PUSAT PERUBATAN UNIVERSITI MALAYA - … · Dextrose stix - High, with CNS involvement. AGE in Shock . PUSAT PERUBATAN UNIVERSITI MALAYA NAMA DOKUMEN: ... PUSAT PERUBATAN UNIVERSITI

PUSAT PERUBATAN UNIVERSITI MALAYA

NAMA DOKUMEN:

GUIDELINES FOR PEDIATRIC TRIAGE TRAUMA AND EMERGENCY DEPARTMENT

NOMBOR DOKUMEN:

DS-0727-E02 MUKA KULIT

TARIKH KELULUSAN : 07-05-2013

TARIKH BERKUATKUASA : 07-05-2013

TARIKH KAJISEMULA : 07-05-2013

PENULIS DOKUMEN : Mohd Idzwan Zakaria Harminder Singh a/l Karam Singh

DISEMAK OLEH : Ketua, Jabatan Trauma dan Kecemasan

DILULUSKAN OLEH : Wakil Pengurusan-QMS

DISAHKAN OLEH WAKIL PENGURUSAN :

DOKUMEN INI ADALAH HAK MILIK SEPENUHNYA PUSAT PERUBATAN UNIVERSITI MALAYA (PPUM). SEBARANG SALINAN SEBAHAGIAN ATAU SELURUHNYA DOKUMEN INI TIDAK DIBENARKAN SAMA SEKALI KECUALI MENDAPAT KEBENARAN SECARA BERTULIS DARI BAHAGIAN PENGURUSAN KUALITI, PUSAT PERUBATAN UNIVERSITI MALAYA.


NAMA DOKUMEN: GUIDELINES FOR PEDIATRIC TRIAGE TRAUMA AND EMERGENCY DEPARTMENT

NOMBOR DOKUMEN: DS-0727-E02 MUKA: 2/18

Tarikh Berkuatkuasa: 07-05-13

No. Kajisemula R00

Pediatric Triage can be very challenging as the children needs and parents

expectations are indeed difficult to be met in an Emergency Department that sees

both children and Adults.

The initial assessment of the severity of illness involves

i. Quick assessment of alertness

ii. Respiratory effort

iii. Perfusion

Remember :

Using the presenting problems to assign triage in pediatric can be complicated by the

fact that complaint given by the care givers might be based on perception

nevertheless Parents know their children best, and recognize when they are unwell.

It is therefore meant that excellent physiological assessment in needed early in the

triage to determine the urgency.

Pediatric Assessment Triangle First Impression

Appearance Breathing Mental status Visible movement Muscle tone Work of breathing Body position (normal/increased)

Circulation Color





No. Kajisemula R00

A specific physiological assessment will assist the triage officer in the less severe

Triages of 2, 3 and 4

a. Assessment of the level of consciousness and interactivity

b. Respiratory rate and effort

c. Heart rate and Perfusion

Hence the same standards for Triage Categorization can be applied for children with

specific considerations. All the 4 Triage categories should be used.





No. Kajisemula R00

TRIAGE 1 (RED)

Assessment and treatment within 10 minutes (assessment and treatment often

simultaneous)

Physiological assessment

i. Unresponsive

ii. Altered consciousness

iii. Respiratory distress or inadequate breathing

iv. Respiratory distress with marked stridor

v. Cardiac arrest or shock or cyanosis

vi. Capillary refill > 4 seconds

Description of Category Clinical Description (indicative only)

Conditions that are threats to life (or

imminent risk of deterioration) and

require immediate aggressive

intervention.

or

The patient’s condition is serious

enough or deteriorating so rapidly that

there is the potential of treat to life or

organ system failure if not treated

within ten minutes of arrival

or

The potential for time critical treatment

(e.g. thrombolysis, antidote) to make a

significant effect on clinical outcome

depends on the treatment

commencing within a few minutes of

the patient arrival to the Emergency

Child infant in respiratory failure

All Dyspnoea of saturation (SpO2) < 95%

All children with Airway compromise

- Gasping

- Severe maxillofacial injury

- Comatosed patients (GCS ~ 13 or

below)

Shock

- Hypovolemic

- Anaphylactic

- Septic / sepsis

Moderate to severe dehydration

Cardio pulmonary arrest

Comatosed child

Altered level of consciousness

Child that requires continuous

assessment

All Fitting children

Dextrose stix - High, with CNS

involvement.

AGE in Shock





No. Kajisemula R00

Department Trauma

- Bilateral fracture femur

- Unstable pelvic fracture

- Poly trauma patients

- All chest trauma patients

Spinal injury

- Neurogenic shock

- Spinal shock

Total Amputation or Near total

amputation limb

Significant bleeding

All burns cases with Airway

compromise.

- Facial

- Lower neck

All third degree burns > 25 %

- Body surface

- Face and Throat

Victims of alleged drowning.

Toxic ingestion

- Overdose / ingestion

Fever with shock

- Age < 3 months > 38oC





No. Kajisemula R00

TRIAGE 2 (YELLOW)

Assessment and treatment within 30 minutes


i. Infant – inconsolable, not feeding

ii. Child – atypical behavior

iii. Respiratory rate increased but within accepted range

iv. Mild respiratory distress or stridor

v. Heart rate increased but within accepted range

vi. Capillary refill > 2 seconds


The patient’s condition may

progress to a life or limb

threatening, or may lead to a

significant morbidity if assessment

and treatment are not commenced

within 30 minutes of arrival

or

There is a potential for adverse

outcome if time-critical treatment is

not commenced within 30 minutes

or

Human practice mandates the relief

of severe pain, discomfort or

distress.

Trauma children with a GCS of 14 / 15.

Trauma children with unequal pupils with

a GCs of 15 / 15.

Trauma children with lower limb fracture

but stable

- Tibia fibula fracture

- Femur fracture

- Stable spinal fracture

- Stable pelvic fracture

Dislocation with inability to walk

- Knee

Second degree burns of < 20% body

surface in adults

Third degree burns of < 10% body surface

area.

Alleged poisoning cases or drug overdose

with a stable vital sign

Severe abdominal pain

CA patients, toxic looking and mild

dehydrated.

Post seizures stable patient (post ictal)

Bleeding with stable BP and normal pulse





No. Kajisemula R00

rate.

Vomiting and diarrhea, stable vital signs.

Acute Exacerbation Bronchial Asthma (mild

to moderate)

Dyspnoea < 25 per minute

Dyspnoea with saturation (SpO2) > 95%

and respiration rate of 20-25 per min.

Fever

- Child > 3 months > 38.5C degrees,

- Bp and pulse stable.

Mild respiratory distress

- Infant < 1 month





No. Kajisemula R00

TRIAGE 3 (GREEN)



i. Child – consolable

ii. Appropriate behavior – but history of atypical behavior

iii. Respiratory rate within normal range for age

iv. Heart rate within normal range for age


The patient’s condition may

deteriorate, or adverse outcome

may result if assessment and

treatment is not commenced within

one hour of arrival in ED.

Symptoms moderate or prolonged

or

There is potential for adverse

outcome if time-critical treatment is

not commenced within hour.

or

Likely to require complex work-up

and consultation and / or inpatient

management.

or

Humane practice mandates the

relief of discomfort or distress

within one hour.

OSCC

- INSAN

- Child Abuse

Glucose-stix high but asymptomatic

Child with vomiting and diarrhea

- No dehydration

- 2 years old

Fever

- Child alert

- Simple complaints eg : earache,

sorethroat, nasal congestion

Head injury

- No symptoms

- GCS full

All stable fracture requiring immobilization

- Upper limb and clavicle fractures

- Ankle fracture

All patients with foreign body removal

All patients for pressure bandaging

POP complication

Moderate bleeding but stable and need

dressing

Partial thickness burn < 10%

Minor injuries





No. Kajisemula R00

- Soft tissue injuries

- Abrasions

- Lacerations

- No active bleed

Simple lacerations

Simple sprains / strains

Moderate Uretheric pain.

AGE with stable blood pressure

Nail prick





No. Kajisemula R00

TRIAGE 4 (BLUE)



i. No history of atypical behavior

ii. Respiratory rate within normal range for age

iii. Heart rate within normal range for age


The patient’s condition is chronic or

minor enough that symptoms or

clinical outcome will not be

significantly affected if assessment

and treatment are delayed up to

two hours.

or

The investigations or interventions

for some of the illness or injuries

could be delayed or even referred

to other areas of the hospital or

health care system.

Cold cases (Can be seen at Outpatient or

polyclinic)

Minimal pain with no high risk features (no

involvement of ABC)

Low risk history and now a symptomatic.

All trauma patients with prolonged history

A febrile

Skin disease / skin rash except

- Steven-Johnson disease.

- Exfoliating dermatitis

- Urticaria

- Allergy

Jaundice

Vomiting alone with no signs of dehydration

Diarrhea alone with no signs of dehydration

Nasal congestion

Lice

Suture removal

Extension of medication prescription or

missed appointments

Extension of MC (medical certificate)





No. Kajisemula R00

PEDIATRIC ASSESSMENT CRITERIA

The following criteria are utilized for the reassessment of children in each of the

areas listed above.

1. Breathing

Assessment Critical / Unstable Potentially Unstable

Stable

Airway Complete or partially obstructed OR

significant blood or secretions

Patient with minimal

secretions Patient

Work of

breathing

Absent or increase work with periods

of weakness Normal Normal

Breath sounds Absent or decreased breath sounds;

Grunting, wheezing, stridor

Normal or slight

wheezing Normal

Respiratory rate Apnea, bradypnea, tachypnea :

irregular breathing rate

Occasionally

increased Normal

Central skin

color Pallid, mottled, cyanotic Pink Pink

Inspection Absent decreased chest movement Normal Normal

Pulse ox Less than 85 % 85% or higher 95% or

higher





No. Kajisemula R00

Age (years) Respiration Rates (per minute)

Infant (birth to 1 year) 30 – 60

Toddler (1 to 3 years) 24 – 40

Preschooler (3 to 6 years) 22 – 34

School aged (6 to 12 years) 18 – 30

Adolescent (12 to 18 years) 12 – 16

Breathing

In children, respiratory arrest is the primary cause of cardiac arrest

Critical window between onset of apnea and onset cardiac arrest in children is

very short – no more than a minute or two.

A child’s airway is narrower at all levels than an adult’s, resulting in higher Airflow

resistance, when further narrowed by edema or secretions, child experiences

greatly increased resistance to airflow

Avoid actions that could agitate or frighten a child who is in respiratory distress

In a child who is able to breathe spontaneously, perform the following detailed

assessments

Evaluate work of breathing and breath sounds

o Inspiratory retractions in the suprasternal, supraclavicular, intercostal or

subcostal areas

o Inspiratory nasal flaring

o Head bobbing

Listen for stridor, grunting, gurgling

Count the respiratory rate for 30-second period

Assess the respiratory depth and pattern

Evaluate central color at the lips, tongue and oral mucosa

Inspect for chest trauma

Auscultate chest by placing stethoscope below each axilla in turn and compare

breath sounds of right and left lung fields to see if equal

o Decreased breath sounds

o Wheezing

o Crackles

Optional : initiate pulse oximetry (this may be time consuming)





No. Kajisemula R00

2. Circulation

Assessment Critical/Unstable Potentially unstable

Stable

Heart rate Tachycardia or bradycardia Normal Normal

Pulse strength Weak central pulse, absent or weak

peripheral pulse Normal Normal

Capillary refill > 3 to 5 seconds < 2 – 3 seconds < 2 – 3

seconds

BP Hypotensive Normal Normal

Skin Pallid, mottled or cyanotic; cool Normal Normal

Age (years) Heart Rate (per minute)

Infant (birth to 1 year) 100 – 160

Toddler (1 to 3 years) 90 – 150

Preschooler (3 to 6 years) 80 – 140

School aged (6 to 12 years) 70 – 120

Adolescent (12 to 18 years) 60 – 100

Circulation

Note skin color at the lips and tongue, the palms, or the soles of the feet;

abnormal skin color (pallor, mottling, or cyanosis) indicates an urgent condition

Palpate the central pulse. Recommended sites :

o Newborn : base of umbilical cord

o Infants and young children : brachial and femoral pulse

o Older children : carotid artery

If central pulse present, evaluate strength; weak pulse can indicate

decompensated shock

Count rate for 30 seconds, double this figure for rate per minute





No. Kajisemula R00

If child uncooperative, count rate by auscultating with stethoscope over left side

of chest between sternum and nipple

Compare peripheral and central pulses; they should be similar; weak or irregular

peripheral pulses indicate shock or hemorrhage

Check skin temperature; cold skin may indicate either poor peripheral perfusion

or exposure to cold ambient temperatures; hot skin may indicate fever, infection

or hyperthermia caused by very warm ambient temperatures (check body

temperature, see below)

Check capillary refill time; delayed capillary refill (more than 3 seconds) may

indicate poor perfusion or exposure to cool ambient temperatures

Abnormal vital signs (heart rate and respiratory rate) are values that are consistently

above or below these ranges; send patient to Resuscitation.

Other factors, such as fever, anxiety, may cause transient abnormal vital signs.

Medical staff discretion is needed for these cases. Send patients to Resuscitation

when there is doubt.





No. Kajisemula R00

3. Appearance

Assessment of mental status in children is age-dependent

An answer that demonstrates an abnormal response by the patient: send

patient to Resuscitation

Appearance – TICLS

Questions to be answered

Tone Is there vigorous movement with good muscle tone, or is the child limp ?

Interactivity

Is the child alert and attentive to surroundings, or apathetic ?

Will the child reach for a toy ?

Does the child respond to people, objects and sounds ?

Consol ability Does comforting the child alleviate agitation and crying ?

Look/Gaze Do the child’s eyes follow your movement, or is there a vacant gaze ?

Speech/Cry Are vocalizations strong, or are they weak, muffled, or hoarse?

Appearance

Level of Consciousness : all well children will constantly interact with their

environment. Proceed with initial assessment, when child is markedly irritable,

agitated, reduce responsiveness

Interaction with Parent : A child will respond to his/her name called. Proceed

with initial assessment, when the child is markedly slow or absent response,

inconsolable crying, or failure to recognize a parent.

Response to Others : A child will recognize your presence. Proceed with initial

assessment when there is no response to your presence.

Muscle Tone and Body Position : A child will assume a comfortable position. An

infant will have his extremities in flexed position. There will be equal movement

with their limbs. Proceed with initial assessment when there is hypotonia, rigidity

or inability to sit.





No. Kajisemula R00

4. Mental status

Assessment of mental status in children is age-dependent Additional

Assessment Points for Children and Infants is given.

If patient is unresponsive or responsive to pain : send patients to

Resuscitation

If patient is responsive to verbal commands, but not acting appropriately:

send patient to Acute Medical care Area

If patient is alert : send patients to Fast Track

Stable Potentially Unstable Critical/Unstable

Patient

Response Alert

Responsive to Verbal

Commands

Responsive to Pain or

Unresponsive

Mental Status Assessment

Knowledge of unique developmental factors is important in evaluating for

normal mental status pediatric patients. Some of these are outlined below,

but it is recommended to refer to other texts for a more comprehensive review

of developmental stages (see “Psychosocial Section” of this tool kit).

Problems arise whenever the caretaker/parent is not present.

A standard Glasgow Coma Scale is provided below. A modified version of the

Glasgow Coma Scale has been adapted for assessing infants and young

children who lack the developmental maturity to speak or respond to

commands. The resultant score may be helpful to detect changes in the

child’s condition over time, but is not designed to help with management

decisions and triage.





No. Kajisemula R00

Standard Glasgow Coma Scale

Eye Opening Pts Best Verbal Response Pts Best Motor Response

Pts

Spontaneous 4 Oriented 5 Follows commands 6

To verbal stimuli 3 Confused 4 Localizes pain 5

To Pain 2 Inappropriate words 3 Withdraws to pain 4

None 1 Incomprehensible Sounds 2 Flexion to pain 3

None 1 Extension to pain 2

None 1

Pediatric Glasgow Coma Scale for infants and young children

Eye Opening Pts Best Verbal Response

Pts Best Motor Response Pts

Spontaneous 4 Coos, babbles 5 Normal 6

To speech 3 Irritable, cries 4 Spontaneous Movement 5

To Pain 2 Cries to pain 3 Withdraws to touch 4

None 1 Moans to pain 2 Withdraws to pain 3

None 1 Abnormal flexion 2

Abnormal extension 1

None 0

Pain Assessment

Measuring pain in infants and children is difficult. Changes in vital signs (heart rate,

breathing rate, and blood pressure), facial expression and behavior are most widely

used to rate pain. Regular measurements should be taken and recorded. There are

different pain rating scales used for infants and children (e.g. faces pain rating scale).





No. Kajisemula R00

Faces Pain Rating Scale

Wong-Bakers faces scale

Documents

PUSAT PERUBATAN UNIVERSITI MALAYA - … · Dextrose stix - High, with CNS involvement. AGE in Shock . PUSAT PERUBATAN UNIVERSITI MALAYA NAMA DOKUMEN: ... PUSAT PERUBATAN UNIVERSITI