Emergency signs include:
■ obstructed breathing
■ Severe respiratory
distress
■ Central cyanosis
■ Signs of shock (cold
hands; capillary refill longer than 3 seconds; weak,
Fast pulse)
■ Coma
■ Convulsions
■ Signs of severe dehydration
in a child with diarrhea (lethargy, sunken eyes,
Very slow return after
pinching the skin—any two of these).
NOTE
Children with emergency
signs require immediate treatment to avert death.
PRIORITY SIGNS
■ Tiny baby: any sick child
aged under 2 months
■ Temperature: child is very
hot
■ Trauma or other urgent
surgical condition
■ Pallor (severe)
If emergency signs are found:
• Call an experienced health professional to help if available, but do not delay
starting the treatment. Stay calm and work with other health workers who
SUMMARY OF STEPS IN EMERGENCY TRIAGE ASSESSMENT AND TREATMENT
3
1. ETAT
may be required to give the treatment, because a very sick child may need
several treatments at once. The most experienced health professional should
continue assessing the child (see Chapter 2, page 37), to identify all
underlying problems and develop a treatment plan.
• Carry out emergency investigations (blood glucose, blood smear, haemoglobin).
Send blood for typing and cross-matching if the child is in shock,
or appears to be severely anaemic, or is bleeding significantly.
• After giving emergency treatment, proceed immediately to assessing,
diagnosing and treating the underlying problem.
Tables of common differential diagnoses for emergency signs are provided
from page 20 onwards.
If no emergency signs are found, check for priority signs:
■ Tiny baby: any sick child aged under 2 months
■ Temperature: child is very hot
■ Trauma or other urgent surgical condition
■ Pallor (severe)
■ Poisoning
■ Pain (severe)
■ Respiratory distress
■ Restless, continuously irritable, or lethargic
■ Referral (urgent)
■ Malnutrition: visible severe wasting
■ Oedema of both feet
■ Burns (major)
The above can be remembered with the help of “3TPR MOB”.
These children need prompt assessment (no waiting in the queue) to determine
what further treatment is needed. Move the child with any priority sign to the
front of the queue to be assessed next. If a child has trauma or other surgical
problems, get surgical help where available.
SUMMARY OF STEPS IN EMERGENCY TRIAGE ASSESSMENT AND TREATMENT
4
1. ETAT
CHART 2. Triage of all sick children
EMERGENCY SIGNS
If any sign positive: give treatment(s), call for help, draw blood for
emergency laboratory investigations (glucose, malaria smear, Hb)
ASSESS TREAT
Do not move neck if cervical
spine injury possible
If foreign body aspiration
➤ Manage airway in choking
child (Chart 3)
If no foreign body aspiration
➤ Manage airway (Chart 4)
➤ Give oxygen (Chart 5)
➤ Make sure child is warm
➤ Stop any bleeding
➤ Give oxygen (Chart 5)
➤ Make sure child is warm
If no severe malnutrition:
➤ Insert IV and begin giving
fluids rapidly (Chart 7)
If not able to insert
peripheral IV, insert an
intraosseous or external
jugular line
(see pages 310, 312)
If severe malnutrition:
If lethargic or unconscious:
➤ Give IV glucose (Chart 10)
➤ Insert IV line and give
fluids (Chart 8)
If not lethargic or
unconscious:
➤ Give glucose orally or by
NG tube
➤ Proceed immediately to full
assessment and treatment
ANY SIGN
POSITIVE
ANY SIGN
POSITIVE
Check for
severe
malnutrition
Airway and
breathing
■ Obstructed breathing,
or
■ Central cyanosis,
or
■ Severe respiratory distress
Circulation
Cold hands with:
■ Capillary refill
longer than
3 seconds,
and
■ Weak and fast pulse
5
1. ETAT
CHART 2. Triage of all sick children (continued)
TREAT
Do not move neck if cervical
spine injury possible
➤ Manage airway (Chart 3)
➤ If convulsing, give diazepam or
paraldehyde rectally (Chart 9)
➤ Position the unconscious child (if
head or neck trauma is suspected,
stabilize the neck first) (Chart 6)
➤ Give IV glucose (Chart 10)
➤ Make sure child is warm.
If no severe malnutrition:
➤ Insert IV line and begin giving fluids
rapidly following Chart 11 and
Diarrhoea Treatment Plan C in
hospital (Chart 13, page 114)
If severe malnutrition:
➤ Do not insert IV
➤ Proceed immediately to full
assessment and treatment (see
section 1.3, page 18)
PRIORITY SIGNS
These children need prompt assessment and treatment
EMERGENCY SIGNS
If any sign positive: give treatment(s), call for help, draw blood for
emergency laboratory investigations (glucose, malaria smear, Hb)
ASSESS
Coma/convulsing
■ Coma
or
■ Convulsing (now)
Severe
dehydration
(only in child
with diarrhoea)
Diarrhoea plus
any two of these:
■ Lethargy
■ Sunken eyes
■ Very slow skin
pinch
IF COMA OR
CONVULSING
DIARRHOEA
plus
TWO SIGNS
POSITIVE
Check for
severe
malnutrition
NON-URGENT
Proceed with assessment and further treatment according to
the child’s priority
■ Tiny baby (<2 months)
■ Temperature very high
■ Trauma or other urgent surgical
condition
■ Pallor (severe)
■ Poisoning (history of)
■ Pain (severe)
■ Respiratory distress
■ Restless, continuously irritable, or
lethargic
■ Referral (urgent)
■ Malnutrition: visible severe wasting
■ Oedema of both feet
■ Burns (major)
Note: If a child has trauma or other
surgical problems, get surgical help
or follow surgical guidelines
6
1. ETAT
CHART 3. How to manage the choking infant
➤ Lay the infant on
your arm or thigh in
a head down
position
➤ Give 5 blows to the
infant’s back with
heel of hand
➤ If obstruction
persists, turn infant
over and give
5 chest thrusts with
2 fingers, one finger
breadth below nipple
level in midline
(see diagram)
➤ If obstruction
persists, check
infant’s mouth for
any obstruction
which can be
removed
➤ If necessary, repeat
sequence with back
slaps again
Back slaps
Chest thrusts
7
1. ETAT
➤ Give 5 blows to the child’s back
with heel of hand with child sitting,
kneeling or lying
➤ If the obstruction persists, go
behind the child and pass your
arms around the child’s body;
form a fist with one hand
immediately below the child’s
sternum; place the other hand over
the fist and pull upwards into the
abdomen (see diagram); repeat
this Heimlich manoeuvre 5 times
➤ If the obstruction persists, check
the child’s mouth for any
obstruction which can be removed
➤ If necessary, repeat this sequence
with back slaps again
CHART 3. How to manage the choking child
(over 1 year of age)
Heimlich manoeuvre in
a choking older child
Slapping the back to clear airway
obstruction in a choking child
8
1. ETAT
CHART 4. How to manage the airway in a child
with obstructed breathing (or who has just stopped
breathing) where no neck trauma is suspected
Child conscious
1. Inspect mouth and
remove foreign
body, if present
2. Clear secretions
from throat
3. Let child assume
position of maximal
comfort
Child unconscious
1. Tilt the head as
shown
2. Inspect mouth and
remove foreign
body, if present
3. Clear secretions
from throat
4. Check the airway by
looking for chest
movements,
listening for breath
sounds and feeling
for breath
■ OLDER CHILD
■ INFANT
Neutral position to open the airway
in an infant
Look, listen and feel for breathing
Sniffing position to open the airway
in an older child
9
1. ETAT
CHART 4. How to manage the airway in a child
with obstructed breathing (or who has just stopped
breathing) where neck trauma or possible cervical
spine injury is suspected
1. Stabilize the neck, as shown in Chart 6
2. Inspect mouth and remove foreign body, if present
3. Clear secretions from throat
4. Check the airway by looking for chest movements, listening for breath
sounds, and feeling for breath
Use jaw thrust without head tilt. Place the 4th and 5th finger behind
the angle of the jaw and move it upwards so that the bottom of the jaw
is thrust forwards, at 90° to the body
If the child is still not breathing after
carrying out the above, ventilate with
bag and mask
10
1. ETAT
Give oxygen through nasal
prongs or a nasal catheter
■ Nasal Prongs
➤ Place the prongs just inside
the nostrils and secure with
tape.
■ Nasal Catheter
➤ Use an 8 FG size tube
➤ Measure the distance from
the side of the nostril to
the inner eyebrow margin
with the catheter
➤ Insert the catheter to
this depth
➤ Secure with tape
Start oxygen flow at
1–2 litres/minute
(see pages 281–284)
CHART 5. How to give oxygen
11
1. ETAT
CHART 6. How to position the unconscious child
■ If neck trauma is not suspected:
➤ Turn the child on the side to reduce risk of aspiration.
➤ Keep the neck slightly extended and stabilize by placing cheek on
one hand
➤ Bend one leg to stabilize the body position
■ If neck trauma is suspected:
➤ Stabilize the child’s neck and keep the child lying on the back:
➤ Tape the child’s forehead and
chin to the sides of a firm board
to secure this position
➤ Prevent the neck from
moving by supporting the
child’s head (e.g. using
litre bags of IV fluid on
each side)
➤ If vomiting, turn on
the side, keeping
the head in line
with the body.
12
1. ETAT
CHART 7. How to give IV fluids rapidly for shock in a child
without severe malnutrition
➤ If the child is severely malnourished the fluid volume and rate are
different, so check that the child is not severely malnourished
Shock in child without severe malnutrition—Chart 7
Shock in child with severe malnutrition—Chart 8 (and section 1.3,
page 18)
➤ Insert an intravenous line (and draw blood for emergency laboratory
investigations).
➤ Attach Ringer's lactate or normal saline—make sure the infusion is
running well.
➤ Infuse 20 ml/kg as rapidly as possible.
Volume of Ringer's lactate
or normal saline solution
Age/weight (20 ml/kg)
2 months (<4 kg) 75 ml
2–<4 months (4–<6 kg) 100 ml
4–<12 months (6–<10 kg) 150 ml
1–<3 years (10–<14 kg) 250 ml
3–<5 years (14–19 kg) 350 ml
Reassess child after appropriate volume has run in
Reassess after first infusion: If no improvement, repeat 20 ml/kg as
rapidly as possible.
Reassess after second infusion: If no improvement, repeat 20 ml/kg as
rapidly as possible.
Reassess after third infusion: If no improvement, give blood 20 ml/kg
over 30 minutes (if shock is not caused
by profuse diarrhoea, in this case repeat
Ringer’s lactate or normal saline).
Reassess after fourth infusion: If no improvement, see disease-specific
treatment guidelines. You should have
established a provisional diagnosis by
now.
After improvement at any stage (pulse slows, faster capillary refill), go to
Chart 11, page 16.
13
1. ETAT
CHART 8. How to give IV fluids for shock in a child
with severe malnutrition
Give this treatment only if the child has signs of shock and is lethargic or has lost
consciousness:
➤ Insert an IV line (and draw blood for emergency laboratory investigations)
➤ Weigh the child (or estimate the weight) to calculate the volume of fluid to be
given
➤ Give IV fluid 15 ml/kg over 1 hour. Use one of the following solutions (in order of
preference), according to availability:
— Ringer's lactate with 5% glucose (dextrose); or
— half-normal saline with 5% glucose (dextrose); or
— half-strength Darrow’s solution with 5% glucose (dextrose); or, if these are
unavailable,
— Ringer's lactate.
Weight Volume IV fluid Weight Volume IV fluid
Give over 1 hour (15 ml/kg) Give over 1 hour (15 ml/kg)
4 kg 60 ml 12 kg 180 ml
6 kg 90 ml 14 kg 210 ml
8 kg 120 ml 16 kg 240 ml
10 kg 150 ml 18 kg 270 ml
➤ Measure the pulse and breathing rate at the start and every 5–10 minutes.
If there are signs of improvement (pulse and respiratory rates fall):
— give repeat IV 15 ml/kg over 1 hour; then
— switch to oral or nasogastric rehydration with ReSoMal (see page 179),
10 ml/kg/h up to 10 hours;
— initiate refeeding with starter F-75 (see page 184).
If the child fails to improve after the first 15ml/kg IV, assume the child has septic
shock:
— give maintenance IV fluid (4 ml/kg/h) while waiting for blood;
— when blood is available, transfuse fresh whole blood at 10 ml/kg slowly over
3 hours (use packed cells if in cardiac failure); then
— initiate refeeding with starter F-75 (see page 184);
— start antibiotic treatment (see page 182).
If the child deteriorates during the IV rehydration (breathing increases by
5 breaths/min or pulse by 15 beats/min), stop the infusion because IV fluid can
worsen the child’s condition.
14
1. ETAT
CHART 9. How to give diazepam (or paraldehyde) rectally
■ Give diazepam rectally:
➤ Draw up the dose from an ampoule of diazepam into a tuberculin (1
ml) syringe. Base the dose on the weight of the child, where possible.
Then remove the needle.
➤ Insert the syringe into the rectum 4 to 5 cm and inject the diazepam
solution.
➤ Hold buttocks together for a few minutes.
Diazepam given rectally Paraldehyde given
10 mg/2ml solution rectally
Age/weight Dose 0.1ml/kg Dose 0.3–0.4 ml/kg
2 weeks to 2 months (<4 kg)* 0.3 ml (1.5 mg) 1.0 ml
2–<4 months (4–<6 kg) 0.5 ml (2.5 mg) 1.6 ml
4–<12 months (6–<10 kg) 1.0 ml (5 mg) 2.4 ml
1–<3 years (10–<14 kg) 1.25 ml (6.25 mg) 4 ml
3–<5 years (14–19 kg) 1.5 ml (7.5 mg) 5 ml
If convulsion continues after 10 minutes, give a second dose of
diazepam rectally (or give diazepam intravenously (0.05 ml/kg =
0.25 mg/kg) if IV infusion is running).
If convulsion continues after another 10 minutes, give a third dose of
diazepam or give paraldehyde rectally (or phenobarbital IV or IM
15 mg/kg).
■ If high fever:
➤ Sponge the child with room-temperature water to reduce the fever.
➤ Do not give oral medication until the convulsion has been controlled
(danger of aspiration).
* Use phenobarbital (200 mg/ml solution) in a dose of 20 mg/kg to
control convulsions in infants <2 weeks of age:
Weight 2 kg—initial dose: 0.2 ml, repeat 0.1 ml after 30 minute
Weight 3 kg—initial dose: 0.3 ml, repeat 0.15 ml after 30 minute
if
convulsions
continue }
15
1. ETAT
CHART 10. How to give IV glucose
➤ Insert IV line and draw blood for emergency laboratory investigations
➤ Check blood glucose. If low (<2.5 mmol/litre (45 mg/dl) in a well
nourished or <3 mmol/litre (54 mg/dl) in a severely malnourished
child) or if dextrostix is not available:
➤ Give 5 ml/kg of 10% glucose solution rapidly by IV injection
Volume of 10% glucose solution
Age/weight to give as bolus (5 ml/kg)
Less than 2 months (<4 kg) 15 ml
2–<4 months (4–<6 kg) 25 ml
4–<12 months (6–<10 kg) 40 ml
1–<3 years (10–<14 kg) 60 ml
3–<5 years (14–<19 kg) 80 ml
➤ Recheck the blood glucose in 30 minutes. If it is still low, repeat
5 ml/kg of 10% glucose solution.
➤ Feed the child as soon as conscious.
If not able to feed without danger of aspiration, give:
—milk or sugar solution via nasogastric tube (to make sugar solution,
dissolve 4 level teaspoons of sugar (20 grams) in a 200-ml cup of
clean water), or
—IV fluids containing 5–10% glucose (dextrose) (see App. 4, p. 357)
Note: 50% glucose solution is the same as 50% dextrose solution or D50.
If only 50% glucose solution is available: dilute 1 part 50% glucose solution to
4 parts sterile water, or dilute 1 part 50% glucose solution to 9 parts 5% glucose
solution.
Note: For the use of dextrostix, refer to instruction on box. Generally, the strip must
be stored in its box, at 2–3 °C, avoiding sunlight or high humidity. A drop of blood
should be placed on the strip (it is necessary to cover all the reagent area). After 60
seconds, the blood should be washed off gently with drops of cold water and the
colour compared with the key on the bottle or on the blood glucose reader. (The exact
procedure will vary with different strips.)
16
1. ETAT
For children with severe dehydration but without shock, refer to diarrhoea
treatment plan C, p.114.
If the child is in shock, first follow the instructions in Charts 7 and 8
(pages 12 and 13). Switch to the present chart when the child’s pulse
becomes slower or the capillary refill is faster.
➤ Give 70 ml/kg of Ringer's lactate solution (or, if not available, normal
saline) over 5 hours in infants (aged <12 months) and over 21/2 hours
in children (aged 12 months to 5 years).
Total volume IV fluid (volume per hour)
Age <12 months Age 12 months to 5 years
Weight Give over 5 hours Give over 21/2 hours
<4 kg 200 ml (40 ml/h) —
4–6 kg 350 ml (70 ml/h) —
6–10 kg 550 ml (110 ml/h) 550 ml (220 ml/h)
10–14 kg 850 ml (170 ml/h) 850 ml (340 ml/h)
14–19 kg — 1200 ml (480 ml/h)
Reassess the child every 1–2 hours. If the hydration status is not
improving, give the IV drip more rapidly
Also give ORS solution (about 5 ml/kg/hour) as soon as the child can
drink; this is usually after 3–4 hours (in infants) or 1–2 hours (in children).
Weight Volume of ORS solution per hour
<4 kg 15 ml
4–6 kg 25 ml
6–10 kg 40 ml
10–14 kg 60 ml
14–19 kg 85 ml
Reassess after 6 hours (infants) and after 3 hours (children). Classify
dehydration. Then choose the appropriate plan (A, B, or C, pages 120,
117, 114) to continue treatment.
If possible, observe the child for at least 6 hours after rehydration to be
sure that the mother can maintain hydration by giving the child ORS
solution by mouth.
CHART 11. How to treat severe dehydration in an
emergency setting after initial management of shock
17
1. ETAT
1.2 Notes for the assessment of emergency
and priority signs
■ Assess the airway and breathing (A, B)
Does the child’s breathing appear obstructed? Look and listen to determine if
there is poor air movement during breathing.
Is there severe respiratory distress? The breathing is very laboured, the child
uses auxiliary muscles for breathing (shows head nodding), is breathing very
fast, and the child appears to tire easily. Child is not able to feed because of
respiratory distress.
Is there central cyanosis? There is a bluish/purplish discoloration of the tongue
and the inside of the mouth.
■ Assess circulation (for shock) (C)
Check if the child’s hand is cold? If so
Check if the capillary refill time is longer than 3 seconds. Apply pressure to
whiten the nail of the thumb or the big toe for 3 seconds. Determine the time
from the moment of release until total recovery of the pink colour.
If capillary refill takes longer than 3 seconds, check the pulse. Is it weak and
fast? If the radial pulse is strong and not obviously fast, the child is not in
shock. If you cannot feel a radial pulse of an infant (less than 1 year old), feel
the brachial pulse or, if the infant is lying down, the femoral pulse. If you
cannot feel the radial pulse of a child, feel the carotid. If the room is very cold,
rely on the pulse to determine whether the child may be in shock.
■ Assess for coma or convulsions or other abnormal mental status (C)
Is the child in coma? Check the level of consciousness on the AVPU scale:
A alert,
V responds to voice,
P responds to pain,
U unconscious.
If the child is not awake and alert, try to rouse the child by talking or shaking
the arm. If the child is not alert, but responds to voice, he is lethargic. If there
is no response, ask the mother if the child has been abnormally sleepy or
difficult to wake. Look if the child responds to pain, or if he is unresponsive to
a painful stimulus. If this is the case, the child is in coma (unconscious) and
needs emergency treatment.
Is the child convulsing? Are there spasmodic repeated movements in an
unresponsive child?
ASSESSMENT OF EMERGENCY AND PRIORITY SIGNS
18
1. ETAT
EMERGENCY TREATMENT FOR THE CHILD WITH SEVERE MALNUTRITION
■ Assess for severe dehydration if the child has diarrhoea (D)
Does the child have sunken eyes? Ask the mother if the child’s eyes are more
sunken than usual.
Does a skin pinch go back very slowly (longer than 2 seconds)? Pinch the skin
of the abdomen halfway between the umbilicus and the side for 1 second, then
release and observe.
■ Assess for priority signs
While assessing for emergency signs, you will have noted several possible
priority signs:
Is there any respiratory distress (not severe)?
Is the child lethargic or continuously irritable or restless?
This was noted when you assessed for coma.
Note the other priority signs (see page 5).
1.3 Notes for giving emergency treatment to the child
with severe malnutrition
During the triage process, all children with severe malnutrition will be identified
as having priority signs, which means that they require prompt assessment
and treatment.
A few children with severe malnutrition will be found during triage assessment
to have emergency signs.
• Those with emergency signs for “airway and breathing” and “coma or
convulsions” should receive emergency treatment accordingly (see charts
on pages 4–16).
• Those with signs of severe dehydration but not shock should not be
rehydrated with IV fluids. This is because the diagnosis of severe dehydration
is difficult in severe malnutrition and is often misdiagnosed. Giving IV fluids
puts these children at risk of overhydration and death from heart failure.
Therefore, these children should be rehydrated orally using the special
rehydration solution for severe malnutrition (ReSoMal). See Chapter 7 (page
179).
• Those with signs of shock are assessed for further signs (lethargic or
unconscious). This is because in severe malnutrition the usual emergency
signs for shock may be present even when there is no shock.
— If the child is lethargic or unconscious, keep warm and give 10% glucose
5 ml/kg IV (see Chart 10, page 15), and then IV fluids (see Chart 8, page
13, and the Note given below).
19
1. ETAT
CHILDREN PRESENTING WITH EMERGENCY CONDITIONS
— If the child is alert, keep warm and give 10% glucose (10 ml/kg) by
mouth or nasogastric tube, and proceed to immediate full assessment
and treatment. See Chapter 7 (page 173) for details.
Note: When giving IV fluids, treatment for shock differs from that for a wellnourished
child. This is because shock from dehydration and sepsis are likely
to coexist and these are difficult to differentiate on clinical grounds alone.
Children with dehydration respond to IV fluids (breathing and pulse rates fall,
faster capillary refill). Those with septic shock and no dehydration will not
respond. The amount of fluid given should be guided by the child’s response.
Avoid overhydration. Monitor the pulse and breathing at the start and every
5–10 minutes to check if improving or not. Note that the type of IV fluid also
differs in severe malnutrition, and the infusion rate is slower.
All severely malnourished children require prompt assessment and treatment
to deal with serious problems such as hypoglycaemia, hypothermia, severe
infection, severe anaemia and potentially blinding eye problems. It is equally
important to take prompt action to prevent some of these problems, if they
were not present at the time of admission to hospital.
1.4 Diagnostic considerations of children presenting with
emergency conditions
The following text provides guidance for the approach to the diagnosis and the
differential diagnosis of presenting conditions for which emergency treatment
has been provided. After you have stabilized the child and provided emergency
treatment, determine the underlying cause of the problem, to be able to provide
specific curative treatment. The following lists and tables provide some guidance
which help with the differential diagnosis, and are complemented by the tables
in the symptom-specific chapters.
1.4.1 Child presenting with an airway or severe breathing problem
History
• Onset of symptoms: slowly developing or sudden onset
• Previous similar episodes
• Upper respiratory tract infection
• Cough
— duration in days
• History of choking
• Present since birth, or acquired
• Immunization history
— DTP, measles (continued on page 21)
20
1. ETAT
CHILD PRESENTING WITH AN AIRWAY OR SEVERE BREATHING PROBLEM
Table 1. Differential diagnosis of the child presenting with an airway
or severe breathing problem
Diagnosis or underlying cause In favour
Pneumonia —Cough with fast breathing and fever
—Development over days, getting worse
—Crepitations on auscultation
Asthma —History of recurrent wheezing
—Prolonged expiration
—Wheezing or reduced air entry
—Response to bronchodilators
Foreign body aspiration —History of sudden choking
—Sudden onset of stridor or respiratory distress
—Focal reduced air entry or wheeze
Retropharyngeal abscess —Slow development over days, getting worse
—Inability to swallow
—High fever
Croup —Barking cough
—Hoarse voice
—Associated with upper respiratory tract infection
Diphtheria —Bull neck appearance of neck due to enlarged lymph
nodes
—Red throat
—Grey pharyngeal membrane
—No DTP vaccination
Table 2. Differential diagnosis of the child presenting with shock
Diagnosis or underlying cause In favour
Bleeding shock —History of trauma
—Bleeding site
Dengue shock syndrome —Known dengue outbreak or season
—History of high fever
—Purpura
Cardiac shock —History of heart disease
—Enlarged neck veins and liver
Septic shock —History of febrile illness
—Very ill child
—Known outbreak of meningococcal infection
Shock associated with severe —History of profuse diarrhoea
dehydration —Known cholera outbreak
21
1. ETAT
CHILD PRESENTING WITH SHOCK
• Known HIV infection
• Family history of asthma
Examination
• Cough
— quality of cough
• Cyanosis
• Respiratory distress
• Grunting
• Stridor, abnormal breath sounds
• Nasal flaring
• Swelling of the neck
• Crepitations
• Wheezing
— generalized
— focal
• Reduced air entry
— generalized
— focal
1.4.2 Child presenting with shock
History
• Acute or sudden onset
• Trauma
• Bleeding
• History of congenital or rheumatic heart disease
• History of diarrhoea
• Any febrile illness
• Known dengue outbreak
• Known meningitis outbreak
• Fever
• Able to feed
Examination
• Consciousness
• Any bleeding sites
• Neck veins
• Liver size
• Petechiae
• Purpura
22
1. ETAT
1.4.3 Child presenting with lethargy, unconsciousness or
convulsions
History
Determine if there is a history of:
• fever
• head injury
• drug overdose or toxin ingestion
• convulsions: How long do they last? Have there been previous febrile
convulsions? Epilepsy?
In the case of an infant less than 1 week old, consider:
• birth asphyxia
• birth injury.
Examination
General
• jaundice
• severe palmar pallor
• peripheral oedema
• level of consciousness
• petechial rash.
Head/neck
• stiff neck
• signs of head trauma, or other injuries
• pupil size and reactions to light
• tense or bulging fontanelle
• abnormal posture.
Laboratory investigations
If meningitis is suspected and the child has no signs of raised intracranial
pressure (unequal pupils, rigid posture, paralysis of limbs or trunk, irregular
breathing), perform a lumbar puncture.
In a malarious area, prepare a blood smear.
If the child is unconscious, check the blood glucose. Check the blood pressure
(if a suitable paediatric cuff is available) and carry out urine microscopy if
possible .
It is important to determine the length of time a child has been unconscious
and his/her AVPU score (see page 17). This coma scale score should be
CHILD PRESENTING WITH LETHARGY, UNCONSCIOUSNESS OR CONVULSIONS
23
1. ETAT
CHILD PRESENTING WITH LETHARGY, UNCONSCIOUSNESS OR CONVULSIONS
Table 3. Differential diagnosis of the child presenting with lethargy,
unconsciousness or convulsions
Diagnosis or underlying cause In favour
Meningitis a,b —Very irritable
—Stiff neck or bulging fontanelle
—Petechial rash (meningococcal meningitis only)
Cerebral malaria (only in —Blood smear positive for malaria parasites
children exposed to —Jaundice
P. falciparum transmission; —Anaemia
often seasonal) —Convulsions
—Hypoglycaemia
Febrile convulsions (not likely —Prior episodes of short convulsions when febrile
to be the cause of —Associated with fever
unconsciousness) —Age 6 months to 5 years
—Blood smear normal
Hypoglycaemia (always seek —Blood glucose low; responds to glucose treatment c
the cause, e.g. severe malaria,
and treat the cause to prevent
a recurrence)
Head injury —Signs or history of head trauma
Poisoning —History of poison ingestion or drug overdose
Shock (can cause lethargy or —Poor perfusion
unconsciousness, but is —Rapid, weak pulse
unlikely to cause convulsions)
Acute glomerulonephritis with —Raised blood pressure
encephalopathy —Peripheral or facial oedema
—Blood in urine
—Decreased or no urine
Diabetic ketoacidosis —High blood sugar
—History of polydipsia and polyuria
—Acidotic (deep, laboured) breathing
a The differential diagnosis of meningitis may include encephalitis, cerebral abscess or tuberculous
meningitis. If these are common in your area, consult a standard textbook of paediatrics for further
guidance.
b A lumbar puncture should not be done if there are signs of raised intracranial pressure (see pages 149,
316). A positive lumbar puncture is one where there is cloudy CSF on direct visual inspection. CSF
examination shows an abnormal number of white cells (>100 polymorphonuclear cells per ml). A cell
count should be carried out, if possible. However, if this is not possible, then a cloudy CSF on direct
visual inspection could be considered positive. Confirmation is given by a low CSF glucose
(<1.5 mmol/litre), high CSF protein (>0.4 g/litre), organisms identified by Gram stain or a positive
culture, where these are available.
c Low blood glucose is <2.5 mmol/litre (<45 mg/dl), or <3.0 mmol/litre (<54 mg/dl) in a severely
malnourished child.
24
1. ETAT
monitored regularly. In young infants (less than 1 week old), note the time
between birth and the onset of unconsciousness.
Other causes of lethargy, unconsciousness or convulsions in some regions of
the world include Japanese encephalitis, dengue haemorrhagic fever, typhoid,
and relapsing fever.
Table 4. Differential diagnosis of the young infant (less than 2 months)
presenting with lethargy, unconsciousness or convulsions
Diagnosis or underlying cause In favour
Birth asphyxia —Onset in first 3 days of life
Hypoxic ischaemic encephalopathy —History of difficult delivery
Birth trauma
Intracranial haemorrhage —Onset in first 3 days of life in a low-birth-weight
or preterm Infant
Haemolytic disease of the —Onset in first 3 days of life
newborn, kernicterus —Jaundice
—Pallor
—Serious bacterial infection
Neonatal tetanus —Onset at age 3–14 days
—Irritability
—Difficulty in breastfeeding
—Trismus
—Muscle spasms
—Convulsions
Meningitis —Lethargy
—Apnoeic episodes
—Convulsions
—High-pitched cry
—Tense/bulging fontanelle
Sepsis —Fever or hypothermia
—Shock
—Seriously ill with no apparent cause
Echocardiogram showing reduced opening of the mitral valve
in diastole. 
Colour Doppler showing turbulent
flow.
" target="_blank">www.acc.org, which has comprehensive
guidelines on valvular heart disease.
