotwaterburntofacewithpossiblesteaminhalationorchemicalburntofaceormouth)maygetrapidswellingoftheairway.Adultspresentingwiththisemergencysignmayhavesingedfacialhairs(eyelashes,eyebrows),carbonaceousmaterialinandaroundtheirnose/mouthandshouldbetriagedRed.Otheremergencysignsforadultsincludeanobstructedairway(patientnotbreathing),apatientconvulsing,andhypoglycaemiawithaglucoselessthan3mmol/Lorcardiacarrest.

3.2 VERY URGEnT sIGns

Highenergytransfer(severemechanismofinjury)Inourcontextthisreferstohighspeedinjuries.Examplesoftheseincludeamotorvehicleaccidentof40km/hormore,pedestrianvehicleaccident,afallfromarooforahighvelocitygunshotwound.

AdultClinicalSigns

Levelofconsciousnessreduced/confusedAnypatientthatisnotfullyalert(i.e.confused, onlyrespondingtoaverbalstimulus,painfulstimulusorunresponsive).

Threatened limbApatientpresentingwith apainful,pale,pulseless, weak,numblimb.

3.3 URGEnT sIGns

haemorrhage - controlled Thisreferstoasituationwhereapatientpresentswithanactivebleedandyouasthetriageproviderapplydirectpressurewithadrydressingandareabletocontrolthebleed. Thisdoesnotrefertoapatientpresentingwithdryblood.

Abdominal painInallfemalesofchild-bearingageadditionalinvestigations(i.e.urinedipstickandurinepregnancytest)shouldbeperformedtopickupapossibleectopicpregnancy.

Assessment QuestionsClearlyindicatewhetherthefollowingstatements aretrueorfalse:

1. Singedfacialhairsandsootaroundthenoseandmouthareanindicationofinhalationburninapatientthathasbeentrappedinaburninghouse.

True False

2. Haemorrhagecontrolledreferstoapatientwhoseactivebleedwascontrolledbythetriageproviderbyapplyingdirectpressurewithadrydressing.

True False

3. ApatientincardiacarrestisimmediatelycategorisedRed.

True False

Choosethecorrectanswer:4. Examplesofhighenergytransfersinclude: (a) Motorvehicleaccidentat60km/h (b) Fallfromaheightoftenmeters (c) Pedestrianvehicleaccidentat50km/h (d) Highvelocitygunshotwound (e) Alloftheabove

5. Athreatenedlimbmaypresentas: (a) Painintheaffectedlimb (b) Apale,pulselessaffectedlimb (c) Aweakornumbaffectedlimb (d) Theaffectedlimbiscoldandhaspoorperfusion (e) Alloftheabove

A threatened limb presents as:P Pain P Pulselessness P CapillaryRefillDelayP Pallor P Paralysisorpins&needles PTemperature

A Isthepatient Alert?Ifnot,V IsthepatientrespondingtoVoice?Ifnot,P IsthepatientrespondingtoPain?U ThepatientwhoisUnresponsivetovoice

AnDtopainisUnconscious.

URGEnT

haemorrhage - controlledDislocationoffingerORtoe

Fracture–closed(nobreakintheskin)Burn - other

Abdominal painDiabetic–glucoseover17(noketonuria)

Vomiting persistentlyPregnancy & trauma

Pregnancy & PV bleed Moderate pain

VERY URGEnT

high energy transfer (severemechanismofinjury)

Focal neurology – acute (stroke)

Burn – circumferential

shortness of breath - acute Aggression Burn – chemical

Levelofconsciousnessreduced / confused

Threatened limb Poisoning/Overdose

Coughing blood Eye injury Diabetic–glucoseover 11 and ketonuria

Chest pain Dislocation of larger joint (notfingerortoe)

Vomiting fresh blood

stabbed neck Fracture - compound (withabreakinskin)

Pregnancy and abdominal trauma

haemorrhage – uncontrolled (arterialbleed)

Burnover20% Pregnancy and abdominal pain

seizure – post ictal Burn – electrical SeverePain


PaediatricClinicalSigns

PAEDIATRIC CLInICAL sIGns

LearningObjectives:

• Befamiliarwiththepaediatricemergencysigns• UnderstandtheABC-c-c-DOapproachforemergencysigns• Befamiliarwiththepaediatricveryurgentandurgentsigns

4.1 EMERGEnCY sIGns: The ABC-c-c-DO approachTriageofpatientsinvolveslookingforsignsofseriousillnessorinjury.TheseemergencysignsrelatetotheAirway-Breathing-Circulation/Coma/Convulsion-Dehydration-Otherandareeasilyrememberedas“ABC-c-c-DO”.Eachletterreferstoanemergencysignwhich,whenidentified,shouldalertyoutoapatientwhoisseriouslyillandneedsimmediateintervention.ItisimportanttonotethatifapatienthasanyemergencysignsthenaTEWSdoesNOTneedtobecalculated.Thereshouldbenodelayintakingthepatienttotheresuscitationarea.Thefirstsetofvitalsmaybetakenintheresuscitationareaorintheambulanceonthewaytothehospital.

EMERGEnCY

Airway and Breathing not breathing or reported apnoeaObstructed breathingCentral cyanosis or spO2lessthan92%Respiratorydistress(severe)

Circulation Cold hands + 2 or more of the following:(i)pulseweakandfast(ii)capillaryrefilltime3secormore(iii)lethargicUncontrolledbleeding(notnosebleed)

Coma AVPU:RespondsonlytoPain(P)ORUnresponsive(U)Confusion

Convulsions Convulsingorimmediatelypost-ictalandnotalert

Dehydration Diarrhoeaorvomiting+2ormoreofthefollowing:(i)Lethargy/floppyinfant(ii)Verysunkeneyes(iii)Skinpinchveryslow-2secormore

Other Facial /inhalation burnhypoglycaemia recorded at any time - glucose less than 3 mmol/LPurpuric rash

HOWTOTriage?KeepinmindtheABC-c-c-DOsteps: Airway,Breathing,Circulation,Coma,Convulsion,DehydrationandOther.

4.1.1 AB AIRWAY AnD BREAThInG ARE UsUALLY AssEssED TOGEThERThe letters AandBin “ABC-c-c-DO”represent“airway and breathing”. Itisevidentthatanopen(patent)airwayisneededforbreathing.Anairway orbreathingproblemislife-threateningandmustreceiveyourattentionbeforeyoumoveontoothersystems.Itisthereforeconvenientthatthefirsttwolettersofthealphabetrepresentthetwomostimportantareastolookforemergencyorprioritysigns.Ifthereisnoproblemwiththeairwayorbreathing,youshouldlookforsignsintheareasrepresentedbyC.

4

Toassessifthechildhasairwayorbreathingproblemsyouneedtoknow:• Isthechildbreathing?• Istheairwayobstructed?• Isthechildblue(centrallycyanosed)?

ISTHECHILDBREATHING? Ifactive,talking,orcrying,thechildisobviouslybreathing.IfinanydoubtyoumustAssEssthreethingstocheckifthechildisbreathing(seeFigure6):

• LOOK-toseeifthechestismoving.• LIsTEn-foranybreathingsounds.

Aretheynormal?• FEEL-Canyoufeelthebreathatthenoseor

mouthofthechild?Ifthechildisnotbreathing(oryouarenotsureifthereisbreathing),youneedtotakethechildtotheresuscitationareawherethebreathingneedstobeartificiallysupportedbyventilatingthechildwithabagvalvemask(BVM)devicewhilstthechildisfurtherassessedandmanagedappropriately.

ISTHEBREATHINGOBSTRUCTED?Noisybreathingcanbeasignthattheairwaymaybethreatenedorpartiallyobstructed.Thisismostcommoninpatientswithadecreasedlevelofconsciousness,upperrespiratorytractinfectionsoraspirationofforeignbodies.Obstructedbreathingcanalsobeduetoblockagebythetongueorthepatient’sownsecretionsifthesearenotbeingswallowed.

ARETHEREABNORMALRESPIRATORYNOISES?Arethereanynoisesheardwhenbreathingin?Aharshnoiseonbreathinginiscalledstridor,ashortnoisewhenbreathingoutinyounginfantsiscalledgrunting.Bothnoisesaresignsofsevererespiratoryproblems.

NB:Ablockednoseisanextremelycommoncauseofnoisybreathing,butitisNOTlife-threatening.

DOESTHECHILDSHOWCENTRALCYANOSIS? DEFInITIOn: Cyanosisoccurswhenthereisanabnormallylowlevelofoxygenintheblood. Thisproducesabluishorpurplishdiscolorationofthetongue,theinsideofthemouthandtheskin.Thissignmaybeabsentinachildwhohassevereanaemia.To AssEssforcentralcyanosis:LOOK-atthemouthandtongue.Abluishorpurplishdiscolorationofthetongueandtheinsideofthemouthindicatescentralcyanosis.MEAsURE-Ifoxygensaturationmonitoringisavailableyoucancheckthechild’soxygenlevels. Firstensurethattheprobeiscorrectlysitedandthatagoodregulartraceisshowingonthemonitor.Ifoxygensaturationis<92%inroomairthechildhaslowoxygenlevelsandthisisanemergency.

DOESTHECHILDHAVESEVERERESPIRATORYDISTRESS?To AssEsswhetherthechildhassevererespiratorydistresscheckforthefollowingsigns:

• Isthechildhavingtroublegettingbreathsothatitisdifficulttotalk,eatorbreastfeed?

• Isthechildbreathingveryfast?• Doesthechildhaveseverechestindrawing?Thiscan

beintercostal(betweentheribs),subcostal(belowtheribcage),suprasternal(abovethesternum)orsternalindrawing(thebreastboneissuckedinoninspiration).

• Doesthechildhavenasalflaringoragruntingnoiseonexpiration?• Isthechildusingtheaccessorymusclesoftheneckforbreathing?Thiscancausetheheadto

nodorbobwitheverybreath.Thisisparticularlyseeninyoungbabies.• Exhaustion:Ifthechild’sbreathingisverylaboured,especiallyifithasbeenlikethisforsome

time,thens/hemaybecomeexhausted?Ifthishappensthenthesignsofincreasedworkofbreathingcanactuallydecreaseasthechildistotired-thisisaverydangeroussign.

Ifyouseethesesignsthenitislikelythatthechildhassevererespiratorydistress.


Figure 6: Look, listen and feel

Signsofsevererespiratorydistress:• Veryfastbreathing• Severelowerchestwallindrawing• Useofauxiliarymuscles• Headnodding• Inabilitytofeedbecauseof

respiratoryproblems• Gruntingandflaring


MEAsURE:Inanychildwithrespiratorydistress,youshouldcheckoxygensaturationlevelsifyouhaveanoxygensaturationmonitor.Firstensurethattheprobeiswellsitedandthatyouhaveagoodtraceonthemonitor–iftheoxygensaturationislessthan92%inroomair,thischildhasanemergencysignandneedsoxygentherapy.Howeverifachildisobviouslyinsevererespiratorydistress,oxygensaturationlevelsdonotneedtobecheckedattriagetoconfirmthisemergencysign,rathertakethechild to the resuscitation area immediately.Ifthechildisbreathingadequately,gotothenextsectiontoquicklycontinuetheassessmentforemergencysigns.Ifthechildhasanairwayorbreathingproblem,youshouldinitiateappropriatetreatmentandthenquicklyresumetheassessment.

4.1.2 C CIRCULATIOn AssEssMEnTFIRsT FEEL ThE ChILDs hAnDs – IF ThEY ARE WARM YOU DO nOT nEED TO ChECK ThE CIRCULATIOn AnY FURThER. MOVE On TO ThE nEXT EMERGEnCY sIGn.IF ThE hAnDs ARE COLD OR COOL – YOU nEED TO RAPIDLY AssEss FOR OThER sIGns OF CIRCULATORY shOCK: PULsE VOLUME AnD RATE; CAPILLARY REFILL TIME AnD LEThARGY.

ISTHEPULSEWEAKANDFAST?Theradialpulse(thepulseatthewrist)shouldbefelt.Ifthisisstrongandnotobviouslyfast,thepulseisadequate;nofurtherassessmentisneeded.Theradialpulseisusedasaninitialscreenbecauseitiseasytoaccesswithoutundressingthepatient.Iftheradialpulseisdifficulttofind,youneedtolookforamorecentralpulse(apulsenearertotheheart).Inaninfant(lessthanoneyearofage)thebestplacetolookisatthemiddleoftheupperarm,thebrachialpulse.Ifthechildislyingdownyoucouldlookforthefemoralpulseinthegroin.Thepulseshouldbestrong.Ifthemorecentralpulsefeelsweak,decideifitalsoseemsfast.Thisisasubjectivejudgementandanexactcountisnottaken.Ifthecentralpulseisweakandfast,thechildneedsfurtherassessmentandpossibletreatmentforshock.Alltheseprocedurescanandshouldbepractisedonyourself,yourfriends,yourchildrenandfamily,andfinallyonrealpatients.Practiceisthebestwaytoimproveonfindingpulsesandmeasuringcapillaryrefill.

Notethatwedonotrecommendbloodpressuretoassessforshockattriagebecauseoftworeasons: 1)Lowbloodpressureisalatesignofshockinchildrenandtheywillalreadyhaveotherobvioussignsand2)thebloodpressureinchildrenislesspredictiveattriagethaninadults.

4.1.3 C-C COMA AnD COnVULsIOns AssEssMEnT

ISTHECHILDINACOMA? Achildwhoisawakeisobviouslyconsciousandyoucanmovetothenextcomponentoftheassessment.Ifthechildisasleep,askthemotherifthechildisjustsleeping.Ifthereisanydoubt,youneedtoassessthelevelofconsciousness.Trytowakethechildbytalkingtohim/her,e.g.callhis/hernameloudly.Achildwhodoesnotrespondtothisshouldbegentlyshaken.Alittleshaketothearmorlegshouldbeenoughtowakeasleepingchild.Ifthisisunsuccessful,applyafirmsqueezetothenail

bed,enoughtocausesomepain.Achildwhodoesnotwaketovoiceorbeingshakenortopainisunconscious.Tohelpyouassesstheconsciousnesslevelofachild,asimplescale(AVPU)isused:Achildwhoisnotalert,butrespondstovoice,islethargic.Anunconsciouschildmayormaynotrespondtopain.Any child with a coma scale of “P” or “U” is an emergency and needs to be taken to the resuscitation area immediately.


Toassessforcomaandconvulsionsyouneedtoknow:(i) Isthechild’slevelofconsciousness

disturbed?(ii) Isthechildconvulsingnow?

A IsthechildAlert?Ifnot,V IsthechildrespondingtoVoice?

Ifnot,P IsthechildrespondingtoPain?U ThechildwhoisUnresponsive

tovoice(orbeingshaken) ANDtopainisUnconscious.

Toassessifthechildhascirculationproblemsyou needtoknow:•Doesthechildhavecoolorcoldhands?IF YEs -Isthecapillaryrefilltime(CRT)3secondsormore? -IftheCRTisprolongedisthepulseweakandfast? -Isthechildlethargic

ISTHECHILDCONVULSINGNOWORPOST-ICTAL? Thisassessmentdependsonyourobservationofthechildandonthehistoryfromtheparent.Childrenwhohaveahistoryofconvulsion,butarealertduringtriage,willneedacompleteclinicalhistoryandinvestigationbyaclinician,butattriagetheyarenotassignedanemergencyclinicalsign,astheydonotusuallyrequireanyresuscitationimmediately.Thechildmaybeseentohaveaconvulsionduringthetriageprocessorwhilewaitingintheoutpatientdepartment.Youcanrecognizeaconvulsionbythesuddenlossofconsciousnessassociatedwithuncontrolledjerkymovementsofthelimbsand/ortheface.Thereisstiffeningofthechild’sarmsandlegsanduncontrolledmovementsofthelimbs.Thechildmaylosecontrolofthebladder,andisunconsciousduringtheconvulsionanddrowsyafterwards.Sometimes,insmallinfants,thejerkylimbmovementsmaybeabsent,buttheremaybemoresubtletwitchingmovementsoftheface,mouth,eyes,handsorfeet.Youhavetoobservetheinfantcarefully.

4.1.4 D sEVERE DEhYDRATIOn AssEssMEnTInthissectionwewilllookattheassessmentofseveredehydrationinthechildwithdiarrhoeaorvomiting.Ifthechildisseverelymalnourishedthesignsofdehydrationarenotasreliable.

DOESTHECHILDHAVEDIARRHOEAORVOMITING? Thisinformationcomesfromtheparentorguardian. Ifthechildhasnodiarrhoeaorvomiting,donotcheckfordehydration.Movetothenextassessment.Ifthechildhasdiarrhoeaorvomitingassessforseveredehydration.Ahistoryofdiarrhoeaorvomitingandthepresenceoftwoormoreofthesignsintheboxabovemeansthechildhasseveredehydrationandneedstobetakentotheresuscitationareaimmediately.

ISTHECHILDLETHARGIC?Intheolderchildlethargyisquiteeasytoassess.YouhavealreadyassessedthestateofconsciousnessofthechildusingtheAVPUscale.Nowobserveifthechildappearsdrowsyanddoesnotshowinterestinwhatishappeningaroundhim/her.Alethargicchildmaynotlookatthemotherorwatchyourfacewhenyoutalk.Thechildmaystareblanklyandappearnottonoticewhatisgoingonaroundhim/her.Doesthechildknowhis/hernameandanswerquestionssensibly?Ifthechildrespondstovoicebutremainsdrowsy,he/sheislethargic.Intheyoungerchild,signsoflethargyarehardertoassess.

DOEs ThE ChILD hAVE VERYSUNKENEYES?Lookatthechild’seyestodetermineiftheyappearunusuallysunkenintheirsockets(seeFigure8).Askthemotherifthechild’seyesaremoresunkenthanusual.

DOESASKINPINCHGOBACKVERYSLOWLY(2SECONDSORMORE)?Thisisasimpletesttolookathowelastictheskinis.Ifthechildisnotdehydrated,theskinwillbeelasticand,whenpinchedandreleased,willreturntonormalstraightaway.Trythisonyourself. Thedehydratedchildwillhavelostfluid.Thebodymovesfluidfromlessimportantplaces,suchastheskin,tomaintainthecirculation.Theskinbecomeslesselasticand,whenpinched,isslowtoreturn.Locatetheareaonthechild’sabdomenhalfwaybetween


Toassessifthechildisseverelydehydratedyouneedtoknow:• Isthechildlethargic?• Doesthechildhavevery

sunkeneyes?• Doesaskinpinchtake2seconds

ormoretogoback?

Figure 8: Sunken eyes

Figure 9: Skin pinch

Figure 7:Feeling the brachial pulse in an infant



theumbilicusandthesideoftheabdomen.Avoidingusingyourfingertips,asthisispainful.Pinchtheskininavertical(headtofoot)directionandnotacrossthechild’sbody.Youshouldpickupallthelayersoftheskinandthefattissueunderneath.Pinchforonesecondandthenrelease.Seewhethertheskingoesbackveryslowly(2secondsormore).Severedehydrationispresentifthechildhasahistoryofdiarrhoeaplusanytwoofthefollowingsigns:lethargy,sunkeneyesorveryslowskinpinch(2secondsormore).

4.1.5 O OThER EMERGEnCY sIGns

Facial inhalational burnsAnychildinwhomtheairwayhaspotentiallybeenexposedtoheat(e.g.trappedinahousefire,hotwaterburntofacewithpossiblesteaminhalationorchemicalburntofaceormouth)maygetrapidswellingoftheairway.ChildrenpresentingwiththisemergencysignshouldbetriagedRed.

Glucose <3mmol/L at any timeChildrenwithalowbloodsugarareoftenverysickandneedtobeseenimmediately.TheyshouldbetriagedRediffoundtohaveabloodglucoseconcentrationoflessthan3mmol/L.

Purpuric RashChildrenwhopresentwithacomplaintofarash-shouldbeassessedtoseeifthespotsblanchwithpressurefromfingertiporglasstest(i.e.turnswhitewhenpressureisapplied).Ifthespotsarenon-blanching(i.e.doesnotturnwhitewhenpressureisapplied)-thenthereisariskofmeningococcaldisease.ChildrenpresentingwiththisemergencysignshouldbetriagedRed.Ifyouareunsureaboutachildpresentingwitharashasktheseniorhealthcareprofessional.Youhavenowlearnedhowtorecognizetheobviousemergencysignsinpaediatricpatients.Thenextsectionwillcovertheveryurgentandurgentsignsrespectively.ItisimportanttonotethatifapatienthasanyemergencysignsthenaTEWSdoesNOTneedtobecalculated.Thereshouldbenodelayintakingthepatienttotheresuscitationarea.Thefirstsetofvitalsmaybetakenintheresuscitationareaorintheambulanceonthewaytothehospital.

• IfanyEMERGENCYsignshavebeenfoundtheTEWSshouldNOTbecalculatedattriage,thechild is within the RED category and should be taken to the resuscitation area.

• ChildrenwithintheRED category need emergency care and should be seen immediately.• AlwaysensurethatthechildwithemergencysignsishandedoverdirectlytoaSHCP.

• If there are no EMERGEnCY signs, check to see whether the child has any VERY URGEnT signs.

4.2 VERY URGEnT sIGnsIfthechilddoesnothaveanyoftheemergency ABC-c-c-DOsigns,thetriageproviderproceedstoassessthechildontheveryurgentsigns.Thisshouldnottakemorethanafewseconds.SomeofthesesignswillhavebeennoticedduringtheABCDtriagediscussedsofar,andothersneedtobere-checked.Followthelistofveryurgentsignstoquicklycompletethissectiontodecidewhetherthechildhasanyveryurgentorurgentsignsthatneedpromptmanagement.

Thefrequencywithwhichchildrenshowingtheseveryurgentsignsappearinyouremergencycentredependsonthelocalepidemiology.

Performafingerprickglucotestinthefollowingcases:• Reducedlevelofconsciousness• Unabletositormoveasusual• Currentorrecentseizure• Knownwithdiabetes• Severemalnutrition

Thepresenceofobviousveryurgentsignsdoesnotautomatically make the child’s triage priority ORAnGE. Always calculate the TEWs and check key additional investigationstoensurethatthechilddoesnotneedtobeassigned to the RED category and taken for emergency care

VERY URGEnTTiny baby - younger than

2 monthsInconsolable crying /

severepainPresenting complaint -

More sleepy than normalPoisoningoroverdoseFocal neurology acute

SeveremechanismofinjuryBurns (circumferential, electrical, chemical,

10%ormore)Eye Injury

Fracture – open or threatened limb

Dislocation of larger joint (notfingerortoe)

Tinybaby(lessthantwomonthsofage) Ifthechildappearsveryyoung,askthemotherhisage.Ifthechildisobviouslynotayoungbaby,youdonotneedtoaskthisquestion.Smallbabiesaremoredifficulttoassessproperly,morepronetogettinginfections(fromotherpatients),andmorelikelytodeterioratequicklyifunwell.Alltinybabiesofundertwomonthsofageshouldthereforebeseenveryurgently.

Inconsolablycrying/severepainTheinconsolablecryingchildisconsciousbutcriesconstantlyandwillnotsettle.Asktheparentofcaregiverifthechildisupset/frightenedbytheunfamiliarenvironmentorwhetherthisisthepresentingcomplaint.Ifachildhasseverepainandisinagony,s/heshouldbeprioritizedtoreceiveveryurgentassessmentandpainrelief.Severepainmaybeduetosevereconditionssuchasacuteabdomen,meningitis,etc.Youarenotrequiredtodoaformalpainscaleassessment,butforyourinformationtherearesomeexamplesofpainscalesappendedattheendofpartfour.

Presenting complaint - ‘more sleepy than normal’ When the mothercomplainsthatherchildthatismoresleepythannormal(NOTjustinnaturalsleep),thechildmaybeintheearlystagesofseriousconditionssuchasmeningitis,hypoglycaemia,septicaemiaetc,andwillneedtobeidentifiedandmanagedveryurgently.EvenifthechildappearsalertattriagestillassignaVeryUrgentclinicalsignaswehavetotakeseriouslythemothersconcern.

PoisoningorOverdoseAchildwithahistoryofswallowingdrugsorotherdangeroussubstancesneedstobeassessedveryurgently,ass/hecandeterioraterapidlyandmightneedspecifictreatmentdependingonthesubstancetaken.Themotherwilltellyouifshehasbroughtthechildbecauseofpossibleintoxication.ConsultSHCPforadviceregardingveryurgentmanagement.

Focal neurology acuteAchildwhoisfullyconsciousbuthasnewfocalneurologicalsignswillneedveryurgentassessment.Inthiscase,thechilddoesnotrequireemergencytreatmentbecausetheydonothaveanyABCDemergencysigns,butmayneedurgentimagingandintervention.Examplesoffocalneurologicalsignsincludecranialnervepalsiesandacutelyparalysedlimbs-theirpresencemayindicateaformofvascularstrokeandmanagementmaybetimedependent.Thechildmayhaveaweaknessononesideofthebodyandmaynotbeabletomoveasnormal.Theparentmayalsocomplainthattheirchildhasanewonsetofasquintoraparalysedface.

SevereTrauma–severemechanismofinjuryUsuallythisisanobviouscase,butoneneedstothinkofmotorvehicleaccidentinjuries,fallsfromaheightgreaterthanonemetreinheight,gunshotwoundsandothertraumaticmechanismsofinjuryinthiscategory.Rememberthe ABC-c-c-DOassessmentwouldalreadyhaveidentifiedanylife-threateningproblemsrequiringimmediateresuscitation.

Burns Theseinclude:Circumferential,Electrical,Chemicalandanyburninvolving10%ormore of body surface area.Burnsareextremelypainfulandchildrenwhoseemquitewellcandeterioraterapidly.


WARnInGAny major burn take to resuscitation area

ADDITIOnAL TAsKPain check with shCP for analgesia initiation

ADDITIOnAL TAsKPoisoning/Overdose Refer to shCP

ADDITIOnAL TAsKBleeding apply pressure to the site of trauma and coveropenwounds

Pain check with shCP for analgesia initiation


ADDITIOnAL TAsKTiny baby Refer to shCP

!ADDITIOnAL InVEsTIGATIOnReducedlevelofconsciousness dofingerprickglucosetest

WARnInGIf glucose less than 3 mmol/L take to resuscitation area


ThesizeoftheburnneedstobedeterminedusingtheRuleofNinesmethod(thepalmarmethodismoresuitableforsmallerburns-seepage23).Foranychildwithamajorburnresuscitationmustbecommenced.Followtheprovincialburnsmanagementguidelines2011includinganalgesia.

Theexampleleftisofaoneyear-oldchild.RefertoTableintheprovincialEmergencyManagementofSevereBurnsmanualfordifferentages.

Fracture – open Anopenfracturemaybeassociatedwithalargevolumeofbloodlossthatmaybeveryobvious(external)ormaybeconcealed(internal)–perhapsonlyrecognisablebyswellingaroundthefracturearea.Thisneedsveryurgentattention.

Threatened limb

Dislocationoflargejoint(notfingerortoe)Apartfrombeingverypainful,alargejointdislocationmaycompromisebloodandnervesupplytothelimbdistaltotheaffectedjoint.Damagetotheneurovascularbundleimpliesseriousinjuryandneedsveryurgentattention.

• If any VERY URGEnTsignshavebeenfoundtheTEWSshouldbecalculatedandkeyadditionalinvestigationsshouldbecheckedtoensurethatthechilddoesnotneedtobeassigned to the RED category and taken for emergency care.

• Children within the ORAnGE category should be seen within 10 minutes.• HandoverallORAnGE category children personally to the health worker in the Orange area,• Always check for additional tasks that should be done.

• If there are no VERY URGEnT signs, check to see whether the child has any URGEnT signs.


ADDITIOnAL TAsKIftheburnoccurredrecently(within3hrs) it is still worthwhile to cool the burnt area with water, for example, by running cool tap water

overtheburntareafor30minutes.Thechildshouldthenbedriedandwrappedinacleansheetorblankettoavoidhypothermia.Theburncanbecoveredinclingwrapifavailable,oracleandrysheetortowelwillalsobesuitable.

A threatened limb presents as:P PainP PallorP PulselessnessP Paralysisorpins&needlesP CapillaryRefillDelayP Temperature

Figure 10: Rule of Nines for burn surface area estimation in a one year old child



ADDITIOnAL TAsKDislocation of large joint HandovertoSHCP.

Pain check with shCP for analgesia initiation

APPEnDIX B: Examples of different pain scales Behavioral Observation Pain Rating Scale

Categories scoring0 1 2

Face Noparticularexpressionorsmile;disinterested

Occasionalgrimaceorfrown,withdrawn

Frequenttoconstantfrown,clenchedjaw,quiveringchin

Legs Nopositionorrelaxed Uneasy,restless,tense Kicking,orlegsdrawnup

Activity Lyingquietly,normalposition,moveseasily

Squirming,shiftingbackandforth,tense

Arched,rigidorjerking

Cry Nocrying (awakeorasleep)

Moansorwhimpers, occasionalcomplaint

Cryingsteadily,screamsorsobs,frequentcomplaints

Consolability Content,relaxed Reassuredbyoccasionaltouching,hugging,ortalkingto.Distractable

Difficulttoconsoleorcomfort

Eachofthefivecategories:(F)Face;(L)Legs;(A)Activity;(C)Cry;(C)Consolability isscoredfrom0-2,whichresultsinatotalscorebetween0and10.

Observethechildandscorethechild’spainaccordingtothe‘FLACC’scale.

‘Faces’ Pain Rating Scale

4.3 URGEnT sIGns ThesechildrendonothaveanyoftheemergencyABC-c-c-DOsignsnordotheyhaveanyoftheveryurgentsigns.Thetriageprovidershouldproceedtoassessthechildontheurgentsigns.Thisshouldnottakemorethanafewseconds.

some respiratory distressWhenyouassessedtheairwayandbreathing,didyouobserveanyrespiratorydistress?Ifthechildhassevererespiratorydistress,thisisanemergency.Theremayhowever,besignspresentthatyoudonotthinkaresevere,e.g.somelowerchestwallindrawing(butnotsevere),orslightincrease


!ADDITIOnAL InVEsTIGATIOnRR scoring 1 point or more measure oxygen saturation

0nO hURT

1hURTs

LITTLE BIT

2hURTs

LITTLE MORE

3hURTs

EVEn MORE

4hURTs

WhOLE LOT

5hURTsWORsT

Asktheolderchildtopointtothefacethatbestdescribeshows/hefeels.

Evenifthereareobviousurgentsigns–calculate the TEWs and carry out additional investigationstoensurethatthepatientisnotpossibly within the RED or ORAnGE category.

WORsT POssIBLE PAIn

nO PAIn

10-

9-

8-

7-

6-

5-

4-

3-

2-

1-

0-

URGEnT

some respiratory distress

some Dehydration - Diarrhoea or diarrhoeaandvomiting+1ormore

of the following: (i)sunkeneyes(ii) restless/irritable(iii) thirsty/decreasedurineoutput(iv)drymouth(v)cryingwithouttears(vi)skinpinchslow-lessthan2sec

some Dehydration - Unable to drink/feed ORvomitseverything+1ormoreofsigns

(i)–(vi)above

Malnutrition(visibleseverewasting)

Malnutrition Oedema (pitting oedema ofBOTHfeet)

Unwell child with known diabetes

Anyotherburnlessthan10%

Closed fracture

Dislocationoffingerortoe


inbreathingrate.Inthiscase,thechilddoesnotrequireemergencytreatmentbutwillneedurgentassessment.Understandingthelevelofseverityofrespiratorydistresscomewithpracticeandexperience.Ifyouhaveanydoubts,consultaseniorhealthcareprofessionalimmediately.

SomeDehydration-Diarrhoeaordiarrhoeaandvomiting+1ormoresignsofdehydrationInfantsandchildrenwithdiarrhoeaorvomitingmayhavelostenoughfluidtoshowoneormoreofthefollowingsignsofdehydration:

Becausethesechildrenhavelossesthatareongoinganddifficulttoquantify,theyneedtocommenceoralrehydrationtherapyassoonaspossibletoavoidbecomingseverelydehydratedorshockedi.e.signsthatwouldnowplacethemintotheREDcategory.MostofthemarethirstyandtheirmothersneedtoofferthemextrafluidsaccordingtotheOralRehydrationCornerguidelines.Infantsandyoungchildrenthatarebreast-fedshouldbeencouragedtocontinuetodosowhilstawaitingfurtherurgentassessment.

Unabletodrink/feedORvomitseverythingInfantsandchildrenthatarenotwellenoughtofeedorarevomitingeverythingmayhaveseriousmedicalorsurgicalconditionsaffectinganyofthebodysystems.Examplesincludesepticaemia,

meningitis,heartconditions,acutesurgicalabdomen,pneumoniaetc.

Malnutrition withvisibleseverewastingSeverewastingisaformofseveremalnutrition.Thesechildrenareeasytopickupbecausetheirmusclesareverywastedandtheyhavelooseskinfoldsparticularlynoticeablearoundtheirupperthighs,buttocksandupperarms.Ifyouareconcernedthatachildmightbemalnourishedlookrapidlyatthesebodyareas.Severelymalnourishedchildrenarepronetohypothermia,hypoglycaemiaandinfectionsandneedtobemanagedurgentlyaccordingtotheWHOseveremalnutritionguidelinestopreventcomplications.

Malnutrition with pitting oedema of both feetThisisanotherformofseveremalnutrition.Itisasdangerousastheonedescribedaboveandisrecognisedbythepittingoedemaofbothfeet;theymayalsopresentwithgeneralbodyswelling.Ifyouareconcernedthatachildmightbemalnourishedlookrapidlyatthechild’sfeetandcheckforoedemaofbothfeet.Thesechildrenoftenappearlistlessandapatheticandhaveskinandhairchanges.Theyarealsopronetohypothermia,hypoglycaemiaandinfectionsandneedtobemanagedurgentlyaccordingtotheWHOseveremalnutritionguidelinestopreventcomplications.


WARnInGIf oxygen saturation below 92% giveoxygenandmovetoresuscitationarea

(i) sunkeneyes-askthemother(ii) restless/irritable(iii) thirsty/decreasedurineoutput

(iv) drymouth(v) cryingwithouttears(vi) skinpinchslow-lessthan2seconds

Vomitingonlyanddehydration:• bewarethechildmayhaveanacutesurgical

bowelproblem• oralfluidsmaybecontraindicated• seekadvicefromaseniorhealthprofessional

!ADDITIOnAL InVEsTIGATIOnMalnutritionwithvisibleseverewasting doafingerprickglucosetest and check with shCP

ADDITIOnAL TAsKVomiting only and dehydration consult with shCP

!ADDITIOnAL InVEsTIGATIOnMalnutritionwithvisibleseverewasting doafingerprickglucosetest and check with shCP

ADDITIOnAL TAsKDiarrhoe start oral rehydrationtherapy(ORT)

WARnInG If glucose is below 3 mmol/L move

to resuscitation

Unwell child with known diabetesChildrenwithdiabetesoftenlosecontroloftheirsugarlevelswhentheyareunwellfromacuteillnessandinfectionse.g.acuterespiratoryinfections, (upperorlower)urinarytractinfectionsordiarrhoea. Theyoftendevelophighorlowbloodglucoselevelsbecausetheirinsulinneedsmayincreaseordecreasewhilsttheyareunwellandtheyarenoteatingasusualbecauseoflossofappetite,nauseaorvomiting.

Burnlessthan10%ofbodysurfaceareaThesizeoftheburnneedstobedeterminedusingthepalmarmethod(patient’soutstretchedopenpalmincludingthefingersis≈to1%ofthebodysurfacearea).

Closedfracture(nobreakintheskin)Thesechildrenoftenpresentwithpainonmovingorrefusaltomovetheaffectedlimb.Theremaybedeformityofthelimbevident.

DislocationoffingerortoeThisoftencausesanobviousdeformity;thedislocateddigitwillneedtobereducedundersomeformofanaesthesia.


WARnInG If glucose is below 3 mmol/L moveto resuscitation

WARnInGIf glucose result is ‘hI’ check with shCP

Figure 11: Palmor method illustrating 1% of the body

ADDITIOnAL TAsKBurnlessthan10% followtheprovincialburns management guidelines. If the burn occurred recently, within the last 3 hours, it is still worthwhile to cool the burnt area with

water, for example, with cool tap water for at least 30minutes.Theburnshouldthenbedriedandcoveredwith cling wrap or a clean dry sheet. The child should also be wrapped in a blanket and kept warm



ADDITIOnAL TAsKClosed fracture If required get a wheelchair or stretcher and immobilise the affected limb with a simple splint e.g. a padded wire splint or triangular bandage that does not interfere with thebloodsupplyornervebundle,andprovideanalgesiaaccordingyoursite’sguidelines.

!ADDITIOnAL InVEsTIGATIOnhistory of diabetes do a fingerprickglucosetest


WARnInG If glucose is less than 3 mmol/L move

to resuscitation



1. Gruntingandnasalflaringaresignsofsevererespiratorydistress.

True False

2. Oxygensaturationlevelsshouldalwaysbecheckedinachildthatlooksblue.

True False

3. Ifnoemergencysignisidentifiedinstepone,butanurgentsignisidentifiedinsteptwo,thepatientisimmediatelytakentothemajorsareaforurgentmanagement.

True False

Choosethecorrectanswer:4. IntheABC-c-c-DOapproachABCstandsforairway,breathing,circulation.

Whatdoesc-c-Dstandfor? (a) convulsions,chestpain,dehydration (b) coma,cancer,disabilities (c) coma,convulsions,dehydration (d) coma,craniopharyngioma,dehydration (e) chronicpain,constipation,dehydration

5. Thefollowingareemergencysigns (a) oxygensaturationlevelsmorethan92% (b) facialorinhalationburn (c) stridor,snoringandsecretions (d) closedfracture (e) bandcabove


• IfanyURGENTsignshavebeenfoundtheTEWSshouldbecalculatedandadditionalinvestigationscheckedtoensurethatthechilddoesnotneedtobeassignedtothe RED or ORAnGEcategoryandtakenforemergencyorveryurgentcare.

• ChildrenwithintheYellowcategoryshouldbeseenwithin60minutes.• Always check for additional tasks that should be done.• IftherearenoURGENTsigns,calculatetheTEWSandcheckforadditionalinvestigationsto

determinewhatthechild’sfinaltriagecolouris.

TRIAGE EARLY WARnInG sCORE TEWs

LearningObjectives:

• BefamiliarwiththedifferentageappropriateversionsoftheTEWS• UnderstandhowtocalculatetheTEWSinpaediatricandadultpatients

TheTEWSisacompositescorerepresentingphysiologicparametersattriage.Therearedifferentageappropriateversions:theyounger child TEWsisforpatientssmallerthan95cmoryoungerthan3years(seeFigure12);the older child TEWsisforpatients96cmto150cmor3yearstoaround12years(seeFigure13);andthe adult TEWsisforpatientsolderthan12yearsortallerthan150cm.Olderchildren,whereyouareunsurewhichformtouse,shouldbemeasured.Iftheyareover150cmthentheadultversionshouldbeused.ThisstandardisedscoringsystemhasbeenvalidatedandmanyoftheboxesintheTEWScalculwrareshadedgrey.Theseboxescannotbeassignedascore.Thismeansthatfortemperature,forexample,itisonlypossibletoscore0or2points,dependingonthevalueoftherecording.

YOUnGER ThAn 3 YEARs

/ sMALLER ThAn 95 cm

YOUnGER ChILD TEWs

3 2 1 0 1 2 3

Mobility Normalforage

Unable to moveasnormal

RR less than 20 20-25 26-39 40-49 50or

more

hR less than 70 70-79 80-130 131-159 160or

more

Temp FeelsCold

Under35˚35˚-38.4˚

FeelsHot Over38.4˚

AVPU Alert ReactstoVoice

ReactstoPain

Unres-ponsive

Trauma No YesFigure 12: Younger Child TEWS (younger than 3 years)

3 to 12 YEARs OLD / 95 to 150 cm

tall

OLDER ChILD TEWs

3 2 1 0 1 2 3

Mobility Normalforage

Unable to walkasnormal

RR less than 15 15-16 17-21 22-26 27or

more

hR less than 60 60-79 80-99 100-129 130 or

more

Temp FeelsCold

Under35˚35˚-38.4˚

FeelsHot Over38.4˚

AVPU Confused Alert ReactstoVoice

ReactstoPain

Unres-ponsive

Trauma No YesFigure 13: Older Child TEWS (age 3 - 12 years)

5

TriageEarlyWarningScoreTEWS


OLDER ThAn 12 YEARs /

TALLER ThAn 150cmtall)

ADULT TEWs

3 2 1 0 1 2 3

Mobility Walking WithHelp Stretcher/Immobile

RR less than 9 9-14 15-20 21-29 more

than29

hR less than 41 41-50 51-100 101 - 110 111-129 more

than129

sBP Less than 71 71-80 81-100 101-199 more

than199

Temp ColdOR Under35˚ 35˚-38.4˚

HotOR Over38.4˚

AVPU Confused Alert ReactstoVoice

ReactstoPain

Unres-ponsive

Trauma No YesFigure 14: Adult TEWS (older than 12 years)

5.1ObservationsattriageTocalculatetheTEWSthefirststepistoperformtheobservationsrequiredbytheTEWS.

REsPIRATORY RATEThepatient’srespiratoryrateiscalculatedbycountingthebreathsfor30secondsandthenmultiplyingbytwo.Thisshouldbedoneatthefirstopportunitywhenthechildisquiet.Ifthechildissmallitisbesttoleavehim/herinthemother’slap.Donotundressthechildtocounttherespiratoryrateasdoingthismayupsethim/her.Countthebreathingratebyobservingratherthantouchingthechild.

hEART RATETomeasuretheheartrate,thetriageprovidercanmanuallycounttheheartratebyfeelingthepulsefor30secondsandthenmultiplyingbytwo.Alternativelyaheartratemonitorcanbeused(ideallynotfromasaturationmonitor–astheheartrateonthesemonitorscanbeunrelaibleandcanchangefrequentlyifthechildmoves).

TEMPERATUREThetemperatureismeasuredusingeitheranelectronicormercurythermometer(preferablyalow-readingthermometer).RectaltemperatureshouldNOTbetakenroutinely.

AVPU AVPUisdonebyseeingifthechildisalert.Ifnotobviouslyalertthenthetriageproviderneedstoobservethechild’sresponsetotheir(ortheparent’s)voice.Ifthechildrespondstovoiceandisthenalert–heisan‘A’–butifheremainsdrowsythenheisa‘V’’.Ifhemakesnoresponsetovoicethenthetriageproviderneedtoassesstheresponsetoapainfulstimulus(e.g.nailbedpressureorsternalrub)–ifthechildrespondstothiss/heisa ‘P’.Ifthereisnoresponsetoeitherverbalorpainstimulithepatientislabelledasunresponsive.


DO nOT UPsET ThE ChILD thisaffectsyourobservationsforTEWS

V meansthepatientisnotfullyalertandREsPOnDs OnLY TO YOUR VOICE. Another way of describing this = ‘lethargic’

P meansthepatientisnotalert anddoesnotrespondtoyourvoicebutREsPOnDs OnLY TO A PAInFUL sTIMULUs

MOBILITY Mobilityisobservedbynotingthemodeinwhichthepatienthastobemobilised.Asmallbabyiscarriedbythecarer–asmightasmallinfantorchild.Youneedtoassessifthelevelofmovementisnormalforthatparticularchild.Intheeventthatthechildoradultisinawheelchairduetopermanentparalysis2pointsaregivenformobilityasthechildinawheelchairismoreatrisk.

TRAUMATraumaispresentifthereisANYinjurytothepatientwithinthepast48hours.

5.2 Terminology and key concepts1. Confusion:Anolderchildmaybereportedtohaveconfusedbehaviourorthismaybe

discoveredattriage.Aconfusedchildappearsdisorientated,s/hemaynotbeinteractingnormallywiththecarerortheenvironment,s/hemaybedeliriousorhallucinating.Aconfusedchildmaybetalkingalotandaggressiveors/hemaybequietandfearfullooking.Thissignisdifficulttodetectinyoungerchildrenwhoareusuallypre-verbal-soitisonlyincludedontheTEWSfortheolderchild.

2. AcutevsChronic:ManypatientsinSouthAfricaarechronicallyunwellwithseriousconditionssuchasTBorHIV/AIDS.Inthesepatients,dailyrestingphysiologysuchasrespiratoryratemaybeabnormal.Thisisimportanttobearinmind,astheirTEWSwillbehighandtheywillbegivenanoverlyhightriagecode(theymaybeovertriaged).Itisnotfortheinexperiencedtriageprovidertodecidewhetherthisisthecaseornot,assickpatientsmaybemissed.However,itisappropriatetoaskaseniordoctororsistertoreviewthepatient’striagecode.

3. The younger and older child:Youngerandolderchildrenhavedifferentrestingvitalsignstoadults.Theseareoftendifficulttoobtain,andthepatientsoftencry,whichpushesuptheirrespiratoryandheartrate.Thevaluesstillneedtoberecordedasyoumeasurethem,sothatacorrectscorecanbegivenintheTEWS,buttelltheseniordoctororsisterthatthechildwascryingwhentheywererecorded.Thesestaffmemberscanthendecidewhetherthechildhasbeenovertriagedornot.


1. IfachildisnineyearsoldweusetheolderchildTEWS.

True False

2. Alwaysundressachildandweighthemsothatitiseasiertoobtaintheirvitalsigns.

True False

3. Toaccuratelyobtainarespiratoryratealwaysstartwhenthepatientisatrest,countrespirationsfor30secondsandmultiplybytwo.

True False

Choosethecorrectanswer:4. TheadultTEWSconsistsofthefollowingparameters: (a) Mobility,respiratoryrate,heartrate,temperatureandbloodpressure (b) Mobility,capillaryrefilltime,heartrate,temperatureandbloodpressure (c) Mobility,respiratoryrate,heartrate,temperature,systolicbloodpressure,AVPUandtrauma (d) Mobility,respiratoryrate,heartrate,temperature,AVPUandtrauma (e) Mobility,respiratoryrate,oxygensaturationlevelandbloodglucoseconcentration

5. TheolderchildTEWSconsistsofthefollowingparameters: (a)Mobility,respiratoryrate,heartrate,temperatureandbloodpressure (b) Mobility,capillaryrefilltime,heartrate,temperatureandbloodpressure (c) Mobility,respiratoryrate,heartrate,temperatureandtrauma (d) Mobility,respiratoryrate,heartrate,temperature,AVPUandtrauma (e) Mobility,respiratoryrate,oxygensaturationlevelandbloodglucoseconcentration



ADDITIOnAL InVEsTIGATIOns

LearningObjectives:

• Befamiliarwiththeadditionalinvestigationsandwhentoperformthem• Knowhowadditionalinvestigationsmaychangethetriageprioritylevel

Forallpatients(especiallychildren)immediateadditionalinvestigationsmaybeindicatedtoidentifypotentiallyseriouscomplicationsoftheirpresentingconditions.Checkifthepatienthasanyoftheconditionslistedbelowandactaccordingly.

RESPIRATORYRATE(RR)SCORESMORETHAN 1 POInT On TEWs:

AraisedRRforagemayindicateseriousunderlyingpathologysuchaschestinfectionrequiringsupplementaloxygen

REDUCED LEVEL OF COnsCIOUsnEssAllpatientsthatarenotfullyalert(i.e.confusedoronlyrespondingtoverbalorpainfulstimulus)needtohaveafingerprickglucotestdoneandshouldbehandedovertotheseniorhealthcareprofessional.Ifthechildisnotalert,orthecaregivervolunteersthatthechildismoresleepythannormal,thismayindicateaseriousevolvingmedicalconditionsuchasmeningitisorifassociatedwithahistoryoftraumatherecouldbeatraumaticbraininjury.Anysickchildwhohasnotbeenfeedingwellorhasbeenvomitingmaybecomedrowsybecauseofalowbloodsugarlevel.Tinybabiesandmalnourishedchildrenareparticularlyatriskofhypoglycaemia.

UnABLE TO sIT OR MOVE As nORMAL Ifthepatientisunabletowalkormoveasnormalorthecaregiverreportsthatthechildislethargicorunabletomoveasusual,thismayalsobeasignofseriousillnessorofalowbloodsugarlevel.

RECEnT sEIZURE/FITThepatientwhoisactivelyfittingwillhavebeentakentotheresuscitationarea.Inanychildwithahistoryofrecentseizuretherecouldbeeasilyidentifiableandtreatablecauses,includinghypoglycaemia,pyrexia(febrileseizure)orhighbloodpressure.

hIsTORY OF DIABETEsAllpatientswithdiabetesareatriskofeitherbecominghypoglyacaemic(usuallydrowsyorconfused)orhyperglycaemicwithdiabeticketoacidosis(DKA).Allthereforeneedaglucotestdoneatpresentation.

AdditionalInvestigations

6

WARnInGIf glucose is below 3 mmol/L movetoresuscitationand handovertoSHCPIf glucose is hi handovertoSHCP

WARnInGFor children if oxygen saturation isbelow92%onroomair Movetoresuscitationareaandadminister nasal prong or facemask oxygen

!ADDITIOnAL InVEsTIGATIOnMeasure oxygen saturation (for childrenonfinger,toe,handorearlobe,dependingonavailable

saturationprobeandco-operation)

WARnInG If glucose is below 3 mmol/L movetoresuscitationand handovertoSHCP

!ADDITIOnAL InVEsTIGATIOnPerformafingerprickglucotest immediately to exclude hypoglycaemia

WARnInG If glucose is below 3 mmol/L movetoresuscitationand handovertoSHCP

!ADDITIOnAL InVEsTIGATIOnPerformafingerprickglucotest immediately to exclude hypoglycaemia

!ADDITIOnAL InVEsTIGATIOnPerformafingerprickglucotestimmediately to exclude hypoglycaemia

DIABETEs AnD hYPERGLYCAEMIA (GLUCOTEST11ORMORE)

Allpatientswithaglucoseconcentrationof11mmol/Lormorerequireaurinedipsticktocheckforketones.

ChILD hAs MALnUTRITIOn WITh sEVERE VIsIBLE WAsTInG or WITh PITTInG OEDEMA OF BOTh FEETThischildisatriskofhypoglycaemia,aswellashypothermia

ABDOMInAL PAIn OR BACKAChE In FEMALEsTheadultfemalewithabdominalpainmayhaveanectopicpregnancyleadingtoseverepainanddiscomfortastimeprogresses.Shemaybeatriskforarupturedectopicorothercomplicationsinpregnancyrequiringemergencysurgery.Theseadditionalinvestigationsmayrapidlyidentifyveryillpatientsandchangetheircategory.Theyalsopreventand/oridentifyseriouscomplications.


1. Apatientwithaglucoseof11mmol/Lneedstohaveaurinedipstickdonetocheckforketonesintheurine.

True False

2. Checkthefingerprickhaemoglobinonallpatientsthathaveahistoryofdiabetes.

True False

3. Doaurinedipstickandurinepregnancytestonalladultfemalespresentingwithabdominalpain.

True False

Choosethecorrectanswer:4. Performafingerprickglucotestonthefollowingcases: (a)Currentorrecentseizure (b) Facialburn (c) Reducedlevelofconsciousness (d) Historyofdiabetes (e) a,candd

5. ThefollowingtwoadditionalinvestigationsmayupgradeapatienttotheRedcategory: (a) Oxygensaturationlevelsinchildrenandfingerprickhaemoglobin (b) Fingerprickhaemoglobinlevelsandurinedipstick (c)Urinedipsticktestandoxygensaturationlevels (d) Fingerprickglucotestandoxygensaturationlevels (e) Fingerprickglucotestandfingerprickhaemoglobin

!ADDITIOnAL InVEsTIGATIOnPerform a urine dipstick to check for ketones

WARnInG If glucose is below 3 mmol/L movetoresuscitationand handovertoSHCP! ADDITIOnAL InVEsTIGATIOn

Performafingerprickglucotest immediately to exclude hypoglycaemia

PERFORM A FInGER PRICK GLUCOTEsT In ThE FOLLOWInG CAsEs:

• Reducedlevelofconsciousness

• Unabletositormoveasusual• Currentorrecentseizure• Knownwithdiabetes• Severemalnutrition !

ADDITIOnAL InVEsTIGATIOnPerform a urine dipstick and urine pregnancy test

AdditionalInvestigations


ADDITIOnAL TAsKs

LearningObjectives:

• Befamiliarwiththeadditionaltasks• Knowwhentoperformadditionaltasks

TInY BABY UnDER 2 MOnThs Smallbabiesunder2monthsaremoredifficulttoassess,theirsymptomsareoftennon-specific,theyhavelowerimmunitythanotherchildrensoaremorepronetoinfections,andtheydeterioratemorequickly.Theythereforeneedtobeassessedasapriority.

POIsOnInG OR OVERDOsEToddlersareinquisitiveandliketoexploretheirenvironments.Theymayaccidentallyingestavarietyofhouseholdsubstances,pesticidesormedications.Achildwhohasingestedapoisoncandeterioratequickly.Theymayrequireaspecificantidoteandifapoisonormedicationhasbeeningestedrecentlyimmediateinterventionmaybeneeded(e.g.activatedcharcoal).ItisthereforeimportanttoconsultaSHCPforchildrenandadultsevenifthepatientappearsstable.

IF ChILD APPEARs TO BE In PAIn or Is InCOnsOLABLY CRYInGThismaybeduetoamedicalcauselikeanearinfectionorfromsevereheadacheduetomeningitis.Ortheremaybeanobviouscausesuchasafractureorlaceration.Painisobviouslyunpleasantforboththechildandcarer.Itisgoodpracticetoinitiateanalgesiaassoonaspossibleforchildrenandadults.

BURnThepatientwillbeexperiencingpainandespeciallychildrenhavethepotentialtodeterioraterapidlyfromsignificantfluidlossesandmaydevelophypothermia.Iftheburnisrecent(<3hrs)immediateinterventionmaylimittheextentoftissuedamage.

TEMPERATURE38.5˚CORMOREAveryhightemperaturewillresultinphysiologicalchangesthatmayaffecttheTEWS,andmakethepatientfeeluncomfortableandinsomechildrenmaybeassociatedwithafebrileseizure.

TEMPERATURE35.5˚CORLESSHypothermiamightbeasignofseveresepsiswithverysmallbabies,ex-prematurebabiesandseverelymalnourishedchildrenbeingthemostatrisk.

DIARRhOEA & VOMITInGEvenifthechildhasnoorsomedehydration,thechildisatriskofbecomingdehydratedwhilstwaitingtobeseenandshouldreceiveoralrehydrationtotreatand/orpreventfurtherdehydration

ADDITIOnAL TAsKTiny baby under 2 months refer to shCP

ADDITIOnAL TAsKPoisoning/overdose refer to shCP

ADDITIOnAL TAsKPain or inconsolable crying check with shCP for initiation of analgesiaandreview

ADDITIOnAL TAsKPain check with shCP for initiationofanalgesiaandreview

ADDITIOnAL TAsKIftheburnoccurredrecently(within3hrs) it is still worthwhile to cool the burnt area with water,forexample,byrunningcooltapwaterovertheburntareafor30minutes.Thechildshouldthenbedriedandwrappedinacleansheetorblankettoavoidhypothermia.

Theburncanbecoveredinclingwrapifavailable,oracleandrysheetortowelwillalsobesuitable.

ADDITIOnAL TAsKhigh temperature removeexcessiveclothing and check with shCP for initiationofanalgesiaandreview

7

ADDITIOnAL TAsKLow temperature warm the patient with additional blankets for children with a

capifavailableandhandovertoSHCP

Forallpatients(especiallychildren)whethertriagedRED, ORAnGE, YELLOW OR GREEnimmediateadditional tasksmaybeindicatedtostabilisethepatientand/oridentifyorpreventpotentiallyseriouscomplications.Checkifthechildhasanyoftheconditionslistedbelowandactaccordingly.

ADDITIOnAL TAsKDiarrhoea&vomiting take child toORTcornerandadvisecaregiverto start ORT by cup and spoon

AdditionalTasks

VOMITInG WIThOUT DIARRhOEA AnD ThE ChILD Is DEhYDRATEDVomitingalonewhichissevereenoughtoresultindehydrationmayindicateadiagnosisotherthansimplegastroenteritise.g.urinarytractinfection;asurgicalproblemwithbowelobstruction,;diabeticketoacidosisorevenmeningitisoranothersevereinfection.Itmaynotbeappropriatetoautomaticallycommencethischildonatrialoforalrehydration–andsosenioradviceshouldbesought.

IF ThE ChILD hAs A CLOsED FRACTUREThesechildrenwillbeexperiencingsignificantpain-bothmedicationandimmobilizationoftheaffectedlimbwillprovidesomerelieffromthepainandshouldbeinitiatedpriortoformalassessment

ChEsT PAInPatientswithchestpainmaybehavinganacutemyocardialinfarct(AMI).AnimmediateECGisrequiredtoruleoutapotentialAMI.

ACTIVE OnGOInG BLEEDInG Childrenhaveasmallcirculatingbloodvolume,andareatriskofbecomingshockedquicklyifthereisongoingbleedingfromatraumasite

hIsTORY OF RECEnT BLEEDInG - EIThER RECTAL, ORAL OR FROM A sITE OF TRAUMAThispatientmaybeanaemicfrombloodloss

PREsEnTInG COMPLAInT Is ABDOMInAL PAInAbdominalpainisacommoncomplaintinchildrenandithasawidevarietyofpossiblecausesincludingurinarytractinfection,diabeticketoacidosis,hepatitisorothercauses.Aurinedipstickforchildrenandadultswillassistinexcludingordiagnosingthese.Theseadditionaltasksmayassisttorapidlyidentifyveryillpatientsandpreventandidentifyseriouscomplications.Theyalsoimprovequalityofcarebyprovidingrelieffrompain.

Additional Tasks at triageADULT PATIEnTs

PROBLEM IMMEDIATE TAsKs1.Temperature38.5°ormore Paracetamol1gorallystat(documentinthenotes)

2.Temperature35°orless Warmthepatientwithblanketsifavailable3.Diabetesandhyperglycaemia

(glucotest11mmol/Lormore)Urinedipsticktocheckforketones

4.Historyofbleeding Fingerprickhaemoglobin5.BleedingPR,POorfromthesiteoftrauma Fingerprickhaemoglobin6.Abdominalpainorbackacheinmales Urinedipsticks7.PVbleeding Urinedipsticks,Urinepreganancytest

Fingerprickhaemoglobin

ADDITIOnAL TAsKVomiting without diarrhoea refer to shCP for assessment

ADDITIOnAL TAsKPain checkwithSHCPforinitiationofanalgesiaandreviewClosed fracture immobilise affected limb with simple padded splint or a triangular bandage sling and get a wheelchair or stretcher if required

ADDITIOnAL TAsKActivebleed apply direct pressure to the site of trauma with a dry dressing andperformfingerprickhaemoglobinto

obtainabaselineandhandovertoSHCP

ADDITIOnAL TAsKhistory of bleeding checkfingerprickhaemoglobin.Iflessthan8g/dlthenhandovertoSHCP

ADDITIOnAL TAsKChest Pain perform an ECG to rule out potential AMIandhandovertoSHCP

ADDITIOnAL TAsKFor a younger child Place a urine bag, ifolderchild,givecontainer

AdditionalTasks

A senior healthcare professional should be alerted in the following cases:• Tinybabyyoungerthan2monthsold•Reducedlevelofconsciousness• Achildinpainincludingfracturesandburns•Poisoningestionoroverdose

•Veryhighorverylowtemperatures•Vomitingonlywithdehydration• Theseverelymalnourishedchild•Achildwithactivebleeding


PAEDIATRIC PATIEnTsPROBLEM IMMEDIATE TAsKs

1.PoisoningORoverdose RefertoSeniorHealthcareProfessional(SHCP)2.ChildinpainORinconsolablecrying CheckwithSHCPforanalgesiainitiation3.Childwithaburn CheckwithSHCPforanalgesiainitiation

Ifburnoccurredwithin3hours,cooltheburntareaCoverburninclingwraporcleandrysheet

4.Temperature38.5°ormore Removeexcessiveclothing&discusswithSHCP5.Temperature35°orless Warmthechildwithblanketsifavailable.RefertoSHCP

6.Diarrhoea TaketoORTcornerandadvisecaregivertogiveORTbycupandspoon

7.Vomitingwithoutdiarrhoeabutwithdehydration RefertoSHCPforassessment

8.Presentingcomplaint-abdominalpain youngerchild-urinebag/olderchild-urinecontainer9.Closedfracture CheckwithSHCPforanalgesiainitiation

Immobilizeaffectedlimbwithasimplepaddedsplintortriagularbandage

10.Activeongoingbleeding ApplypressuretothesiteoftraumaPerformfingerprickhaemoglobintoobtainabaselineRefertoSHCP

11.Historyofrecentbleeding PerformfingerprickhaemoglobinIflessthan8g/dlthenrefertoSHCP


1. AtinybabyundertwomonthsshouldalwaysbereferredtotheSHCPoncetheyhavebeencomprehensivelytriaged.

True False

2. Apatientwithanactiveongoingbleedshouldplacethebleedingareaunderrunningwater.

True False

3. AchildthatisvomitingonlywithnodiarrhoeashouldfirstbereferredtotheSHCPforfurtherassessmentbeforecommencingthechildonatrialoralrehydration.

True False

Choosethecorrectanswer:4. Inachildwithaburninjuryfromboilingoilthatoccurred20minutesago: (a) Theburntareamaybecoveredinclingwrapifavailable (b) Coolrunningtapwaterovertheburntareafor30minutesmay

limittheextentoftissuedamage (c) Theburntareashouldbewrappedinacleansheettopreventhypothermia (d) aandb (e) a,bandc

5. Theseniorhealthcareprofessionalshouldbeconsultedinthefollowingcases: (a) Poisoningestionandoverdose (b) Aseverelymalnourishedchild (c) Vomitingonlywithdehydration (d) aandc (e) a,bandc

AdditionalTasks

TRIAGE In COnTEXT

8.1 Pre-hospitalTheuseoftriagewithinapre-hospitalsettingisgenerallywellacceptedandunderstooduniversally.Whilstthisneedisquiteobvious(evencritical)duringmajorincidents,it’sthedailyapplicationoftriageprinciplesinthedespatchofambulanceresourceswhereithasthemostbenefit.Inthesescenarios,triagepermitstheEMSdespatchertoapplyrulesbaseddecisionmakingtowhatisanotherwiseimpossiblechoice.Thepre-hospitaluseoftriageinthefieldvariesfromregiontoregion,butisgenerallycategorisedintofourpriorities(representedbythecoloursred,yellow,greenandblue).Suchtriagetypicallyusesinstabilityofvitalsignstodifferentiatehighfromlowprioritypatients.Discrepanciesintriageappearwhenpersonnelofdifferinglevelsofmedicalexperienceandqualificationsneedtoassesspatientsastherearenocleardefinitionsof‘unstable’physiology.Theterms‘stable’and‘unstable’arepoorlyunderstoodandfailtoaccuratelyreflectthepatient’sclinicalcondition.Accuratepre-hospitaltriageisessentialforappropriatecalloutofsecondaryresources;,accuratenotificationofreceivinghospitals,andqualityassessmentandauditoftheambulanceservice.Thisisparticularlypertinentinaeromedicalcalloutrequestsanduseofthisspecialisedresource.Forthesereasonstriagetoolsbasedonobjectivephysiologicaldiscriminatorsareessential.

8.2 Patient streamingTriageassignsthepatienttoanacuitylevel,whichthendictatestheamountoftimethepatientcanwaitsafelybeforebeingseen:Redimmediate,Orangewithin10minutes,YellowwithinanhourandGreenwithinfourhours.Itistherecommendedpracticeto“stream”thesepatientcategoriestodifferentareasand/orhealthcareproviderswithinthefacility.ThenormalstreamingpatternwouldbeRedstoresus,OrangesandYellowstoMajorsandGreenstoMinors,whichwouldbemannedbystaffdedicatedtotheseareas.Forthemostpart,streamingpatientsaccordingtoacuitywillalsostreamthemaccordingtoresourceuse:fullmonitoring,accesstohigh-powereddrugsandinterventionswithfullteamresponseisnecessarytoeffectivelytreattheRedpatient,whilearoomwithachairandasinglepractitionermaybeallthatisnecessarytoseeandtreatthepatientsintheGreenstream.Howandwherepatientsarestreameddependsontheload,manningandinfrastructureoftheEmergencyCentreorHealthFacility.Itisimportantinanysystemthatprioritisesorder-to-be-seenbyanythingotherthan“first-come-first-served”tohaveaplantoseethelowerprioritypatients.Streamingisapossiblemechanismtoachievethis.Withoutstreaming,theGreenpatientwillkeepbeingpushedtothebackofthequeuebythepatientofhigheracuity,whobynecessityshouldbeseenfirst.Withstreaming,thehigheracuitypatientsareseenbeforetheydiewhiletheloweracuitypatientsareseeninanotherareabeforetheyleave!

8.3 InfrastructureTriageisaprocess,notaplace,butforthemostpartwillneedanareafortriageofthosepatientsnotsentdirectlythroughtoresusormajors.ThisareashouldallowforprivacyandbesetupinordertoperformthevitalsignsfortheTEWS,additionalinvestigationsandtasks.Theroomshouldpreferablyallowforone-wayflowofpatientsfromthewaitingroomintoasubwaitingareaintheareatowhichtheyhavebeenstreamed.Ifnotpossible,somesortofdemarcationoftheareaorpatientsshouldbemadeinordertoseparatethosealreadytriagedfromthosewhohavenotbeenassessedbythetriageofficer.

8.4AlignmentofstafftotemporalflowofpatientsItisimportantthattriage,thetooltoensurethatpatientsareassessedtimeously,doesnotbecomethebottleneckinthesystem.Importantly,ifthedoctorisreadyforthenextpatient,butcannotseethemastheyare“firstgettingtriaged”,theobjectisbeingdefeated!Moreoftenthebottleneckoccursduetofailuretoalignstaffwiththeflowofpatients.Forthemostpart,itispossibletopredictthetimesofdaywhentheflowofpatientsintotheECisheavier(typical“saddle-shaped”curve).Staffingfortriageneedstoreflectthisflow.Thereshouldalsobesomesortofplaninplacetodealwithunexpectedinfluxofpatients:eachfacilityshouldhaveanupperlimitofpatientsthattheyarewillingtohavewaitingfortriage,overwhichacontingencyplanneedstobeactivated:egaregionalhospitalhasanagreementthatiftherearefiveormorepatientsneedingtriage,anurseiscalledfrommajorstohelptriagethepatientsuntilthelevelisbackdowntolessthanfivewaiting.

8

TriageinContext

34 SATS TRAINING MANUAL 2012

sUMMARY

Triageisanessentialfirststepinefficientandeffectiveemergencycare–whetherontheroadsideorinthepublicorprivatehospitalarena.Arobusttriagetoolwillhelptosavelivesandreducemorbidity.TheSouthAfricanTriageScalehasbeenderivedbyapanelofexpertsinEmergencyMedicine(doctors,nursesandparamedics),andisscientificallyproven.Ithasbeenshowntoimprovewaitingtimesandmaketheemergencycentrerunmoresmoothly.However,attentionneedstobepaidtothosepatientstriagedGreen,especiallyinpeaktimes,andtheSATGrecommendstheuseofstreamingwithaclinicalnursepractitionerordoctortoseethisgroup.TheSATShasbeenvalidatedaspartofaMastersinPhilosophy(MPhil)with700publicsectorpatients,anMPhilwith2000privatesectorpatientsandaPhD.Feedbackfollowingpublicationinfourmajorjournalshascontributedtotheprocess.ThisisEdition3andweacceptthatthetoolmaynotbeperfect,thatiswhyyourfeedbackissoimportant.Inaddition,therewillbeongoingresearchaimedatkeepingthetoolaccurateandappropriate.Ifnecessary,subsequenteditionswillfollow.

Online resources:

Forfurtherinformationpleasevisit

www.emssa.org.za/sats

Contact details:

MicheleTwomey

SATSImplementationAdvisor

0828503281

[email protected]

REFEREnCEs

1. BruijnsSR,WallisLA,BurchVC.EffectofintroductionofnursetriageonwaitingtimesinaSouthAfricanemergencydepartment.EmergMedJ2008;25:395-397.

2. TwomeyM,WallisLA,ThompsonML,MyersJE.TheSouthAfricanTriageScale(adultversion)providesreliableacuityratings.IntEmergNurs.PublishedOnlineFirst:19September2011.doi:10.1016/j.ienj.2011.08.002.

3. TwomeyM,WallisLA,ThompsonML,MyersJE.TheSouthAfricanTriageScale(adultversion)providesvalidacuityratingswhenusedbydoctorsandenrollednursingassistants.AfricanJEmergMed2012;2:3-12.

4. BruijnsSR,WallisLA,BurchVC.AprospectiveevaluationoftheCapetriagescoreintheemergencydepartmentofanurbanpublichospitalinSouthAfrica.EmergMedJ.2008;25:398-402.

5. PolicyforimplementationofthetriageofpatientsinWesternCapeemergencyunits.CircularH7of2006.DepartmentofHealth,ProvincialGovernment,update2012.

6. GottschalkS,WoodD,DeVriesS,WallisL,BruijnsS,OnbehalfoftheCapeTriageGroup.Thecapetriagescore:anewtriagesystemSouthAfrica.ProposalfromtheCapetriagegroup.EmergMedJ2006;23:149-153.

7. AugustynJ.TheSouthAfricanTriageScale:atoolforemergencynurses.ProfNursToday2011;15:24–29.8. IsaacsAA,HellenbergD.Implementingastructuredtriagesystematacommunityhealthcentre(CHC)using

Kaizen.SAFamPract.2009;519. GoudgeJ,CornellJ,McIntyreD,etal.Privatesectorfinancing.In:NtuliA,SulemanF,BarronP,McCoyD:editors.

SouthAfricanHealthReview2001.Durban:HealthSystemsTrust;2001.10.BradshawD,GroenewaldP,LaubscherR,NannanN,NojilanaB,NormanR,PieterseDandSchneiderM.Initial

BurdenofDiseaseEstimatesforSouthAfrica,2000.CapeTown:SouthAfricanMedicalResearchCouncil,2003.11.IsersonKV,MoskopJC.TriageinMedicine,PartI:Concept,History,andTypes.AnnEmergMed.2007;49:275-281.12.FitzGeraldG,JelinekGA,ScottD,GerdtzMF.EmergencydepartmentTriagerevisited.EmergMedJ2010;27:86-92.13.MollHA.ChallengesinthevalidationofTriagesystemsatemergencydepartments.JClinEpi2010;63:384-88.14.TwomeyM,deSaA,WallisLA,MyersJE.Inter-raterreliabilityoftheSouthAfricanTriageScale:Assessingtwo

differentcadresofhealthcareworkersinarealtimeenvironment.AfricanJEmergMed2011;1:113-118.

9

10

SummaryandReferences

Department of Health

PO Box 2060, Cape Town, 8000

Mobile:

For more information contact: Michele Twomey (SATS Implementation Advisor)

+27 850 3281 email: [email protected]

The South AfricanTriage Scale

(SATS)

Training manual 2012

Departmental Website: www.health.gov.za

Provincial Website: www.westerncape.gov.za

the south african triage scale - emssa · hard work in developing paediatric triage based on two...

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