Introduction to triage

Objective
• Define triage and describe the concept of triage for sick
children
• Assess the emergency signs in 2-59 months children using
ABCD concept
• Assess priority signs in 2-59 months children
• Assess the danger signs (emergency/priority) of sick
infants 0-2 months of age
• Explain the algorithm of triage of sick children from 2 to 59
months age
• Explain the algorithm of triage of sick infants 0-2 months
of age
 Introduction to triage
• Read 2.1.2 to 2.1.5
Assessing Emergency and
Priority Signs
 Emergency signs
• A: Airway
• B: Breathing
• C: Circulation/Convulsions/Consciousness
• D: Dehydration
If the child has any emergency sign of the ABCD,
it means the child has an emergency “E” sign
and emergency treatment should be started
immediately.
 A and B
• Check whether there is any airway or breathing problem
– Is the child breathing? Look, listen and feel for air
movement
– Is the airway obstructed? (due to tongue fall, foreign body,
croup or neck swelling)
– Is the child blue (centrally cyanosed)?
– Does the child have severe respiratory distress?
• Is the child having trouble getting breath so that it is
difficult to talk, eat or breastfeed?
• Is he breathing very fast and getting tired, does he
have severe chest in drawing or is he using accessory
respiratory muscles?
 C
• Quickly check circulation and decide whether
the child is in shock or has impaired
circulation.
– Does the child have cold hands?
– Is the capillary refill time longer than 3 seconds?
– Is the pulse weak and fast? Check radial pulse.
May check brachial or femoral pulse in infant.
 C
• Then, quickly determine whether the child is unconscious.
– A rapid assessment of conscious level can be made by
assigning the patient to one of the AVPU categories:
• Alert
• V- responds to Voice (lethargic)
• P- responds to Pain (coma)
• U- unresponsive (coma)
• And ask and look for convulsion.
– If the child is convulsing when brought to hospital or
during examination, this is an emergency, requiring
immediate treatment
 D
• Ask whether the child is having diarrhoea. If
yes, assess for signs of severe dehydration
– If the child is lethargic or unconscious
– If the child has sunken eyes
– If the skin pinch goes back very slowly
 Need for Frequent reassessment
• During and after providing emergency treatment,
the child should be re-assessed using the
complete ABCD sequence.

• The disease course is dynamic and there could be

new developments within a short time.

• Reassessment should begin with assessment of

the airway and through the ABCD sequence.
 Priority Signs
• Checked for if no emergency signs
• Remembered- 3TPR-MB
1. Tiny baby: Any sick child aged < 2 months is more likely to
deteriorate quickly, has higher chances of infection and is
more difficult to assess
2. Temperature: A child that feels very hot may have high
fever, needs to check temperature by thermometer, give
an antipyretic, or do investigations like a blood film for
malaria.
3. Trauma or other urgent surgical condition: May require
specialist consultation or care for acute abdomen, head
injury or fractures.
 Priority signs
4. Pallor (severe): Compare the child’s palm with yours. If
it is very pale, including the creases, the child may
have severe anemia requiring urgent blood
transfusion.
5. Poisoning: A child with history of swallowing
drug/poisonous substance or stings/bites may
deteriorate quickly and may need specific treatments
like antidotes or anti-venoms urgently.
6. Pain (severe): If the child has severe pain, it may be
due to serious conditions and may need early
assessment and pain relief.
 Priority signs
4. Respiratory distress (not severe): Chest indrawing,
tachypnea or difficulty breathing may be signs of
respiratory distress, but not severe enough to require
emergency treatment. However, if in doubt, initiate
treatment immediately.
5. Restless, continuously irritable, or lethargic: A lethargic
child responds to voice but is drowsy and uninterested
(V in the AVPU scale). The continuously irritable or
restless child is conscious but cries constantly and will
not settle. The causes for this may be serious, such as
meningitis, cerebral malaria etc.
 Priority signs
9. Referral (urgent): Ask the mother if she was referred
from another facility and for any note that may have
indicated referral for urgent problem.
10. Malnutrition (severe acute): A child with visible severe
wasting or oedema of both feet may have severe acute
malnutrition, which requires specific management
approach.
11. Burns (major): Burns are extremely painful and children
who seem quite well can deteriorate rapidly. Get surgical
help or follow surgical guidelines and appropriate fluid
resuscitation protocol.
 Others
• Non urgent: Proceed with assessment and
further treatment

• If patient has trauma or other surgical

problems, get surgical help or follow surgical
guidelines
 Triage of sick newborn
• See for temperature, airway, breathing,
circulation, coma/ convulsion and weight
 Triage of sick newborn
Emergency signs
• Weight <1500g
• Hypothermia (temp<36ºC,
96.8°F)
• Apnea or gasping respiration
• Severe respiratory distress
(rate>60, severe retractions,
grunt)
• Central cyanosis
• Shock (cold periphery, CRT>3
secs, weak & fast pulse)
• Coma, convulsions
Priority signs
• Weight 1500-1800g or >4000g
• Cold stress (temp 36.5ºC -36ºC,
97.7°F-96.8°F )
• Respiratory distress (rate ≥ 60,
no retractions)
• Irritable/restless/jittery
• Abdominal distension
• Severe jaundice
• Severe pallor
• bleeding from any sites
• major congenital malformations
 Triage of sick newborns
• Non- urgent signs
• Weight >1800g-2500g
• Transitional stools
• Posseting( regurgitation)
• Minor birth trauma
• Superficial infections
• Minor malformations
• Jaundice
• All cases not categorized as Emergency/Priority
• See Chart 2.1 for triage of all sick children
• See Chart 2.2 and 2.3 for triage and treatment
of sick newborn
 Drill exercises
1. Define triage
2. Where should triage be done?
3. Who should do the triage?
4. Put the actions in the right chronological order: what will you do
first, what next, what after that, and so on, and what last?
– Ask about head or neck trauma
– Call a senior health worker to see any emergency
– Have blood specimens taken for laboratory analysis
– Look for any priority signs
– Look for emergency signs
– Move on to the next patient
– Place priority patients at the front of the queue
– Start treatment of any emergency signs you find
 Drill questions
5. Below what age is a child always a priority?
6. What should you do if the child has a priority
sign?
7. What signs of malnutrition do you check
during triage?
• A three-year old girl is carried in her mother's
arms wrapped in a blanket, in the queue. Her
airway and breathing are OK. She has cold
hands. Her capillary refill is 1.5 seconds. She is
alert. Asked if the child has had diarrhoea, the
mother answered "YES. Four loose stools per
day". The skin pinch takes 3 seconds. How do
you triage this child?
9. A four-year old male child was rushed in. He
convulsed one hour ago. He is breathing fast
but there is no cyanosis and no respiratory
distress. He feels very hot, but responds
quickly to questions. He has no diarrhoea or
vomiting. How do you triage this child?
9. A two-year old male is rushed to your clinic
acutely convulsing. How do you triage this
child?
• A one-year old had a seizure at home; then
again outside the clinic. He became
unconscious. His breathing sounds very wet
and noisy and there is drooling coming from
his mouth. He is looking blue. How do you
triage this child?
12.Mayank, three weeks old, is brought to you with
complaints of 4 days of diarrhea and vomiting.
His temperature is 36.2ºC and he is lethargic,
breathing normally, his hands are cold and
capillary refill is < 3 sec. The eyes are normal,
skin pinch takes more than 3 sec, and he has a
weak and fast pulse. On the basis of the triage
chart, categorize the child. List the signs on the
basis of which you assigned the category.
• An 8-day-old baby fed on top milk is brought
to a health facility with complaints of
diarrhoea. The eyes and skin pinch are normal
and baby is alert. On the basis of the triage
chart, categorize the child. List the signs on
the basis of which you assigned the category.
14.Monu, one year old, had a seizure outside
the hospital. He became unconscious. His
breathing sounds very wet and noisy and
there is drooling from his mouth. He has
central cyanosis. On the basis of the triage
chart, categorize the child. List the signs on
the basis of which you assigned the category.
Airway and Breathing
 Objectives
• Assess signs of abnormal airway and breathing
• State the signs of severe respiratory distress
• Explain and demonstrate the technique of
positioning to improve the airway
• Explain and demonstrate the technique of
positioning to improve the airway if neck
trauma is possible
• Explain and demonstrate the technique of bag
and mask ventilation
 Objectives
• Explain the management of a choking child
• Explain and demonstrate the
Cardiopulmonary Resuscitation procedure
• Explain and demonstrate the procedure of
delivering oxygen therapy
• Demonstrate the process of basic life support
 Airway and breathing
Severe respiratory distress
 Assessment of breathing
• Read section 2.2.1 for assessment of breathing
 Positioning the airway
• Read 2.2.2 and 2.2.3 and Fig 2.1, 2.2 and 2.3
 Bag and mask ventilation
• Read contents 2.2.4 , Figure 2.4 and Box 2.2
• Refer to Box 2.3 for rescue breathing
• Demonstrate bag and mask ventilation using
Checklist 2.1
 Choking in a conscious child
• Read 2.2.5
 Choking in unconscious child
• Read 2.2.6
• Demonstrate CPR using checklist 2.2 for chest
compression
 Giving oxygen
• Read 2.2.7
• If limited time, read at home
 Drill questions
1. List the three things you do to check airway and
breathing
2. List the signs of severe respiratory distress
3. Does stridor occur in inspiration or expiration?
4. When opening the airway of an infant (<12 months)
who has not been subjected to trauma, name the
part of the body that should point upwards.
5. What size of tubing should you use for a nasal
catheter?
 Drill questions
6. At what flow (volume/time) should oxygen be started?
7. You have successfully removed a coin from the trachea
(windpipe) of a three-year old boy by applying Heimlich's
maneuver. You checked his respiration and found that he
was breathing normally. What do you do next?
8. A three-year old boy is carried into the outpatient
department in his father's arms. He is pale, floppy and
having difficulty breathing. His father says he has been
unwell and coughing for 3 days. Weight 14kg.He breathes
fast with heavy severe chest in drawing. The airway is
patent. He is alert. How do you triage this child? What do
you do?
Circulation
 Objectives
• Assess the status of circulation
• Define and classify shock in children
• Explain the clinical progression of shock from
compensated state to multi-organ failure.
• Describe the general management of shock
• Explain and re-demonstrate the procedure of
insertion of
– intravenous cannula
– intraosseous access
– preparation and administration of Dopamine
 Objectives
• Describe the fluid resuscitation for a child in shock
– without severe malnutrition
– With severe malnutrition
• Describe the procedure of blood transfusion
• Explain the monitoring of children with signs of
circulatory impairment but not in shock
• Describe the fluid management in sick children
 Assessment of circulation status
1. Does the child have warm hands?
2. Is the capillary refill time (CRT) longer than 3 seconds?
a. how quickly blood returns to the skin after pressure is
applied
b. the pink part of the nail bed of the thumb or big toe in a
child and over the sternum or forehead in an infant for 5
seconds
c. Normal <3 secs
d. If checking in limb, slightly lift above
heart level
e. Abnormal during hypothermia
 Assessment of circulation status
3. Is the pulse weak and fast?
a. Check for the carotid pulse in a child. In infants, check
brachial pulse. If the infant is lying down, you may check the
femoral pulse.
b. If you do not definitely feel a pulse within 10 seconds, start
chest compressions.
c. Demonstrate how to locate carotid, brachial and femoral
pulses
d. If pulse < 60/min despite adequate oxygenation and
ventilation, start chest compression
e. Fast- >160/min in infants and > 140/min in children
Blood pressure is not checked during ETAT as it can be normal in
early compensated shock .
Shock
 Definition of shock
• Shock is a critical condition that results from
inadequate delivery of oxygen and nutrients,
to meet tissue metabolic demand and is
characterized by inadequate peripheral and
end-organ perfusion.
• Shock can occur with a normal, increased or
decreased systolic blood pressure.
 Definition of shock
• In children, most cases of shock has low
cardiac output; however, in some types of
shock (e.g. caused by sepsis or anaphylaxis),
cardiac output may be high.
• All types of shock can result in impaired
function of vital organs, such as the brain
(decreased level of consciousness) and
kidneys (low urine output)
 Types of shock
• Hypovolemic shock
• Cardiogenic shock
• Obstructive shock
• Septic shock
• Anaphylactic shock
• Neurogenic shock
 Types of shock
• Hypovolemic shock
– due to fluid loss from diarrhoea, vomiting
– third space loss in intestinal obstruction, dengue,
burn
– blood loss from trauma or bleeding disorder)
• Cardiogenic shock
– due to impaired cardiac contractility resulting
from congenital or acquired heart diseases or
myocarditis
 Types of shock
• Obstructive shock
– due to obstructed blood flow resulting from
pneumothorax or cardiac tamponade
• Septic shock
– due to capillary leak and inappropriate distribution
of blood volume, resulting from severe infections
 Types of shock
• Anaphylactic shock
– due to severe allergic reaction

• Neurogenic shock
– inappropriate distribution of blood volume
and flow
 Types of shock
• Commonest cause of shock in children
– due to loss of fluid from circulation, either through
loss from the body as in severe diarrhoea or when
the child is bleeding,
– through capillary leak in a disease such as severe
dengue fever.
• In all cases, it is important to replace this fluid
quickly. An intravenous line must be inserted
and fluids given rapidly in children with shock
and without severe acute malnutrition.
 Clinical progression of shock from
compensated state to multi- organ failure
• compensatory mechanism-
Com • tachycardia
pens • increased peripheral vascular resistance
ated
shock

•Blood pressure decreases

Hypo •Blood supply to the end organs becomes compromised
tensi
ve
shock

• Cardiac arrest
Deat
h
 Clinical progression of shock from
compensated state to multi- organ failure
• For quick estimation of hypotension in a child,
use the following formula for systolic BP
– 1-10 years of age < 70 + (age in years x 2) mmHg
– Infants < 70 mmHg is hypotension
– Term neonates < 60 mmHg is hypotension
– >10 years < 90 mmHg is hypotension
 Clinical progression of shock from
compensated state to multi- organ failure
• Pulse pressure
– Difference between systolic and diastolic
pressure, helps to identify the type of
shock.
– Narrow- hypovolemic and cardiogenic
shock
– Wide- distributive shock like septic shock
and anaphylactic shock.
 General management of shock
1. If the child has any bleeding, apply pressure
to stop the bleeding (do not use tourniquet)
2. Management of airway and breathing-
Maintain a patent airway and support
breathing as described in ETAT section.
Give 100% oxygen and provide positive
pressure ventilation if there is no
spontaneous breathing
 General management of shock
3. Establish IV access at an appropriate site or intra-
osseous access .
Begin fluid resuscitation & start specific treatment
for the condition leading to shock. Follow aseptic
technique to insert the intravenous cannula.
4. Correction of underlying metabolic, electrolyte and
acid base abnormalities.
Check and correct hypoglycemia, hypocalcemia and
acidosis.
Make sure the child is warm.
 General management of shock
5. Monitoring: Assess the effectiveness of fluid resuscitation
and inotropic therapy by frequent monitoring of:
– Heart rate
– Pulse rate
– Level of consciousness
– Temperature
– SpO2
– Blood pressure
– Urine output- If child can pass urine, collect and measure urine
but if child is not able to pass urine child should be catheterised
to monitor urine output.
 General management of shock
6. Laboratory studies: Take blood samples for emergency
laboratory tests including
– CBC
– Blood glucose
– Serum electrolytes (sodium, potassium, calcium)
– Other investigations if facilities are available:
– CRP, Blood culture
– Chest X-ray
7. Medications: Use vasopressors like dopamine
8. Referral- If no improvement after dopamine at 20
mcg/kg/min
Technique of insertion of IV cannula
(Page 12 of participants workbook)
• Administration of IV bolus
 Methods of giving injections:
IM/SC/ID

• Steps:
– Find out whether the child has reacted adversely to drugs
in the past.
– Wash your hands thoroughly. Where possible, use
disposable needles and syringes. Or else, sterilize reusable
needles and syringes.
– Clean the chosen site with an antiseptic solution.
– Carefully check the dose of the drug to be given and draw
the correct amount into the syringe. Expel the air from the
syringe before injecting. Always record the name and
amount of the drug given.
– Discard disposable syringes in a safe container.
 Methods of giving injections:
IM/SC/ID

• Intramuscular Injections:
– Locate the injection site
– Children < 2 years/ severely malnourished children- Anterolateral
upper thigh
– Children >2 years outer aspect of upper arm
– Clean skin with alcohol
– Pinch muscle with free hand and insert 23 or 25 gauge, 1 inch
needle until the hub is flush wih the skin surface
– Insert the needle at 45 degrees in anterolateral thigh and 90
degrees in outer aspect of forearm.
– Aspirate the blood and then inject medication
– Remove the needle and press firmly over the site with a dry swab.
 Methods of giving injections:
IM/SC/ID

• Subcutaneous Injections:
– Locate site: Upper outer arm or outer aspect of
upper thigh
– Clean site with alcohol
– Insert 25 or 27 gauge, 0.5 inch needle into the
subcutaneous layer at 45 degree angle to the skin.
Aspirate for blood, then inject medication
– Remove the needle and press firmly over the site
with a dry swab.
 Methods of giving injections:
IM/SC/ID

• Intradermal injection:
– Locate an undamaged and uninfected area of skin.
– Stretch the skin between the thumb and forefinger of
one hand.
– With the other hand slowly insert 25 gauge needle bevel
upwards for 2 mm just under the skin at 15 degrees
almost parallel to skin.
– Inject the medication. Considerable resistance should be
felt.
– A raised, blanched bleb is formed.
– Remove the needle.
Technique of intraosseous line insertion( Page 13 of participants workbook)
• Ask participants to read contents on 2.3.6
(Fluid resuscitation of children in shock
without severe malnutrition)

• Open and discuss Chart 2.4

• Demonstrate the use of dopamine using
checklist 2.5.( Page 14 of participants
workbook) (15 mins)
• Discuss the technique of blood transfusion
using checklist 2.9 in page 19 of participants
workbook
• Ask participants to read contents on 2.3.7
(Fluid resuscitation of children in shock with
severe malnutrition)
• Open and discuss chart 2.5
 Monitoring children who are not in shock
but have signs of circulatory Impairment
• Ask participants to read Section 2.3.8
• Ask participants to read section 2.3.9 (Fluid
Management.)

• Queries
1. In triage of an 18-month old, you find his
hands are cold. What do you do next?
2. If you cannot feel the radial pulse in an older
child, which pulse should you look for next?
3. In triage of a 10-year old boy who was rushed
to emergency after falling from a coconut
palm half an hour earlier, you find his hands
are cold and the capillary refill time is longer
than three seconds. What do you do next?
4. What fluid and volume of fluid would you
give to a well nourished one-year old
weighing 11 kg who is in shock? Calculate
the amount of Dopamine you would give to
this child.
• In the given clinical scenario, what is the initial
action and based on the response to the initial
action, what would be the second step?
 Fluid resuscitation
Child's age and First action
weight
Respons Second action
e
10 months, 5 kg, Better
visible severe
wasting, no shock

18 months, 8 kg, If lethargic or Improved

oedema of both comatose:
feet, shock
Coma and convulsion
 Objective
• State and define the different levels of
consciousness
• Assess the neurological status of the child and
identify coma and convulsion
• Explain and demonstrate the positioning of a
patient in coma; including log roll and cervical
spine immobilisation
• Describe the process of insertion of
oropharyngeal airway in infant and children
 Objective
• Explain the procedure of suctioning
• Explain the management of a convulsing child
• Discuss the process of administration of
diazepam
• Explain the components of supportive care to
be provided to the child with convulsion or
coma
• State the indications for referral
 Various levels of consciousness
• Coma, lethargy, and convulsions indicate
impaired neurological state.
• Impaired consciousness, implies a significant
alteration in the awareness of self and of the
environment, with varying degrees of
wakefulness.
• Coma, is characterized by the total absence of
arousal and of awareness.
 Various levels of consciousness
• Encephalopathy, describes a clinical syndrome of
altered mental status, manifesting as reduced
consciousness or altered behavior.

• Acute Encephalitis Syndrome, clinically is defined as

person of an age, at any time of year with the acute
onset of fever and a change in mental status
(including symptoms such as confusion,
disorientation, coma or inability to talk) AND/OR new
onset of seizures (excluding simple febrile seizure).
 Assessment of neurological status
• To assess the child’s neurological status, you
need to know:
– Is the child in coma?
– Is the child convulsing?
 Assessment of neurological status
• Is the Child in Coma?
• A child who is awake is obviously conscious
and you can move to the next component of
the assessment.
• If the child is asleep, ask the mother if the
child is just sleeping.
• If there is any doubt, you need to assess the
level of consciousness
 Assessment of neurological status
• Is the Child in Coma?
• Try to wake the child by talking to him/her, e.g. call his/her
name loudly.
• A child who does not respond to this should be gently
shaken. A little shake to the arm or leg should be enough
to wake a sleeping child. Do not move the child’s neck.
• If this is unsuccessful, apply a firm squeeze to the nail bed,
enough to cause some pain.
• A child who does not wake up to voice or being shaken or
to pain is unconscious.
 Assessment of neurological status
• To assess level of consciousness of a child, a simple
scale (AVPU) is used:
– A: Is the child Alert? If not,
– V: Is the child responding to Voice? If not,
– P: Is the child responding to Pain?
– U: The child who is Unresponsive to voice (or being
shaken) AND to pain is considered Unconscious.
• A child with a coma scale of “P” or “U” will receive
emergency treatment for coma as described below.
 Assessment of neurological symptoms
• Is the Child Convulsing Now?
• This assessment depends on your observation
of the child and not on the history from the
parent.
• Children who have a history of convulsion, but
are alert during triage, need a complete
clinical history and investigation, but no
emergency treatment for convulsions.
 Assessment of neurological symptoms
• Is the Child Convulsing Now?
• Recognized by the sudden loss of consciousness
associated with uncontrolled jerky movements of the
limbs and/or the face. There is stiffening of the
child's arms and legs and uncontrolled movements of
the limbs. The child may lose control of the bladder,
and is unconscious during and after the convulsion.
• Sometimes, in infants, the jerky movements may
be absent, but there may be twitching (abnormal
facial movements) and abnormal movements of the
eyes, hands or feet
• Read the contents on 2.4.3

• Explain and demonstrate the recovery position and

log roll on the dummy

• Explain and demonstrate the technique of insertion

of oropharyngeal airway in infant and children

• Explain the technique of suctioning

Administration of Diazepam for convulsion

• Checklist 2.11 ( Page 21 of participants

workbook)
• Discuss Wall chart 2.65 on management
algorithm for status epilepticus
• Box 2.6 on Diazepam to stop convulsions
Supportive care in patient with convulsion
and coma

1. Maintenance intravenous fluids:

Target maintain euvolemia, normoglycaemia,
prevent hyponatremia.
Give isotonic fluids.
Serum sodium should be monitored
 Supportive care in patient with convulsion
and coma
2. Management of raised intracranial pressure:
Important to recognize and promptly manage signs
of raised ICP- hypertension, bradycardia, irregular
respiration, irregular pupils, decerebrate posturing
Decerebrate posturing mistaken for seizures, and
inappropriately treat with anti- epileptic drugs.
Mannitol should be given with loading dose 5 ml /kg/
dose followed by 2 ml/ kg /dose 6 hourly, up to 48
hours.
Frusemide at the dose of 1-2 mg/kg 12 hourly may be
added to mannitol.
Supportive care in patient with convulsion
and coma
3. Maintain euglycaemia:
Identify and treat hypoglycemia with
intravenous dextrose (5 ml/kg 10% dextrose,
then glucose infusion rate of 6–8
mg/kg/min).
Blood glucose should be monitored and both
hypo- and hyper-glycaemia should be
avoided.
 How to prevent hypoglycemia
• If the child is able to breastfeed:
– Ask the mother to breastfeed the child
• If the child is notable to breastfeed but is able to swallow:
– Give expressed breast milk or abreast-milk substitute
– If neither of these is available, give sugar water*
– Give 30-50 ml of milk or sugar water* before departure
• If the child is notable to swallow:
– Give 50 ml of milk or sugar water* by nasogastric tube
– If no nasogastric tube available, give1 teaspoon of sugar moistened with
1-2 drops of water sublingually and repeat doses every20 minutes to
prevent relapse.
• *How to make sugar water: Dissolve 4 level tea spoons of sugar
(20grams) in a 200-ml cup of clean water.
 Supportive care in patient with convulsion
and coma
4. Treatment and prevention of seizures:
A benzodiazepine should be given
(Lorazepam 0.1 mg/kg, diazepam 0.3 mg/kg,
or midazolam 0.1 mg/kg) to terminate
seizure followed by phenytoin loading (20
mg/kg).
Empirical anti convulsants may be considered
in children with deep coma or features of
raised intracranial pressure.
 Supportive care in patient with convulsion
and coma
5. Prevention of complications or
rehabilitation: Regular posture change must
be done to prevent the development of bed
sores. Passive movements of major joints and
measures to prevent contractures are
important.
• Read 2.4.6 for indication for referral

• Additional reading- 2.4.7

 Drill exercise
1. What do the letters AVPU stand for?
2. What is the cut-off level for low blood sugar?
3. How much 10% glucose would you give to a six-
month-old weighing 8 kg and having a low blood
sugar?
4. How much rectal diazepam (in ml of the 10mg/2ml
solution) would you give to a four-yearold weighing
15 kg who is having a convulsion? How long should
you wait before giving a second dose if the
convulsion does not stop?
5. 15-month old girl has been sleeping all day.
She does not answer to a call from her
mother. But she responds to a pinch on her
chest. What stage of AVPU do you assign
her? While on examination, she started to
move her limbs abnormally and her eyes
rolled sideways and there were frothy
secretions in her mouth. What is the most
appropriate measure to take?
Dehydration
 Objective
• Assess the signs of dehydration and classify
dehydration
• Revise the management of dehydration according to
Plan C fluid management
• Describe the management of dehydration according
to Plan B fluid management
• Describe the management of dehydration according
to Plan A fluid management
• Explain the procedure of nasogastric tube insertion
and rehydration
 Assess and classify dehydration
• Most of the diarrheal deaths occur due to
dehydration so should be immediately
managed

• For all children with diarrhea, their hydration

status should be assessed & classified as
severe dehydration, some dehydration or no
dehydration using the following four features
 Assess and classify dehydration
1. LOOK at the general condition - Is the child lethargic
or unconscious? Restless and irritable?
• If the child is not alert but responds to voice, he or she is
lethargic.
• If the child is restless and irritable all the time or every
time s/he is touched and handled, then this is the
restless and irritable sign.
• If an infant who is irritable initially, becomes calm when
breastfeeding but again becomes restless and irritable
when he stops breastfeeding then he has the sign
"restless and irritable".
 Assess and classify dehydration
2. LOOK for sunken eyes.
• The eyes of a child who is dehydrated may
look sunken. Decide if you think the eyes are
sunken.
• In case of doubt, ask the mother if she thinks
her baby's eyes look unusual.
 Assess and classify dehydration
3. PINCH the skin of the abdomen. Does it go
back: Very slowly (longer than 2 seconds)
• Ask the mother to place the child on the
examining table so that s/he is lying flat on the
back with arms at the sides and legs straight.
Or ask the mother to hold the young infant or
child so s/he is lying flat in her lap.
 Assess and classify dehydration
• Locate the area on the child's abdomen halfway between the umbilicus and
the side of the abdomen. To do the skin pinch, use your thumb and first
finger. Do not use your fingertips because this will cause pain.
• Place your hand so that when you pinch the skin, the fold of skin will be in a
line with the child's body and not across the child's body. Firmly pick up all of
the layers of skin and the tissue under them. Pinch the skin for one second
and then release it. When you release the skin, look to see if the skin pinch
goes back:
– Very slowly (longer than 2 seconds)
•

– Slowly
•

– Immediately
•

• If the skin stays up for even a brief time

after you release it, decide that the skin pinch
goes back slowly.
 Assess and classify dehydration
4. OFFER the child fluid - Is the child not able to drink or
drinking poorly? Drinking eagerly, thirsty?
• Ask the mother to offer the child some water in a cup or
spoon. Watch the child drink.
• A child is not able to drink if he is not able to suck or swallow
when offered a drink.
• A child has the sign drinking eagerly, thirsty if it is clear that
the child wants to drink. When the water is taken away, see if
the child is unhappy because he wants to drink more.
• If the child takes a drink only with encouragement and does
not want to drink more, he does not have the sign "drinking
eagerly, thirsty" and has normal thirst
 Assess and classify dehydration
• Table 2.4
• Discuss plan A and B
 Management of child with severe
dehydration
• Discuss plan C using Box 2.8
 Insertion of Nasogastric Tube
• Insertion of nasogastric tube in children and
rehydration through NG tube (2.5.3 ) using
checklist 2.8. ( Page 18 of participants
workbook)
• Add video for nasogastric tube insertion
 Drill exercise
First give Then give Total

Age,Weight of Amount Durati Amount Duratio Amount Durati

child on n on
14 months, 9 kg
8 months, 7 kg
3 years, 13 kg
3 months, 5 kg
2 years, 12 kg
15 months, 10 kg
4 years, 15 kg
23 months, 11.5
kg
Basic life support
 Objectives
• Describe the basic life support in children
Concept of basic life support in children
• Paediatric basic life support (BLS) is not simply
a scaled-down version of that provided for
adults
• Some of the techniques employed need to be
varied according to the size of the child
• A somewhat artificial line is generally drawn
between infants (less than 1 year old) and
children (between one year and puberty), and
this chapter follows that approach.
Concept of basic life support in children
• Once the child has been approached safely and a simple
test for unresponsiveness has been carried out,
assessment and treatment follow the familiar ABC
pattern
• Most causes of paediatric cardiorespiratory arrest are
due to hypoxia. It means that oxygen delivery rather
than defibrillation or chest compression is the critical
step in children.
• This underlines the major differences with the adult
algorithm, which follows C-A-B (Circulation-Airway-
Breathing) algorithm.
 Difference in Basic Life Support in Infants and Children

Airway
Head-tilt position Neutral Sniffing
Breathing
Initial slow breaths Five Five
Circulation
Pulse check Brachial or femoral Carotid
Landmark Lower half of the sternum Lower half of the sternum
Technique Two fingers or two One or two hands
thumbs
CPR ratio 15:2 ( two rescuer) 15:2 ( two rescuer)
30:2 ( one rescuer) 30:2 ( one rescuer)
• Discuss the techniques of basic life support
using wall chart 2.7
• Discuss Checklist 2.6,2.1,2.2

• Wall chart 2.7

 Classroom simulation
• Requirement
– ETAT case recording form(Checklist 2.7)-3
– Transfer checklist(Checklist 1.1)-3
– Referral form for pediatrics(Chart 1.4)- 3
– Referral form for neonate(Chart 1.3)-3
 Classroom simulation
• Divide the participants in three groups and rotate each group among
following three skill stations: Group A , B and C. Number each participants
within group like A1, A2, A3, B1, B2, B3, C1, C2, C3 , etc
• Skill station 1- Conduct case studies on Approach a sick child, using ETAT
pro-forma (30 mins) and complete the transfer and referral form ( 30
mins)
• Skill station 2- Conduct simulation on positioning airway, bag and mask
ventilation and basic life support in infants and children in mannequin,
using checklists. ( 60 mins)
• Skill station 3 - Practice following skills on mannequin using checklist (20
mins each)
• 3a. Putting NG/OG tube
• 3b. Putting IV cannula
• 3c. Establishing an Intra-osseous access
 Orientation for clinical session next day
• Orientation for clinical session of next day
– Approach a sick child using ETAT guideline ( Complete the pro-forma, transfer and
referral checklist)
– Elicit signs of respiratory distress, shock and severe dehydration
– Manage cases with emergency and/ or priority signs (real case scenario)
– Perform following procedures
• Measure SpO2 using pulse oximeter
• Give oxygen and nebulisation
• Insert an IV cannula (preferably in a sick child with shock)
• Give IM injection
• Give IV fluid (NS) and Dextrose bolus
• Prepare and give dopamine
• Give blood transfusion
• Perform urinary catheterization and collect urine sample
• Divide into two group
• What is expected
• Review checklist and related chapters at home
 Checklist to be used

• ETAT case recording form(Checklist 2.7)-3

• Transfer checklist(Checklist 1.1)-3
• Referral form for pediatrics(Chart 1.4)- 3
• Referral form for neonate(Chart 1.3)-3
• NG tube insertion( Checklist 2.8)
• IV cannulation(Checklist 2.3)
• Intraosseous insertion(Checklist 2.4)
• Preparation and giving diazepam( Checklist 2.11)
• Blood transfusion( Checklist 2.9)
• Urinary catheterization ( Checklist 2.10)
• Wearing Sterile glover( Checklist 1.4)
• Handwashing ( Checklist 1.3)