As soon as a sick child arrives in the emergency room, the immediate aim is to identify and treat any life-threatening condition to save life and prevent further deterioration. The process should be quick, sequential, and systematically performed in such a way that several signs are assessed and managed simultaneously by a team. The approach is simple ABCDs in this sequence.
STEP A: EXCLUDE CERVICAL SPINE INJURY AND MAINTAIN TEMPERATURE
Check: Airway and breathing.
- If obstructed breathing due to complete obstruction by a foreign body is suspected. Begin:
- Infants: Back slaps and chest thrusts
- Post infancy: Heimlich maneuver
- Not breathing and gasping and central pulse is felt
- Action: Open airway and start bag and mask ventilation.
- Not breathing/gasping and no central pulse is felt
- Action:
- Start cardiopulmonary resuscitation (CPR)
- Chest compression
- Open airway
- Start bag and mask ventilation.
- Attach monitors and automated external defibrillator (AED)
- Collect blood sample
- Secure intravenous (IV) line
- Central cyanosis
- Action:
- Ensure airways are open
- Give oxygen.
- Attach monitors.
- Severe respiratory distress identified with any one of the following signs:
- Labored or very fast breathing
- Use of accessory muscles of respiration
- Severe lower chest in-drawing
- Head nodding with each breath
- Inability to feed because of respiratory problem
- Abnormal respiratory noises, e.g., stridor, grunting, marked wheezing
- SPO2 < 90%
- Action:
- Ensure position and airways are open.
- Give oxygen.
- Start specific treatment, e.g., bronchodilators.
STEP B: CIRCULATION
- Assess for shock.
- Cold hands
- Capillary refill time (CRT) ≥ 3 seconds
- Weak and fast pulse(In infants >160 per minute; post infancy >140 per minute)
- Action
- Stop bleeding if any
- Position head at level
- Give oxygen
- Keep warm
- Secure IV line
- Attach monitors
- If not SAM (identified by visible severe wasting or bilateral pitting edema if Anthropometry could not done): Normal saline (NS) bolus and continuous monitoring
- If severe acute malnutrition (SAM):
- Give IV glucose
- IV 0.45% saline + 5% dextrose 15 mL/kg in 1 hour
- Assess continuously for volume overload after 1 hour decide further treatment.
STEP C: COMA/CONVULSION
Action:
- Ensure airways are open.
- Position to prevent aspiration.
- Give oxygen.
- Attach monitors.
- Secure IV line, collect sample.
- Correct hypoglycemia.
STEP D: DEHYDRATION
Severe in a case of acute watery diarrhea.
Any two signs:
- Lethargy
- Sunken eyes
- Very slow skin pinch
- If child is not SAM: Secure IV line and begin rapid infusion of NS/Ringer's lactate (RL) according to plan C
- If child is SAM:
- No IV fluids unless shock is present
- Give ORS orally/through nasogastric tube (NGT)
Further management after initial stabilization will depend on response to initial treatment, result of findings on monitors, investigation and imaging study results with continuous monitoring and modifying treatment accordingly.
SUGGESTED READING
- Guidelines: Updates on paediatric emergency triage, assessment and treatment: care of critically ill children, 2016. WHO Library Cataloguing-in-Publication Data, ISBN 978 92 4 151021 9.
- Kliegman RM, St Geme J. Emergency medicine and critical care. In: Wright JL, Krug SE (eds). Nelson TB of Pediatrics, 21st edition. Philadelphia: Elsevier; 2019.