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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
5SATS TRAINING MANUAL 20124 SATS TRAINING MANUAL 2012
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
7SATS TRAINING MANUAL 20126 SATS TRAINING MANUAL 2012
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
YES NO
NO
NO
LOOK FOREMERGENCY
SIGNS AND ASK FORPRESENTING COMPLAINT
VERYURGENT
TEWS5 OR 6
EMERGENCYTEWS7 OR
MORE
TAKE TORESUS
URGENTTEWS
3 OR 4
ROUTINETEWS
0, 1 OR 2 DEC
EASE
D
LOOK FOR
URGENTSIGNS
CALCULATETEWS
SENIOR HEALTHCAREPROFESSIONAL’S DISCRETION
ADDITIONALINVESTIGATION
MEASUREVITAL SIGNS
YES
LOOK FORVERY URGENT
SIGNS
YES
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
Assessment QuestionsClearlyindicatewhetherthefollowingstatementsaretrueorfalse:
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
9SATS TRAINING MANUAL 20128 SATS TRAINING MANUAL 2012
TheSATSprocessflowchart TheSATSprocessflowchart
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11SATS TRAINING MANUAL 201210 SATS TRAINING MANUAL 2012
Figu
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13SATS TRAINING MANUAL 201212 SATS TRAINING MANUAL 2012
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
15SATS TRAINING MANUAL 201214 SATS TRAINING MANUAL 2012
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.
PaediatricClinicalSigns
Figure 6: Look, listen and feel
Signsofsevererespiratorydistress:• Veryfastbreathing• Severelowerchestwallindrawing• Useofauxiliarymuscles• Headnodding• Inabilitytofeedbecauseof
respiratoryproblems• Gruntingandflaring
17SATS TRAINING MANUAL 201216 SATS TRAINING MANUAL 2012
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.
PaediatricClinicalSigns
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
PaediatricClinicalSigns
Toassessifthechildisseverelydehydratedyouneedtoknow:• Isthechildlethargic?• Doesthechildhavevery
sunkeneyes?• Doesaskinpinchtake2seconds
ormoretogoback?
Figure 8: Sunken eyes
Figure 9: Skin pinch
Figure 7:Feeling the brachial pulse in an infant
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PaediatricClinicalSigns
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.
PaediatricClinicalSigns
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 TAsKPain 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
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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.
PaediatricClinicalSigns
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 TAsKPain check with shCP for analgesia initiation
ADDITIOnAL TAsKPain check with shCP for analgesia initiation
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
PaediatricClinicalSigns
!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
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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.
PaediatricClinicalSigns
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.
PaediatricClinicalSigns
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 TAsKPain check with shCP for analgesia initiation
ADDITIOnAL TAsKPain check with shCP for analgesia initiation
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
ADDITIOnAL TAsKPain check with shCP for analgesia initiation
WARnInG If glucose is less than 3 mmol/L move
to resuscitation
25SATS TRAINING MANUAL 201224 SATS TRAINING MANUAL 2012
Assessment QuestionsClearlyindicatewhetherthefollowingstatementsaretrueorfalse:
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
PaediatricClinicalSigns
• 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
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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.
TriageEarlyWarningScoreTEWS
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.
Assessment QuestionsClearlyindicatewhetherthefollowingstatementsaretrueorfalse:
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
TriageEarlyWarningScoreTEWS
29SATS TRAINING MANUAL 201228 SATS TRAINING MANUAL 2012
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.
Assessment QuestionsClearlyindicatewhetherthefollowingstatementsaretrueorfalse:
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
31SATS TRAINING MANUAL 201230 SATS TRAINING MANUAL 2012
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
33SATS TRAINING MANUAL 201232 SATS TRAINING MANUAL 2012
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
Assessment QuestionsClearlyindicatewhetherthefollowingstatementsaretrueorfalse:
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
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.
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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