ETAT Ethiopian Guideline PDF

Emergency Triage Assessment and Treatment (ETAT + Ethiopia) Manual for Participants Ethiopia Federal Democratic Republic of Ethiopia Ministry of Health Emergency Triage Assessment and Treatment (ETAT + Ethiopia)...

Emergency Triage Assessment and Treatment (ETAT + Ethiopia) Manual for Participants Ethiopia Federal Democratic Republic of Ethiopia Ministry of Health Emergency Triage Assessment and Treatment (ETAT + Ethiopia) Manual for Participants Ethiopia September, 2014 Acknowledgements This first edition of Emergency Triage Assessment and Treatment Plus Ethiopia (ETAT + Ethiopia) adapted from the WHO generic ETAT material (2005) through the technical and financial assistance of WHO/Ethiopia and with the support and input of many experts in the field. Great effort has been made to harmonize each chapter of the training manual to with the existing national care and treatment guidelines. It is our strong belief that this guideline will contribute significantly to the efforts being made to improve quality of Pediatric care for children with acute problems. The Federal Ministry of Health (FMOH) of Ethiopia is very grateful for the all rounded support of WHO/Ethiopia and the commitment and devotion shown by the Child Health Team of the country office for the accomplishment of this work. We would like to sincerely acknowledge the remarkable contribution of Dr. Mehretie Kokeb and Dr. Tigist Bacha who served as consultants in the adaptation of the generic WHO ETAT guideline. The FMOH gratefully acknowledges the technical contribution of all professionals who were involved in the development of this national ETAT+ Ethiopia guideline particularly the following experts: Dr. Amha Mekasha, Prof. Bogale Worku, Dr. Berhanu Gudeta, Dr. Sirak Hailu, Dr. Solomon Emyu, Dr. Wegen Shiferaw, Dr. Amezene Tadesse, Dr. Muluwork Tefera, Dr. Yiheyis Feleke Dr. Mesfin Zerfu, Dr. Loko Abraham, Dr. Temesgin Tsega, Dr. Zemene Tigabu, Dr. Netsanet Workneh, Dr. Lisanu Tadesse, Dr. Gezahagn Nekatibeb and Mohammedamin Adem. Special thanks go to Salem Fisseha and Tewodros Emiru of CHAI Ethiopia for their technical assistance in editing and formatting of the material. Finally, the Ministry of Health would like to recognize all the program managers and technical staff in the Medical Services Directorate who contributed to the finalization of the document. Design: Tewodros Emiru, Clinton Health Access Initiative (Design is Based on Emergency Triage Assessment and Treatment (ETAT) Facilitator Guide and Manual for participants - Publications of the World Health Organization.) IV  Table of Contents Acknowledgements IV Table of Contents V Introduction 1 Learning objectives of the training course 2 Module One: Triage and the “ABCDO” Concept 3 The ABCDO concept 4 Emergency signs include: 4 Priority signs 5 The triaging process 5 Who Should Triage? 9 How to Triage? 9 Assessing priority signs 10 Tiny infant (less than two months of age) 10 Temperature: hot/cold (fever – high/low Temperature) 11 Trauma (or other urgent surgical condition) 11 Poisoning 11 Severe Pain 11 Lethargy or Irritable and Restless 11 Respiratory distress 11 Urgent Referral 12 Severe wasting (Severe Malnutrition) 12 Oedema of both feet 12 Burn 12 General Treatment for Priority Signs 13 The Need for Frequent Reassessment 13 Assessment Questions: Triage 14 Module Two: Airway and Breathing 17 Assessment of the Airway 18 Management to open the airway 19 Simple techniques to open the airway 19 Advanced intervention 19 Maneuvers to open the airway 19 Manage Anatomic obstruction (hypo pharyngeal tissue blocking the airway). 19 Chin lift and head tilt 20 Jaw trust 20 Log roll 21 V  Insertion of an Oropharyngeal (Guedel) Airway 22 Infant 22 Child 22 Management of foreign body aspiration (a choking child) 23 Management of young infant with foreign body aspiration (see Figure 15) 23 Management of child with foreign body (see Figure 16) 24 Assessment of breathing 24 Is the Child Breathing? 24 Ventilate with Bag and Mask 25 Does the Child Show Central Cyanosis? 26 Give Oxygen 26 Sources of oxygen to treat hypoxemia 27 Oxygen Delivery 27 Assessment Questions: Airway and Breathing 30 Module Three: Circulation 33 Does the Child have Warm Hands? 34 Is the Capillary Refill Time ≥ 3 Seconds? 34 Is the Pulse Weak and Fast? 35 Shock 35 Treatment of Shock 36 Stop any bleeding 36 Give oxygen 36 Make sure the child is warm 36 Select an appropriate site for administration of fluids 36 Give intravenous fluid 36 Assessment Questions: Circulation 40 Module Four: Coma and convulsion 43 Assess the child for coma and convulsion 43 Is the Child in Coma? 43 Is the Child Convulsing Now? 45 Treatment of coma and convulsion 45 Manage the Airway 45 Coma 45 Convulsion 45 Position the Child 46 Coma 46 Convulsion 46 Check the Blood Sugar 46 Coma and convulsion 46 Give IV Glucose 47 Coma and convulsion 47 Give an Anticonvulsant 48 Convulsion 48 Assessment Questions: Coma and convulsion 50 Module Five: Dehydration 53 Does the Child Have Diarrhoea? 53 Is the Child Lethargic? 54 Does the Child have Sunken Eyes? 54 Is the Child Unable to Drink? 54 Treatment of severe dehydration in an emergency setting 55 Severe Dehydration (Without Shock or Severe Malnutrition) 55 VI  Give oral fluids 56 Give Fluids by Intraosseous if Setting an IV Line is Not Possible. 56 Dehydration in Severely Malnurshed child 58 Assessment Questions: Dehydration 60 Module Six: Cardiopulmonary Resuscitation in the Newborn and Children 65 Cardiopulmonary Resuscitation (CPR) 65 Introduction: 65 Management of cardiac arrest 65 Deciding to Terminating Resuscitative Efforts: 67 Neonatal resuscitation 69 Drying and keeping the baby warm 69 Airway 69 Breathing 69 Circulation 70 Drugs 70 Post resuscitation stabilization 70 Cessation of resuscitation 70 Assessment Questions: Cardiopulmonary Resuscitation and Neonatal Resuscitation 73 Module Seven: Common Respiratory Emergencies in Children 75 What is stridor? 75 What is Croup? 75 Clinical Manifestations 76 How do you manage croup? 76 Wheezing in Children 76 What is asthma? 77 Rapid Acting Bronchodilators 77 Assessment Questions: Child presenting with stridor 79 Assessment Questions: Wheezing 80 Module Eight: Pediatric Trauma 81 Evaluation of trauma patients 81 Primary survey 81 A - Airway maintenance with cervical spine protection 82 Is the airway open? 82 B - Is the breathing normal? 82 C - Assess Circulation 82 Management of Circulation 83 Cm,n – Assess consciousness (Cm)and Convulsion (Cn) 83 Ds - Disability 83 O - Assess for other emergencies (abnormalities) 83 Adjuncts to primary survey: 83 Secondary survey 83 Common Conditions Presenting with Trauma: 84 Assessing the Child with Head Trauma 84 Overview of pediatric head trauma 84 Classification of Head Injuries 84 Management of Head Injury 84 Airway & Breathing management: 84 Circulation management: 85 VII  Secondary survey 85 Spinal Cord Injury 86 X-ray examination 86 Management 86 Assessing the Child with Thoracic Trauma 86 Thoracic Traumas of Importance: 86 Is air in the pleural space? 87 Assessing the Child with Abdominal or Pelvic Injuries 88 Skin Traction 91 How to do skin traction? 91 Managment of open fractures 91 Assessment Questions: Pediatric Trauma 92 Module Nine: Burn Injury 95 Classification of burn 96 Body surface area Estimation 96 Emergency treatment 97 Airway & Breathing: 97 Circulation: 97 Indication for Hospital Admission 98 Monitoring: 98 Prevention and Treatment of Infection 99 Pain control 100 Nutrition 100 Addressing Different Types of Burns 100 Circumferential Extremity Burns 101 Child Abuse in Burn Injuries: 101 Assessment Questions: Burn Injury 102 Module Ten: Common Childhood Poisoning 105 History and physical examination: 106 General Principles of Management 106 Gastrointestinal decontamination 106 Activated charcoal 107 Whole bowel irrigation (WBI) 107 Skin Decontamination 108 Eye Decontamination 108 Decontamination for Inhaled poisons 108 Multiple-Dose Activated Charcoal 108 Assessment Questions: Common Childhood Poisoning 114 Module Eleven: Pain Management in Children 117 Barriers for pain management in children 117 Ways of assessing level of pain in children 117 Non-Pharmacological Management of Pain 119 Glucose analgesia: 120 Pharmacologic Treatments of pain 120 Assessment Questions: Assessment and management of pain 121 Module Twelve: Case management scenarios 123 Module Thirteen: Implementing ETAT 125 Objectives of the chapter/session 125 Implementing ETAT in your hospital 126 Advocacy 126 VIII  Manual for participants Patient flow and tasks 126 Material Resources 127 Developing individual plans of actions 127 Annex One: Practical procedures 129 Giving Parenteral fluids 129 Vascular Access 129 Peripheral Vein 129 Scalp Veins 130 Care of the Cannula 130 External Jugular Vein 130 Intraosseous Needle Insertion 131 Contra-indications: 131 Complications 132 IV Drug Administration Through an Indwelling Cannula 132 Insertion of a nasogastric tube 132 Contraindications: 133 Needle chest decompression / Needle thoracostomy 134 Needle thoracostomy: Procedure 134 Needle cricothyroidotomy 135 Splinting Techniques 137 Application of skin fraction 137 Pop cast application 137 Nebulizer Use 139 Umbilical Catheterization 140 Indication 140 Contraindication 140 Equipment 140 Technique 140 Complications of umbilical vein catheterization include the following: 141 Orogastric tube 141 Indication 141 Contraindication 141 Equipment 142 Technique 142 Confirmation that it is in the stomach 142 Annex Two: Resources required to implement emergency care of children in hospitals 143 Annex Three: ETAT charts 147 Annex Four: Anaphylaxis 163 Annex Five: Management of Diabetes Ketoacidosis 165 Annex Six: Pain Assessment and Management 169 References 172 IX  Manual for participants Introduction The Emergency Triage Assessment and Treatment (ETAT) course is designed to familiarize health workers with the ETAT guidelines and help them acquire the necessary knowledge and skills for applying the guidelines. Triage is the process of rapidly examining all sick children when they first arrive in health facility in order to place them in one of the following categories: E-Emergency- Priority and Q- Queue (non-urgent). Deaths in hospital often occur within 24 hours of admission. Many of these deaths could be prevented if very sick children are identified soon after their arrival in the health facility, and treatment were started immediately. Therefore, a process of rapid triage for all children presenting to hospital needs to be put in place to determine whether any emergency or priority signs are present. Triage may be done in 15-20 seconds by medical staff or by non-medical staff (after appropriate training) as soon as the child arrives, and no special equipment is needed for this. Once emergency signs are identified, prompt emergency treatment needs to be given to stabilize the condition of the child. WHO has developed Emergency Triage Assessment and Treatment (ETAT) guidelines. These are adapted from the Advanced Pediatric Life Support guidelines used in western countries. Using the guideline allows for the immediate identification of children with life-threatening conditions which are most frequently seen in developing countries, such as obstruction of the airway and other breathing problems caused by infections, shock, neurologic emergencies (coma or convulsions), and severe dehydration. The generic WHO guidelines were developed in Malawi, and were field-tested in several other countries including Angola, Brazil, Cambodia, Indonesia, Kenya and Niger. Since Ethiopia does not have a national training manual on Pediatric Emergencies, it adapted the WHO generic ETAT manual as the ETAT training manual for Ethiopia with the addition of common pediatrics emergencies in Ethiopia based on recommendations of experts from different health facilities and universities in Ethiopia. The guidelines are contained in the manual “Management of the child with a serious infection or severe malnutrition” and in the “Pocketbook of hospital care for children”, on which this training course is based. This course manual is primarily meant for the participants of a 5 and 1/2 days training course in Emergency Triage, Assessment and Treatment. It provides participants with the reading materials to prepare themselves for the modules taught in the course. 1 Emergency Triage Assessment and Treatment (ETAT + Ethiopia) Some of the reading might be done during the course. In addition, it provides questions for self-assessment which participants can respond to after having gone through the training. Apart from use in a full-time training course, the reading will be useful for trainers and participants who take part in training as a series of seminars. Guidance on how to conduct such training is contained in a parallel facilitator’s guide. This training course does not stand on its own. It can be included in a quality improvement process which targets the whole hospital or it can start such a process. At the end of the course, participants plan for introducing an ETAT process at their institution, by comparing the existing situation with international standards, and suggesting actions to solve identified problems and to document and evaluate such a process. Lessons learned in this process can be applied to other areas of child health in hospital and to care of other patient groups. Emergency management is done by team, rather than by individual players, so team work is emphasized and practiced throughout the course. Learning objectives of the training course At the end of the course, trainee will be able to:  Triage all sick children when they arrive at a health facility, into the following categories: –– those with emergency signs –– those with priority signs –– those who are queue cases.  Assess a child’s airway and breathing and give emergency treatments  Assess the child’s status of circulation and level of consciousness.  Assess and manage DKA and anaphylaxis in children  Manage shock, coma, and convulsions in a child.  Assess and manage severe dehydration in a child with diarrhoea.  Give cardiopulmonary resuscitation and neonatal resuscitation  Manage a child with stridor and wheezing  Assess and manage a child with trauma and acute burn  Assess and manage a child with acute poisoning  Asses and manage pain in children  Plan to implement ETAT in your own hospital. 2  Manual for participants Module One Triage and the “ABCDO” Concept Learning Objectives: At the end of this Module, you will be able to:  Triage all sick children when they arrive at a health facility, into the following categories: –– those with emergency signs –– those with priority signs –– those who are non-urgent cases TRIAGE  Describe the “ABCDO” concept is the sorting of patients into priority groups Many deaths in hospital occur within 24 hours of admission. Some of these deaths according to their need can be prevented if very sick children are quickly identified on their arrival and and the resources treatment is started without delay. In many hospitals, children are not checked available before a senior health worker examines them; as a result, some seriously ill patients have to wait a very long time before they are seen and treated. Children are known to have died of a treatable condition while waiting in the queue for their turn. The idea of triage is to prevent this from happening. The word “triage” means sorting. Triage is the process of rapidly examining all sick children when they first arrive in hospital in order to place them in one of the following three categories: Those with EMERGENCY SIGNS (E), require immediate emergency treatment: If you find any emergency signs, do the following immediately:  Start to give appropriate emergency treatment.  Call a senior health worker and other health workers to help.  Carry out emergency laboratory investigations. Those with PRIORITY SIGNS (P), indicating that they should be given priority in E Emergency the queue, so that they can rapidly be assessed and treated without delay. P Priority Those who have no emergency or priority signs and therefore are non-urgent or Q Queue (non-urgent) they are patients assigned as QUEUE (Q). These children can wait their turn in the queue for assessment and treatment.1 The majority of sick children will be non- urgent and will not require emergency treatment. After these steps are completed, proceed with general assessment and further treatment according to the child’s priority. 1 Sometimes it is discovered that a child in the queue is waiting for immunization. These children do not need assessment and can be referred to the right department without delay. 3  Emergency Triage Assessment and Treatment (ETAT + Ethiopia) All children should be checked on their arrival in a health facility by a person who is trained to assess how ill they are. This person decides whether the patient will be seen immediately and will receive life-saving treatment, or will be seen soon, or can safely wait his/her turn to be examined. Categories after Triage Action required EMERGENCY CASES Need immediate emergency treatment PRIORITY CASES Need assessment and rapid attention QUEUE CASES Can wait their turn in the queue A Airway The ABCDO concept B Breathing C Circulation, Coma, Triage of patients involves looking for signs of serious illness or injury. These Convulsion emergency signs related to the Airway-Breathing-Circulation/Consciousness- Dehydration/Disability, and Other Emergencies are easily remembered as D Dehydration (severe), Disability “ABCDO”. O Others (immediate Each letter refers to an emergency sign which, when positive, should alert you to a Poisoning, Major patient who is seriously ill and needs immediate assessment and treatment. Trauma with open fracture, Bleeding Child) Emergency signs include:  obstructed or absent breathing  severe respiratory distress  central cyanosis  signs of shock (cold hands, capillary refill time longer than 3 seconds, weak and fast pulse)  coma (or seriously reduced level of consciousness)  convulsions  signs of severe dehydration in a child with diarrhoea  Disabilities like motor deficiet (paraplegia/paresis, hemiplegia/paresis, facial palsy…)  Other emergency signs (bleeding child, immediate Poisoning, Major Trauma) Bleeding child:  Bleeding due to trauma  Spontaneous bleeding (epistaxis, hematemesis, rectal bleeding, umbilical bleeding…) Immediate poisoning:  Acute eye or skin poisoning  Ingested poison within one hour Major trauma:  Compound (open) fracture 4  Manual for participants Priority signs These children need prompt assessment (no waiting in the queue) to determine what further treatment is needed. Besides the group of emergency signs described above, there are priority signs, which should alert you to a child who needs prompt, but not emergency assessment. These signs can be remembered with the symbols 3 TPR - MOB:  Tiny baby: any sick child aged less than two months  Temperature: child is very hot or very cold  Trauma or other urgent surgical condition  Pallor (severe)  Poisoning (other than those require emergency care)  Pain (severe)  Respiratory distress  Restless, continuously irritable, or lethargic  Referral (urgent)  Malnutrition: Visible severe wasting  Oedema of both feet  Burns The triaging process Triaging should not take much time. For a child who does not have emergency signs, it takes on average 20 seconds. The health worker should learn to assess several signs at the same time. A child who is smiling or crying does not have severe respiratory distress, shock or coma. The health worker looks at the child, observes the chest for breathing and priority signs such as severe malnutrition and listens to abnormal sounds such as stridor or grunting. Several methods are available to facilitate the triaging process. One example is a stamp consisting of “ABCDO” signs in which the health worker circles the correct step and initiates emergency treatment for those with “E” or put them in priority groups “P” or “Q” for children who can wait in the queue. Colors can also be used in differentiating the three groups (red stickers to emergency, yellow for priority and green for the queue. A B C Cm Cn D Ds O E P Q Stamp for triage 5  Emergency Triage Assessment and Treatment (ETAT + Ethiopia) Chart 1: Sick Child triage chart REFERENCE TABLE 1 Receive the Sick Child Emergency Signs A: Airway problem B: Breathing problem C: Circulation or shock Cm: Coma or Unconscious Check for Cn: Convulsion EMERGENCY Signs? D: Dehydration, Severe Ds: Disability (see REFERENCE TABLE 1) O: Bleeding child, poisoning (immediate) open fracture. REFERENCE TABLE 2 YES NO Priority Signs “3TPR - MOB” T iny baby (sick child < 2 months) Temperature (child is very hot/cold) EMERGENCY Check for P RIORITY Trauma or other (E) Signs? urgent surgical condition patient (see REFERENCE TABLE 2) Pallor (severe) Poisoning (history of) YES NO Pain (severe) R espiratory distress PRIORITY QUEUE R estless, irritable, (P) (Q) Child to EMERGENCY room or lethargic or patient patient CRITICAL CARE a rea R eferral (urgent) M alnutrition (visible severe CHILD to OPD CHILD to OPD wasting) START Management Oedema IMMEDIATELY FRONT of the queue WAITS for his/her TURN (of both feet) in the queue B urn 6  Manual for participants When and Where Should Triaging Take Place? Triage should be carried out as soon as a sick child arrives in the health facility, well before any administrative procedure such as registration. This may require reorganization of the flow of patients in some locations of the hospital. Chart 2: Emergency Management of Triaged Children 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 1. ASSESS: AIRWAY AND  Do not move neck if cervical spine BREATHING injury possible.  If foreign body aspiration: manage  Obstructed or absent breathing Any Sign Positive airway in choking child  Central cyanosis  If no foreign body aspiration:  Severe respiratory distress manage airway  Give oxygen 2. ASSESS: CIRCULATION  Stop any bleeding  Give oxygen  Cold skin with: –– Capillary refill longer than 3 Signs Positive  Make sure child is warm seconds, and If no severe malnutrition: –– Weak and fast pulse –– ­Insert an IV and begin giving fluids rapidly –– If not able to insert peripheral IV, insert an intraosseous or external Check for jugular line Severe If severe malnutrition: Malnutrition  If lethargic or unconscious: –– 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 3. ASSESS: COMA/  Do not move neck if cervical spine CONVULSION injury possible  Manage airway  Coma If the Child is in –– If convulsing, give diazepam OR rectally Coma or Convulsing  Convulsing (now) –– Position the unconscious child (if head or neck trauma is suspected, stabilize the neck first  Give IV glucose 7 Emergency Triage Assessment and Treatment (ETAT + Ethiopia) Chart 2: Emergency Management of Triaged Children 4. ASSESS: SEVERE  Make sure child is warm DEHYDRATION If no severe malnutrition ( In a child with diarrhoea) Two Signs Positive  Insert an IV line and begin giving fluids rapidly Diarrhoea plus any two of these signs: If severe malnutrition:  Lethargy  Do not insert IV  Sunken eyes  Proceed immediately to full  Very slow skin pinch Check for assessment and treatment  Unable to drink Severe Malnutrition 5. OTHERS: MAJOR TRAUMA,  Manage ABC IMMEDIATE POISONINGS  Airway Protection  Immediate poisoning, actively Any Sign Positive  Arrest bleeding bleeding child, compound fracture  Decontaminate acute poisoning  Stabilize fracture Proceed with assessment and further treatment according to the child’s priority PRIORITY(P) SIGNS: Move a child with any priority sign to the front of the queue These children need prompt assessment and treatment Any Sign Positive Note: If a child has trauma or other surgical problems, get surgical help or  Tiny baby ( 1 year of age:)  Then 5-10ml/kg/hour for the next 4-10 should initiate –– 30 ml/kg in the first 30 minutes hours appropriate –– 70 ml/kg in the next 2.5 hours  Give more ReSoMal if child wants more treatment, and then  Assess the child every 1- 2 hours or large stool loss or vomiting quickly resume the If the signs of dehydration are not  Check blood glucose and Treat if 24 hr since injury). If TIG is unavailable, then use of human IGIV may be considered.  If neither of these products is available, use equine or bovine-derived TAT may be given intramuscularly after testing for hypersensitivity (Dose: Newborn-750U, Todllers-1500U and Older Children-3000U). Pain control  The simple measure of wrapping burns with a clean sheet and developmentally  appropriate verbal reassurance can decrease pain.  Pain should be controlled during change of dressing. Intravenous analgesics is preferable than IM injections or PO doses because with significant burns circulation to muscle and gut is reduced, and absorption of medication erratic, additionally intramuscular injections are painful. Nutrition  During the acute phase, oral feeding may not be tolerated for which IV fluids as maintenance is used. When acute conditions get resolved and start to tolerate oral feeds, IV fluids will be decreased.  In general, burn patients should get a high calorie, protein, and vitamins particularly vitamin B group, vitamin C, vitamin A, mineral zinc and iron supplements. Addressing Different Types of Burns Electrical burn:  Significantly deep and internal injuries may occur with small external burns.  Fluid requirements are higher than those predicted by formulas based on percent of BSA because mostly the injury is internal.  Minor electrical burns usually occur as a result of biting on an extension cord which causes injury to the corner of the mouth and lip.  Treatment with topical antibiotic creams is sufficient but needs follow up in the outpatient since it has tendency to bleed after weeks.  Injuries resulting from high voltage particularly at high-voltage installations or lightening causes Cardiac arrhythmias and renal damage. Inhalational injury: This injury is serious in the infant and child, particularly if pre-existing pulmonary conditions are present. Evaluation aims at early identification of inhalational airway injuries. These may occur from (1) direct heat (greater problems with steam 100  Manual for participants burns), (2) acute asphyxia, (3) carbon monoxide poisoning, and (4) toxic fumes, including cyanides from combustible plastics. Chemical Burns: Caustic chemicals on the skin cause a prolonged period of burning compared with most thermal injury regardless of the substance involved. caustic chemicals need copious irrigation to dilute and remove the chemical. Circumferential Extremity Burns Edema formation in the underlying tissues is often caused from deep burns. Circumferential burns, especially in the extremities, may produce significant vascular and neurologic compromise if not recognized and treated in a timely manner. The first sign of compromise is pain upon passive stretch of the involved extremity. Other indications of decreased blood flow are slowing of capillary refill, diminished pulses, numbness, tingling, pain, paralysis and coolness. Repeated pulse checks are essential. If these problems are suspected, urgent surgical consultation is vital. Child Abuse in Burn Injuries: Burn is one the mechanisms of child abuse. Suspect child abuse if the burn is:  Not proportional with the child’s developmental milestone  Incompatible with the history  Deep and localized  Glove and stock type  Cigarette burn The ultimate goal in the management of child abuse is the protection of the child from further injury and the initiation of therapeutic measures to restore the family to a stable and healthy environment In a child with acute burn:  Immediate assessment of ABC is vital to save life  Assessment of surface area of Burn is important for management SUMMARY  In a burn injury of BSA >10%, securing IV line and giving RL by the Parkland Formula (4ml/%BSA/kg) PLUS maintenance fluid over 24hrs. Give 50% of the total fluid over the 1st 8hrs and remaining 50% over the next 16hrs  Considering the wound, tetanus prophylaxis should be done  Early nutrition prevention of infection, pain control and psychological support is part of the burn management 101 Emergency Triage Assessment and Treatment (ETAT + Ethiopia) Assessment Questions: Burn Injury Answer all the questions on this page, writing in the given spaces. If you have a problem, ask for help from one of the facilitators. 1. How do you assess the extent of burn? 2. How do you manage a child whom you saw catch on fire? 102  Manual for participants 3. How do you manage a 10 year old who sustained a burn from a house fire on his face and both thighs anteriorly and posteriorly? (weight = 30 kgs) 4. What do you do for a child presented with electrical burn? 5. A four years old child who sustained scald burn injury was referred from the nearby health center after he received the initial bolus fluid and antipain. His body weight is 22 kgs and with a working diagnosis of 21% second degree burn. He is immunized for his age. How do you manage this child? 103  Manual for participants Module Ten Common Childhood Poisoning Learning Objectives: At the end of this module, you will be able to:  Assess a child with Acute Poisoning  Apply gastrointestinal, skin, eye decontamination procedures in acute poisoning  Assess and manage a child with common specific poisoning  Give antidote for specific poisons  Asses and manage a child with snake bite  Asses and manage a child with drowning Suspect poisoning in any unexplained illness in a previously healthy child. The principles of management of common poisons are discussed in this module. If the child arrives within 1hr of ingestion of poisons he/she will be taken as an emergency because this needs urgent treatment. Primary survey: Assess ABCDO with additional consideration of the poisoning agent Airway: Remove excessive secretions, look for any inhalational injury that might potentially worsen with time. Check for signs of burns in or around the mouth or of stridor (upper airway/laryngeal damage) suggesting ingestion of corrosives. Consider consultation for early intubation, if the patient has severe airway compromise. Breathing: Look for signs of respiratory distress and give oxygen if indicated (see module 2). Circulation: Check the pulse, capillary refill and skin color. If there is shock treat accordingly (see module 3, Circulation) Coma: check the AVPU and pupillary response  Determine blood sugar and give Dextrose if hypoglycemic or if the child has reduced level of consciousness treat as if hypoglycaemic. Dehydration: Assess hydration status (dry tounge, buccal mucosa and sunken eyeball) 105 Emergency Triage Assessment and Treatment (ETAT + Ethiopia) Exposure: Remove all clothing and wash with soap and water and check body temperature Secondary survey: more specific evaluation with history and physical examination and laboratory to identify the exact cause and extent with simultaneous detoxification of the patient History and physical examination: History  Find out full details of the poisoning agent  Attempt to identify the exact agent involved requesting to see the container, where relevant  Try to find the best estimate of the agent dose or amount (keep in mind one pill can kill)  The route of exposure (inhalation, injection, ingestion, contact)  The time of ingestion to presentation (important for the management of the child)  Check that no other children were involved. Physical exam Do detailed examination which help to identify the causes: breath odor, temperature, eye sign( dilated vs. constricted pupil), skin (hot flushed, dry) and bowel sound. General Principles of Management Management of a child with acute poisoning includes four principles:  Decontamination (GI, skin, eye)  Enhancing elimination  Giving antidote and  Supportive care Gastrointestinal decontamination This is most effective if done within one hour of ingestion, and after this time there is usually little benefit, except with agents that delay gastric emptying, sustained release preparations and massive pill ingestions. Methods of gastrointestinal tract (GIT) decontamination includes ipecac induced vomiting, use of cathartics, gastric lavage, activated charcoal and whole bowel irrigation (WBI) Syrup of ipecac and cathartics are not recommended to manage children with acute poisoning Gastric emptying with lavage  Gastric lavage is useful only if it is done within one hour of ingestion of poisons (specially liquid) 106  Manual for participants During the procedure:  Make sure a suction apparatus is available in case the child vomits.  Place the child in the left lateral/ head down position.  Measure the length of tube to be inserted.  Pass a 24–28 French gauge tube through the mouth into the stomach ( as a smaller size nasogastric tube is not sufficient to let particles such as tablets pass)  Ensure the tube is in the stomach by aspiration  Perform lavage with 15 ml/kg/cycle body weight of normal saline (0.9%) maximum 200 to 400ml  The volume of lavage fluid returned should approximate to the amount of fluid given  Lavage should be continued until the recovered lavage solution is clear of particulate matter. Contraindications to gastric lavage are:  Ingestion of corrosives or petroleum products  unconscious child with unprotected airway Activated charcoal  It is more effective if used with in 1 hour may be given as late as 4 hours if the toxic agent causes delayed intestinal movement.  The usual dose of activated charcoal is 1 g per kg; adolescents should receive maximum of 50 g  The amount of water is 8-10 times of the amount of the charcoal, e.g. 5 g in 40 ml of water  If possible, give the whole amount at once; if the child has difficulty in tolerating it, the charcoal dose can be divided.  It can be mixed with caffeine free diet cola or juice to improve the child intake  Don’t force the child, you can insert NG tube to facilitate intake Toxins poorly or not adsorbed by charcoal are:  Caustics (alkali and acids)  hydrocarbons  alcohol  heavy metals (lead)  iron and lithium Whole bowel irrigation (WBI)  WBI is administration of large volume of polyethylene glycol solution with balanced electrolyte.  Usually given by NGT  Effective after ingestion of slowly absorbed substances, substances poorly adsorbed to activated charcoal (lithium, iron) and pills  For children 35ml/kg/hr can be given and adolescents can take 1-2 lts per hour 107 Emergency Triage Assessment and Treatment (ETAT + Ethiopia) Skin Decontamination  Remove all clothing and personal effects and thoroughly clean all exposed areas with copious amounts of tepid water.  Use soap and water for oily substances.  Attending staff should take care to protect themselves from secondary contamination by wearing gloves and apron.  Removed clothing and personal effects should be stored safely in a see- through plastic bag that can be sealed, for later cleansing or disposal. Eye Decontamination  Rinse the eye for 10–15 minutes with clean running water or saline, taking care that the run-off does not enter the other eye by lying on the side and running into the inner canthus and out of the outer canthus.  Evert the eyelids and ensure that all surfaces are rinsed.  Where possible, the eye should be thoroughly examined under fluorescein staining for signs of corneal damage.  If there is significant conjunctival or corneal damage, the child should be seen urgently by an ophthalmologist. Decontamination for Inhaled poisons  Remove from the source of exposure.  Urgently call for help  Administer supplemental oxygen, if there is respiratory distress or cyanosis or oxygen saturation ≤90%  Inhalation of poisonous gases may cause swelling and upper airway obstruction, bronchospasm and delayed pneumonitis Multiple-Dose Activated Charcoal  This method enhances poison elimination by interfering with enterohepatic recirculation GI dialysis  Give 0.25 to 0.5 g/kg every 3 to 4 hour until the patient condition is improved  Considered in drug poising including phenobarbital, carbamazepine, phenytoin, digoxin, salicylates, and theophylline Further Management of the Poisoned Child  Give specific antidote if this is availble and indicated  Keep the child under observation for 4–24 hours depending on the poison swallowed  Keep unconscious children in the recovery position.  Refer the child to the next level health facility, only when appropriate and where this can be done safely  If the child is unconscious or has deteriorating conscious level, has burns to mouth and throat, is in severe respiratory distress, is cyanosed or is in heart failure, stabilize him/her before referral Specific poisons 1. Corrosive compounds  Acid and alkali corrosives are common household agents which causes immediate severe burning of exposed surfaces, usually with intense difficulty 108  Manual for participants of feeding. Eg. sodium hydroxide, potassium hydroxide, acids, bleaches or disinfectants  Do not induce vomiting or use activated charcoal or gastric lavage when corrosives have been ingested as this may cause further damage to the mouth, throat, airway, lungs, esophagus and stomach.  Give milk or water within 30 minutes to dilute the corrosive agent. This is only recommended as first aid in mildly symptomatic children.  In the event of esophageal injury or perforation, fluids may extravasate from the esophagus to the mediastinum.  Don’t try to neutralize with acid/alkaline as this occur exothermic reaction may occur that also can worsen esophageal injury  Secure IV line. Do not give anything by mouth and arrange referal for surgical review. 2. Hydrocarbons These are highly volatile substances which can cause comical pneumonitis even after ingestion of small volume Eg. kerosene, turpentine substitutes, petrol, benzene Do not induce vomiting or give activated charcoal or gastric lavage as this increases aspiration. Specific treatment includes oxygen therapy if in respiratory distress, do chest X-ray on presentation and after 6 hours as the first could be normal. If clinically stable after 6 hours consider discharge. Don’t give steroid or prophylactic antibiotic unless the patient develops signs of infections. 3. Organophosphate and carbamate poisoning These are commonly used insecticides and herbicides  Eg. organophosphorus (malathion, parathion, TEPP, mevinphos/Phosdrin) and carbamates (methiocarb and carbaryl)  These compounds can be absorbed through the skin, ingested or inhaled.  The child may complain central nervous system symptoms (dizziness, headache, ataxia, convulsions, and coma)  Muscarinic effects of these poisons can be memorized with mnemonic "DUMBBELLS" –– Diarrhoea –– Urination –– Miosis –– Bradycardia –– Bronchorrhea –– Emesis –– Lacrymation –– Salivation 109 Emergency Triage Assessment and Treatment (ETAT + Ethiopia) Management  Remove poison by irrigating eye or washing skin (if in eye or on skin) as you learnt before.  Give activated charcoal within 1 hours of ingestion, however it could be given up to 4 hours after ingestion of the poison.  In a serious ingestion where activated charcoal cannot be given, consider careful aspiration do gastric lavage (the airway should be protected).  After decontamination, antidotal therapy begins with administration of atropine sulfate  Give a dose of 0.05 to 0.1 mg per kg to children and 2 to 5 mg for adolescents IV or IM. This dose should be repeated every 10 to 30 minutes or as needed until chest secretions and pulmonary rales cleared.  Therapy is continued until all absorbed organophosphate has been metabolized and may require 2 mg to more than 2,000 mg of atropine may be required for a few hours to several days.  If muscle weakness develops after atropinization, give pralidoxime (cholinesterase reactivator) 25–50mg/kg diluted with 15 ml water by IV infusion over 30 minutes repeated once or twice, or followed by an intravenous infusion of 10 to 20 mg/kg/hour, as necessary. 4. Paracetamol Paracetamol is administered about 15-20mg/kg/dose and ingestion of 150-200mg/ kg will cause toxicity in children  Give activated charcoal within 4 hours of ingestion  Decide if antidote is required to prevent liver damage: ingestions of 150 mg/ kg or more, or toxic 4 hour paracetamol level where this is available.  Antidote is more often required for older children who deliberately ingest paracetamol or when parents overdose children by mistake.  If within 8 hours of ingestion give oral methionine or IV acetylcysteine.  Methionine can be used if the child is conscious and not vomiting (