When attempting to locate the pulse of child found in a state of collapse How much time should be taken?

Triage is the process of rapidly examining sick children when they first arrive in order to place them in one of the following categories:

• Those with EMERGENCY SIGNS who require immediate emergency treatment.

• Those with PRIORITY SIGNS who should be given priority in the queue so they can be rapidly assessed and treated without delay.

• Those who have no emergency or priority signs and are NON-URGENT cases. These children can wait their turn in the queue for assessment and treatment. The majority of sick children will be non-urgent and will not require emergency treatment.

Triage is the sorting of children into priority groups according to their medical need and the resources available.

After these steps are completed, proceed with a general assessment and further treatment according to the child's priority.

Ideally, all children should be checked on their arrival by a person who is trained to assess how ill they are. This person decides whether the child will be seen immediately and receive life-saving treatment, or will be seen soon, or can safely wait for his or her turn to be examined.

The triaging process

Triaging should not take much time. In the child who does not have emergency signs, it takes on average twenty seconds.

• Assess several signs at the same time. A child who is smiling or crying does not have severe respiratory distress, shock or coma.

• Look at the child and observe the chest for breathing and priority signs such as severe malnutrition.

When and where should triaging take place?

Triage should be carried out as soon as a sick child arrives, before any administrative procedure such as registration. This may require reorganizing the flow of patients in some locations.

Triage can be carried out in different locations, e.g. in the queue. Emergency treatment can be given wherever there is room for a bed or trolley for the sick child, enough space for the staff to work, and where appropriate drugs and supplies are accessible. If a child with emergency signs is identified in the queue, he or she must quickly be taken to a place where treatment can be provided immediately.

Who should triage?

All clinical staff involved in the care of sick children should be prepared to carry out rapid assessment to identify the few children who are severely ill and require emergency treatment.

How to triage?

Follow the ABCD steps:

• Airway

• Breathing

• Circulation/Coma/Convulsion

• Dehydration.

1. Airway

2. Breathing

3. Circulation/Coma/Convulsion

4. Dehydration (severe)

When ABCD has been completed the child should be assigned to one of:

• Emergency (E)

• Priority (P)

• Non-urgent and placed in the Queue (Q).

Emergency signs

Triage of patients involves looking for signs of serious illness or injury. These emergency signs are connected to the Airway - Breathing - Circulation/Consciousness - Dehydration and are easily remembered as ABCD. Each letter refers to an emergency sign which, when positive, should alert you to a child who is seriously ill and needs immediate assessment and treatment.

Assess airway and breathing

The most common cause of breathing problems in children during emergencies is pneumonia. However, other causes can also lead to breathing problems, including anemia, sepsis, shock and exposure to smoke. Obstructed breathing can be caused by infection (for example croup) or an object in the airway.

The child has an airway or breathing problem if any of these signs are present.

• Child is not breathing.

• Severe respiratory distress with fast breathing or chest indrawing.

Assess for an airway or breathing problem.

• Is the child breathing?

• Is there severe respiratory distress?

• If there is severe respiratory distress, does breathing appear obstructed? The child with obstructed breathing will appear to have difficulty breathing with little air entering the lungs. Sometimes the child will make a sound (stridor) as some air moves past the obstruction.

Assessment of fast breathing.

• Count breaths FOR ONE FULL MINUTE to assess fast breathing.

  If the child is:	The child has fast breathing if you count:
  Less than 2 months	60 breaths per minute or more
  2 months up to 12 months	50 breaths per minute or more
  12 months up to 5 years	40 breaths per minute or more

• Chest indrawing is the inward movement of the lower chest wall when the child breathes in and is a sign of respiratory distress. Chest indrawing does not refer to inward movement of the soft tissue between the ribs. N.B. Refer to annex 1 for definition of technical terms.

For management of the child with airway or breathing problems, go to chapter 2.

Assess the circulation for signs of shock

Common causes of shock include dehydration from diarrhoea, sepsis, anaemia (for e.g. due to severe blood loss after trauma, poisoning or severe malaria).

The child has shock (a blood circulation problem) if the following signs are present:

• cold hands AND

• weak and fast pulse.

Capillary refill is the amount of time it takes for the pink colour to return after applying pressure to whiten the nail of the thumb or big toe for 3 seconds.

Assess the child's circulation.

• Is the child's hand cold?

• If yes, is the capillary refill longer than 3 seconds? Classify the child as having SHOCK if the capillary refill takes longer than 3 seconds.

• Check the pulse. Is the pulse weak and rapid?

  • To check the pulse, first feel for the radial pulse. If it is strong and not obviously rapid, the pulse is adequate. No further examination is needed.

  • If you cannot feel a radial pulse or if it feels weak, check a more central pulse.

  • In an infant (age less than one year), move up the forearm and try to feel the brachial pulse, or if the infant is lying down, feel for the femoral pulse.

  • If the more central pulse feels weak, decide if it also seems rapid.

Classify the child as having SHOCK if the pulse is weak and rapid.

For management of the shocked child, go to chapter 2.

Figure 1Location of the major arteries to assess the pulse

Assess for convulsions1 and coma

Common causes of convulsions in children include meningitis, cerebral malaria and head trauma.

Signs of convulsions include:

• sudden loss of consciousness

• uncontrolled, jerky movements of the limbs

• stiffening of the child's arms and legs

• unconscious during and after the convulsion.

For management of the convulsing child, go to chapter 2.

Common causes of loss of consciousness or lethargy or irrifability and restlessness include meningitis, sepsis, dehydration, malaria, low blood sugar and severe anemia.

Assess the child for unconsciousness or lethargy.

• If the child is not awake and alert, try to rouse the child by talking to him or her.

• Then shake the arm to try to wake the child.

• If there is no response to shaking, squeeze the nail bed of a fingernail to cause mild pain.

• If the child does not respond to voice or shaking of the arm, the child is unconscious.

For management of the unconscious child, please go to chapter 2.

Assess the child for irritability or restlessness by looking for:

• difficulty in calming the child.

• persistent signs of discomfort or crying.

• continued, abnormal movement without periods of calm.

If you suspect trauma which might have affected the neck or spine, do not move the head or neck as you treat the child and continue the assessment.

• Ask if the child has had trauma to his head or neck, or a fall which could have damaged his spine.

• Look for bruises or other signs of head or neck trauma.

For more detailed assessment and management of the child with head or neck trauma, go to chapter 10.

Causes of low blood glucose include sepsis, diarrhea, malaria and burns.

How to measure the blood glucose using a glucose strip:

• Put a drop of the child's blood on the strip.

• After 60 seconds, wash the blood off gently with drops of cold water.

• Compare the color with the key on the side of the bottle.

• If the blood glucose is less than 2.5 mmol/litre, the child has low blood glucose and needs treatment.

For management of the child with low blood glucose, go to chapter 2.

Assess for severe dehydration

Diarrhoea is one of the commonest causes of death among under-five children. Death most commonly is due to dehydration. Children with signs of severe dehydration (such as sunken eyes, severely reduced skin pinch, lethargy or unconsciousness, or inability to drink or breastfeed) need emergency management with replacement fluids.

For more detailed assessment and management of the child with severe dehydration, go to chapter 3.

Priority conditions

If the child does not have any emergency signs, the health worker proceeds to assess the child for priority conditions (box 2). This should not take more than few seconds. Some of these signs will have been noticed during the ABCD triage and others need to be rechecked.

Box 2

Priority conditions. Tiny baby: any sick child aged under 2 months (Chapter 8) Temperature: child is very hot (Chapter 5)

1

If a child convulses repeatedly, then the child may have epilepsy. Epilepsy is a condition characterized by repeated seizures. A seizure (also referred to as a convulsion, fit or attack) is a result of excessive nerve-cell discharges in the brain seen as sudden abnormal function of the body, often with loss of consciousness, an excess of muscular activity, or sometime a loss of it, or abnormal sensation.Such a child needs careful follow-up with an expert in hospital. Refer for assessment and follow-up care.

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