Pediatric Triage

Dr C. Naveen Kumar
PG in Pediatrics
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

What is Triage?
• French verb “trier”, means to separate or select.
• Triage is the process of rapid assessment of a
patient with a view to define urgency of care &
priorities in treatment.
• It helps in rational allocation of limited resources,
when demand exceeds availability.
• Triage is the first step in the management of a
sick child admitted to a hospital.

STEPS IN THE MANAGEMENT OF THE SICK CHILD ADMITTED TO HOSPITAL
TRIAGE
Check for emergency signs
Check for priority signs
Emergency treatment
Rapid assessment & treatment
Non-urgent cases & stabilized cases
• History and examination
• Laboratory and other investigations
• List and consider DIFFERENTIAL DIAGNOSES
• Select MAIN (WORKING) DIAGNOSIS and Secondary diagnoses
• Plan and begin INPATIENT TREATMENT (including supportive care)
YES
NO
NO
COUNSELING

STEPS IN THE MANAGEMENT OF THE SICK CHILD ADMITTED TO HOSPITAL
(Contd.)
Monitor for
• Response to treatment
• Complications
INPATIENT TREATMENT
• Continue treatment
• Plan for discharge
• Revise treatment
• Treat complications
• Refer if not possible
IMPROVING
NOT IMPROVING OR
NEW PROBLEM
COUNSELING

When should Triage take place?
• As soon as the sick child arrives at hospital.
• Before any administrative procedure such as
registration.
Where should Triaging be done?
• Can be carried out any where.
• At Emergency Room, at OP queue, at ICU or at
ward.

Who should triage?
• All the staff working in a health care facility
should be trained to carry out rapid assessment
of sick child and triage.

Different Triage systems
• WHO – ETAT (Emergency Triage Assessment and
Treatment) guidelines
 Pediatric Triage according to F-IMNCI module:
EPN (Emergency, Priority & Non-urgent) system
 Triage of newborns according to FBNC module:
EPN (Emergency, Priority & Non-urgent) system
• Emergency Severity Index
• Canadian Triage and Acuity Scale

• Rapid screening of the child to decide to which
one of the following groups, the child belongs:
• Emergency treatmentEmergency cases
• Rapid assessment & actionPriority cases
• Can waitNon-urgent cases
Check for emergency signs
Check for priority signs
Emergency treatment
Rapid assessment & treatment
Non-urgent cases & stabilized cases
YES
NO
NO

Emergency signs (ABC3D)
Assessed & managed in the following five domains
in sequential order:
• Airway & Breathing
• Circulation
• Coma
• Convulsions
• Severe Dehydration

Airway & Breathing - assessment
• Is the child breathing?
• Is there central cyanosis?
• Does the child have severe respiratory distress?
AB

Is the child breathing?
• Look: If active, talking, or crying, the child is obviously
breathing. If none of these, look again to see whether the
chest is moving.
• Listen: Listen for any breath sounds.
• Feel: Feel the breath at the nose or mouth of the child.
Gasping is spasmodic open mouth breathing associated
with sudden contraction of diaphragm & retraction of hyoid
apparatus. It is a manifestation of brain hypoxia.
AB

Is there central cyanosis?
• To assess for central cyanosis, look at the mouth
and tongue.
• A bluish or purplish discoloration of the tongue
and the inside of the mouth indicates central
cyanosis.
AB

Does the child have severe respiratory distress?
• Respiratory rate ≥ 70/min
• Severe lower chest in-drawing
• Head nodding
• Apneic spells
• Unable to feed due to respiratory problem
• Stridor (A harsh noise on breathing in is called
stridor.)
• Grunting (A short noise when breathing out in young
infants is called grunting.)
AB

Airway & Breathing - management
Airway management
•If there is history of foreign body aspiration or
if the child is choking with increasing
respiratory distress, suspect foreign body.
•Clear any secretions in present.
AB

Management of choking in young infant
 Lay the infant on arm or thigh in a
head down position.
 Give 5 blows to the infant’s back
with heel of hand. (Back slaps)
 If obstruction persists, turn infant
over and give 5 chest thrusts with 2
fingers, one finger breadth below
nipple level in midline. (Chest
thursts)
 If obstruction persists, check infant’s
mouth for any obstruction which can
be removed.
 If necessary, repeat sequence with
back slaps again.
AB

Management of choking in older child
 Give 5 blows to the child’s back with
heel of hand with child sitting, kneeling
or lying. (Back slaps)
 If the obstruction persists, go behind the
child and pass your arms around the
child’s body; form a fist with one hand
immediately below the child’s sternum;
place the other hand over the fist and
pull upwards into the abdomen; repeat
this Heimlich maneuver 5 times.
 If the obstruction persists, check the
child’s mouth for any obstruction which
can be removed.
 If necessary, repeat this sequence with
back slaps again.
AB

Neck trauma – Suspect when there is history of
trauma to head and neck region or history of fall or
external injuries to head and neck region on
examination.
• Keep the child lying on the
back on a flat surface.
• Tape the child’s forehead to
the sides of a firm board to
secure this position.
• Prevent the neck from moving
by supporting the child’s head.
• Place a strap over the chin.
AB

Neck trauma
Jaw thurst is a way of opening the airway without moving
the head. Place two or three fingers under the angle of the
jaw on both sides, and lift the jaw upwards. (towards head
end)
AB

Opening the airway in an infant & older child
AB

•Manage airway
•Provide BLS - Basic Life Support
•Give Oxygen
•Make sure child is warm
AB

Circulation - assessment
• Does the child have warm hands?
• If not, is the capillary refill time longer than 3
seconds?
• And is the pulse weak and fast?
C1

1. Does the child have warm hands?
•Take the child’s hand in your own. If it feels
warm, the child has no circulation problem
and you do not need to assess capillary refill
or pulse.
•If the child’s hands feel cold, you need to
assess the capillary refill time.
C1

2. Is capillary refill time longer than 3 seconds?
• Capillary refill is a simple test that assesses how
quickly blood returns to the skin after pressure is
applied.
• It is prolonged in shock because the body tries to
maintain blood flow to vital organs and reduces
the blood supply to less important parts of the
body like the skin (peripheral vasoconstriction).
The vessels open slowly because of low pulse
pressure.
C1

2. Is capillary refill time longer than 3
seconds?
•This sign is reliable except in cold
environment, as it can cause vasoconstriction
and a delayed capillary refill.
•In such a situation, check the pulses and
decide about shock.
C1

How to assess Capillary Refill Time?
• Apply pressure to the pink part of the nail bed of the
thumb or big toe in a child and over the sternum or
forehead in a young infant for 3 seconds.
• While applying pressure, count zero-zero-one-zero-zero-
two-zero-zero-three to make sure that it is 3 seconds.
And do the same while releasing pressure.
• The capillary refill time is the time from release of
pressure to complete return of the pink colour. It should
be less than 3 seconds.
• Lift the limb slightly above heart level to assess
arteriolar capillary refill and not venous stasis.
C1

3. Is the pulse weak and fast?
• In an infant (less than one year of age) the brachial
pulse may be palpated in the middle of upper arm. In
older children radial pulse can be palpated.
• If it is of normal volume and not obviously fast (Rate >
160/min in an infant and > 140/min in children above
1 year), the pulse is adequate and no further
assessment is needed.
• If peripheral pulses are of low volume, palpate central
pulses. If central pulses (femoral or carotid) are also
weak it is an ominous sign of shock.
C1

Circulation - management
• If the child has any bleeding, apply pressure to stop
the bleeding. Do not use a tourniquet
• Give Oxygen
• Make sure the child is warm
• Select an appropriate site for administration of fluids
• Establish IV or intraosseous access
• Rapidly assess if the child has severe acute
malnutrition.
• Begin giving appropriate fluids for shock.
C1

Check for severe malnutrition
Look for visible severe wasting
• A child with visible severe wasting
has a form of malnutrition called
marasmus.
• Look rapidly at the arms, legs &
chest for severe muscle wasting.
• Typically, the child appears to be
appears to be all skin and bone.
• The head may appear relatively
large because of wasting of the
body.

Check for severe malnutrition
Check for oedema of both feet
• Oedema is a major sign of
kwashiorkor, a severe form of
longstanding malnutrition.
• Press the top of the foot gently
with your thumb for a few seconds.
• Oedema is present if a definite
dent is left in the tissues.
• Check if the other foot also has
oedema. Localized oedema can be
due to injury or infection.

Circulation - summary
C1

Coma & Convulsion - assessment
• Is the child in coma?
• Is the child convulsing now?
C2,3

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.
• Try to wake the child by talking to him/her, e.g.
call his/her name loudly.
C2,3

Is the child in coma?
• A child who does not respond to this should be
gently shaken (Little shake to the arm or leg).
• Don’t move the neck.
• If this is unsuccessful, apply a firm squeeze to the
nail bed, enough to cause some pain.
• A child who does not wake to voice or being
shaken or to pain is unconscious.
C2,3

Is the child convulsing now?
• Children who are actively convulsing should be
attended on an emergency basis.
• 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.
C2,3

AVPU Scale
• 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 Unconscious.
A child with a coma scale of “P” or “U” will receive
emergency treatment for coma
C2,3

Coma & Convulsion - management
C2,3

Position the child
Unconscious child – No neck trauma
• Keep the child in recovery position.
• Turn the child on the side to reduce risk of
aspiration.
• Keep the neck slightly extended and stabilize by
placing the cheek on one hand.
• Bend one leg to stabilize the body position
• This position helps to reduce the risk of vomit
entering the child’s lungs.
C2,3

C2,3
Recovery Position: Turn the child on the side. Keep the
neck slightly extended and stabilize by placing the cheek
on one hand. Bend one leg to stabilize the body position.Dr Naveen Kumar Cheri

Position the child
Unconscious child – Neck trauma suspected
• Stabilize the child while lying on the back.
• Use the “log roll” technique to turn the child on
the side if the child is vomiting.
C2,3

C2,3
LOG ROLL: One person should stand at the head end of the
patient, hold the patient’s head, and place the fingers under
the angle of the mandible with the palm over the ears maintain
gentle traction to keep the neck straight and in line with the
body, while others are rotating the body.

Check blood sugar and correct hypoglycemia
C2,3
Age Blood glucose cut off Management
< 2 months < 45 mg/dL
2 mL/Kg of 10%
Dextrose I.V
> 2 months < 54 mg/dL
5 mL/Kg of 10%
Dextrose I.V

Severe Dehydration - assessment
Assess for severe dehydration if ABC3 assessments
are normal.
If there is history of diarrhoea/vomiting look for
presence of any two of the following signs:
• Is the child lethargic?
• Does the child have sunken eyes?
• Does the skin pinch take longer than 2 seconds
to go back?
 Also look if the child has severe malnutrition.
D

Is the child lethargic?
• Appears drowsy, may stare blankly and does not show
interest in what is happening around him/her.
Does the child have sunken eyes?
• Look at the child’s eyes to
determine if they appear unusually
sunken in their sockets.
• Ask the mother if the child’s eyes
are more sunken than usual, or if
the skin around them appears
darker than usual.
D

• Locate the area on the child’s abdomen
halfway between the umbilicus and the
side of the abdomen.
• Pinch the skin in a vertical (head to
foot) direction. Don't use finger tips.
• All the layers of the skin and the tissue
underneath should be picked up. Pinch
for one second and then release.
Does the skin pinch goes back very slowly
(> 2 sec?)
D

Severe Dehydration – management
(In the absence of shock and severe malnutrition)
• Give the child a large quantity of fluids quickly
according to Plan C.
• Fluid of choice: Ringer Lactate
• For infants:
o 30 ml/kg in the first hour
o 70 ml/kg in the next 5 hours
• For children > 1 year of age:
o 30 ml/kg in the first 30 minutes
o 70 ml/kg in the next 2.5 hours
D

(In the absence of shock and severe malnutrition)
• Assess the child every 1-2 hours
• If the signs of dehydration are not improving, give
fluid more rapidly
• As soon as the child can drink:
o Give oral fluids in addition to the drip
o Give ORS 5 ml/kg every hour
oEncourage breast feeding
• If IV line couldn't be secured: Give 20 ml/kg/hour
of Oral Rehydration Solution through nasogastric
tube, for six hours.
D

(In severe malnutrition, in the absence of shock)
• Do not give IV fluids if possible.
• Give ReSoMal 5ml/kg every 30 minutes for the
first 2 hours
• Then 5-10ml/kg/hour for the next 4-10 hours
• Give more ReSoMal if child wants more or large
stool loss or vomiting
• Check blood glucose and treat hypoglycemia.
D

(In severe malnutrition, in the absence of shock)
ReSoMal (Rehydration Solution for Malnourished)
INGRADIENT QUANTITY
Water 2 Liters
ORS One 1 Liter sachet
Household sugar (Sucrose) 50 grams
Electrolyte / Mineral solution 40 ml
D

Priority signs (3TPR MOB)
• Tiny infant (< 2 months
of age)
• Temperature (Fever)
• Severe Trauma or other
urgent surgical
condition
• Severe Pallor
• Poisoning &
Envenomation
• Severe Pain
• Restless and Irritable
or Lethargic
• Respiratory distress
• Urgent Referral
• Severe Malnutrition
• Oedema of both feet
• Major Burns

• Tiny infant (< 2 months of age)
Difficult to assess properly, more prone to get
infections and are more likely to deteriorate quickly
if ill.
So they should be attended on a priority basis.
• Temperature (Fever)
Children with high fever on touch need prompt
treatment.
Check temperature with thermometer and give
antipyretic while awaiting in the queue.

• Severe Trauma (or other urgent surgical
condition)
Like acute abdomen, injuries and fractures.
• Severe Pallor
It is a sign of severe anemia,
Which might need urgent
transfusion. It can be detected
by comparing the child’s
Palms with your own.

• Poisoning / Envenomation
Children with a history of swallowing drugs or other
dangerous substances or any bites need to be
assessed immediately, as they can deteriorate
rapidly and might need specific treatments.
• Severe Pain
If a child has severe pain and is in agony, she/he
should be prioritized to receive pain relief and early
full assessment.

• Lethargy or Irritable and Restless
AVPU scale - A lethargic child responds to voice but
is drowsy and uninterested in surroundings.
Irritable or restless child is conscious but cries
constantly and will not settle.
There may be signs present which are not severe,
e.g. mild lower chest wall in-drawing , Respiratory
rate < 70/min.
Such cases should be attended on priority.

• Severe wasting (Severe Malnutrition) & Oedema
of both feet
A child with visible severe wasting has a form of
malnutrition called Marasmus.
Oedema of both feet is an important diagnostic
feature of Kwashiorkor.
• Major Burns
Extremely painful and children who seem quite well
can deteriorate rapidly.

EMERGENCY SIGNS
• Hypothermia (Temperature < 35.50 C)
• Apnea or gasping respiration
• Severe respiratory distress (rate > 70/min, severe retractions,
grunt)
• Central cyanosis
• Shock (cold periphery, CFT > 3 sec, weak & fast pulse)
• Coma, convulsions or encephalopathy
 These neonates are at high risk.
 Require urgent intervention and emergency measures.

PRIORITY SIGNS
• Tiny neonate (<1800 gms)
• Cold stress (Temperature 36.40C
– 35.50C)
• Respiratory distress (rate 60 –
70/min, no or minimal
retractions)
• Irritable/restless/jittery
• Refusal to feed
• Abdominal distension
• Severe pallor
• Severe jaundice (appears in <24
hrs / stains palms and soles /
lasts > 2weeks)
• Bleeding from any site
• Major congenital malformations
(Tracheoesophageal fistula,
Meningomyelocele, Anorectal
malformation)
• Large baby
 The neonates with priority signs are sick and would need immediate
assessment.
 They should be attended to on a priority basis. Dr Naveen Kumar Cheri

NON - URGENT CASES
• Jaundice
• Transitional stools
• Developmental peculiarities
• Minor birth trauma
• Posseting
• Superficial infections
• Minor malformations
• All cases not categorized as Emergency/Priority

EMERGENCY SIGNS PRIORITY SIGNS NON URGENT CASES
• Hypothermia (temp<360
C)
• Apnea or gasping
respiration
• Severe respiratory distress
(rate>70, severe
retractions, grunt)
• Central cyanosis
• Shock (cold periphery,
CFT>3secs, weak & fast
pulse)
• Coma, convulsions or
encephalopathy
• Cold stress (temp 36.40C -
360C)
(rate>60, no retractions)
• Tiny neonate (<1800gms)
• Large baby
• Irritable/restless/jittery
• Refusal to feed
• Abdominal distension
• Severe jaundice
• Severe pallor
• Bleeding from any sites
• Major congenital
malformations
• Jaundice
• Transitional stools
• Developmental
peculiarities
• Minor birth trauma
• Posseting
• Superficial infections
• Minor malformations
• All cases not
categorized as
Emergency/Priority

Pediatric Triage

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