Triage and the “ABCD” Concept, Lecture notes of Nursing

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Triage and the “ABCD” Concept

ETAT Module 1

Adapted from Emergency Triage Assessment and Treatment (ETAT): Manual for Participants, World Health Organization, 2005

Learning Objectives

• Understand the importance of continually assessing the medical needs of all children from arrival at the healthcare facility until discharge
• Recognize emergency (ABCD) and priority signs
• Assign children triage categories, based on emergency and priority signs
• Identify the appropriate immediate response for children in each triage category

Overview

• What is triage?

• Performing a rapid

assessment

• The ETAT tool

• Emergency signs

• Priority signs

Triage: what and why

• What : Sorting patients into priority groups according to their needs and the resources available
• Why : Identify and treat seriously ill children as soon as possible to prevent deterioration in their conditions

How to perform a rapid

assessment

• Look and listen
• What is the overall appearance of the child? - Is he playful and interactive? - Is she quiet or poorly responsive?
• For children who are ill appearing, systematically look for the presence of emergency and priority signs

ETAT: Emergency Triage Assessment

Treatment Tool

• Reliably sorts children into the following treatment categories: - immediate emergency treatment (E) - rapid assessment and treatment (P) - with non-urgent conditions (N)

Adapted from ETAT manual for participants, Chart 2 page 67

Emergency signs

• Airway
• Breathing
• Circulation
• Coma
• Convulsion
• Dehydration (severe)

Airway

• Is the airway obstructed?
• Signs of airway obstruction
  • Complete obstruction: no air movement
  • Partial airway obstruction: noisy breathing during inspiration

She is in severe distress and choking

but she is not making any sound.

What is her triage category?

What should you do next?

Emergency

Call the triage nurse.

Breathing (2)

• Is there increased work of breathing?
  • Can the child nurse or talk?
  • Is there severe indrawing of the chest?
• What is the rate and pattern of breathing?
  • Too fast
  • Too slow
  • Agonal breathing: irregular, slow
  • Abnormal patterns
    • Deep, slow (as with acidosis)
    • Irregular (as with brain abnormalities)

Increased Work of Breathing

• Anxious
• Nasal flaring
• Indrawing of chest
  • Between the ribs
  • Below the breast bone

PALS: Rapid Cardiopulmonary Assessment, American Heart Association 2001

He is sick.

What should you do next?

Assess airway and breathing.

There is no noisy breathing. The

respiratory rate is rapid and there is

marked indrawing of the chest.

Describe his respiratory status.