Pediatric health assessment

Abreham Assefa (BScM,

MScN)
March, 2024

1
 Objectives 2

 At the end of this session the students are able to:

 Demonstrate newborn assessment (subjective and
objective)
 Demonstrate appropriate techniques of essential
newborn care
Identify deference's of pediatrics assessment from adults
 Demonstrate Pediatrics assessment (subjective and
objective)
 Identify emergency triage and treatment for sick child
Newborn Assessment

3
 When Should a Newborn Exam Be 4
Performed?
Within the first few minutes of life to assess clinical
stability
 If danger signs → immediate exam and
intervention
 If infant stable, complete full assessment after a few
hours (~2)
 Whenever there is any clinical concern, during the
neonatal period
 Why is a Thorough Newborn Exam 5
Important?
 Assess overall condition and adaptation to
extrauterine life
 Promptly identify problems that require
immediate treatment such as:
 cardiorespiratory compromise
 congenital anomalies
 Any sign of infection
 Screen for malformations that require further
investigation
 Establish a baseline for subsequent examinations
 A. Neonatal history taking 6

Maternal profile: age of the mother,

occupation, parity, blood group and Rh,
chronic maternal illnesses, thyroid diseases,
history of sexually transmitted diseases,
Hepatitis B infection
 Current pregnancy: LNMP (last normal
menstrual period), gestational age, ANC check-
up, bleeding, hypertension, diabetes,
eclampsia, acute infection, Immunization.
 7
Neonatal History taking cont…
 Previous pregnancy: history of abortion, fetal
death, early neonatal death, premature birth,
history of early neonatal jaundice, history of
birth defect.
 Drug history: history of alcohol ingestion,
cigarette smoking , any medications during
pregnancy (anticonvulsants, anti TB, warfarin,
thyroid treatment drugs, antenatal steroid use,
contraceptives)
 Neonatal history taking cont…
 Labor and delivery: onset of labor, duration of8
rapture of membranes, duration of labor, mode
of delivery, baby presentation, presence of
meconium, breathing condition at birth,
resuscitation, birth weight, place of delivery.
 Social, personal and family history: Family
size, marital status, housing conditions, water
source, waste disposal, personal hygiene (hand
washing habits, toilet use, bathing)
 9
Neonatal History taking cont…
 Presenting compliant: like failure to suckle the
breast, fever, breathing difficulty, abnormal body
movement, jaundice, altered mentation,
vomiting, bleeding, birth defects, etc.
 B. Physical Examination of the Newborn 10

 Initial examination: APGAR scoring

The APGAR score is now used worldwide to
quickly assess the health of an infant at one
minute and five minutes after birth.
The 1- minute APGAR score measures how
well the newborn tolerated the birthing
process.
The 5-minute APGAR score assesses how
well the newborn is adapting to the
environment.
 11
Apgar Score of the Newborn
 Apgar Score of the Newborn cont… 12

Three levels of score:

 Low APGAR score 0-3

 Moderate APGAR score 4-6

 Normal APGAR score 7-10

 Note: A newborn with an APGAR score of less

than 7 needs special attention.
 13
General Examination
Simply watch to gain an impression of overall
wellness
Assess:
 Body symmetry
 State of alertness
 look for movement of the extremities
 14
Anthropometric Measurements
† Weight: 2, 500g – 4, 000g
† Physiologic weight loss : it is normal for the
newborn infant to loose 5-10% of weight in
the first 7 days of life (causes: mainly due fluid
loss through urination, defecation…)
† Length: 45-55 cm
† HC: 33-37 cm, 2-3 cm larger than chest
† CC: 30-33cm
† AC: 29-33 cm
15
 16
Head
† fontanels ( anterior, posterior): Normally soft and
flat
† Sutures  craniosynostosis

† Head size and shape, symmetry

†Cephalhematoma
†Caput succedaneum
†Moulding
†Subgaleal haemorrhage
17
18
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Face
† Dysmorphic features:

†Epicanthal folds

†Micrognata

†Low-set ears

†Flat nasal bridges

†Upslating palpebral
fissures
micrognantia
 21
EYES
The eyes open spontaneously
if the infant is held up & tipped
gently forward & backward.
eye discharge
 Icterus ( Jaundice)
Any sub-conjunctival
hemorrhages
Presence of Red reflex
 Abnormal: White reflex
 Ear
 Position: abnormal (low 22
placement of ear, <10% of
pinna bellow the epicanthal
folds)
The tympanic membrane
Normally appears dull gray
Unilateral or bilateral
preauricular skin tags or pits
usually associated with greater
risk of permanent hearing
impairment(5x normal
population)
 23
Nose, Mouth, neck
 Nose: symmetric and patent.
 Dislocation of the nasal cartilage
results in asymmetric nares
 Mouth
Intact, high arched palate
Any other abnormality: cleft
lip/palate
Tongue : normal/ protrude
 Neck: Redundant skin or
webbing (congenital
anomalies),Both clavicles should
be palpated for fractures.
 Respiratory and Cardiovascular
 Respiratory system: 24
 Check for signs of respiratory distress, breathing
pattern, respiratory rate, air entry to the lungs
 presence of abnormal sounds in the lungs
 symmetry of the chest
 strider
 Cardiovascular:
 heart rate, Pericardial assessment (heart
murmurs, gallop rhythm, Point of Maximum
impulse (PMI)
 femoral pulses
 Abdomen
Shape : soft, cylindrical, 25
Abnormality: Umbilical hernia;
any other mass, abdominal wall
defect
Umbilical cord: presence of two
arteries and one vein / one artery;
Umbilical cord bleeding
Peristalsis
Optional
Liver : Palpable ≈ 2cm below
costal margin
Spleen : tip may be palpable
Kidneys : palpable on deep
palpation
 26
Genitalia
Female genitalia
Labia and clitoris
Vaginal opening
 Vaginal bleeding or
discharge
 Male genitalia
Urethral opening:
Central/ventral surface/dorsal
surface
Testes: palpable in each
scrotum
Ambiguous genitalia
 Extremities (arms and legs) and Joints 27

 limb defects (club foot,

syndactyl, polydactyl)
 Symmetry and movement
of extremities to see
fractures and birth injuries
 Joint : normal flexion/
hypoflextion/ hyperflextion,
hip should be examined to
detect developmental
dysplasia of the hip
 28
Back and Rectum
Spine: spine straight,
flat and intact( no
opening)
 Gluteal fold symmetry
Any abnormality: tuft
of hair in the spine,
Spina bifida, sacral
agenesis, sacral dimple
 Anal patency: may
require insertion of the
little finger/rectal tube ;
Meconium may be
present
 Skin 29

 Rash, jaundice, plethora, meconium staining,

pallor, cyanosis, birth marks, Mongolian spots
and etc…
 30
Neurologic
 Neurological examination: level of alertness,
spontaneous movements, muscle tone,
reflexes ...
 Moro reflex, check for completeness and
symmetry
 Rooting reflex, absent or present
 Sucking reflex, absent, weak or vigorous
Grasp reflex (arm and plantar)
Tonic neck reflex
 31

ESSENTIAL NEWBORN CARE

 Essential newborn care 32

Essential newborn care is care given to all newborn

infants at birth to optimize their chances of survival.
Currently there are eleven steps of essential
newborn:
1. Dry and stimulate, 7. Apply Chlorohexidine 4% on
the cord
2. Evaluate breathing,
8. Administer vitamin k
3. Cord care,
intramuscularly (IM)
4. Place the baby in skin-to-skin
9. Place the newborn’s
contact with the mother.
identification bands on the
5. Initiate breastfeeding in the first wrist and ankle
one hour
10.Weigh baby & classify
6. Apply Tetracycline eye ointment
11. record observations
once on both eyes.
 Essential newborn care cont… 33

Step 1: Dry and stimulate

 Keep the newborn warm by placing on the
abdomen of the mother
 Immediately dry the whole body including
the head and limbs.
Stimulate by rubbing the back or flicking the
soles of the feet or Slapping
 Remove the wet towel
 34
Essential newborn care cont…
Step 2: Evaluate Breathing
 Check if the baby is crying while drying it.
 If the baby does not cry, see if the baby is
breathing properly.
 If the baby is not breathing and/or is gasping:
clamp or tie and cut the cord rapidly leaving a
stump at least 10 cm long for now and start
resuscitation.
 Functional resuscitation equipment should
always be ready and close to the delivery area
since you must start resuscitation within 1 minute
of birth.
 Essential newborn care cont… 35

Evaluate Breathing cont…

If the baby breathes well, continue routine
essential newborn care.
 Suck the mouth and nose only if there is
Meconium, thick mucus, or blood.
 Unnecessary suctioning can cause apnea,
vagal-induced bradycardia, low oxygen
saturation and possible mucosal trauma.
 Essential newborn care cont… 36

Step 3. Cord care

 If the baby does not need resuscitation, wait
for cord pulsations to cease or approximately
1-3 minutes after birth
Cutting the cord soon after birth can
decrease the amount of blood that is
transfused to the baby from the placenta
In preterm babies; it is likely to result in
subsequent anemia and increased chances
of needing a blood transfusion.
 37
Essential newborn care cont…
Cord care cont…
Tie/clamp the cord one finger (2 cm) from
abdomen and another tie/clamp one finger
from the 1st one. Cut the cord between the 1st
and 2nd tie (clamp).
 Make sure that the thread you used to tie
the cord is clean and safe.
 Use a new razor blade, or sterile scissors.
 Be careful not to cut or injure the baby
Do not put anything on the cord stump,
except 4% Chlorohexidine
 Essential newborn care cont… 38

 Step 4. Place the baby in skin-to-skin contact

with the mother. (Prevent Hypothermia)
Keep the baby warm by placing it in skin-to-
skin contact on the mother’s chest
The first skin-to-skin contact should last
uninterrupted for at least 1 hour after birth
or until after the first breastfeed.
Cover the mother, and baby’s body and head
with clean cloth.
 Essential newborn care cont… 39

 Skin-to-skin contact helps to

Prevent hypothermia
initiate colonization of the newborn with
maternal flora (as opposed to hospital flora)
 facilitates olfactory learning
successful intake of colostrum and
sustained breastfeeding
 Essential newborn care cont… 40

Keep the newborn warm cont…

The baby should not be bathed at birth
because a bath can cool him dangerously.
 After 24 hours, the baby can have the first
sponge bath, if the baby’s temperature is
stabilized.
Bathing not only exposes newborns to
hypothermia, but also removes maternal
bacteria and the vernix caseosa (a potent
inhibitor of Escherichia coli)
 41
Essential newborn care cont…
Step 5. Initiate breastfeeding in the first one
hour (Early initiation of breastfeeding)
Babies typically are ready to initiate
breastfeeding between 15 and 55 minutes; on
average 20-to-40 minutes
Early initiation of breastfeeding prevent
hypoglycemia, reduces the risk of infection and
increases the likelihood of sustained
breastfeeding.
Help the mother at the first feed. Make sure the baby has
a good position, attachment, and suck effectively.
Counsel the mother on breast feeding
 42
Essential newborn care cont…
Step 6. Apply Tetracycline eye ointment once
on both eyes (while the baby is held by his
mother)
 Give tetracycline eye ointment/drops within 1
hour of birth usually after initiating breast
feeding
Wash your hands with soap and water before
administering
 Eye care protects the baby from serious eye
infection which can result in blindness.
 Essential newborn care cont… 43

 Step 7. Apply Chlorohexidine (4%) on the cord.

 Applying Chlorohexidine daily for seven days is
efficacious broad spectrum topical antiseptic agents
active against aerobic and anaerobic organism.
 Never apply Chlorohexidine to the eye.
 Step 8. Give Vitamin K IM on anterior lateral
thigh (while baby held by his mother)
 This prevents bleeding
 1 mg for babies with gestational age of 34 weeks or
above
 0.5 mg for premature babies less than 34 weeks of
gestation
 44
Essential newborn care cont…
 Step 9. Place the newborn’s identification bands
on the wrist and ankle
 Putting the identification bands on the hands and
ankle will save you from misshaping babies in busy
delivery rooms.
 Step 10. Weigh the baby after an hour of birth or
after the first breastfeed.
This step is used for assessing and classifying the
baby for birth weight and gestational age.
 Step 11. Record all observations and treatment
provided in the registers/appropriate chart/cards
 45

Pediatrics Assessment
Comparison of Functional health Pattern, Head-to- toe, and Body systems 46
 History Taking 47

General principles of pediatric history taking

Don’t consider children as small adults( there is
differences in both content and source of history)
LISTEN CAREFULLY to what the mother is telling
you: “A smart mother makes often a better
diagnosis than a poor doctor.” Don’t interrupt
mother except to guide her
Get the respect of the mother in order to get the
confidence of the child.
Get involve the child 4 year of age or older
Always consider CHILD PROTECTION issues
 Differences of a Pediatric History Compared to an
48
Adult History:

Content Differences
Prenatal and birth history
Developmental history
 Social history of family: environmental risks
Immunization history
Parent as Historian/ Source/
 Parent’s interpretation of signs, symptoms may vary
 Parental behaviors/emotions are important
 Distractions to parents may interfere with history
taking
 Components of Pediatrics History 49

1. Identification data
Date of history.
Patient’s profile:-
Name of patient.
Age
Sex
Address
Referred from …….
Informant(source of history) :- Mother, father,
grandmother, school teacher,…..
 Components of Pediatrics History cont… 50

2. Chief complaints:-
 When did you notice that your child has
changed?
 what he is complaining of?
 what do you think he is sick with?
 Use, when possible, patient’s or patient’s mother
own words.
 Arrange complaints according to significance to
child’ health.
 Onset / Course/ and Duration of each
complaint.
 Components of Pediatrics History cont… 51

3. History of present illness:-

 Start with one of the following sentences:-
 The patient was doing well until ……..
 The patient was in his/her usual state of health
until…..
 Analysis of symptoms respecting the
chronological order of symptoms(i.e. Sequence of
events).
 Any medical advice sought or any medication
given.
 Other associated symptoms.
 Pertinent negative symptoms related to the
complaints.
 Components of Pediatrics History cont… 52

4. Past medical history:

 Major illnesses
 Recurrent infections
 Hospitalizations
 Operations
 Accidents/ injuries
 Any medications taken before
 Drug allergy (if no known drug allergy, may
write NKDA)
 Components of Pediatrics History cont… 53

5. Pregnancy and Birth History  Especially

important during the first 2 years of life.
A. Maternal health during pregnancy
(Diseases/infections/Nutritional status);
Medications during pregnancy
Antenatal care: - attended / not attended? ,
where? frequency of visits.
 (If all well; you may write UNEVETFUL
after asking all the questions)
 Components of Pediatrics History cont… 54

B. Labor and delivery history:- duration of labor,

Gestational age, Place of delivery; Mode of delivery
( SVD, assisted vaginal, C/S); Maternal risk factors
for sepsis (PROM, maternal UTI, maternal fever…)
C. Neonatal period: Apgar scores, breathing problems,
use of oxygen, need for intensive care,
hyperbilirubinemia, infection, congenital anomalies,
birth injuries, feeding problems, birth weight
 (If all well; you may write UNEVETFUL after
asking all the questions).
 Components of Pediatrics History cont… 55

6. Vaccination history: Vaccines taken, Additional

vaccines, Any vaccine side effects.
7. Feeding history
 Type and amount of semisolid/ solid foods, & If
started
 Breast feeding or milk formula (for less than 2
years).
 Difficulty encountered during feeding/ any
change in feeding /
 Any vitamin or iron supplementation.
 Any known food allergy.
 Components of Pediatrics History cont… 56

8. Developmental history:
 Ages at which milestones were achieved and
current developmental abilities:-
 Smiling, rolling, sitting alone, crawling,
walking, running, 1st word, toilet training etc…
 School: present grade, specific problems,
interaction with peers
 Behavior: enuresis, temper tantrums, thumb
sucking, pica, nightmares etc…
 Adolescent history [ HEADS history]: Home,
Education, Activities, Drugs, Sexual activity.
 Components of Pediatrics History cont… 57

9. Review of systems :-
 Not important in the pediatrics history if you ask
about:-
 All the complaints in the history of present illness in
details.
 Complete analysis of each complaint.
 All the pertinent negative symptoms related to the
complaints.
Review about:
 Weight - recent changes, weight at birth
 Skin and Lymph - rashes, adenopathy, lumps, bruising
and bleeding, pigmentation changes
 Components of Pediatrics History cont… 58

Review about…
 HEENT - headaches, unusual head shape; strabismus,
conjunctivitis, visual problems, hearing, ear infections,
draining ears; cold and sore throats, tonsillitis, mouth
breathing, snoring, oral thrush, epistaxis, caries
 Cardiac - cyanosis and dyspnea, exercise tolerance,
squatting, chest pain, palpitations
 Respiratory - wheezing, chronic cough, sputum,
hemoptysis
 GI: stool color and character, diarrhea, constipation,
vomiting, hematemesis, abdominal pain.
 Components of Pediatrics History cont… 59

Review about…
 GU - frequency, dysuria, hematuria, discharge,
abdominal pains, quality of urinary stream,
polyuria, previous infections, facial edema
 Musculoskeletal - joint pains or swelling, fevers,
myalgia or weakness, injuries, gait changes
 Pubertal - secondary sexual characteristics,
menses and menstrual problems, pregnancies,
sexual activity
 Allergy - urticaria, allergic rhinitis, asthma,
eczema, drug reactions
 Components of Pediatrics History cont… 60

9. Family history
 Illnesses - cardiac disease, hypertension,
stroke, diabetes, cancer, abnormal bleeding,
allergy and asthma, epilepsy, communicable
diseases
 Anomalies: Mental retardation, congenital
anomalies, chromosomal problems.
If family history of disease detected,
Consanguinity ( blood relation ship)
 Components of Pediatrics History cont… 61

10.Social history:-
 Living situation and conditions: daycare,
safety issues
 Composition of family
 Parental education & occupation.
 Any risks: Smoking at home!!!!
 Any advice against it; negative smoking is
as bad as active one.
 PEDIATRICS PHYSICAL EXAMINATION 62

 General Approach
 Gather as much data as possible by observation
first
 Stay at the child’s level as much as possible. Do
not tower!!
 Examine the child in the most comfortable way
according to his age
 Exam table, mother’s hands, mother’s lap,
while playing with a toy…).
 Postpone the painful and/or irritating examination
(temperature/throat/ears).
PEDIATRICS PHYSICAL EXAMINATION cont… 63

 General Approach cont…

 Rapport with child

 Include child - explain to the child’s level

 Distraction is a valuable tool

 Be honest. If something is going to hurt, tell

them that in a calm fashion.

 Don’t lie or you lose credibility!

 PEDIATRICS PHYSICAL EXAMINATION cont… 64

1. Vital signs : See “code card” for charts of age-

adjusted normal
. Temperature: axillary vs. rectal
. Heart Rate:
Auscultate apical pulse or palpate femoral pulse in
infant
Palpate antecubital or radial pulse in older child
. Respiratory Rate: Observe for a minute
O2 Saturation if abnormality detected.
. Blood Pressure: Appropriate size cuff - 2/3 width of
upper arm
 Normal Range of Vital sign in Children 65

Age of BP (mmHg) PR RR Axillary

the child beats/min beats/min To (oc)

< 1yr 65–90/45-65 110–160 30–50 36.5-

<37.5
1-2 yrs 90-105/55-70 100–150 25–40

2-5 yrs 95-110/60-75 95–140 25–40

5-12 yrs 100-120/60- 80–120 20–25

75
>12 yrs 110-135/65- 60–100 15–20
85
PEDIATRICS PHYSICAL EXAMINATION cont… 66

2. Anthropometric Measurements (Wt, Ht, HC).

 Always use growth charts and indicate the
percentiles.
 Use appropriate scale for age to measure the
weight.
 Measure recumbent length till 2 years of age
and then standing length (height) after that.
 Head circumference is the occipitofrontal
circumference and measures: the
circumference passing through the most distal
points on the occiput and the frontal area.
67
 68

Stadiometers for Measuring Children and Adolescents

69
70
71
 PEDIATRICS PHYSICAL EXAMINATION cont… 72

3. General appearance:-
 Sick (acute, chronically) or well looking
 State of alertness/ level of consciousness.
 Awareness to environment
 Nutritional status
4. Skin and nails
 Skin: - Color, rash, elasticity, turgor, texture
(smooth or rough),
 Nails: - Color, texture, shape, capillary refill
time
PEDIATRICS PHYSICAL EXAMINATION cont… 73

5. Head and Neck

 Head: size, shape, fontanelles, sutures
 Hair: Texture (smooth, coarse), color, distribution,
areas of hair loss).
 Face: shape, complexion (pallor, cyanosis,
jaundice), Edema.
 Eyes: - Pupils, Conjunctiva, sclera, cornea,
palpebral fissure for degree of slanting, eyelids,
eyelashes, epicanthal folds, Squint, sunset, Sunken.
 Nose: Nasal septum, patency, polyps, Discharge,
Sinus tenderness
PEDIATRICS PHYSICAL EXAMINATION cont… 74

Head and neck cont…

Ears:
Position: Observe from front and draw line from
inner canthi to occiput
Deformity ( pinna)
 discharge
External canal
Tympanic membranes (shape, color, light reflex),
optional.
Mouth: -
 lips, tongue, gum, teeth, palate
Throat and uvula.
 75
PEDIATRICS PHYSICAL EXAMINATION cont…

 Neck: Thyroid, webbing, trachea position,

Masses (cysts, nodes), Presence or absence of
nuchal rigidity
6. Lymph nodes:-
Examine all groups (occipital, cervical,
axillary, groin)
Size, consistency, matting, tenderness.
 PEDIATRICS PHYSICAL EXAMINATION cont… 76

7. Lungs/Thorax
Inspection
Any chest deformity
 Pattern of breathing
–Rhythm: Periodic breathing is normal in infants
(pause < 15 seconds)
Use of accessory muscles: retraction location and
degree, flaring (nose)
Respiratory rate
Auscultation
Equality of breath sounds
Rales, wheezes, rhochi
Percussion and palpation often not possible and rarely
helpful
PEDIATRICS PHYSICAL EXAMINATION cont… 77

8. Cardiovascular
 Inspection: Central cyanosis, Jugular vein
distention
 Palpation: Pulse rate
Quality in upper and lower extremities
Auscultation
Rhythm
Quality of heart sounds
Pericardial assessment (aortic, pulmonic,
erbs’, and mitral area): Murmurs, PMI
 PEDIATRICS PHYSICAL EXAMINATION cont… 78

9. Abdomen
 Inspection
 Shape: Infants usually have protuberant
abdomens
 Umbilicus (infection, hernias)
 Auscultation: normal abdominal sound
4-30/min
 Percussion and Palpation
Tenderness - avoid tender area until end of
exam
Liver, spleen, kidneys
Any other masses
PEDIATRICS PHYSICAL EXAMINATION cont… 79

10. GU and Rectum

 External genitalia
 Hernias and Hydroceles
Can gently palpate; do not poke finger into
the inguinal canal
 Cryptorchidism(testis)
 Rectal and pelvic exam not done routinely -
special indications may exist
 PEDIATRICS PHYSICAL EXAMINATION cont… 80
11. Musculoskeletal
Extremities
Deformity ( bow legs, club
foot)
Symmetry, Edema
Joints (motion, stability,
swelling, tenderness)
Muscle: Muscle tone and
strength
Back
Any mass
Spine: Kyphosis, lordosis or
scoliosis
Sacrum: Sacral dimple, sacral
PEDIATRICS PHYSICAL EXAMINATION cont… 81

12. Neurologic - most accomplished through

observation alone
 Cranial nerves
 Sensation ( five senses)
 Cerebellum: balance/gait
 Reflexes
 Deep tendon reflex (DTR)
 Neonatal primitive ( if infant)
PEDIATRICS PHYSICAL EXAMINATION cont… 82
 83

Emergency Triage Assessment and Treatment

(ETAT)

principles
 84
ETAT cont…
 Many deaths in hospital occur within 24 hours of
admission.
 Some of these deaths can be prevented if very sick
children are quickly identified on their arrival and
treatment is started without delay.
 This quick method of sorting is called “triage”.
 TRIAGE is the sorting of patients into priority
groups according to their need and the resources
available.
 The Categories are:
 Emergency cases, priority cases, and Queue
cases.
 85
ETAT cont…
 Emergency cases: Those with EMERGENCY
SIGNS (E), require immediate emergency
treatment.
 Priority Cases: Those with PRIORITY
SIGNS (P): indicating that they should be given
priority in the queue, so that they can rapidly be
assessed and treated without delay.
The QUEUE (Q) cases: Those who have no
emergency or priority signs and therefore are
non-urgent and can wait for their turn in the
queue.
 86
Emergency cases
 Emergency cases are those with signs of serious
illness or injury related to airway, breathing,
circulation/consciousness, dehydration/disability,
and others (immediate Poisoning, Major Trauma
with open fracture, Bleeding Child), remembered as
“ABCDO”.
A = Airway
B = Breathing
C = Circulation, Coma, Convulsion
D = Dehydration (severe), Disability
O = Others (immediate Poisoning, Major
Trauma with open fracture, Bleeding Child).
 87
Priority cases
These children need prompt assessment (no waiting in the
queue) to determine what further treatment is needed.
These signs can be remembered with the symbols 3 TPR -
MOB:
 3-T: Tiny baby: any sick child aged less than two
months; Temperature: child is very hot or very cold;
Trauma or other urgent surgical condition
 3-P: Pallor (severe); Poisoning (other than those require
emergency care), Pain (severe)
 3-R: Respiratory distress; Restless, continuously
irritable, or lethargic; Referral (urgent)
 Malnutrituion: Visible severe wasting
 Oedema of both feet
 Burns
 88
The triaging process
 The triaging process should be short (average
of 20 seconds) and a continuous processes with
frequent assessment.
One of the following can be used to differentiate
the groups:
-Stamp method
or
- Colored sticker (Red, Yellow, Green)
 89
The Triaging process cont…

- Receive the
sick child - Does the child has QUEUE(Q)
NO
No -
Priority sign?
- Does the child patient
has Emergency
Sign?
- Yes • CHILD to
- Yes
OPD
• EMERGENCY
• PRIORITY (P)
(E) patient patient • WAITS for
• Child to
EMERGENCY room his/her TURN
or • CHILD to OPD in the queue
CRITICAL CARE a
rea
START Management • FRONT of the
IMMEDIATELY queue
Emergency Management of Triaged Children 90

EMERGENCY(E) SIGNS: If any sign positive: give treatment(s) for

ABCDO, call for help, draw blood for emergency laboratory
investigations (glucose, malaria smear, Hb and cross match if
necessary)
TREAT
ASSESS: AIRWAY AND BREATHING

• Do not move neck if cervical

• Obstructed or spine injury possible.
absent breathing • If foreign body aspiration:
manage airway in choking
• Central cyanosis Any Sign child
• Severe Positive
• If no foreign body aspiration:
respiratory • manage airway
distress • Give oxygen
• Make sure the child is warm
 91
ASSESS: CIRCULATION
Signs Treat
 Cold skin  Sign • Stop any bleeding, if there is
with: s • Give oxygen
 Capilla Posit • Make sure child is warm
ry refill ive • If no severe malnutrition:
longer • Insert an IV and begin giving fluids
than 3  Chec rapidly
second k for • If not able to insert peripheral IV,
s, and Seve insert an intraosseous or external
 Weak re jugular line
and Maln • If severe malnutrition:
fast utriti • If lethargic or unconscious:
pulse on • Give IV glucose
• Insert IV line and give fluids
• If not lethargic or unconscious:
• Give glucose orally or by NG tube
 Full assessment and treatment
 92
ASSESS: COMA/CONVULSION
Signs Treat
• Coma (Cm): The  If the • Manage the airway
child has Coma (P Child is in • Position the child,
U) Coma or • (if head or neck
OR Convulsin trauma is
 Convulsing (now) g
suspected,
(Cn)
stabilize the neck
first)
• If not, place in
recovery position
• Give oxygen, if needed
• If convulsing, give
diazepam rectally
• Check the blood sugar
• Give IV glucose
 93
ASSESS: SEVERE DEHYDRATION
Signs Treat
 Diarrhea  Diarrhoea  IF NO SEVERE
plus any two plus 2 MALNUTRITION:
of these: positive  Insert IV line and
 Lethargy signs begin giving fluids
rapidly following
 Sunken Plan C.
eyes  Check for  IF SEVERE
 Unable to Sévère MALNUTRITION:
drink? Malnutritio  Do not insert IV,
 Very slow n but proceed
skin pinch immediately to
assessment and
treatment
 ASSESS: MAJOR TRAUMA, IMMEDIATE POISONINGS 94

Signs Treat
 Immediate  Any  Manage ABC
poisoning ( within sign  Airway
1 hour, skin and eye positiv Protection
poisoning) e  Arrest bleeding
 Actively bleeding
 Decontaminate
child (trauma,
epistaxis, acute poisoning
hematemesis, rectal  Stabilize
bleeding, umbilical fracture
bleeding)
 Compound (open)
fracture
 ASSESS: PRIORITY(P) SIGNS 95
Signs Treat
 Tiny baby (<2 months)  Any  Move a child with
 Temperature very high or cold Sign any priority sign to
 Trauma or other urgent Positiv the front of the
surgical condition e queue
 Pallor (severe)  Note: If a child has
 Poisoning (history of) trauma or other
 Pain (severe) surgical problems,
 Respiratory distress get surgical help or
 Restless, continuously irritable, follow surgical
or lethargic guidelines
 Referral (urgent)  If has severe pain,
 Malnutrition: visible severe or fever give
wasting paracetamol at the
 Oedema of both feet or face queue
 Burns (major)
 96
Summary of ETAT
 Triage is the sorting of patients into priority
groups according to their need.
 All children should undergo triage.
 The main steps in triage are:
 Look for emergency signs
 Treat any emergency signs you find
 Call a senior health worker to see any
emergency
 Look for any priority signs
 Place priority patients at the front of the
queue
THANK YOU!

97