Download Triage and Emergency Treatments: Quick Check Essentials

IMAI second-level
learning programme
for district clinicians
working at hospitals
in limited-resource
settings
Participant training manual
for clinicians:
Triage and Emergency
Treatments: Quick Check
Essentials
This manual covers the training of nurses,
clinical officers and medical doctors in the
recognition and care of emergency patients
using the Quick Check method.
June 2014
Integrated Management
of Adolescent and Adult
Illness (IMAI)
IMAI second-level learning programme for district clinicians
working at hospitals in limited-resource settings
Participant training manual:
Triage and Emergency Treatments:
Quick Check Essentials
This manual covers the training of nurses, clinical officers and medical doctors in
the recognition and care of emergency patients using the Quick Check method.
This training course is based on guidelines in the IMAI District Clinician Manual:
Hospital Care for Adolescents and Adults
June 2014
Produced by IMAI-IMCI Alliance for WHO HSE/PED
Comments to:
[email protected]
Development of the Quick Check+ training curriculum was supported by funding
from the government of USA (DOD DTRA) and the Government of Japan through
grants to WHO/HSE/ Pandemic and Epidemic Diseases ( PED) (project manager
Nikki Shindo) , with the support of WHO regional office for Africa (Francis Kasolo,
Benido Impouma) and the WHO country offices in affected countries.
Produced by the IMAI-IMCI Alliance. Design and illustrations: Robert Thatcher
Table of contents
Introduction: Quick Check ................................................................................................ 1
Chapter 1: Quick Check: Assess emergency and priority signs ................................... 2
DRILL 1-1: Quick Check Assessment.......................................................................................... 7
Assessment questions: Triage..................................................................................................... 9
Chapter 2: Airway and Breathing ................................................................................... 10
DRILL 2-1: Manage Patient on Oxygen: What would you do next? ............................................ 24
DRILL 2-2: What is the next emergency treatment? .................................................................. 25
Assessment questions: Airway and Breathing ........................................................................... 28
Chapter 3: Circulation ..................................................................................................... 29
DRILL 3-1: What you would do next? ........................................................................................ 35
DRILL 3-2: What you would do next? ........................................................................................ 37
Assessment questions: Circulation ............................................................................................ 38
Chapter 4: Altered level Consciousness/Convulsing ................................................... 39
DRILL 4-1: AVPU Scale ............................................................................................................ 40
DRILL 4-2: First-line emergency treatment: What would you do next? ...................................... 48
Assessment questions: Altered level of Consciousness and Convulsion ................................... 50
Chapter 5: Pain from life-threatening cause .................................................................. 52
DRILL 5-1: Quick Check ............................................................................................................ 59
Assessment questions: Severe pain .......................................................................................... 61
Chapter 6: Priority signs and their immediate management ....................................... 63
Assessment questions: Priority patients .................................................................................... 70
Chapter 7: Continue with urgent management of patients with emergency signs .... 71
DRILL 7-1: Continue with urgent management .......................................................................... 77
Assessment questions: Continued urgent management of patients with emergency signs ........ 82
Chapter 8: Implementing the Quick Check and emergency treatments ..................... 83
Quick Check Implementation Exercise ...................................................................................... 88
Introduction: Quick Check
This training course will teach you to triage and give first line emergency treatments for
adults and adolescents using the IMAI Quick Check (QC) method. The Quick Check is the
adult version of the paediatric Emergency Triage Assessment and Treatment (ETAT) and
is designed to be compatible with it.
Many deaths can be prevented if very sick patients are identified quickly on their arrival to
the health facility and treatment is started without delay. The QC assessment is a triage
system that sorts patients out into groups who need emergency or urgent treatment. With
appropriate training, the QC assessment can be done in less than one minute.
Effective emergency management is accomplished by a team. Teamwork therefore is
emphasized and practiced throughout the course. This training course should be part of a
quality improvement process which targets the whole hospital. The appropriate sections of
the IMAI District Clinician Manual (DCM) should be used as a clinical reference for details
on patient management.
After you have completed the Quick Check training, you will be able to:
•
triage adolescents and adults at the health facility
•
provide life-saving first-line emergency treatments and stabilize the patient
•
plan and implement the Quick Check in your own hospital as part of a clinical team.
Participant training manual: Quick Check, triage and emergency treatments
Introduction – 1
Chapter 1:
Quick Check: Assess emergency
and priority signs
Learning objectives:
1. Triage (sort) patients according to the severity of illness using the Quick Check in your facility.
2. Recognize patients with Quick Check emergency signs (E).
3. Recognize patients with Quick Check priority signs (P).
4. Recognize patients who are non-urgent (can wait their turn in the queue) (Q).
Around the world, many deaths in hospitals occur within 24 hours of admission. Often,
patients wait in long queues and are not checked before a senior health worker
examines them. As a result, seriously ill patients with treatable conditions have died while
waiting to be seen and treated.
A triage system will enable you to quickly identify sick patients who require immediate
attention versus patients who can wait their turn. The word “triage” means sorting. Triage
is the process of rapidly screening all sick patients when they first arrive in the hospital and
categorizing them according to the order in which they need to be seen based on the
severity of illness.
After triage occurs, assess all patients with a complete history and physical exam.
How do you triage patients in your hospital?
Triage is a rapid process that is conducted as soon as a
patient arrives at the hospital or anytime a patient’s
clinical condition changes in the hospital ward. When no
emergency treatments are needed, you should be able to
use the Quick Check to triage a patient in less than one
minute. Do not delay triage for administrative procedures
such as registration.
Triage
Sorting of patients into groups
based on their need and the
severity of their condition
•
All clinical staff involved in the care of sick patients should be trained to triage and give
basic emergency treatments.
•
Other auxiliary staff in the hospital such as gatemen, record clerks, cleaners, and
janitors who have early patient contact should also be trained to assess for emergency
and priority signs. If a patient with a life-threatening condition is recognized, staff
should immediately call for help and/or take the patient to where they can receive
emergency care. A seriously ill patient should be taken to the triage nurse at the front
of the queue.
2 – Chapter 1
Participant training manual: Quick Check, triage and emergency treatments
During triage, you will find that some patients require immediate emergency care. Provide
emergency treatments wherever there is room for a bed or trolley for the sick patient and
enough space for the staff to work on the patient. Ensure that an emergency trolley with
drugs and supplies is easily accessible (see DCM, QC p.38 for Emergency trolley). Always
use universal precautions for infection control.
Triage categories: Recognize emergency, priority, or queue
Triage categories
Action required
EMERGENCY cases
Need IMMEDIATE emergency treatment
PRIORITY cases
Need assessment and RAPID attention
QUEUE cases
Non-urgent, can wait their turn in the QUEUE
EMERGENCY (E): Patients require immediate emergency treatment for a potentially lifethreatening condition. If you see any emergency signs, call for help and start first-line emergency
treatments.
PRIORITY (P): Patients with serious conditions that require rapid assessment and treatment. Give
these patients priority in the queue so they are evaluated quickly by a healthcare worker.
QUEUE (Q): Patients who do not have a life-threatening or serious condition are non-urgent.
These patients can wait their turn in the queue for evaluation. Most patients will be triaged to this
category.
Emergency signs
Check for emergency signs
Emergencies of Airway, Breathing, and
Circulation, Consciousness, Convulsions are
life threatening. Every time you evaluate a
patient immediately assess for airway,
breathing, circulation, consciousness, or
convulsions and treat without delay. If a
patient deteriorates, reassess and manage the
ABCs first.
A B C

Airway

Breathing

Circulation

Consciousness

Convulsing
In the children's ETAT, the ABC concept is expanded to include “dehydration” in the
emergency assessment and is remembered as “ABCD”. In the Quick Check, the ABC
concept has been expanded to include “pain from life-threatening cause.” As in the ETAT
(ABCD), pain from life threatening cause can be remembered as “Dolor.”
On the Quick Check wallchart, the emergency signs are located in the white boxes on the
left of the chart. Emergency signs can be assessed quickly without any equipment. If any
emergency sign is identified, call for help. If you are trained, start necessary emergency
treatments. In this chapter, you will learn how to conduct this Quick Check for emergency
and priority signs only. In the following chapters, you will learn how to do the assessments
in the arrows on the Quick Check wallchart and to provide first-line treatments.
Participant training manual: Quick Check, triage and emergency treatments
Chapter 1 – 3
The Quick Check assessment for emergency signs
FIRST ASSESS: AIRWAY AND BREATHING

Appears obstructed
or
 Central cyanosis
or
 Severe respiratory distress
THEN ASSESS: CIRCULATION (SHOCK or heavy BLEEDING)

Weak or fast pulse
or
 Capillary refill longer than 3 seconds
or
 Heavy bleeding from any site
or
 Severe trauma
THEN ASSESS: ALTERED LEVEL CONCIOUSNESS/CONVULSING

Altered level consciousness
or
 Convulsing
THEN ASSESS: PAIN FROM LIFE-THREATENING CAUSE

Severe abdominal pain
and
 Abdomen hard on palpation

Severe headache
or
 Stiff neck
or
 Trauma to head/neck
4 – Chapter 1

New onset chest pain

Major burn

Snake-bite
Participant training manual: Quick Check, triage and emergency treatments
Priority signs
Check for priority signs
If no emergency signs are found, check for priority signs. Priority signs alert you to a
patient who needs urgent (but not emergency) treatment for potentially serious acute
problems. Priority patients should ideally be evaluated within 30 minutes of arrival at the
hospital.
As with all patient care, it is important to remember infection prevention and control. If
cough or other signs of respiratory illness, apply source control (use of tissues,
handkerchiefs or medical masks) on the patient in the waiting room when coughing or
sneezing, and perform hand hygiene. If possible, accommodate patient at least 1 meter
away from other patients or in a room, and evaluate as soon as possible – see Section 6.
If history of exposure or fever, bleeding or other signs during an outbreak suggest viral
haemorrhagic fever: isolate the patient, use standard precautions and personal protection
equipment, call for help. See Section 11.46 in IMAI District Clinician Manual and VHF
guidelines.
Priority signs for urgent care – these patients should not wait in queue:















Any respiratory distress/complaint of difficulty breathing*
Violent behaviour towards self or others or very agitated
Very pale
Very weak/ill
Recent fainting
Bleeding:
 Large haemoptysis
 GI bleeding (vomiting or in stools)
 External bleeding
Fractures or dislocations
Burns
Bites from suspected venomous snake or from rabid animal
Frequent diarrhoea >5 times per day
Visual changes
New loss of function (possible stroke)
Rape/abuse (maintain a high index of suspicion)
New extensive rash with peeling and mucus membrane involvement (Stevens-Johnson)
Acute pain, cough or dyspnea, priapism, or fever in patient with sickle cell disease
* Patients in severe distress are categorized as having an emergency sign.
These are suggested priority signs that may need to be adapted to include commonly
seen urgent conditions and based on local epidemiology of disease.
Class activity
Stand by the Quick Check wallchart. Using the Quick Check wallchart, identify the
emergency and priority signs.
As a group, repeat the emergency and priority signs aloud.
Participant training manual: Quick Check, triage and emergency treatments
Chapter 1 – 5
Class exercise 1-1
You have many patients waiting in line. You must triage these patients. Label each patient as
(E)mergency, (P)riority, or (Q)ueue. Use the Quick Check wallchart to help you.
1. 33-year-old asthmatic with severe respiratory
distress, unable to speak in complete
sentences
2. 18-year-old male with pain and swelling to left
ankle for 2 days
3. 50-year-old female with severe headache and
confusion
4. 30-year-old female with severe abdominal pain
who is in her first trimester of pregnancy
5. 38-year-old male who is too weak to stand
6. 26-year-old female with cough and mild
respiratory distress
7. 30-year-old male with severe abdominal pain
after a motorbike accident
8. 17-year-old pregnant female with convulsions
9.
54-year-old male with rash to the legs for 1
month
10. 22-year-old female with depression and
suicidal ideation
After initial triage
Give first-line emergency treatments
The assessment for emergency signs and need for first-line emergency treatment will be
covered in detail throughout the rest of this course. The triage, assessment, and initial
treatments should occur quickly and address immediate, life-threatening emergency signs.
These steps can be critical to the care of a severely ill patient. They should be initiated
even if senior health workers are not immediately available.
C AU T I O N !
Patients with trauma may have injuries to their spine. Check for trauma when providing
treatments to make sure that you immobilize spine when moving patient. There are
special considerations for injured patients in column 3 of the Quick Check wallchart.
6 – Chapter 1
Participant training manual: Quick Check, triage and emergency treatments
If emergency sign identified:
•
call for help
•
give first line emergency treatments
•
establish IV access
•
draw blood for emergency laboratory investigations
•
stay calm
•
work as a team
•
use infection control precautions.
More than one treatment may need to be given as quickly as possible. Several people
may need to work together as a team. The person in charge should assign tasks such has
placing an IV or giving emergency medications. These guidelines are intended to help
guide management of patients with severe illness and may not be appropriate for all
patients. If the situation is complicated by other underlying co-morbidities (i.e. cardiac
disease, renal failure, severe anaemia) or diseases (dengue fever, severe malaria), the
district clinician can determine if the guidelines need to be modified. Protocols developed
by your hospital adapted to the local epidemiology should also be followed. While these
management principles may be used for most patients, they are not intended to replace
the sound clinical judgement of trained clinicians.
Treat for priority signs
Patients with priority signs should be moved to the front of the queue. These patients have
potentially serious conditions that may worsen if care is delayed. Some hospitals may
choose to place priority patients in a separate room or treatment area. While waiting,
supportive treatments should be provided, for example holding pressure on a bleeding
wound.
If the patient presents with no emergency signs or priority signs, the patient can wait in
the queue.
Reassess
Frequent reassessment of patients is critical. Patients initially triaged as “Priority” or
“Queue” can later develop emergency signs if their condition worsens. Thus, it is important
to reassess patients and change their triage category to “Emergency,” when appropriate.
DRILL 1-1:
Quick Check Assessment
Your facilitator will lead a DRILL reviewing the Quick Check aloud. Stand around the Quick
Check wallchart to help you. You will soon be able to go through all the signs in order without
looking. Practice this exercise throughout the course.
Now try the Quick Check on each other. Divide into pairs. Do the Quick Check, saying out loud
what you are doing.
Participant training manual: Quick Check, triage and emergency treatments
Chapter 1 – 7
Summary
Triage is the process of sorting patients into priority groups based on their need and the
severity of their condition.
Triage all patients upon arrival into one of the following categories:
E – Patients with Emergency signs
P – Patients with Priority signs
Q – Patients who are non-urgent and can wait in the Queue
Triage steps:
1.
2.
3.
4.
5.
6.
Look for emergency signs.
Give first-line emergency treatments.
Call a senior health worker immediately to see emergency cases.
If no emergency signs are identified, look for priority signs.
If a priority sign is identified, send patient to the front of the queue.
Move on to the next patient.
Remember to check for trauma.
Pay attention to infection control.
Reassess patients as appropriate.
8 – Chapter 1
Participant training manual: Quick Check, triage and emergency treatments
Assessment questions:
Triage
Answer all the questions on this page. Write your responses in the given spaces. If you
have a problem, ask a facilitator for help.
1. Define “triage”.
2. When and where should triage take place?
3. What do the letters E, P and Q stand for?
4. True/False: Trained personnel should triage patients.
5. What do the letters A, B, and C in "ABC" stand for?
6. List three priority signs:
7. Put these actions in the right chronological order. What will you do first, what next, and
so on, and what last?
___ Look for any priority signs
___ Look for emergency signs
___ Move on to the next patient
___ Place priority patients at the front of the queue
___ Start treatment of any emergency signs you find
Participant training manual: Quick Check, triage and emergency treatments
Chapter 1 – 9
Chapter 2:
Airway and Breathing
Learning objectives
1.
Assess patient for emergency signs of airway or breathing.
2.
Give first-line emergency treatments for airway obstruction.
3.
Measure oxygen saturation with a pulse oximeter.
4.
Give oxygen and adjust flow.
5.
Treat wheezing with salbutamol.
The letters A and B in “ABC” represent
“airway and breathing”. An airway or
breathing problem is life-threatening and must
receive attention before moving on to other
systems. First check whether the airway is
open to allow proper breathing. If the airway is
open and the patient is breathing, assess if
breathing (ventilation) and oxygenation are
adequate or impaired. If there is no problem
with the airway or breathing, move on and look
for
emergency
signs
of
circulation,
consciousness, and convulsing.
A B C

Airway

Breathing

Circulation

Consciousness

Convulsing
Patients who are alert and having difficulty breathing will usually position themselves to
optimize their breathing. Patients with breathing difficulties may prefer to sit upright rather
than lying flat. Do not force a patient with respiratory distress to lie down on a stretcher.
Help the patient get to a comfortable position.
Supplemental oxygen
Supplemental oxygen can be a life-saving treatment. Oxygen therapy is indicated as a
treatment in many emergency presentations such as severe respiratory distress,
myocardial infarction, stroke, sepsis, and trauma. In low resource settings, effective
oxygen systems may be in limited supply. Where available, oxygen systems can be
sustainable and can significantly improve patient care.
Assess need for supplemental oxygen
Is the patient in severe respiratory distress?
Is the patient cyanotic or are their lips blue?
Is the patient convulsing?
Is the patient altered or confused?
Is the measured oxygen saturation <90%?
10 – Chapter 2
Participant training manual: Quick Check, triage and emergency treatments
How to measure oxygen saturation (SpO2):
A pulse oximeter measures oxygen saturation of haemoglobin in the blood by comparing
absorbance of light at different wavelengths across a translucent part of the body. Pulse
oximetry is very easy to use, and is the best method available for detecting and monitoring
hypoxemia (low oxygen saturation).
Pulse oximetry can also ensure the most efficient use of an expensive resource in your
hospital.
Class demonstration
Your facilitator may demonstrate how to use a pulse oximeter. When you go to the hospital you
should practice using the pulse oximeter on yourself and your colleagues so that you understand
how to use it in an emergency situation.
How to Set Up Oxygen
The oxygen source is attached to oxygen tubing. The oxygen tubing is then attached to a
device that allows the delivery of oxygen to the patient.
Participant training manual: Quick Check: triage and emergency treatments
Chapter 2 – 11
How to deliver oxygen
This section will cover three of the most common devices used to deliver oxygen in adults
and adolescents. It is important to familiarize yourself with the different devices and
understand how much flow can be delivered by each method.
Nasal cannula or prongs
•
Simple, flexible tubing systems with soft prongs that rest within the nasal openings.
•
Deliver relatively low flow rates of oxygen (generally 2–6 litres/minute).
•
Nasal cannula can be more comfortable for patients than face masks, allowing the
patient to eat and talk easily.
Face mask
•
Covers both the nose and mouth of a patient.
•
Used to deliver higher flow rates of oxygen (>5 litres/minute).
•
Delivery of oxygen to the patient can be variable based on how fast and deeply the
patient is breathing.
Face mask with reservoir (non-rebreather)
•
Only use with high flow rates of oxygen (10–15 litres/minute).
•
Deliver very high percentages of oxygen to a patient (60–95% FIO2).
•
High flows are needed to inflate the reservoir bag.
•
Use for patients who continue to be hypoxic despite lower oxygen flow.
•
Oxygen given by high flow should be humidified to prevent drying of air passages.
12 – Chapter 2
Participant training manual: Quick Check, triage and emergency treatments
FiO2
FiO2
FiO2
24–40%
35–55%
70–100%
1–5 litres/min
5–9 litres/min
10–15 litres/min
Follow a stepwise approach when assessing and managing
emergency signs of airway and breathing
1.
2.
3.
4.
5.
6.
Assess airway.
Open airway if airway obstructed.
Insert airway device to keep airway open and give oxygen if needed.
Assess ventilation and oxygenation.
Assist ventilation and/or supplement oxygenation as needed.
Assess need for advanced airway management.
Each of these steps is discussed in more detail in the following pages .
FIRST assess: Airway and Breathing:

Appears obstructed
or

Central cyanosis
or

Check for obstruction
(noisy breathing,
wheezing, choking,
not able to speak)
Severe respiratory distress
Give first line
emergency
treatments
If trauma patient with possible neck or spine injury, immobilize spine.
Look at the assessment box in the far left column of the Quick Check. There are three
emergency signs of airway and breathing.
1. Does the airway appear obstructed?
2. Is there central cyanosis?
3. Is the patient in severe respiratory distress?
Call for help and give first-line emergency treatments for airway and breathing if any of
these signs are detected.
Participant training manual: Quick Check: triage and emergency treatments
Chapter 2 – 13
Step 1: Assess airway
 Talk to the patient. If the patient is speaking clearly the airway is open.
 Look/listen for signs of airway obstruction

Snoring or gurgling

Stridor or noisy breathing
 Foreign body or vomit in mouth
Is the airway obstructed?
Rapid recognition of an obstructed airway and initiation of treatment to relieve the
obstruction can be life-saving. Patients can have a partial or full airway obstruction.
Patients should be under constant observation until the obstruction is removed because a
partial obstruction can rapidly progress to a full obstruction. Obstruction of the airway may
occur in several ways:
• the tongue may fall backwards and obstruct the airway in an unconscious patient
• blood or vomit in the mouth may obstruct the airway particularly in cases of trauma
• swelling and laryngeal oedema may obstruct the airway in anaphylaxis
• infection or swelling in the throat, such as an abscess or goitre
• foreign bodies, particularly poorly chewed food such as meat.
Look for:
• any visible obstruction (vomit in mouth, trauma, swelling, foreign body)
• the universal choking sign
• a patient who is unable to swallow secretions or saliva (may be spitting into a bucket).
Listen for:
• noisy breathing, snoring, gurgling, stridor, or wheezing
• a strong or weak cough
• a clear, normal voice. When asked a question, is the patient’s voice muffled, gasping,
or is the patient unable to speak at all?
• Is the patient in severe respiratory distress or coughing, but you do not hear any noise
(unable to speak or cough, no wheezing or stridor)?
Is there central cyanosis?
Cyanosis indicates that the patient is not getting enough oxygen.
Look:
• Do you see blue discoloration around the lips and mouth?
Is the patient in severe respiratory distress?
Look:
• Is the patient having visible difficulty breathing?
• Is the patient breathing very fast?
• Do you see retractions or the use of accessory muscles?
• Is the breathing laboured?
• Is the breathing shallow?
14 – Chapter 2
Participant training manual: Quick Check, triage and emergency treatments
•
•
•
Do you see nasal flaring?
Is the patient able to lie flat or does he/she need to sit forward to help breathing?
Is the patient agitated, confused, uncooperative, or unconscious?
Listen:
• Is the patient able to speak in full sentences without pausing to catch breath?
• Do you hear abnormal breathing sounds (stridor, wheezing)?
Other considerations
Make a quick visual decision if the patient is breathing too fast. You will not count the
respiratory rate as part of the quick check assessment, as counting the respiratory rate
accurately takes 30-60 seconds. Practice counting the respiratory rate on stable patients
first so you can quickly recognize the difference between normal and abnormal respiratory
rates. Once you complete the Quick Check and administer first-line emergency treatments,
count the respiratory rate along with the rest of the vital signs as you continue to monitor
the patient.
The respiratory rate increases if the patient has difficulty breathing or is not getting enough
oxygen. Be aware that other conditions such as fever, pain, and anxiety may also increase
the respiratory rate.
Patients who are in severe respiratory distress and not getting enough oxygen may
become very agitated, combative, confused, or lethargic. In any patient who is not
behaving normally, first check their airway and breathing.
The airway of an unconscious patient can become obstructed by the tongue at any time.
Unconscious patients should be placed near the nurses’ station in the recovery position if
possible, under continuous observation (see DCM-QC).
If patient presents with emergency signs of Airway and Breathing, call for
help and give:
First-line emergency treatments
If obstructed airway:



Appears obstructed
or
Central cyanosis
or
Severe respiratory
distress
Check for obstruction
(noisy breathing),
wheezing, choking,
not able to speak

If foreign body aspiration, treat choking
patient (see QC p. 11).

If suspect anaphylaxis, give 1:1000
epinephrine (adrenaline) IM – 0.5 ml if 50 kg or
above, 0.4 ml if 40 kg, 0.3 if 30 kg (see QC p.
11).
For all patients:
 Manage airway (see QC p. 12).

Give oxygen 5 litres (see QC pp.14–16).

If inadequate breathing, assist ventilation
with bag valve mask (see QC p. 13).

Help patient assume position of comfort.

If wheezing, give salbutamol.
Participant training manual: Quick Check: triage and emergency treatments
Chapter 2 – 15
Step 2: Open airway if airway obstructed
If foreign body aspiration, treat choking patient
If a patient appears to be choking but is still able to cough and appears to be getting
adequate ventilation, allow them to continue to try to clear the object on their own. If the
cough is weak and ineffective or there is evidence for increased respiratory distress and
worsening ventilation, it is time to step in and assist (see DCM-QC).
If suspect anaphylaxis (wheezing and facial swelling), give epinephrine
Anaphylaxis is a life threatening allergic reaction that can rapidly cause swelling of the
airway and obstruction. Insect bites, foods, or medications are common causes of
anaphylaxis.
Patients may present with swelling of the face and airway, wheezing, hives, and shock.
 How to give epinephrine

For anaphylaxis: give 1:1000 epinephrine (adrenaline) IM.
0.5 ml if 50 kg or above, 0.4 ml if 40 kg, 0.3 ml if 30 kg.


Give IM in anterior lateral thigh.
Repeat in five minutes if no response.

See Section 3.1.3 for further management.
Treating patients with allergic reactions with hydrocortisone will help to control the allergic
reaction once the epinephrine wears off. An antihistamine may help to provide
symptomatic relief of itching.
Observe patients given epinephrine for at least four hours prior to discharge.
16 – Chapter 2
Participant training manual: Quick Check, triage and emergency treatments
Techniques to open airway
In an unconscious patient, if airway obstruction occurs due to the tongue falling backward,
simple positioning manoeuvres can open the airway. If there is concern for trauma,
proceed with caution before attempting these manoeuvres. Improper use of these
procedures can further injure a patient with neck trauma. There are two ways to open the
airway that are generally recommended-the head tilt-chin lift manoeuvre and the jaw-thrust
manoeuvre.
Head tilt-chin lift manoeuvre
If there is NO concern for cervical spine injury, use the head-tilt chin-lift to open the airway
of an unresponsive patient. This manoeuvre lifts the tongue and epiglottis away from
obstructing the posterior pharynx and is demonstrated in the following diagram:
One hand tilts the forehead back while the other hand firmly lifts the chin
upward using two fingers, relieving the obstruction.
Jaw-thrust manoeuvre
If there is concern for possible cervical spine injury, first stabilize the spine. The jaw-thrust
manoeuvre is a safer choice for opening the airway in cases of trauma. It allows the airway
to be opened without extending the neck backward.
The clinician stabilizes both hands on either side of the patient’s head and
uses index and long fingers to grasp and lift jaw at the angles of the
mandible to displace the jaw forward (moving the tongue away from upper
airway).
Participant training manual: Quick Check: triage and emergency treatments
Chapter 2 – 17
Step 3: Insert airway device and give oxygen if needed
Once the airway is opened an airway device may be needed to keep the airway open.
Airway devices maintain an opening for air to move through, bypassing blockage due to an
obstructing tongue.
These devices do not protect an unconscious patient from aspiration of secretions or
gastric contents, nor should they be used if you suspect an obstruction due to a foreign
body. Oropharyngeal airways may not be tolerated by a semiconscious patient with an
intact gag response and may cause unintended vomiting or aspiration (remove device if
patient begins to gag or vomit with placement).
Care must be taken to choose the correct size. Obstruction by pushing the tongue further
back in the oropharynx may also be caused when placing an oral device with poor
technique.
Once the airway device is placed, make sure to administer oxygen.
Simple instructions on how to choose the correct device and insert are as follows:
Inserting an oropharyngeal airway
Inserting a nasopharyngeal
To insert an oropharyngeal airway in an adolescent or
adult, begin by inserting the device concave side up
until the tip reaches the soft palate, then carefully turn
concave side down while sliding tip back over curve of
tongue.
To insert a nasopharyngeal airway select a tube
approximately the size of the nostril, and gently insert
a well lubricated tube into nostril. The stopper at the
tip of the tube should be up against the end of the
nostril.
18 – Chapter 2
Participant training manual: Quick Check, triage and emergency treatments
Step 4: Assess ventilation and oxygenation
Is ventilation impaired?
Ventilation refers to movement of air in and out of the lungs. This air movement is impaired
in patients with a decreased drive to breathe (low respiratory rate), from altered
consciousness. Common conditions include patients with drug overdose, meningitis, or
head injury.
Ventilation can also be impaired when breaths are shallow or ineffective such as in
patients with severe pneumonia, bronchospasm, or chest trauma. In contrast, these
patients are often breathing very rapidly.
ASSESS VENTILATION
If ventilation is inadequate, or patient is cyanotic or unconscious with respiratory distress, then
assist breathing via bag valve mask ventilation (go to STEP 5).
If ventilation is adequate, give oxygen and titrate flow .
Look:
•
Is the chest wall rising?
•
Is the movement of the chest wall symmetric?
•
Is the respiratory effort adequate?
Listen:
•
Do you hear air movement?
•
Do you hear breath sounds and are they equal?
If ventilation is impaired, give oxygen and prepare to assist ventilation.
Step 5: Assist ventilation with bag valve mask
If a patient is not ventilating adequately, assistance can be given using a bag-valve-mask
device. A self-inflating bag delivers air when squeezed to ventilate the patient, and then
refills when released. Attach the bag to oxygen to deliver a higher concentration of oxygen
than room air.
The bag is connected via a valve to the face mask. The face mask should fit the face
starting at the bridge of the nose, resting evenly over both cheeks, and ending in the area
between the lower lip and chin (mandibular alveolar ridge). It is important to use the right
size face mask to prevent air leakage.
Using this device correctly can be difficult. When ventilating a patient, you have to
maintain an adequate seal with the mask so that no air escapes from around the mouth.
Practice is helpful. Instructions for a single-handed mask hold and a double-handed two
person mask hold are described below. Note that the hand holds serve two purposes: first
to produce an effective mask seal, and second to open the airway with a chin-lift or jawthrust.
Participant training manual: Quick Check: triage and emergency treatments
Chapter 2 – 19
Three major points must be observed during the use of a bag-valve-mask:
• Is the airway still open (or does positioning need adjustment)?
•
Is there an adequate mask seal (or is there air escaping)?
•
Are you giving proper ventilation (breath volume, rate, rhythm)?
ASSIST VENTILATION WITH BAG VALVE MASK
 Attach the bag valve mask (BVM) to highest available flow oxygen.
 Place mask over patient’s mouth and nose (if two people: one person squeezes bag and other holds
mask on patient’s face).
 Create a seal so that air does not leak out.
 If the patient is breathing on their own, deliver breaths during inspiration. Do not attempt to deliver a
breath as the patient exhales.
 Squeeze bag to give one breath every 6 seconds.
 If unable to effectively ventilate, reconsider possibility of foreign body obstruction or air leak. Insert oral
or nasal airway device if not already in place (see STEP 3).
If the chest does not rise, re-check to make sure the airway is still open (adjust mask hold
to ensure head-tilt chin-lift or jaw-thrust position and check position of airway device if
using) and that air is not leaking out of the side of the mask.
One person
Single-hand mask hold: The mask connector rests between
the thumb and index finger pushing evenly down to seal mask
against face while the three other fingers lift mandible up into
mask. Listen for air leaks and adjust hold if needed.
Two people
Two-hand two-person mask hold: One provider uses
both hands to hold mask using index fingers and thumbs
on the mask to produce a good seal, and uses the other
three fingers of both hands to lift mandible up (chin-lift) and
into mask. The other provider holds the bag.
20 – Chapter 2
Participant training manual: Quick Check, triage and emergency treatments
How to bag patient
 Hold the bag in one hand and depress a two-litre bag to about 1/3 of its volume.
 After each breath allow the patient to completely exhale before giving another breath.
 Watch the chest rising and falling evenly with each breath.
 Avoid over-aggressive bagging, as it will result in damage to lungs.
Step 6: Assess need for advanced airway management
Despite efforts to give maximal oxygen delivery (via non-rebreather device) and an open
airway, hypoxemia (decreased oxygen in blood) may persist. Further support of ventilation
and oxygenation may be accomplished if equipment for positive pressure mechanical
ventilation is available. The provision of mechanical ventilation is resource-intensive, and
is not readily available in many district level hospitals. If your patient fails to improve
despite oxygen and basic airway treatments, consider whether transfer to a centre where
mechanical ventilation can be delivered is indicated. Further information on advanced
airway management is provided in the Advanced Module on Airway and Breathing.
ASSESS NEED FOR ADVANCED AIRWAY MANAGEMENT
Some patients with easily reversible conditions may quickly improve and be able to ventilate on their own
after emergency treatments are given.
Others may need continued assistance with ventilation or intubation to protect airway.
Look for signs:
•
Is SpO2< 90, cyanosis or severe respiratory distress on high flow oxygen therapy?
•
Is there impending airway failure (e.g. inhalation injury, angioedema)?
•
Are these basic airway manoeuvres (Steps 1 to 5) failing to maintain or protect airway?
•
Is prolonged ventilation likely needed (e.g. suspect continued failure from drug overdose, snake-bite)?
If yes, call for help from district clinician and see advanced airway management (DCM-QC)
Participant training manual: Quick Check: triage and emergency treatments
Chapter 2 – 21
Delivery and titration of oxygen
Start all adults who need oxygen at five litres via nasal cannula.
After starting a patient on oxygen recheck for signs and symptoms of respiratory distress
and check SpO2. Most patients will have improvement in their symptoms and oxygen
saturation within a few minutes.
Once an emergency patient is stabilizing, assess whether they are getting the correct
oxygen flow. If the initial flow of oxygen does not seem to be enough and the patient’s
oxygen saturation is low or the patient is still in significant respiratory distress, increase the
oxygen flow.
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Participant training manual: Quick Check, triage and emergency treatments
Only start to decrease the flow of oxygen once you are convinced that the patient is
receiving enough oxygen with the current flow and you have completed other first-line
emergency treatments.
Every time you make a change to a patient’s oxygen treatment, directly observe the
patient for two to three minutes to ensure that they are stable. If the patient remains stable,
reassess in 15 minutes and record their clinical exam and SpO2. If the patient develops
severe respiratory distress or the SpO2 is <90% when you decrease the oxygen level, then
increase the oxygen flow to the initial level.
The following is an example of how oxygen may be titrated in a patient who is stabilizing:
•
If after 15 minutes the oxygen saturation on five litres NC is >90% or the patient is no
longer in respiratory distress, decrease the oxygen flow to four litres NC and observe.
•
Check patient. If after 15 minutes the oxygen saturation on four litres NC is >90% or
the patient is no longer in respiratory distress, decrease the oxygen flow to two litres
NC and observe.
•
Check patient. If after 15 minutes the oxygen saturation on two litres NC is >90% or the
patient is no longer in respiratory distress, stop the oxygen and observe the patient on
room air.
•
Check patient. If after 15 minutes the oxygen saturation on room air is >90% or the
patient is no longer in respiratory distress, keep the patient off oxygen. You must
recheck the SpO2 or for any signs or symptoms of respiratory distress in ONE hour as
patients may develop delayed hypoxia.
In some cultures, families may be worried about giving oxygen to their loved ones fearing
that giving oxygen means that the patient is going to die. Remember to address the
family’s concerns and explain that oxygen can be used like a medicine to treat disease
and improve a patient’s condition.
Participant training manual: Quick Check: triage and emergency treatments
Chapter 2 – 23
DRILL 2-1: Manage Patient on Oxygen: What would you do next?
Clinical situations
1. 23-year-old male with cyanosis,
respiratory distress, oxygen saturation
cannot be measured
2. 26-year-old female with complaint of
difficulty breathing, but no emergency
signs of airway or breathing on exam and
oxygen saturation of 94%
3. 45-year-old male on five litres NC, with
continued severe respiratory distress and
oxygen saturation
of 84%
4. 62-year-old female on a face mask at six
litres, who is improving and has a
saturation of 94%
5. 24-year-old male who was initially
improving on three litres NC oxygen, but
has suddenly deteriorated with severe
respiratory distress and oxygen saturation
of 82%
6. 36-year-old female with an oxygen
saturation of 93%, who had her oxygen
flow rate decreased to four litres/min 15
minutes ago
Managing the patient with wheezing
If wheezing, give salbutamol
Bronchospasm usually has audible wheezing. If the bronchospasm is extremely severe,
you may hear no wheezing at all. Bronchospasm or wheezing is an important and
treatable cause of severe respiratory distress. It is common in patients with asthma and
chronic obstructive lung disease (COPD), but can also complicate pneumonia in patients
without these chronic conditions.
Salbutamol is medication which opens the airways. Give salbutamol via a metered dose
inhaler with a spacer or using a nebulizer. The mist form via a nebulizer may be the most
effective method of delivery when there is severe respiratory distress.
Patients should be reassessed within a few minutes after receiving a salbutamol
treatment. Many patients may need more than one treatment to treat their wheezing. If
wheezing is severe, patients can continuously be administered salbutamol via nebulizer.
Salbutamol should always be delivered by a nebulizer or metered dose inhaler with
a spacer when available. Avoid giving salbutamol tablets or liquid by mouth as they
are ineffective for bronchospasm.
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Participant training manual: Quick Check, triage and emergency treatments
Salbutamol administered via metered dose inhaler should always be given with a spacer.
A spacer is easily made from a plastic soda bottle (see DCM-QC).
DRILL 2-2: What is the next emergency treatment?
Clinical situations
1. 18-year-old male with rash, facial swelling,
impending airway obstruction
2. 42-year-old male who is unconscious and cyanotic,
gurgling noise heard when breathing
3. Patient who is unable to speak, and began grabbing
at neck after coughing while eating a piece of meat
4. Patient who is on five litres via nasal cannula for a
pneumonia and oxygen saturation is 96%
Participant training manual: Quick Check: triage and emergency treatments
Chapter 2 – 25
Group exercise: Count respiratory rate
After the Quick Check and first line emergency treatments always check a complete set of vital signs,
which includes the respiratory rate. Monitoring the respiratory rate frequently in seriously ill patients will
help to follow the patient’s progress and determine the need for additional treatments.

The respiratory rate is a critical vital sign to check on every patient.
In the Quick Check determine the respiratory rate by quickly looking at a patient to see if he/she is
breathing fast or normally.
Once you have instituted emergency treatments, go back and count the respiratory rate and record it.
Arrange yourselves in pairs and practice counting respiratory rate. You should become familiar with what
a patient looks like who is breathing normally or fast.
What is a normal respiratory rate?
*******************************START HOME STUDY***************************
Management of trauma-related
respiratory emergencies
During the initial evaluation for airway and
breathing, the provider should be aware of
special
considerations
if
trauma
is
suspected, particularly if there is a risk of
head, neck, or spinal injury.
Treat tension pneumothorax with urgent
needle decompression
A small hole in the lung surface, known as
the pleura or along the tracheobronchial tree,
can result in collapse of the lung, called a
pneumothorax. A tension pneumothorax is a
life- threatening emergency that must be
treated immediately. It may occur as a result
of trauma (blunt or penetrating), a medical
procedure such as placement of a central
venous catheter, or spontaneously.
Suspect a tension pneumothorax if:
1. Severe, rapidly progressive respiratory
distress.
2. Absent lung sounds.
3. Shift of the trachea, visible directly above
the sternum, away from the side of the pneumothorax.
4. Low blood pressure or shock.
If these signs are present, the provider must act immediately and treat the pneumothroax
with needle decompression. Do not wait to contact senior health officers (if they are not in
the immediate area) or for an X-ray confirmation.
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Participant training manual: Quick Check, triage and emergency treatments
A hiss of air may be heard once the needle is in place and the blood pressure stabilizes
and improves. Needle decompression is an immediate life-saving intervention that should
be followed-up with the placement of a chest tube.
Massive haemothorax
Significant chest trauma (penetrating or blunt) may also result in bleeding into the pleural
space of the lungs (haemothorax). Insertion of a chest tube to drain the fluid is necessary
to treat a massive haemothorax. Suspect a haemothorax if:
1.
2.
3.
4.
Trauma to the chest wall
Shock
Respiratory distress
Loss of breath sounds and dullness to percussion on side of the injury.
If haemothorax is suspected, give oxygen and call for district clinician. Ensure the patient
has at least two large bore IV lines. Send blood for type and cross match.
***********************************END HOME STUDY****************************
Summary
Assess airway and breathing:
 Give oxygen and titrate
 Does the airway appear obstructed?
 If patient is wheezing, treat with inhaled
salbutamol
 Is there central cyanosis?
 Is there severe respiratory distress?
If the patient has an airway/breathing
emergency:
 If suspected anaphylaxis, treat with
epinephrine.
 Observe frequently
 Remove any obstruction and open the
airway
If trauma with possible neck or spine injury:
 Place an oral or nasal airway if indicated
 If chest trauma suspect tension
pneumothorax or haemothorax.
 Assist ventilation with bag valve mask if not
breathing or ventilating adequately
 Manage airway and protect spine
Participant training manual: Quick Check: triage and emergency treatments
Chapter 2 – 27
Assessment questions:
Airway and Breathing
Answer all the questions on this page. Write your responses in the given spaces. If you
have a problem, ask a facilitator for help.
1. List the airway and breathing emergency signs.
2. List five signs of severe respiratory distress.
3. For patients with emergency airway and breathing signs, what is the recommended
initial oxygen flow rate?
4. What is the recommended technique to open the airway in a patient with suspected
head or neck trauma?
5. Describe three steps that you would take to manage a patient who is unconscious and
whose tongue you suspect is obstructing the airway?
6. List the first-line emergency treatments for patients with emergency signs of airway
and breathing.
7. True/False: As part of the Quick Check, you should check all vital signs and oxygen
saturation for any patient with airway/breathing signs before you provide first-line
treatment.
8. True/False: Inhaled salbutamol can be a life-saving treatment for a patient who is in
severe respiratory distress and is wheezing.
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Participant training manual: Quick Check, triage and emergency treatments
Chapter 3:
Circulation
Learning objectives
1.
Assess the patient for emergency signs of circulation (shock).
2.
Give first-line emergency treatments for shock or heavy bleeding.
3.
Place IV and give fluids rapidly.
A B C

Airway

Breathing
The letter C in “ABC” stands for three key
areas, the first of which is:

Circulation (assessment and
management of shock)
After you assess a patient for emergency
signs of airway and breathing, and give them
 Consciousness
first-line emergency treatments, assess for
emergency signs of circulation. If you detect
 Convulsing
an emergency sign of circulation, measure the
blood pressure (BP) and heart rate. If BP <90 OR pulse (P) >110 with an emergency sign
of circulation, initiate first-line emergency treatments and call for help. If a patient does not
present with emergency signs of circulation, move onto the rest of the Quick Check and
triage the patient into the appropriate category.

Circulation
Class discussion
Think about some common causes of shock in patients. What have these patients looked or
acted like?
Then assess:
Circulation (shock or heavy bleeding)

Weak or fast pulse
or


Capillary refill longer than
three seconds
Check SBP, pulse
or
Is she pregnant?
Heavy bleeding from any
site
Give first-line
emergency
treatments
or

Severe trauma
Participant training manual: Quick Check, triage and emergency treatments
Chapter 3 – 29
The Quick Check is designed to rapidly screen patients during triage for the presence of
poor perfusion to vital organs (i.e., shock). This rapid assessment includes the items in the
first column of the Quick Check (the first column of the table above). If any of these
emergency signs are present, you must check the blood pressure and pulse and
determine the need for first-line emergency treatments. Other signs of poor perfusion
commonly seen in severely ill hospitalized patients include decreased urinary output and
confusion.
If you identify emergency sign of circulation in patient:
•
check SBP (systolic blood pressure)
•
check pulse
If patient is a woman of child bearing age:
•
Is she pregnant?
Adjust the BP cuff size according to the patient’s arm size. Make sure the inflatable part of
the blood pressure cuff goes all around the arm. Using a blood pressure cuff that is too
small will result in a falsely high (and falsely reassuring) blood pressure and one that is too
large can result in a falsely low blood pressure.
Is the pulse weak or fast?
Feel the radial pulse (the pulse at the wrist). If strong and not obviously fast, the pulse is
adequate. Move on to the next step in assessing circulation. A strong radial pulse means
that the systolic blood pressure is at least 80 mmHg.
If the radial pulse is difficult to find, weak or very fast, this is an emergency sign of
circulation and you should suspect shock. A patient, who is not in shock, should have
an easily palpable radial pulse.
If the radial pulse cannot be felt, check for a more central pulse. In an adult, adolescent or
older child, feel for the carotid pulse in the neck or for the femoral pulse in the groin. To
find the carotid pulse, place two or three fingers on the Adam’s apple then slide into the
groove between the Adam’s apple and the muscle. To find the femoral pulse, feel along
the line that runs from the groin to the hip. It should be at 2/3 the distance, closer to the
groin.
If pulse palpable
Then systolic BP is at least
Radial pulse
80 mmHg
Femoral pulse
70 mmHg
Carotid pulse
60 mmHg
Do not spend too much time trying to find a carotid or femoral pulse. If unable to
easily detect a pulse, assume that the patient has an emergency sign of circulation
and move on to the next step to treat the patient.
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Is the capillary refill time longer than three seconds?
Capillary refill is a simple test that assesses how quickly blood returns to the skin after
pressure is applied. Check capillary refill by applying pressure to the pink part of the nail
bed of the thumb or big toe. The capillary refill is the time it takes from release of pressure
to complete return of the pink colour in the nail bed. A normal capillary refill is 3 seconds or
less. Capillary refill is generally a reliable sign except when the room temperature is low. A
cold environment causes vasoconstriction and thus causes a delayed capillary refill.
How to check capillary refill:
•
Grasp the patient’s thumb or big toe
between your finger and thumb.
•
Apply minimal pressure for 3 seconds to
produce blanching (a change in colour from
pink to white) of the nail bed and then
release.
•
Time the capillary refill from the moment of
release until total return of the pink colour.
•
If the refill time is longer than 3 seconds, the
patient may be in shock.
•
To confirm shock, check the pulses and
blood pressure.
Checking capillary refill
A. Applying pressure to the nail
bed for 3 seconds
B. Check the time to the return of
the pink colour after releasing
the pressure
Class activity
Arrange yourselves in groups of two or three and practice checking pulses and capillary refill.
It is important to know what is normal and practice often so that you can quickly recognize what
is abnormal.
Is there any heavy bleeding from any site?
•
Look for obvious heavy bleeding such as bleeding from the nose, vaginal bleeding,
rectal bleeding, or vomiting blood.
•
Look for a tender, distended abdomen that may be a sign of internal bleeding such as
from a ruptured ectopic pregnancy.
Is there any severe trauma?
•
Always suspect internal bleeding if a patient presents with severe trauma and shock.
•
Look for visible bleeding from the wound.
•
Look for a tender, distended abdomen which may be a sign of internal bleeding.
Patients who are subjected to trauma (road traffic accidents, falls, and violence) may have
significant blood loss and can quickly go into shock. Life-threatening internal bleeding may
not be apparent until a large amount of blood has been lost. If your assessment of a
trauma patient shows an emergency sign of circulation with an SBP< 90 mmHg or heart
rate greater than 110 bpm, always suspect that the patient has internal bleeding.
Participant training manual: Quick Check, triage and emergency treatments
Chapter 3 – 31
If patient has emergency signs of Circulation, call for help
and begin first-line emergency treatments:
If systolic BP<90 mmHg or pulse
>110 per minute or heavy bleeding:
 Give oxygen 5 litres if respiratory
distress or SpO2<90.
 Weak or fast pulse
or
 Insert IV, give 1 litre bolus crystalloid
(LR or NS) then reassess (see give fluids
rapidly p. 18)
 Capillary refill longer than
three seconds
or
 Heavy bleeding from any
site
or
 Severe trauma
Check SBP, pulse
 Keep warm (cover)
Is she pregnant?
 If in second half of pregnancy,
place on her side (preferably on
the left), not on back
 If anaphylaxis (rash, wheezing, facial
swelling, low SBP) give 1:1000
epinephrine (adrenaline) IM – 0.5 ml if 50
kg or above, 0.4 ml if 40 kg, 0.3 ml if 30
kg (p. 11).
If you detect an emergency sign of circulation, call for help and begin emergency
treatments if you are trained. Remember to always use universal precautions, particularly
if there is any active bleeding.
Document the SBP and pulse and respond to any abnormal vital signs.
Note: There are different types of shock including septic shock, haemorrhagic shock,
cardiogenic shock, and neurogenic shock. The management of different types of shock will
be addressed in other chapters.
Give oxygen at five litres if respiratory distress or SpO2<90
Patients who are in shock have decreased perfusion to their tissues. These patients may
have a primary respiratory problem or may need oxygen because of decreased
oxygenation to their tissues. Refer to the previous section (Chapter 2) to review the proper
administration of oxygen.
Insert IV, give one litre bolus crystalloid (LR or NS) rapidly, then reassess.
 How to insert IV and give fluids rapidly

If heavy bleeding or shock, insert two large bore cannulae – at least 16 or 18 gauge.

Attach LR or NS. Give one litre as rapidly with infusion wide open.

Assess response of pulse, SBP and signs of perfusion (urine output, mental status).

If still in shock and no evidence of fluid overload, give another bolus.
 If still in shock after 2 litres and suspect ongoing blood loss, start blood transfusion and search again
for source of bleeding.
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 If still in shock after 2 litres, call for help from district clinician.

Insert urinary catheter (see Section 7.3.2 and 7.3.6) and monitor hourly urine output. A urine output of at
least 30 ml/hour suggests adequate hydration.
See sections 3.1 (Shock) and 4 (Trauma) for further information on fluid management.
If not able to insert peripheral IV, use alternative:

Call for more experienced help, consider:

External jugular vein cannulation

Femoral vein cannulation (or internal jugular or subclavian vein cannulation if trained).

Venous cut-down –see 7.3.10.
A large bore IV (at least 16 or 18 gauge) will allow you to give IV fluids rapidly. These large
IVs should always be used for resuscitations. Place the IV in a large vein, such as in the
antecubital fossa. If a patient is very unstable, give rapid fluids through two different IV
sites at the same time.
If you are unable to insert an IV quickly, call for help. Consider alternate sites (femoral
vein, external jugular vein) or venous cut down (see Surgical Care at the District Hospital
for further information). In addition, some hospitals may have access to intraosseous
cannulation for adults.
Only crystalloid fluid (Lactated Ringer’s (LR) or normal saline (NS)) should be used in
resuscitation. Give fluids fast and warm if possible. Gravity will help make the fluid run
faster. Hang the bag as high as possible. Patients in shock should have the first litre of
fluid infused as fast as possible, and at least over 30 minutes.
Immediately assess patient after first bolus. If SBP<90, pulse >110 or any signs of poor
perfusion (poor urine output, mental status) persists, give a second one litre bolus of
crystalloid rapidly.
If patient remains in shock after two litre bolus of crystalloid, and you suspect patient
suffers from trauma or hemorrhagic shock, transfuse blood. Search for and treat source of
bleeding. Patients with severe anaemia may also require blood transfusion. For further
details regarding blood transfusion in the patient with traumatic injury see Section 4 of the
DCM.
Urine output should be used to help guide fluid resuscitation in severely ill patients with
shock. Ideally, a urinary catheter should be placed for any patient in shock, and urine
output monitored hourly. In the average size adult urine output should be at least 30
ml/hour.
If a patient has a history of congestive heart failure, renal failure, severe anaemia, or
clinical signs of pulmonary oedema, assess for cardiogenic shock and give fluids more
cautiously. Give a 250 ml bolus and reassess for respiratory distress, increased jugular
venous pressure, or crackles (rales) on pulmonary exam. Further details on management
of patients in congestive heart failure are discussed in the module on severe respiratory
distress.
Participant training manual: Quick Check, triage and emergency treatments
Chapter 3 – 33
Keep warm (cover)
Keep a patient in shock warm. Ensure that the patient is dry and covered with blankets or
warm clothing.
If pregnant, place on left side
If pregnant, place the woman on her side, preferably in the left lateral decubitus position
(left side down).
The enlarging uterus in the second half of pregnancy may compress the inferior vena cava
(the largest vein which brings blood back to the heart) when she is lying on her back.
Placing the woman on her left side if possible helps to prevent this situation and increases
blood flow to the heart.
If anaphylaxis (rash, wheezing, facial swelling, low BP), give epinephrine
(adrenaline) IM
If the patient has low blood pressure and is wheezing, has facial swelling, or a rash such
as hives suspect anaphylactic shock. Anaphylaxis is a severe allergic reaction that is a
result of exposure to an allergen, such as medication, food, or insect bites. It is caused by
a massive release of histamine in the body resulting in shock or airway swelling.
 How to give epinephrine

For anaphylaxis: give 1:1000 epinephrine (adrenaline) IM.
0.5 ml if 50 kg or above, 0.4 ml if 40 kg, 0.3 ml if 30 kg.

Give IM in anterior lateral thigh.

Repeat in five minutes if no response.

See Section 3.1.3 for further management.
Treat anaphylactic shock immediately with epinephrine. This is an emergency and the
epinephrine should be given right away.
Also give IV fluids to treat low blood pressure.
After giving epinephrine, also treat the patient with hydrocortisone to help to control the
allergic reaction. An antihistamine may also help to provide symptomatic relief of itching.
Observe patients given epinephrine for at least four hours prior to discharge.
Monitoring the patient
Patients with emergency signs of circulation require frequent reassessment and
monitoring to see if further treatment is needed. After any intervention, reassess vital
signs. Has the blood pressure improved? Has the pulse slowed?
If a patient presents with shock, assess with the Quick Check, and then look for and treat
the underlying problem. Other modules cover in detail the management and monitoring of
patients in shock. Also see DCM, Section 3.1.
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Participant training manual: Quick Check, triage and emergency treatments
DRILL 3-1: What you would do next?
Clinical situations
1. 40-year-old male presents to the hospital with fever and generalized weakness. You assess
this patient for emergency signs and find that their airway and breathing is intact. You note
that their pulse is weak and the measured blood pressure is 80/40. You decide to place an IV
and start IVF. What IVF would you give and how fast should they be given?
2. 45-year-old male is waiting in the queue to be registered. You see that the patient is able to
talk to you in full sentences, is not cyanotic, and is not in any respiratory distress. What is the
next step in your assessment?
3. 28-year-old female who is 8 ½ months pregnant presents with dizziness and a weak pulse.
How should you position the patient? How will this affect her blood pressure?
4. 19-year-old male presents with acute onset of an itchy rash and weakness after starting an
antibiotic. His pulse is weak and fast. You then check his blood pressure which is 70/30.
What would you do next?
******************************START HOME STUDY****************************
If trauma administer first-line emergency treatments for
Circulation
If a patient presents with emergency signs of circulation and trauma, assume that the
patient is bleeding. Initial management of trauma is similar to all patients with shock.
Systematically examine the patient for possible sources of bleeding. Send blood
immediately for haemoglobin and type (grouping) and cross match, and stop any active
bleeding. If you suspect the patient has internal bleeding call for help and arrange for
transport to the operating theatre as soon as possible.
Give oxygen five litres if SpO2<90 or respiratory distress
Trauma patients often have injuries also leading to respiratory problems. Treat these
patients initially with oxygen. Preventing hypoxia is also critical in patients with head injury,
to prevent secondary injury to the brain. Once the patient is stabilizing, reassess to
determine if the oxygen is still needed and titrate flow (see Chapter two: titrate oxygen).
Participant training manual: Quick Check, triage and emergency treatments
Chapter 3 – 35
Give rapid IV fluids
As in other patients with shock, trauma patients
with shock should be treated with rapid IVF. Only
use crystalloid (LR or NS) fluid and infuse warm if
possible.
Keep warm
As with all patients in shock, keep trauma patients
covered and warm after they have been
completely assessed.
Urgently send blood for type and cross-match.
Trauma patients suffering from ongoing
hemorrhage may require rapid blood transfusion.
If pregnant, position the patient left side down
If you are unable to roll the patient because of
concern for spinal trauma, manually displace the
uterus to the left side.
If external bleeding
Haemorrhage control is the first priority in anyone
who is actively bleeding. Always try to control
bleeding with direct pressure.
• Apply firm, direct compression.
•
Reinforce dressings as needed.
Only use a tourniquet if other bleeding control measures have failed and bleeding is lifethreatening.
Infection control!
The person applying the pressure should be wearing personal protective equipment such as
gloves, gowns and eye protection.
If suspect internal bleeding
Uncontrolled, non-compressible haemorrhage (abdomen, chest, pelvic, and around long
bone fractures) requires emergency surgical intervention
•
•
If possible femur fracture → splint
If possible pelvic fracture → apply a pelvic binder or sheet.
If patient remains in shock after two litres of IVF and you suspect ongoing blood loss,
arrange for transport to the operating theatre to look for and control internal bleeding and
consider blood transfusion. Call for help and plan emergency surgical intervention or
arrange transport to a referral facility as soon as possible.
******************************END HOME STUDY****************************
36 – Chapter 3
Participant training manual: Quick Check, triage and emergency treatments
Summary
To assess circulation
 Is the pulse fast and weak?
 Is the capillary refill time longer than 3 seconds?
 Is there any heavy bleeding?
 Is there a history of significant trauma?
If any emergency sign of circulation is present, then check if blood pressure < 90 mmHg
OR pulse > 110 bpm and give first-line emergency treatments:
 Give oxygen if needed.
 If the patient has any external bleeding, apply pressure to stop bleeding.
 Quickly establish IV access and begin giving fluids for shock.
 Make sure the patient is warm.
 If pregnant and with vaginal bleeding, position left side down.
 Take blood samples for emergency laboratory tests.
 If ongoing bleeding, arrange blood transfusion and transport to the operating theatre.
 Always use universal precautions for infection control.
Participant training manual: Quick Check, triage and emergency treatments
Chapter 3 – 37
Assessment questions:
Circulation
Answer all the questions on this page. Write in the given spaces. If you have a problem,
ask a facilitator for help.
1. True/False: A patient with a capillary refill of 4 seconds has an emergency sign of
circulation.
2. What is the minimum blood pressure if you can feel a strong radial pulse?
3. Name types of fluid you can give to treat shock. What amount do you initially give?
How quickly do you administer the fluid?
4. A 40-year-old man was rushed to the hospital after collapsing at home. You find his
hands are cold and the capillary refill time is longer than three seconds. List four things
that you would do as part of the Quick Check assessment?
5. A 25-year-old woman is brought to hospital with fever and rapid breathing. She has
had five episodes of vomiting and watery diarrhoea for one day. She weighs 50 kg.
The capillary refill is greater than three seconds. The radial pulse is not palpable, but
the femoral pulse is fast and weak. There is no respiratory distress or cyanosis and no
abnormal respiratory noises. How do you triage this patient? What initial emergency
treatments would you give?
38 – Chapter 3
Participant training manual: Quick Check, triage and emergency treatments
Chapter 4:
Altered level Consciousness/Convulsing
Learning objectives
1. Recognize altered level of consciousness.
2. Recognize and treat convulsions.
3. Assess using AVPU scale.
4. Give first-line emergency treatment for altered consciousness.
5. Give first-line emergency treatment for convulsions.
In addition to circulation, C represents the
need to assess consciousness and
convulsing.
A B C
An alteration in consciousness means that
 Airway
the patient is not behaving normally. There
 Breathing
are many reasons your patient may
 Circulation
experience
an
altered
state
of
consciousness. These include severe
 Consciousness
infection, a metabolic problem such as low
 Convulsing
blood sugar or low sodium, severe head
injury, acute psychosis from a psychiatric
problem, or alcohol or drug intoxication. Patients with shock or severe respiratory
distress can also present with altered levels of consciousness.
If a patient is awake, alert, not confused, talking and coherent, consciousness is not
altered.
Class discussion
Think about some common causes of altered level of consciousness that you have seen in
patients before. What have these patients looked or acted like?
Then assess:
Altered level consciousness/convulsing
 Altered level
consciousness
or
Is she pregnant?
Give first-line
emergency
treatments
 Convulsing
Participant training manual: Quick Check, triage and emergency treatments
Chapter 4 – 39
Is there altered level of consciousness?
First, look to see if the patient is conscious (awake or alert). A simple scale known as
AVPU is used to do this assessment.
A
V
P
U
Is the patient Alert? If not,
Is the patient responding to Voice? If not,
Is the patient responding to Pain?
The patient who is Unresponsive to voice (or being shaken) AND to pain is
Unconscious.
Alert
•
Is the person awake? Make sure the patient is not just sleeping.
Voice
If the patient is not awake and alert, try to rouse the patient. If the patient is not alert but
responds to voice, you can describe patient as being lethargic.
•
Call his/her name loudly.
•
If the patient does not respond to this, gently shake the arm.
Pain
If the patient does not respond to voice or gentle shaking of the arm, see if the patient will
respond to pain. If the patient is not alert and responds only to pain, you can describe the
patient as unconscious.
•
Apply a firm squeeze to the nail bed of a fingernail, enough to cause some pain.
•
If the patient does not respond, briefly use your knuckles to grind firmly on the sternum
(sternal rub).
Unresponsive/unconscious
If the patient does not respond to voice (or being shaken) and to pain, the patient is
unconscious.
DRILL 4-1: AVPU Scale
How would you classify these patients on the AVPU scale?
1.
Patient is found with eyes closed in waiting room slumped in a chair. You call out her name
loudly, and she slowly opens her eyes but then closes them again.
2.
Patient is brought in to you by his family who says that he passed out at home. When you
see him, he looks weak and tired but is talking.
3.
Patient is brought in after a car accident. He is not awake. You call his name. No response.
You shake his arm. No response. You then try a sternal rub. He moves his left arm and
grimaces.
4.
Patient was found on the floor at home and brought in by family. You call his name and
shake his arm. No response. You then try squeezing his fingernail. No response. You also
try sternal rub. No response.
5.
Patient is waiting in queue at district hospital because she has been feeling dizzy. Suddenly
she falls to the ground. You run over to see if she is okay but she is not moving. You say
“madam!” loudly and she mumbles while her eyes open.
40 – Chapter 4
Participant training manual: Quick Check, triage and emergency treatments
If patient is Alert, then assess for confusion
•
Does the patient know his/her name, where they are and why they have come to the
hospital?
•
Is the patient answering questions appropriately?
•
Is the patient agitated, screaming, uncooperative, or slurring words?
If a patient has an alteration of consciousness (V, P or U) or is alert and confused, then
give first-line emergency treatments. Protect yourself and hospital staff if a patient is
agitated.
Then assess:
For Convulsing
A convulsion or generalized seizure results in the sudden loss of consciousness. When
associated with stiffening and uncontrolled jerky movements of the limbs, it is called
a generalized tonic clonic seizure (also known as a fit). Sometimes patients may have
subtle convulsions that do not result in obvious movement of their arms and legs. These
patients may have rhythmic eye movements to one side or you may just see one limb
moving rhythmically. A patient who is alert, following commands, or purposeful in their
movements is not convulsing.
To determine if a patient is suffering from a convulsion, ask yourself the following
questions:
•
Is your patient unconscious?
•
Is there rhythmic or uncontrolled jerking movement of the arms or legs?
•
Is there rhythmic eye movement?
•
Is the tongue lacerated?
•
Is there bowel and bladder incontinence?
•
Is there a history of trauma?
During a convulsion, a patient may bite their tongue or cheek or have bowel and bladder
incontinence. If your patient has an altered level of consciousness and has these findings,
suspect that the patient may have had a convulsion.
If you suspect a convulsion in a woman of child bearing age, determine whether she is
pregnant. A convulsion in a pregnant patient can be a sign of a life-threatening condition
known as eclampsia.
After a convulsion, a patient is normally sleepy for up to several hours (post-ictal period).
They should gradually become more alert during that time. If the patient is not waking up
at all, the patient may be having continuous seizures known as “status epilepticus”.
A patient may arrive at the hospital alert, but with a history of having had a convulsion
several days ago. This patient does not require first-line emergency treatment. Make sure
that a family member or caregiver remains with this patient until they are evaluated. Ask
the caregiver to alert a healthcare worker if the patient has a second convulsion.
Participant training manual: Quick Check, triage and emergency treatments
Chapter 4 – 41
Then give:
First-line emergency treatments for altered level of Consciousness
or Convulsing
Do not move neck if cervical spine injury possible.
For all:
 Altered level
consciousness
or


Is she
pregnant?



 Convulsing

Protect from fall or injury.
Manage airway and assist into recovery position
(see QC p. 19).
Give oxygen five litres.
Call for help but do not leave patient alone.
Give glucose (if blood glucose is low or unknown)
(see QC p. 19).
Check (then monitor and record) level of consciousness on
AVPU scale.
If convulsing:

Give diazepam IV or rectally (see QC p. 19).

If convulsing in second half of pregnancy or post-partum
up to one week, give magnesium sulphate rather than
diazepam (see QC p. 28).
Then check SBP, pulse, RR, temperature.
If convulsions continue after 10 minutes:




Continue to monitor airway, breathing, circulation.
Recheck glucose.
Give second dose diazepam (unless pregnant/post-partum).
Consult district clinician to start phenytoin (Section 3.5).
Protect patient from fall or injury
Patients who are unconscious or convulsing are not aware of what they are doing. It is
important to prevent further injury.
• Make sure someone is with the patient at all times. If necessary, engage family
members to help watch the patient with your instruction.
• Place patient on a stretcher and raise railings when available.
• If the patient is convulsing, pad the side of the railings with blankets.
• Place patient where he/she can be continuously observed by the staff and as close to
the nursing station as possible.
• If there is concern for trauma or an injury to the spine, protect the patient’s cervical
spine at all times.
Manage the airway and assist into the recovery position
Patients who are altered or convulsing are particularly at risk for airway obstruction
because of their tongue. Secretions or vomit may also cause obstruction or aspiration.
For altered patient who is not convulsing:
• manage airway
• suction secretions or vomit if present
• if the patient vomits, turn on his/her side to avoid aspiration.
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Participant training manual: Quick Check, triage and emergency treatments
If neck trauma is not suspected place patient in recovery position:
• Turn the patient on the side to reduce risk
of aspiration.
• Keep the neck slightly extended and
stabilize by placing the cheek on one
hand.
• Bend one leg to stabilize the body
position.
For a convulsing patient:
• Do not attempt to hold patient down.
• Do not put anything in mouth. Tongue depressors can become easily dislodged and
cause airway obstruction.
• Turn patient on his/her side to avoid aspiration.
• Once convulsion has stopped and the airway is clear, place the patient in the recovery
position.
Give oxygen five litres
Initially administer five litres of oxygen to patients with altered level of consciousness or
convulsions. If the patient is suffering from hypoxemia, the patient’s mental status may
improve after treatment. After stabilization, assess if additional oxygen is needed and
titrate as appropriate.
Call for help but do not leave patient alone
Give glucose (if blood glucose is low or unknown)
Low blood glucose can cause confusion, agitation, unconsciousness, and convulsions. If a
patient is in an altered state because of low blood glucose, they will often rapidly return to
a normal level of consciousness after glucose is administered. If glucose testing is
unavailable or a delay in obtaining results is expected, assume that the unconscious or
convulsing patient has hypoglycaemia and treat with glucose.
 How to give glucose if symptoms of hypoglycaemia or if glucose low
(< 3 mmol/l (54 mg/dl))
 Give IV glucose:
 make sure IV is running well
 for adolescent or adult, give D50 25 to 50 ml; if D10 available, give 125 to 250 ml rapidly (D50
is the same as dextrose 50% and glucose 50%).
 If no IV glucose is available, give sugar water by mouth (if conscious) or nasogastric tube.
 dissolve four level teaspoons of sugar (20 grams) in a 200 ml cup of clean water.
 Repeat if necessary.
Checking blood glucose
Where blood glucose results can be obtained quickly, measure the glucose level
immediately. Remember, hypoglycaemia is present if the measured blood glucose level is
low <3 mmol/litre (54 mg/dl). Finger-prick testing is one way to get blood glucose levels
rapidly.
Participant training manual: Quick Check, triage and emergency treatments
Chapter 4 – 43
Check (then monitor and record) consciousness level on AVPU scale.
It is important to monitor and record the patients consciousness level so that you can
rapidly detect any change and communicate with other health care providers who may be
caring for the patient.
If convulsing:
Give diazepam IV or rectally
Diazepam is the first line medication to treat convulsions (anticonvulsant). Give diazepam
intravenously or rectally. If the convulsion has stopped on its own, do not automatically
give diazepam. Call for help, and discuss further management with the district clinician.
Rectal diazepam acts within 2 to 4 minutes. If IV is in place, give diazepam slowly over
1 minute.
How to give diazepam rectally:
• Base dose on the weight of the patient.
• Draw up the dose from an ampoule of diazepam into a syringe.
• Remove the needle.
• Insert the syringe 4 to 5 cm (about the length of your little finger) into the rectum and
inject the diazepam solution.
• Hold the buttocks together for a few minutes.
If convulsions continue after 10 minutes:
• Monitor airway, breathing, and circulation.
• Recheck glucose and treat if low.
• Give second dose of diazepam.
The maximum dose of IV diazepam is 30 mg. Diazepam can affect the patient’s breathing
by causing ventilatory depression.
• Consult district clinician to add second antiepileptic drug (phenobarbital or phenytoin).
These patients need to be continuously monitored and have vital signs assessed
frequently. If the patient develops a very low respiratory rate, call for help from a senior
clinician and assist with bag valve mask ventilation.
44 – Chapter 4
Participant training manual: Quick Check, triage and emergency treatments
If convulsing and in second half of pregnancy or post-partum up to one
week, suspect eclampsia and give magnesium sulfate.
Pre-eclampsia in pregnant women is associated with hypertension, visual changes,
headache and protein in the urine. This situation can progress to a life-threatening
condition that causes seizures in pregnant women known as eclampsia. Along with giving
first-line therapy, call for help from a senior clinician. Medications can be used temporarily
to control the seizures but delivery of the baby is the definitive treatment for eclampsia.
After giving first-line emergency treatments, check vital signs
• Measure BP, pulse, RR, SpO2, and temperature
• Respond to abnormal vital signs
• Continue with the urgent management of patients with emergency signs.
Participant training manual: Quick Check, triage and emergency treatments
Chapter 4 – 45
******************************START HOME STUDY****************************
Management of trauma-related neurologic emergencies
Patients with altered level of consciousness or convulsions following trauma may have
intracranial bleeding or brain swelling and serious spinal injury.
•
Protect the spine if spinal injury is
suspected.
•
Look/feel for deformity of skull. Does
it feel even? Is there a laceration or
open skull fracture?
•
Do the pupils react to light?
•
Is there bloody fluid coming from ear
or nose?
In an unconscious trauma patient, one
pupil larger than the other is a sign of a
severe brain injury and impending brain
herniation. If there is fluid coming from
ear or nose, suspect a fracture at the
base of the skull. Call for help
immediately.
Protect the spine
To determine that there is no injury to
the spine, the patient must be conscious, cooperative, not intoxicated, and able to
concentrate on the exam (no other major injuries). If the patient is conscious, check for:
•
posterior neck pain at rest
•
tenderness with palpation of posterior cervical spine
•
sensory or motor deficit.
If the patient has none of these symptoms, ask them to move their neck. If there is no pain
or neurological signs when the patient moves the neck, the spine is clear. If the patient
cannot be cleared clinically, he or she should remain immobilized until X-ray rules out
damage to the cervical spine. Three X-ray views are needed to clear the cervical spine
(lateral, AP, open mouth odontoid). The most important view is the lateral X-ray. An
adequate lateral X-ray must view to C7/T1. If the patient is unconscious, then the cervical
spine needs to be immobilized until an X-ray rules out damage.
46 – Chapter 4
Participant training manual: Quick Check, triage and emergency treatments
Give oxygen five litres
It is important to make sure patients with head injuries have enough oxygen to prevent
further brain damage. After the patient is stabilized, reassess the need for supplemental
oxygen and titrate as needed.
Expose the patient fully
The patient should be completely undressed including undergarments to look for any
additional injuries. Be sure to roll the patient using spinal precautions and look at the back.
Look for traumatic injuries to chest, abdomen or pelvis
Look for any bruising, abrasions, lacerations, visible bone or tissue, or other wounds.
Palpate the chest for any crepitus (feeling of bubbles under the skin) or rib fractures.
Listen to the chest to check for equal breath sounds. Check if the abdomen is distended
and palpate the abdomen to check for tenderness, rebound, or guarding. Palpate the
pelvis to check for tenderness and compress the pelvis to check for any instability.
Participant training manual: Quick Check, triage and emergency treatments
Chapter 4 – 47
Log roll technique: Try this as an exercise
Objective: Move head and body as one unit to
keep the spine in line.
Need three to four people for the exercise.
1. First person kneels at the patient’s head
facing the patient and places his/her hands
on each side of the patient’s head and jaw.
2. Two to three more people should kneel at
the patient’s side at the level of the
shoulder, hip, and knee.
3. These three persons reach across the patient and grasp the patient’s shoulder and waist
(one person), hip and thigh (one person), and knee and ankle (one person).
4. Three persons then roll the patient toward them slightly as the first person turns the patient’s head
slightly to keep in line with the spine. The first person holding the head should count to three, and the
patient should be turned on his/her count at three.
******************************END HOME STUDY****************************
DRILL 4-2: First-line emergency treatment: What would you do next?
Clinical situations
1. A 22-year-old female presents four days after giving birth with alteration of consciousness. Her family
states she has been having “fits” at home. While assessing the patient she begins to have a
convulsion. What actions would you initially take? What is the best medication to stop the convulsion?
2. A 34-year-old male presents with stumbling, slurred speech, and inability to answer questions
appropriately. His friend states he was drinking alcohol. What would you do for this patient?
3. A 42-year-old male presents unresponsive. His family states he has had fever for several days. You
check for emergency signs of airway, breathing, and circulation and the patient has none. What would
you do next?
4. A 27-year-old male with a history of epilepsy presents after having a seizure. He is lethargic, but
responding to pain. His family states he ran out of his medication. What would you do next?
48 – Chapter 4
Participant training manual: Quick Check, triage and emergency treatments
Summary
Assess for altered level of consciousness or convulsions:
 Use AVPU scale for consciousness
 Look for signs of convulsions
Give first line emergency treatments for altered consciousness:
 Position the patient/protect from fall or injury
 Manage the airway
 If no trauma, recovery position
 Give oxygen if oxygen saturation is low.
 Call for help
 Give glucose if low or unknown
 Assess pregnancy status
Give first line emergency treatments for convulsions (in addition to treatment for
consciousness):
 Do not put anything in the mouth
 Give diazepam IV or rectally
 Give magnesium sulfate if in second half of pregnancy or if one week post-partum
If trauma:
 Do not move neck if injury to spine is suspected
 Look for signs of serious head injury
 Log roll when moving patient
 Expose patient fully

Look for other traumatic injuries
Participant training manual: Quick Check, triage and emergency treatments
Chapter 4 – 49
Assessment questions:
Altered level of Consciousness and
Convulsing
Answer all the questions on this page. Write in the given spaces. If you have a problem, ask a
facilitator for help.
1. Write out the AVPU scale.
A
V
P
U
2. A 50-year-old man is brought to you at the district hospital by his brother who found him on the
floor of their house. He is not awake nor is he responding to his name. You shake his arm but
he does not respond. You then rub his sternum firmly, but he still does not move. What stage of
AVPU do you assign him?
3. A 39-year-old woman was brought to the hospital family for fever and weakness. While triaging
patients in the queue. You notice that she is slumped over. You assess her quickly and note
that she does not have Airway/Breathing or Circulation signs. She is not awake and does not
respond to her name. When you push firmly on her fingernail bed, she pulls her hand away.
What stage of AVPU do you assign her?
4. A patient who is unconscious, with no history or trauma, should be placed in what position to
protect the airway?
5. What technique can you use to move an unconscious patient with signs of serious trauma?
6. At what blood sugar level is a patient considered hypoglycaemic?
7. A 25-year-old pregnant woman is waiting to see the doctor for a headache when she loses
consciousness and starts seizing. You are working in the triage area and see her. You run over
to help her. What are the first steps in managing this patient?
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Participant training manual: Quick Check, triage and emergency treatments
8. A patient is brought to the district hospital after falling off a ladder right outside the hospital
where he had been repairing the building. You determine that he is lethargic but does respond
to voice. His airway is clear, and he is breathing adequately. You would like to check his blood
sugar and are told that the machine is not working. What should you do next?
9. How much rectal diazepam (from a 10 mg/2 ml solution) should you give to a 50 kg woman
who is having a convulsion? How long should you wait before giving a second dose if the
convulsion does not stop? What are the side effects of diazepam?
10. A 28-year-old woman who is 8 months pregnant and weighs approximately 65 kg is rushed in
by family because she started seizing. What would you do to manage this patient? Calculate
the dosage of any medication you would give her.
Participant training manual: Quick Check, triage and emergency treatments
Chapter 4 – 51
******************************START HOME STUDY****************************
Chapter 5:
Pain from life-threatening cause
A B C D

Airway

Breathing

Circulation

Consciousness

Convulsing

“Dolor” – pain from life-threatening cause
Learning objectives
1.
Distinguish characteristics of pain from life-threatening causes versus pain from nonlife-threatening causes.
2.
Recognize signs of specific life-threatening conditions presenting with pain.
3.
Give first-line emergency treatments for life-threatening causes of pain.
In the first four chapters, you learned about triage and giving emergency treatments for
patients with emergency signs of airway, breathing, circulation, consciousness or
convulsions.
Pain can also be a prominent symptom of many of these life-threatening problems.
For example, a pregnant female with severe abdominal pain may have a ruptured ectopic
pregnancy that can rapidly haemorrhage and lead to death. Many of these patients can be
saved if these life-threatening conditions are recognized early and treated. These patients
should also be managed as patients with “emergency signs”.
However, pain is also a very common complaint in health facilities and may be caused
by different conditions. Some conditions may be life-threatening (e.g. myocardial
infarction) while others are not. Patients also have different levels of pain tolerance and
different patients may behave differently with the same problem.
It is important to be able to recognize patients with life-threatening causes of pain. In this
chapter, you will learn how to recognize and manage patients with life threatening causes
of pain.
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Participant training manual: Quick Check, triage and emergency treatments
Recognize
To recognize a patient with pain from an immediately life-threatening illness, look for the
following:
•
Is the patient able to walk? Was the patient carried in by their family?
o A patient who has peritoneal signs indicating an abdominal catastrophe, such as
•
rebound or guarding, or severe abdominal pain may not be able to walk because
every movement irritates the peritoneum. These are warning signs for a perforated
viscous (perforated appendix or perforated ulcer).
Is the patient sweating? Are there beads of sweat on their face?
o Sweating can be a physiological response to severe pain
o A patient presenting with severe chest pain, sweating and pallor should raise your
•
suspicion for an acute myocardial infarction.
Is the patient guarding against certain movements or positions?
o A patient with severe pain in the neck and head who feels resistance to any
•
movements or positions of the neck or head should raise the suspicion for acute
meningitis.
o A patient who takes only small, shallow breaths and presents with severe chest pain
that worsens with inspiration may be suffering from a pneumothorax, pneumonia or
infected pleural effusion.
o A patient with severe abdominal pain and peritoneal signs may avoid sudden
movements and resist examination of the abdomen with deep palpation.
Is the patient silent or moaning?
o A patient in severe pain may either be making very little noise or making a lot of
noise because any movement makes the pain worse.
If you determine that a patient has pain from a life threatening cause then call for help,
check vital signs and if trained, give emergency treatments. Always check for pregnancy in
women of child-bearing age.
Group activity
Discuss some life-threatening causes of pain that you have seen before in patients. What
signs and symptoms did these patients have?
Participant training manual: Quick Check, triage and emergency treatments
Chapter 5 – 53
Then assess for pain from a life-threatening cause
54 – Chapter 5
Participant training manual: Quick Check, triage and emergency treatments
Severe abdominal pain and abdomen hard on palpation
There are a number of causes for abdominal pain. An abdomen that is painful and also
hard on palpation however, can be a sign of a life-threatening illness. This can include a
perforated viscous, internal haemorrhage, or a severe intra-abdominal infection. These
conditions need emergency treatment to prevent progression to severe sepsis, shock
(haemorrhagic or septic) or the development of acute lung injury.
What should you do when faced with these conditions?
•
Call the district clinician for help.
•
Call for surgical help. Acute onset of severe abdominal pain will often be caused by a
surgical emergency. The patient may need surgery urgently.
•
All patients with abdominal pain should be NPO (nothing by mouth). Some conditions
that cause abdominal pain such as pancreatitis are treated by withholding food.
•
Insert IV and give fluids slowly as instructed in Quick Check. These fluids keep the
patient hydrated. If patient goes into shock, then give fluids rapidly.
 Insert IV and give fluids slowly
Infuse at 30 drops/minute (to keep open) = 1.5 ml/min = 90 ml/hr.
•
•
•
•
Give oxygen if respiratory distress or SpO2 <90%
Give emergency IV/IM antibiotics:
o If you suspect an intra-abdominal infection or ruptured viscous, empirical antibiotics
should be started with broad spectrum activity against potential abdominal
pathogens.
o Use national or institutional guidance in choosing the antibiotic.
Treat pain:
o Morphine IV is usually preferred for patients with acute abdominal pain. Start with
2–5 mg IV.
o Reassess the patient shortly after getting the pain medication to see if the pain is
controlled.
o Monitor BP and HR, as morphine can lower both.
Send blood for type and cross-match:
o If a patient is going to surgery or you suspect internal bleeding send blood
immediately for a type and cross-match.
Abdominal pain in a woman of childbearing age
•
•
•
Perform a rapid pregnancy test to confirm pregnancy as some patients with an early
pregnancy may not know if they are pregnant.
In early pregnancy, suspect an ectopic pregnancy.
In late pregnancy, suspect placental abruption or a ruptured uterus.
Participant training manual: Quick Check, triage and emergency treatments
Chapter 5 – 55
Severe headache AND stiff neck or trauma to head/neck
A number of reasons can cause severe headache, but when a patient presents with
associated stiff neck or a history of trauma, consider life-threatening causes such as acute
bacterial meningitis.
If the patient is responsive, ask them the following questions about their headache. The
presence of any of the following should make you suspect a life-threatening cause.
• Is this headache the most severe headache of your life?
• Does this headache seem different from headaches you have experienced in the
past?
• Do you also have a stiff neck, fever, vomiting, head injury or visual changes? Consider
stroke with focal neurologic changes.
If severe headache with stiff neck and fever, consider acute bacterial meningitis:
(See the DCM Section 10.10b for how to treat patients with possible meningitis.)
•
Give IV empirical antibiotics within one hour
o A common choice is two grams of ceftriaxone.
o Use national or institutional guidance in choosing the antibiotic.
•
Call clinician to do a lumbar puncture. If the lumbar puncture can be done within 15
minutes of patient’s arrival, then wait to give antibiotics until the procedure is done.
However, it is important to avoid delaying antibiotic treatment. If a lumbar puncture
cannot be performed within 15 minutes, give antibiotics immediately and do lumbar
puncture as soon as possible.
If malaria suspected, give antimalarials. Cerebral malaria from P. falciparum infection
usually presents with severe headache and altered level of consciousness.
•
If current or recent pregnancy, elevated BP, and headache, consider pre-eclampsia
or eclampsia
In a pregnant or recently pregnant woman who presents with a headache and elevated
blood pressure, consider pre-eclampsia or eclampsia. This patient should be treated with
magnesium sulfate as described in the Quick Check.
New onset chest pain
A number of reasons can cause chest pain. However, there are some characteristics, such
as chest pain with nausea or dizziness, or crushing pain, that should make you suspect a
life-threatening cause, such as myocardial infarction. Other life-threatening causes of
chest pain include pulmonary embolism, aortic dissection, and a tension pneumothorax.
If the patient is responsive, ask the following questions:
• Do you have crushing pain in your chest? Does it radiate to the left jaw or arm? Are
you experiencing nausea, dizziness, dyspnoea (shortness of breath), or diaphoresis
(sweating)?
• Is the chest pain located in the centre of the chest behind the sternum (breastbone)?
What were you doing before it happened? Where you very active?
• Do you have risk factors for heart disease, such as hypertension, diabetes, high
cholesterol, family history or tobacco use?
• Do you have a history of trauma?
56 – Chapter 5
Participant training manual: Quick Check, triage and emergency treatments
If suspect acute myocardial infarction:
•
•
•
•
•
•
Give aspirin (300 mg, chewed).
Give oxygen if SpO2 less than 90%.
Insert IV, give fluids slowly if no signs of shock.
Give morphine for pain (see DCM, Section 20).
Perform ECG.
Call district clinician for help.
Refer to national guidelines for management of the patient with acute myocardial
infarction.
Major burn
Burns are a severe form of trauma that can cause significant soft tissue injury as well as
metabolic changes affecting fluid balance. Major burns are a life-threatening emergency.
How well a patient recovers from a major burn depends on the extent of the burn, age of
the patient, other co-morbidities, and the circumstances surrounding the injury.
Patients with major burns have one or more of the following:
•
Burns involving ≥ 15% of the total body surface area
•
Any circumferential burn
•
Inhalation injury
•
Significant associated trauma OR
•
Any burn in the elderly, or in patients with significant
pre-burn illness (e.g. diabetes, HIV, malnutrition)
Patients with major burns can develop respiratory problems
from smoke inhalation. Warning signs for inhalation injury include face and neck burns,
black sputum, wheezing, hoarse voice, and burned nasal hair. Airway oedema (swelling)
may progress rapidly in the first hours after injury. Any patient with suspected inhalation
injury and should be seen immediately by the senior clinician.
Carbon monoxide poisoning should be suspected in anyone who loses consciousness
during a fire. These patients should be started on high flow oxygen immediately.
Patients with burns can rapidly go into shock from rapid loss of fluid. They will require
aggressive and closely monitored fluid resuscitation.
•
•
Give oxygen if SpO2<90% or respiratory distress
Insert IV x 2 into non-burned skin and give fluids (Lactated Ringer’s or normal saline)
rapidly
• Monitor urine output, if possible
• Manage associated trauma
• Treat pain
• Apply clean sterile bandages
Other major burns requiring emergency evaluation and treatment include electrical
conduction burns (burns resulting from high-voltage electricity through the body) and
chemical burns. Chemical burns can be hazardous so staff should wear gloves at all times
when caring for these patients. Depending on the severity of the burns the patient may
need to be decontaminated in a shower prior to a full examination or evaluation.
See Section 3.10 in DCM for further details on management of burn patients.
Participant training manual: Quick Check, triage and emergency treatments
Chapter 5 – 57
Pain and snake-bite
Snake-bites from some venomous snakes can cause rapid cardiovascular collapse and
death. Other snake-bites can cause paralysis in respiratory muscles. Managing these
patients emergently can be life-saving. If possible, it is important to identify the type of
snake-bite to see if antivenom is available. See DCM Section 3.9.2 for details on
management.
•
Give oxygen if SpO2<90% or respiratory distress.
•
Insert IV and give fluids rapidly.
•
Treat pain.
•
Treat with antivenom if available.
Pain from life-threatening cause in the trauma patient
Abdominal pain and history of trauma
In a patient with history of trauma, severe abdominal pain that is hard on palpation should
raise the suspicion of internal bleeding from injury to liver, spleen, or vasculature. This can
result from either penetrating or blunt trauma. Monitor closely for development of shock.
• Place 16 or 18 gauge IV (at least 2). Give rapid IV fluids if signs of shock.
•
Obtain urgent surgical consult.
o If a patient has a blunt or penetrating trauma and peritoneal signs, send patient to
surgery for an exploratory laparotomy to manage internal bleeding and repair
injuries.
•
Check Hb; send blood for type and cross-match.
•
If the diagnosis is not clear, consider performing a deep peritoneal lavage or abdominal
ultrasound (if you are trained and equipment is available) to look for internal bleeding.
Headache or neck pain associated with trauma
If the patient has a headache or neck pain associated with trauma, suspect head or spinal
injury.
•
Immobilize the cervical spine as described in the Quick Check.
•
Manage head trauma as indicated in DCM, Section 4.
Chest pain associated with trauma
In patients with a history of trauma, chest pain may be caused by rib fractures or more lifethreatening conditions such as a pneumothorax or haemothorax. These conditions require
immediate treatment to prevent development of shock or severe respiratory distress.
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Participant training manual: Quick Check, triage and emergency treatments
DRILL 5-1: Quick Check
Read the following scenarios of patients with possible life- threatening causes of pain. Say
aloud what you would do to manage the patient. We will go around the room.
1. 60-year-old male presents to the ED. The patient has a history of hypertension and high
cholesterol and is complaining of severe crushing chest pain. What actions would you take?
2. A 22-year-old male presents with severe headache, stiff neck, and fever. The patient is
awake and alert and has no emergency signs of airway, breathing, or circulation. What
actions would you take?
3. A 34-year-old female presents with a severe burn affecting 30% of the lower half of her
body. Her skirt caught on fire while she was cooking dinner. She is awake and alert and has
no emergency signs of ABC at this time. What actions would you take?
4. A 27-year-old male presents 30 minutes after being bitten by a venomous snake? He has
no emergency signs of ABC. What actions would you take?
5. A 45-year-old male with a history of ulcers presents with a painful abdomen which started
hurting suddenly 30 minutes prior to arrival. The patient is sweating and guarding against
pain. His abdomen is tender and hard on palpation. What actions would you take?
6. A 22-year-old female approximately seven weeks pregnant presents with acute onset of severe
Participant training manual: Quick Check, triage and emergency treatments
Chapter 5 – 59
abdominal pain. She is pale and moaning. Her abdomen is hard and tender on palpation. What
actions would you take?
7. -Send blood for type and cross 25-year-old man was brought in by family after a car accident.
The patient was in the front seat without a seat belt and has a hard abdomen on palpation.
What action do you take?
Summary
Patients with pain from life-threatening causes usually present with one of the following:

Unable to walk, sweating, guarding against pain, or are very silent or moaning.
Identify location of pain and look for other symptom(s) or sign(s) of life threatening conditions,
such as:





Severe abdominal pain AND hard abdomen on palpation
Severe headache AND neck stiffness or head trauma
Severe chest pain AND symptoms or signs of myocardial infarction
Severe pain and major burns
Severe pain and snake-bites
Initial management steps include:

Give oxygen five litres/minute if respiratory distress or SpO2 <90%.
 Insert IV. Give fluids if indicated.
 Call for help.
 Look for and treat underlying etiology.
60 – Chapter 5
Participant training manual: Quick Check, triage and emergency treatments
Assessment questions:
Severe pain
Answer all the questions on this page. Write in the given spaces. If you have a problem,
ask a facilitator for help.
1. A 20-year-old woman who is six weeks pregnant arrives at your triage desk looking
pale with complaints of severe abdominal pain.
a. Does this patient have a quick check emergency sign?
b. What would you do to assess the patient?
c. During your evaluation, you discover that her systolic blood pressure is 80 and her
abdomen is hard and very tender to palpation. What will you do next?
2. A 66-year-old male is brought to the emergency department after being hit by a car. He
complains of shortness of breath with severe left-sided chest pain
a. Does this patient have a quick check emergency sign?
b. What would you do to assess the patient?
c. The patient is in severe respiratory distress with high respiratory rate, tachycardic,
and falling blood pressure. List a possible complication from his chest injury that
may be causing his respiratory distress?
Participant training manual: Quick Check, triage and emergency treatments
Chapter 5 – 61
3. A patient presents with fever, headache, and stiff neck.
a. What diagnosis do you suspect?
b. This patient has no emergency signs of airway, breathing, circulation, or altered
consciousness/convulsions. What first line emergency treatments would you begin?
c. You are informed that the district clinician will be there in 2 hours to perform a
lumbar puncture. Should you wait before initiating treatment?
4. A 55-year-old man who is on medication for hypertension and is a heavy smoker
presents with complaints of intermittent crushing chest pain in the centre of his chest
that worsens with exertion. All of the following are appropriate initial steps EXCEPT:
a.
b.
c.
d.
e.
Give chewable aspirin 160 mg or 325 mg
Give oxygen if respiratory distress or SpO2<90
Triage the patient to wait in the queue.
Perform an EKG and call the district health clinician
Place an IV line
5. A 31-year-old man is brought from a factory after an explosion with burns to his right
upper and lower extremity and torso. He is awake, alert, speaking clearly, in no
respiratory distress and with no emergent signs of this ABCs. What initial steps would
you take to manage this patient?
6. A woman in her 28th week of pregnancy comes to the hospital with a headache. Her
blood pressure is 170/105. What is the most appropriate medication to use to treat her
condition?
a. Morphine
b. Magnesium sulfate (IV)
c. Antivenom
d. Chewable aspirin
e. Valium
7. What are some of the major life-threatening complications you see from a venomous
snake-bite?
******************************END HOME STUDY*********************************
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Participant training manual: Quick Check, triage and emergency treatments
******************************START HOME STUDY*******************************
Chapter 6: Priority signs and their
immediate management
Learning objectives
1.
Assess for priority signs.
2.
Manage specific priority signs.
3.
Calm, protect and restrain violent or agitated patients.
After screening for emergency signs, screen all patients for priority signs
Patients who do not present with emergency signs should still be screened for priority
signs as soon as possible. Priority patients may also have potentially life-threatening
conditions which require timely treatment. Patients who are an infection control risk or a
danger to themselves or others should also be triaged as a priority. Priority patients should
be brought to the front of the queue (or isolated when appropriate) and assessed and
treated as soon as possible.
Depending on how your facility is arranged, it may be necessary to triage the priority
patients to a different room or location instead of just moving these patients to the front of
the line. Other patients already waiting in the queue may get upset if they think that certain
patients are getting preferential treatment. Having a consistent system in place can help
avoid any conflict while triaging patients. Priority signs may need to be adapted to local
diseases and conditions.
If a priority sign is identified, check vital signs.
The Quick Check triage system is designed to rapidly screen patients. We do not check
the vital signs on all patients in triage, as that process would take too long to make the
Quick Check screening rapid. However, if a priority sign is detected, prioritize the patient
for evaluation, check vital signs and respond.
Priority conditions requiring infection control
It is important at triage to start infection control and limit the exposure to patients with
highly infectious conditions. For patients with cough, institute respiratory precautions to
prevent transmission of respiratory diseases. For example, patients with suspected TB or
influenza-like illness during a pandemic should be given a mask to wear or moved to a
separate location. While these patients do not necessarily need to be seen before others,
it is a priority to start infection control procedures as soon as possible after the patient
arrives at the hospital.
You should be familiar with the different approaches to infection control and respiratory
precautions at your health facility.
Participant training manual: Quick Check, triage and emergency treatments
Chapter 6 – 63
Priority signs for urgent care – these patients should not wait in queue:















Any respiratory distress/complaint of difficulty breathing*
Violent behaviour towards self or others or very agitated
Very pale
Very weak/ill
Recent fainting
Bleeding:
 Large haemoptysis
 GI bleeding (vomiting or in stools)
 External bleeding
Fractures or dislocations
Burns
Bites from suspected venomous snake or from rabid animal
Frequent diarrhoea >5 times per day
Visual changes
New loss of function (possible stroke)
Rape/abuse (maintain a high index of suspicion)
New extensive rash with peeling and mucus membrane involvement (Stevens-Johnson)
Acute pain, cough or dyspnea, priapism, or fever in patient with sickle cell disease
Group exercise
Break into groups of two or three. Refer to the list of priority signs above. Your facilitator will ask
your group to discuss three or four of the priority signs. Why do these patients take priority over
other patients waiting in the queue? What conditions might these patients have? Afterwards,
your facilitator will go through the whole list with the class.
Identify and manage priority signs
Patients with priority signs are at risk for rapidly deteriorating. Once a patient is triaged as
priority, he/she should be placed at the front of the queue for urgent evaluation. If the
patient is in the queue for more than 20 minutes, repeat the Quick Check and look for new
emergency signs which may have developed. Respond to any abnormal vital signs. Start
any necessary urgent treatments. If the patient has no emergency or priority signs, the
patient is non-urgent and should be triaged to wait in the queue.
Identify respiratory distress or complaint of difficulty breathing
These patients may have signs or symptoms of dyspnea but do not have Quick Check
emergency signs of Airway or Breathing (e.g., mild/moderate asthma exacerbation).
• Measure SpO2; give oxygen 5 litres if SpO2 <90
• If wheezing, give salbutamol (see QC, p. 17)
• Appropriate infection control measures
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Participant training manual: Quick Check, triage and emergency treatments
Violent behaviour toward self or others or very agitated
If the patient is violent or very agitated, protect, calm and sedate the patient as appropriate
(see QC, p. 29). The goal of managing violent or agitated patients is to prevent them from
harming themselves, you, or others. It is always wise to get help from others. Do not try to
manage them alone.
•
First check for and treat reversible causes of altered consciousness. Check glucose
and SpO2 and consider causes including infection (see DCM, Section 3.4)
•
Attempt to calm the agitated patient who is cooperative and non-aggressive
•
Take any threats of violence seriously
o Make sure other providers are within earshot
o Remove any objects that are unsafe or could be used as weapons; consider if the
patient might be armed
•
For the patient who is non-cooperative, aggressive and uncontrollable, consider
restraining the patient.
o Always enlist the help of others and use a coordinated, safe approach.
o Physical restraints should only be considered to ensure the safety of the patient and
staff in the most uncontrollable situations. Patients should not be physically
restrained for long periods.

While restraining a patient take care to avoid putting pressure on the neck or
chest

If you must use restraints, be sure to protect the wrists and ankles with soft
padding and have the patient lying face up – never lying face down. If the
patient vomits, position them lying down on one side.

Do not leave the patient unattended and frequently monitor vital signs.
o Two medications, diazepam and haloperidol are commonly used to sedate very
agitated patients. Patients receiving these medications should not be left alone and
airway and breathing should be frequently monitored.

Diazepam (see QC, p. 29; DCM, Sections 3.6 and 3.7):
Use for agitated patients with suspected cocaine, amphetamine, or alcohol
use or who are suffering from sedative withdrawal.
o Avoid sedatives such as diazepam in elderly patients as they are much more
sensitive to them.
Haloperidol:
o

Recommended for other agitated patients and acute psychosis
o For severe agitation, give haloperidol 5 mg IM every hour up to three
injections, for a maximum of 15 mg
o
Participant training manual: Quick Check, triage and emergency treatments
Chapter 6 – 65
Some notes and cautions on haloperidol:
Haloperidol will usually calm the person immediately after the first dose, but psychotic symptoms such as
delusions or hallucinations may take some time (a few weeks) to disappear completely.
Haloperidol can be administered through po, IM, or IV routes but when the patient needs immediate
sedation, administer parenterally (usual initial dose is 5 to 10 mg). It is important to monitor pulse, blood
pressure and respiration. These patients can develop life-threatening side effects including neuroleptic
malignant syndrome, arrhythmias and acute dystonia. If these conditions are suspected:
• maintain an airway
• stop the haloperidol
• give biperiden 5 mg IM or IV if it is available
• if not available, give diazepam 5 mg rectally
• call for help from district clinician
Other less severe nervous system manifestations can also occur in patients with long term anti-psychotic
use.
Very pale, weak/ill-appearing, recent fainting and bleeding (without
emergency signs of Circulation)
These patients may not present with Quick Check emergency signs but may have serious
conditions requiring urgent evaluation. Vital signs should be checked as soon as possible
to determine the need for emergency evaluation and treatment. Examples include a
patient with severe malaria, diabetic ketoacidosis, haemoptysis or GI bleeding.
If a clinician is not immediately available, monitor airway, place IV, send blood for
haemoglobin, type and cross-match and check pregnancy status.
• If blood pressure is low or patient presents with very heavy bleeding, treat as
emergency sign of circulation. Otherwise, triage the patient as a priority patient.
•
Patients with a gastrointestinal (GI) bleed may lose blood very quickly. Though they
may initially have stable vital signs, they should be assessed rapidly to determine if
they are actively bleeding. A patient is actively bleeding if they are vomiting bright red
blood, have tarry black stool, have maroon coloured stool, or are passing bright red
blood rectally.
•
Place a mask on the patient if there is an infectious disease concern.
•
Institute infection control precautions for viral hemorrhagic fever if a patient with acute
onset of fever (<3 weeks) is from a known endemic area or is seen during a known
outbreak, and has 2 of the following:
o haemorrhagic or purpuric rash
o epistaxis
o haematemesis
o haemoptysis
o blood in stool
o other haemorrhagic symptoms and no known predisposing factors for haemorrhagic
manifestations (e.g., gingival bleeding, vaginal bleeding)
If patient has not been evaluated within 30 minutes, reassess patient for any
emergency signs and repeat HR and BP.
•
66 – Chapter 6
Participant training manual: Quick Check, triage and emergency treatments
Fractures, dislocations, and non-major burns
These patients do not fulfill any Quick Check emergency signs criteria and should be
triaged as priority for urgent assessment of complications from trauma and burns.
If visible deformity, assess and treat possible fractures or dislocations (see DCM, Section
4.6).
• Assess for serious traumatic injuries resulting in emergency signs.
• Treat pain.
• Check neurovascular status distal to injury – look to see if the extremity is warm and
well-perfused and that neurological function is intact.
• If the patient has neurovascular compromise, reduce fracture/dislocation immediately
to prevent permanent neurovascular damage. Do not wait for X-rays prior to reduction.
• Recheck neurovascular status immediately after reduction and document.
Manage burns (see DCM, Section 3.10).
• Monitor for emergency signs of airway, breathing and circulation.
• Treat pain as soon as possible.
Bites from suspected rabid animal
These patients require supportive therapy, urgent evaluation to determine if rabies
prophylaxis and infection control are needed (see DCM, Section 11.30).
Frequent diarrhoea >5 times per day
These patients may rapidly develop dehydration, electrolyte abnormalities and shock.
Assess vital signs and determine need for emergency treatment and infection control (see
DCM, section 10.7d).
Visual changes or new loss of function (possible stroke)
Patients with new visual changes or loss of function (e.g., focal weakness, difficulty
speaking, difficulty walking) may be having a stroke.
1. Check for and treat reversible causes such as hypoglycemia or hypoxia.
2. Determine time of onset and if indicated and possible, refer patient for brain imaging.
3. Do not leave the patient unattended and regularly monitor for airway and breathing
complications.
Rape or abuse
•
•
•
A patient who has been raped or abused will often be experiencing emotional trauma
as well. It is important to make sure that the patient feels safe and is cared for as soon
as possible.
Assure confidentiality. If possible, triage the patient in a private area.
Manage injuries (see DCM, Section 4.4).
Participant training manual: Quick Check, triage and emergency treatments
Chapter 6 – 67
New extensive rash with peeling and mucous membrane involvement
(Stevens-Johnson syndrome)
Stevens-Johnson syndrome is a severe drug reaction resulting in extensive peeling and
sloughing of skin and mucosa in greater than 10% of total body surface area and more
than one mucosal surface (oral, conjunctival, genital). Constitutional symptoms and
systemic involvement can occur. As with major burn patients, these patients can also
exhibit emergency signs for circulation when their condition deteriorates into profound
dehydration and shock.
• Vital signs should be checked as soon as possible to determine the need for
emergency evaluation and treatment (see DCM, Section 10.2.3).
• Treat pain and local wound care.
Acute pain, cough or dyspnea, priapism or fever in patient with sicklecell disease
Patients with sickle cell disease can develop acute vaso-occlusive crises. Complications
can include acute bone pain, joint swelling and priapism. Life-threatening complications
include:
• Acute chest syndrome, which can rapidly progress to emergency signs of Airway or
Breathing
• Neurologic emergencies such as stroke or seizure
• Thrombotic events including pulmonary embolism
• Haematologic crises such as splenic sequestration, aplastic crisis due to infection, and
haemolytic crisis
• Sepsis
Vital signs should be checked as soon as possible to determine the need for emergency
evaluation and treatment (see DCM, Section 10.18.3).
• Rehydrate with oral fluids and, if necessary, intravenous fluids
• Give oxygen if SpO2 < 90%
• Treat pain – strong analgesics including opiates are likely to be needed
68 – Chapter 6
Participant training manual: Quick Check, triage and emergency treatments
Group exercise
Management of patients with priority signs
Your facilitator will give you a clinical scenario. Discuss these cases as a group. Discuss what
you would do next for the patient. Use the Quick Check wallchart to help you.
1. 22-year-old female with a history of asthma presents with difficulty breathing. Patient is
speaking in full sentences and has no emergency signs of airway or breathing. How would
you triage this patient? What actions would you take?
2. 47-year-old male with a history of ulcers presents after vomiting bright red blood at home.
Patient is awake and alert, and has no emergency signs. How would you triage this patient?
What actions would you take?
3. 26-year-old male with a history of schizophrenia presents with acute agitation. The patient is
spitting and biting at staff members. How would you triage this patient? What actions would
you take?
4. 22-year-old female in her second trimester of pregnancy presents complaining of fever. On
examination she appears very weak and is leaning on a family member to help her stand up.
She has no emergency signs of ABC. How would you triage this patient? What actions would
you take?
5. A 55-year-old female presents with over 12 episodes of watery, non-bloody diarrhoea in one
day. She appears weak. How would you triage this patient? What actions would you take?
Participant training manual: Quick Check, triage and emergency treatments
Chapter 6 – 69
Assessment questions:
Priority patients
Answer all the questions on this page. Write your responses in the given spaces. If you
have a problem, ask a facilitator for help.
1.
What is the major side-effect of haloperidol administration for sedation? How would
you manage a patient with this complication?
2.
Once a patient is determined to be a priority, what is your next step in the patient’s
assessment?
3.
Which of the following patients would you classify as priority?
a. A 40-year-old male with a history of alcohol abuse who vomited a large amount
of bright red blood while waiting and has a HR of 130.
b. A female in her ninth week of pregnancy with right lower abdominal pain,
abdominal tenderness and rigidity on examination, and a BP of 85/55.
c. A 20-year-old male who is actively seizing.
d. A 35-year-old female with complaint of difficulty breathing with a RR of 16 and an
O2 saturation of 97%.
e. A 60-year-old man who is confused with a history of increasing headache and
stiff neck, and a temperature on presentation of 39.5°C.
4.
You are seeing an agitated, but non-violent and cooperative patient. What steps
would you initially take to calm this person down? If the patient becomes violent what
steps will you take?
5.
List 3 life-threatening complications of sickle-cell disease.
********************************END HOME STUDY*********************************
70 – Chapter 6
Participant training manual: Quick Check, triage and emergency treatments
Chapter 7:
Continue with urgent management
of patients with emergency signs
Learning objectives
1.
Reassess the patient with emergency signs.
2.
Give urgent treatments for suspected diagnosis.
3.
Monitor your patient.
4.
Prepare patient for disposition and transport.
In the earlier chapters you learned how to triage patients and administer first-line
emergency treatments to patients presenting with emergency signs. After the Quick Check
and administration of first-line emergency treatment, reassess the patient for response to
treatment and give additional treatment as needed. At this point, you can complete taking
the patient’s history and conduct a physical examination. Give urgent treatments for
suspected diagnosis as needed. These urgent treatments are critical to prevent morbidity
and mortality in patients and should not be delayed once life-threatening emergencies
have been managed. For example, in a patient with severe malaria or septic shock,
antibiotics and antimalarials need to be provided immediately. The last column in the
Quick Check describes some of the urgent treatments for common conditions and refers
you to relevant sections of the IMAI DCM for detailed management.
Case Scenario
The following case scenario is an example of how to use the Quick Check, and continue
with the urgent management of patients with emergency signs. Use the wallchart to follow
along as you review this case out loud.
A 23-year-old female presents with fever, cough, and shortness of breath. At triage the patient is
noted to be in severe respiratory distress with fast breathing, cyanosis, and wheezing. The triage
nurse recognizes that the patient has Quick Check emergency signs of airway and breathing.
The nurse gives first-line emergency treatments giving oxygen five litres via nasal cannula and
salbutamol via Metre Dose Inhaler (MDI) with spacer. The nurse finishes the Quick Check and
does not detect any emergency signs of circulation, altered consciousness, or convulsions.
Next, the nurse proceeds to the Quick Check column “continue with urgent management of
patients with emergency signs”. Accordingly, she does the following:
• Counts pulse, RR; measure SBP, temperature, SpO2
• Titrates oxygen to SpO2 90.
• Gives antibiotics if fever and RR >30.
• Gives antiviral if suspect influenza.
• Inserts IV and start fluids at 1 ml/kg/hour.
Go to Section 3.2 of the DCM to manage the severely ill patient with difficulty breathing.
Participant training manual: Quick Check, triage and emergency treatments
Chapter 7 – 71
After giving first-line emergency treatments do the following:
Step 1: Call for help
Make sure help is on the way. In some hospitals, the district clinician may not be
immediately available and urgent treatments may need to be started by the nurse.
Step 2: Reassess the patient for the response to treatment and document response
Patients with emergency signs are severely ill and require frequent reassessment and
monitoring. Check immediate response after every emergency treatment. Record the
treatment given and your findings.
•
Check vital signs (HR, RR, BP, temperature, oxygen saturation, AVPU).
•
Check that all emergency medications have been given.
•
Check that emergency laboratory tests have been sent.
•
Check the patient response to treatment.
Step 3: Complete history and physical examination
The Quick Check is a fast, screening history and physical exam to identify life-threatening
conditions. After giving first-line emergency treatments, the treating clinician must
complete a thorough history and physical examination (see relevant sections of the DCM).
Step 4: Give urgent treatments for suspected diagnosis
After completing the history and physical examination, you will start to develop a
differential diagnosis. Always consider life-threatening conditions first. Always reconsider
the diagnosis if the patient’s condition is worsening.
In caring for patients with immediately life-threatening illnesses, clinical reasoning must be
part of a systematic approach to patient management – appropriate, empirical treatments
are given without delay while clinical information is being integrated. Clinical reasoning is
an art, and an important skill that helps in clinical decision-making. At any time, if the
patient fails to respond to a treatment, the differential diagnosis list should be reviewed
and alternate causes reconsidered
Once you take the patient’s history and conduct the physical exam, create a problem list
for the patient, including the main problem or problems. You can use the list to develop a
differential diagnosis (list of possible diagnosis). At first, this differential diagnosis list is
usually very broad in scope, arranged by categories with most immediately life-threatening
illnesses on the top. Sometimes at this stage little information may be known. This is
especially true if the patient cannot give a history and the initial exam was cursory. The
IMAI DCM provides broad differential diagnosis lists for these problems.
As needed, gather more information from family members or friends. Perform a more
thorough physical examination and consider further investigations such as laboratory and
radiological tests to help support or refute the diagnosis. In resource-constrained settings,
clinical decisions are often made with limited diagnostic support services.
Prioritizing the differential diagnosis involves integrating the information gathered and
weighing the likelihood of one diagnosis over other possible diagnoses. When little
information is available, it may be necessary to treat for several different conditions at the
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Participant training manual: Quick Check, triage and emergency treatments
same time. Be cautious not to remove a diagnosis too early from the list. As additional
information is gathered, conditions which were initially categorized as low priority may
become more likely. If the patient fails to improve with empirical treatments, reconsider the
prioritization of your differential diagnosis list.
For example, if during the Quick Check you find a patient is in shock, the five types of
shock should be on your initial differential diagnosis. First-line emergency treatments such
as inserting an IV and giving a fluid bolus should be started without delay. If the patient
also has a fever, then septic shock should rise to the top of the differential diagnosis and
empirical antibiotics should be administered. The initial physical examination and
laboratory investigations should aim to make sure there is no alternate cause of shock,
such as active bleeding, in addition to recognizing the source of infection. It may be
obvious that the patient has pneumonia based on a lung exam or it may be unclear that
the patient has a kidney infection until the urine results are back. Even though it takes time
to find the cause of the infection, it is imperative that empirical treatments for all potential
sources of infections are administered without delay. Once the infection is recognized,
appropriate treatment can be targeted for this infection.
The symptom-based sections of the IMAI District Clinician Manual all follow this systematic
approach to the diagnosis and management of patients, with minor variations between
sections:
1.
2.
3.
4.
5.
6.
7.
Perform Quick Check (QC) and give first-line emergency treatments.
Complete history and physical exam.
Assess HIV status.
Classify illness and consider differential using differential diagnosis (DDx) tables.
Give urgent treatments.
Perform investigations.
Initiate definitive management and monitor response.
Urgent management of emergency signs of airway and breathing
During the Quick Check patients with emergency signs of airway or breathing should have
had first-line emergency treatments including airway management, administration of
oxygen and administration of bronchodilators if wheezing.
•
After starting a patient on oxygen for an emergency sign of airway or breathing, titrate
the oxygen flow to SpO2 ≥ 90%.
•
In severely ill patients with emergency signs of airway or breathing and fever, suspect
severe pneumonia or other infectious process. If patient with emergency sign of airway
or breathing, fever, and RR>30, give empirical antibiotics for suspected pneumonia
(see DCM, Section 3.2). Early administration of antibiotics within one hour saves
lives.
•
If influenza is suspected, early treatment with antivirals can help decrease morbidity
and mortality in severely ill patients. Treatment with antivirals should be based on local
epidemiology of disease and local or national guidelines.
•
All severely ill patients should have IV access. Insert IV (16 or 18 gauge) and start
fluids at 1 ml/kg/hour. If the patient has emergency signs of circulation or volume
overload is suspected, adjust the rate of fluid administration accordingly.
Participant training manual: Quick Check, triage and emergency treatments
Chapter 7 – 73
•
Additional urgent management of emergency signs of airway and breathing:
o
o
o
o
o
o
difficulty breathing (see DCM, Section 3.2)
continued moderate to severe wheezing (see QC p.17; DCM, Section 3.2)
pinpoint pupils – suspect organophosphate intoxication (DCM, Section 3.8)
pinpoint pupils – suspect opioid intoxication (see QC p. 18; DCM, Section 3.6)
suspect other poisoning or snake-bite (DCM, Sections 3.8, 3.9)
inhalation burn (DCM, Sections 3.2, 3.10)
Urgent management of emergency signs of circulation
In addition to the first-line general treatment of shock described in the Quick Check
(oxygen, fluids, temperature and haemorrhage control), look for the cause of shock and
give urgent treatment. If bleeding, use universal precautions including mask and eye
protection. If during an outbreak or in an endemic region for viral hemorrhagic fevers,
ensure appropriate infection control procedures are in place.
There are different etiologies of shock. Septic shock occurs from an overwhelming
infection. Hypovolaemic shock occurs from severe dehydration or fluid loss (diarrhoea).
Cardiogenic shock occurs from cardiac failure. Anaphylactic shock occurs from a severe
allergic reaction. Haemorrhagic shock occurs from severe blood loss. Neurogenic shock
occurs from acute spinal injury.
•
If fever, strongly consider septic shock and severe malaria.
o One of the most important treatments when caring for patients with septic shock is
administration of anti-infective therapy as soon as possible. Within the first hour,
give empirical antibiotics or antimalarials if P. falciparum is suspected; give
antivirals if influenza is suspected. If the first-line treatment is unavailable, do not
delay and use an alternative medication.
o If feasible, send blood culture before starting antibiotics.
If malaria is a consideration, give antimalarials based on local guidelines. Dose artemether
and quinine based upon the patient’s weight (see DCM-QC). If the patient’s glucose level
is low or unknown, give glucose along with quinine as quinine can cause hypoglycaemia.
See DCM, Section 8.4 for more details on dosing, side-effects, and contraindications. The
second part of this course will review in more detail the management of patients with
septic shock.
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Participant training manual: Quick Check, triage and emergency treatments
•
In patients complaining of chest pain or with a history of cardiomyopathy, valvular heart
disease, congestive heart failure or ischemic heart disease, suspect cardiogenic shock.
o Patients with heart failure, cardiogenic shock, or severe anaemia can rapidly
become volume overloaded when receiving intravenous fluids. Small IV fluid
boluses (200 ml), or oral hydration if tolerated, are recommended with frequent
evaluation to determine need for additional hydration. Look for signs of pulmonary
oedema such as respiratory distress with increasing RR, crackles on lung
auscultation, elevated jugular venous pressure and lower extremity oedema (see
DCM, Section 3.2).
•
If history of diarrhoea or dehydration, suspect hypovolaemic shock.
o A patient with severe diarrhoea can rapidly become dehydrated and go into shock.
Immediately begin IV and oral fluids using the approach outlined below (Plan C in
DCM 5.7.4).
IV Rehydration (Plan C)
Start IV fluid immediately. If the patient can drink, give ORS by mouth while the drip is set up. Give 100
ml/kg Ringer’s Lactate Solution (or, if not available, normal saline), divided as follows:
Age
First give 30 ml/kg in
Then give 70 ml/kg:
Infants (under 12 months)
1 hour*
5 hours
Older (12 months or older, including adults)
30 minutes*
2 ½ hours
* Repeat once if radial pulse is very weak or not detectable.
Reassess the patient every 1–2 hours. If hydration status is not improving, give the IV drip more rapidly.
Also give ORS (about 5 ml/kg/hour) as soon as the patient can drink, usually after 3–4 hours (infants) or
1–2 hours for children, adolescents and adults.
Reassess patient after 3 hours. Classify dehydration.
Then choose the appropriate plan (A, B, or C) to continue treatment.
******************************START HOME STUDY******************************
Vaginal bleeding can lead to shock in both pregnant and non-pregnant women
o If the patient has vaginal bleeding, assess pregnancy status and amount of
bleeding. Insert IV line, give rapid IV fluids and send haemoglobin, type and cross.
o If early pregnancy with light bleeding, consider ectopic pregnancy. With heavy
bleeding (pad or cloth soaked in < 5 minutes), consider spontaneous or complicated
abortion. Initiate empirical antibiotics if fever or foul-smelling vaginal discharge.
o If bleeding in late pregnancy or during labour, consider placenta previa, abruptio
placenta, or ruptured uterus. Avoid performing vaginal exam as it my increase risk
for infection and worsen bleeding. Call for help from senior clinician.
o If postpartum with heavy bleeding (pad or cloth soaked in < 5 minutes, constant
trickling of blood, bleeding > 250 ml or delivered outside hospital and still bleeding),
massage uterus and give oxytocin.
•
Large nosebleed (epistaxis) can lead to shock, particularly in patients with poor clotting
or bleeding from the posterior part of their nose. Hold pressure by pinching nostrils
tightly between fingers and thumb. Manage airway.
Participant training manual: Quick Check, triage and emergency treatments
Chapter 7 – 75
Send blood for type and cross-match and haemoglobin if major bleeding and anticipate
a blood transfusion.
o Follow emergency treatment for management of epistaxis (see DCM-QC)
• If a patient presents with large amounts of bloody vomiting, they are most likely having
upper gastrointestinal bleeding and can quickly develop haemorrhagic shock. Patients
can vomit blood as a result of an ulcer, severe gastritis, a tear in their oesophagus
caused by vomiting or oesophageal varices.
 Manage heavy upper gastrointestinal bleeding








Call for help
Insert nasogastric tube to decompress (do not lavage – see Section 7.2).
Insert IV and give fluids rapidly (see QC p. 18).
Send blood specimen for type and cross match then transfuse as needed.
Repeat Quick Check and monitor pulse, SBP and haemoglobin.
If endoscope and trained provider: locate site and cauterize.
Give proton pump inhibitor in high dose (e.g. omeprazole 80 mg).
Check whole blood clotting time if available.
******************************END HOME STUDY*******************************
Urgent management of emergency signs altered consciousness/ convulsions
Patients with altered consciousness require frequent reassessment and monitoring of
airway and breathing until patient is fully alert. If consciousness improves after first-line
emergency treatment, obtain further history. If unable to obtain further history from the
patient, try to obtain information from friends and family members. Patients with certain
conditions such as alcohol intoxication or recent seizure should gradually become more
alert. If the mental status does not improve as expected, reconsider your diagnosis. For
example, in the alcoholic patient reassess for occult head trauma that may have been
missed in the initial evaluation.
•
Use the appropriate Section of the IMAI manual to help form a differential diagnosis
and determine the appropriate treatment plan.
o Altered consciousness (DCM, Section 3.4); convulsions (DCM, Section 3.5).
o If fever with altered consciousness or convulsions, suspect meningitis or cerebral
malaria, if in endemic malaria area. If suspect meningitis and no focal neurological
deficits or papilloedema on fundoscopic examination, perform lumbar puncture. Do
not delay giving antibiotics if cannot be done within 15 minutes (see QC p. 19).
o Pinpoint pupils – suspect organophosphate intoxication (DCM, Section 3.8).
o Pinpoint pupils – suspect opioid intoxication (see QC p. 18; DCM, Section 3.6).
o Alcohol intoxication or withdrawal (DCM, Section 3.7).
o Other poisoning or snake-bite (DCM, Sections 3.8, 3.9).
Step 5: Monitor your patient
Monitor patients treated with first-line emergency treatments and urgent treatments
carefully and frequently. In advanced learning units, we will discuss the use of a patient
monitoring form for the severely ill patient to record the patient information and treatments.
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Participant training manual: Quick Check, triage and emergency treatments
Step 6: Prepare your patient for transport
After receiving urgent treatment, prepare patient for transport to where they will receive
definitive treatment (ward, intensive care unit, operating theatre, or higher level of care). If
patient requires transfer to a higher level of care, do not delay transport for additional
diagnostic testing if testing can be performed at the receiving facility.
The transport period is one of the most hazardous phases in caring for patients. Ensuring
patient safety during transfer requires resources and monitoring.
Prior to transport:
•
If possible, stabilize emergency signs.
•
Give urgent treatments.
•
Communicate with receiving hospital or ward.
•
Document vital signs.
•
Document all treatment given.
•
Assign staff or family member to accompany patient.
•
Keep patient comfortable. Treat anxiety and pain. Cover patient and keep warm.
DRILL 7-1:
Continue with urgent management
Discuss the following patient scenarios. What would be the next steps? Refer to appropriate
section in DCM for further management guidance.
1. 19-year-old female patient with severe respiratory
distress, cough and bronchospasm.
-
First line emergency treatments given: oxygen
and salbutamol.
Reassessment vital signs: T 38C, BP 120/70,
HR 100, RR 35, SpO2 92%.
What urgent treatments would you give next (if any)?
2. 26-year-old male patient is brought in to hospital
unconscious with alcohol on his breath.
-
First line emergency treatments given: airway
management, oxygen, IV fluids and glucose.
Reassessment: T 36 C, BP 120/70, HR 100,
RR 20, SpO2 98% and patient is starting to
wake up.
What urgent treatments would you give next (if any)?
3. 37-year-old male presents with fever and lethargy
and has weak, fast pulse. Initial BP was 70/30 and
HR was 120.
-
First line emergency treatments: oxygen and
1 litre IV fluids bolus of NS.
Reassessment: T 38.5 C, BP 75/40, HR 110,
RR 25 and SpO2 98%.
What urgent treatments would you give next (if any)?
Participant training manual: Quick Check, triage and emergency treatments
Chapter 7 – 77
4. 23-year-old pregnant female 8 months gravida
presents with hypertension and convulsion.
-
-
First line emergency treatments: oxygen,
patient placed in recovery position, IV
glucose, and IV magnesium sulfate.
Reassessment: T 36 BP 150/80, HR 100,
RR 25, SpO2 95%. Patient begins to have
another convulsion.
What urgent treatments would you give next (if any)?
• 16-year-old male presents confused with
fever and meningismus. His family states he
had a headache earlier in the day.
-
-
First line emergency treatments: oxygen,
patient placed in recovery position, IV
glucose, IV fluid bolus of NS.
Reassessment: T 40 BP90/50 HR 125 RR
27 SpO2 98%. The patient’s condition is
unchanged.
What urgent treatments would you give next (if any)?
Clinical scenarios
The cases below are designed to allow you to practice this approach, especially the
application of the differential diagnosis tables, in realistic clinical situations. The following
approach will guide you in using the differential diagnosis tables. Complete case 7-1 now,
and the remainder at home.
1.
2.
3.
4.
5.
Use the differential diagnosis tables to establish links between clinical features and
possible underlying diagnoses
Prioritize the list of possible diagnoses from the table based on what conditions are
most likely in the setting and/or life threatening
Request and perform specific diagnostic tests in order to support or refute diagnoses
from the initial differential list
Do clinical findings and/or diagnostic test results support a condition from the initial
differential diagnosis list?
If yes, treat accordingly.
If treatment is successful, follow patient as indicated.
If treatment is unsuccessful, re-evaluate patient, modify differential diagnosis, and
return to step 1.
If no, re-evaluate patient, modify differential diagnosis, and return to step 1.
If diagnosis is uncertain
• consider initiating empirical therapy for serious or life threatening conditions;
• consider initiating empirical therapy for non-severe conditions when a diagnosis is
likely and treatment is accessible and likely to be effective
Review the first case as a group, and then practice the remaining cases on your own or
with a partner. Use the relevant sections of your district clinician manual to help guide you.
78 – Chapter 7
Participant training manual: Quick Check, triage and emergency treatments
CASE 7-1
History of presenting complaint
A 32-year-old woman has been transferred from a health centre associated with your district
hospital due to severe shortness of breath. The woman gave birth to her third child two months
ago. Her shortness of breath began soon after delivery and has been gradually worsening. She
has also developed a cough that is productive of clear sputum. She finally decided to walk to the
health centre for help.
What should you do next?
Initial findings
She has no signs of airway obstruction but does appear to be in severe respiratory distress. She is
unable to speak in full sentences due to her shortness of breath. Oxygen saturation is 85%. Pulses
and capillary refill are normal, and her husband tells you she has not been complaining of any
vaginal bleeding and has not had any major trauma. She does not appear to be in any pain. The
triage nurse administers oxygen.
DDx
In favour
Physical examination
Her temperature is 37°C, respirations 27, heart rate 90, blood pressure 120/65, and oxygen
saturation remains in the upper 80s. She prefers to stay seated and refuses to lay flat. Veins on
her neck appear prominent. Heart exam is otherwise unremarkable. On lung exam, she has
crackles in both lower lung fields extending half-way up. Abdominal exam is unremarkable. Her
legs appear very swollen, and she has 2+ oedema bilaterally to just below the knee.
DDx
In favour
Investigations
Blood glucose, malaria smear, and haemoglobin are all normal. PA chest radiography shows
cardiomegaly with bilateral infiltrates. Fortunately, your facility has ultrasound equipment, and you
see that the left ventricular function appears severely depressed; there is no obvious mitral
stenosis.
Likely diagnosis
Management plan
Participant training manual: Quick Check, triage and emergency treatments
Chapter 7 – 79
CASE 7-2
History of presenting complaint
A 54-year-old man presents to the emergency ward with chest pain. The nurses have seen him
many times when he has come in for being very drunk and losing consciousness. Today he
appears alert and is complaining loudly of chest and abdominal pain.
What should you do next?
Initial findings
There are no emergency signs of airway/breathing signs. His pulse is fast and the nurse notes that
his heart rate is 110. His capillary refill is normal and his blood pressure is 110/50. An IV is inserted
and he is given a bag of normal saline. He has never had this pain before. He has no history of
high blood pressure, smoking, or diabetes. He has been told his father died while very young. He
has no idea why he died, but thinking about it too much makes him sad.
DDx
In favour
Physical examination
His temperature is 39°C. His oxygen saturation is 88%. He is holding the right side of his chest and
keeps telling you that it hurts. He talks to you while you examine him. Apparently the pain began
last week, a day after he was found on the roadside after losing consciousness. He had vomited all
over himself. He is tachycardic, but heart exam is otherwise normal. On lung exam he has
pronounced crackles on the right side. His abdominal examination is normal.
DDx
In favour
Investigations
Blood glucose, malaria smear, and haemoglobin are all normal. PA chest radiography shows right
middle lobe infiltrate.
Likely diagnosis
Management plan
80 – Chapter 7
Participant training manual: Quick Check, triage and emergency treatments
CASE 7-3
History of presenting complaint
A 31-year-old woman presents with a decreased level of consciousness. She opens her
eyes on command but her speech is confused and incoherent.
What should you do next?
Initial findings
She has no emergency signs of airway/breathing or circulation. She is given oxygen and
glucose by the triage nurse. Her blood pressure, heart rate, and respiratory rate are all
normal. Her temperature is 38.6°C.
DDx
In favour
Physical examination
Your initial examination reveals a temperature of 38.6°C, heart rate of 78, blood pressure
120/65, respirations 16. Her chest is clear and the abdomen is soft and nontender. Her
reflexes are normal and plantar reflex are down-going.
While you are examining her, a woman claiming to be her mother-in-law arrives and is
able to give additional information. The patient has had a severe headache with fever and
neck pain for a week. At times over the course of the last few days she has been
complaining of double vision. She was recently widowed and has three children who are
all well. She does not drink alcohol.
DDx
In favour
Investigations
Blood glucose, malaria smear, and haemoglobin are all normal. Rapid HIV testing is
positive. A lumbar puncture is done and the India ink stain is positive.
Likely diagnosis
Management plan
Participant training manual: Quick Check, triage and emergency treatments
Chapter 7 – 81
Assessment questions:
Continued urgent management of
patients with emergency signs
Answer all the questions on this page. Write your responses in the given spaces. If you
have a problem, ask a facilitator for help.
1. After completion of the Quick Check and administration of first-line emergency
treatments, what is the next step?
2. Continued urgent management of a patient with airway and breathing emergency signs
would include everything EXCEPT:
a.
b.
c.
d.
e.
Count HR, RR, measure oxygen saturation
Place the patient back in the queue
Titrate oxygen to SpO2>90%
Give antibiotics if fever and RR >30
Insert IV
3. True/False: Antibiotics should be given within one hour for patients with septic shock.
4. List three conditions which can lead to hypovolaemic or haemorrhagic shock?
5. A patient has been in your emergency ward for several hours with decreased level of
consciousness and alcohol intoxication. On reassessment the patient’s mental status is
not improving. What other condition(s) should you check for?
6. True/False: A patient presents to the emergency ward immediately after a convulsion
and is not waking up. If the patient had a simple convulsion, you expect the patient
would gradually wake up over the next several hours.
82 – Chapter 8
Participant training manual: Quick Check, triage and emergency treatments
Chapter 8:
Implementing the Quick Check and
emergency treatments
Learning objectives
1. Understand the system changes (process improvement) needed to successfully implement
the Quick Check.
2. Create a plan to train key staff in the Quick Check in your hospital.
3. Develop action plans to initiate the system changes (improvement process) needed to
implement the Quick Check in your hospital.
4. Monitor the implementation of the Quick Check in your hospital.
Now that you have been trained in the Quick Check (QC), you will be able to use the QC
process to improve the triage and emergency care of patients in your hospital. However,
training is only the first step. Successful implementation is a multi-step process that
requires a system-wide change and commitment from both clinical and managerial staff.
Discuss the following case scenario and then fill in the table as a group.
1. Case scenario. A 26-year old male who has had fever and headache for 2 days
comes to your health facility. He waits for his card and registration in the queue for 1
hour, and then waits to see the primary care nurse. While waiting to see the primary
care nurse, he becomes too weak to sit up and lies down on the floor. Two hours later
his family members are unable to arouse him, and he is noted to have shallow
respirations. He is then put onto a trolley and taken to the consulting room to wait to
see the doctor. Several minutes later he stops breathing. The nurse finds a breathing
bag that she had seen others use to assist patients with breathing; however, she does
not know how to use it. The nurse knows to give oxygen therapy, but the one oxygen
cylinder in the hospital is being used in the operating theatre. The patient becomes
blue, his heart stops beating, and he dies.
Answer the following questions.
Identify some of the problems encountered in this case scenario that may have contributed
to the death of this patient, using the following categories.
Problems with health
worker skills
Problems with health
system
Participant training manual: Quick Check, triage and emergency treatments
Problems with
monitoring and
evaluation
Chapter 8 – 83
Now identify solutions that may have improved the care of this patient, using the same
categories.
Improving health worker
skills
Improving the health
system
Improving monitoring
and evaluation
The QC is the first component in the WHO referral care manual entitled IMAI District
Clinician Manual: Hospital Care for Adolescents and Adults in Limited Resource Settings.
Thus, depending upon your position, you may choose to implement the QC as a single
initiative or as the first component of an overall effort to improve the quality of care of
seriously ill patients in your hospital. Likewise, your hospital may choose to implement the
QC on its own, or it may become part of a multiple-hospital quality improvement
collaboration to implement the QC.
Implementing the IMAI strategy to improve care at the district hospital requires:
• improvements in case management skills of health staff through the provision of locally
adapted guidelines on integrated management of adolescent and adult illness and
activities to promote their use;
• improvements in the health system and cultural change required for effective case
management of adolescent and adult illness;
• a system that enables the collection of relevant data to inform programme assessment
and modification.
84 – Chapter 8
Participant training manual: Quick Check, triage and emergency treatments
IMAI strategy planning and management activities
Improving health worker
skills
Improving the health
system to deliver IMAI
Monitoring and
evaluation
•
•
•
•
•
•
•
Develop/adapt case
management guidelines
and standards.
Train all cadres of
hospital staff, including
non-clinical staff with
patient contact, in the
recognition of patients’
with severe illness.
Train clinical staff in
clinical management of
the severely ill patient.
Improve and maintain
health worker
performance through
clinical mentoring,
supportive supervision,
performance evaluation,
and other on-going
learning opportunities.
Teach quality
improvement techniques
to health workers to
assist them in identifying
problems and creating
innovative solutions in
order to provide quality,
efficient, and safe care.
•
•
•
•
•
•
•
•
•
Improve consistent
availability of necessary
drugs, supplies, and
equipment.
Develop a sustainable
system for essential
equipment maintenance.
Optimize the physical
environment to improve
flow of the severely ill
patient through the
hospital and patient
monitoring.
Optimize staff
organization to be able to
deliver timely care to
severely ill patients.
Improve referral systems
between and within
health centres to optimize
continuity and patient
safety.
Create a culture of
teamwork that promotes
effective, professional,
and respectful
communication.
Identify/develop methods
for sustainable finance.
Promote efficient use of
scarce resources.
Promote patient safety at
all times.
Ensure equity of access.
Participant training manual: Quick Check, triage and emergency treatments
•
•
•
•
Use patient monitoring
systems to more
effectively care for
severely ill patients.
Evaluate performance
through monitoring key
process and outcome
indicators and then
comparing them to
standards of best
practice (benchmarks).
Create a quality
assurance system that
provides timely and
accurate performance
evaluation.
Create a
multidisciplinary quality
improvement team
responsible for
evaluating trends in
performance to
determine if changes
are successful and
should be expanded, or
if they need to be
adjusted.
Provide feedback to
health workers about
performance to keep up
morale and to continue
to inspire their drive for
improvement.
Chapter 8 – 85
Implementing QC in your hospital
Reflect on your current emergency department or casualty ward. Answer the following
questions.
1. Does you casualty ward currently have a triage system that effectively identifies
emergency patients in a timely fashion? If yes, please explain the system.
2. Does your casualty ward currently have all the necessary staff and supplies to provide
emergency treatments? If no, what is missing?
3. Do your casualty and hospital wards have a monitoring system to follow severely ill
patients?
Planning for implementation
When preparing to implement the QC, the following questions will first need to be
answered.
Why?
What arguments can you give to decision-makers to implement the QC in your
work place? (advocacy)
Who?
What staff categories should be involved in QC?
Where? Where should the QC be implemented?
When?
When should it be done? (patient flow and tasks)
What?
What extra staff, training, equipment, supplies, and medications are needed that
are not yet available now?
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Participant training manual: Quick Check, triage and emergency treatments
Planning is a key component to successful implementation. Below is a table with general
descriptions of key resources necessary for effective implementation.
Category of key
resource
Non-clinical staff
General description
Clinical staff
Sufficient staff members adequately trained in triage and the
delivery of emergency treatments and management of patients with
severe pneumonia and septic shock
Readily available and functioning (see more detail below)
Supplies and
equipment
Monitoring system
Infrastructure and
organization
Communication
system
Coordination with
other health care
sectors
Quality Assurance
System
Sufficient staff members adequately trained in triage
An easy-to-use and easily accessible monitoring form should be
available in the OPD and on the wards
An OPD area that is well organized to triage all patients upon arrival
and to deliver appropriate and timely emergency care and infection
preventions and control interventions. Physical space that allows
safe patient transfer between the OPD and hospital wards. Hospital
wards that are well organized to closely monitor severely ill patients
and deliver on-going treatments.
Effective and respectful communication to promote team work and
ensure continuity of care
Coordination with the ministry of health, referral hospitals, health
centres, non-governmental organizations, academic institutions, and
research enterprises to optimize resource procurement and
allocation
A system that monitors patient outcomes, observes trends (good
and bad), identifies areas for improvement, and then supports the
implementation, monitoring and sustainability of quality improvement
projects. Create a multidisciplinary Quality Team with project
leaders and methods of dissemination of performance evaluations to
staff.
Case scenario
Read the following case description. As a group discuss what resources are necessary to
care for this patient.
A 28-year old HIV-positive woman presents to the OPD with difficulty breathing, cough,
malaise, and fever for 4 days. She is confused and appears to be in severe respiratory
distress. Fill in the table below.
Category
Human resources
Necessary resources
Supplies and equipment
Medications
Laboratory and diagnostic test
Infrastructure/organization
Participant training manual: Quick Check, triage and emergency treatments
Chapter 8 – 87
Quick Check Implementation Exercise
Now that we have discussed some of the general concepts regarding implementation of
the Quick Check, we will work on developing individualized action plans that can be used
when you return to your hospital. In groups you will develop action plans as a way forward,
and then present them to the larger group and share ideas and solutions.
Directions: Develop an action plan to implement the QC in your hospital. Work as a hospital group
and use the table to guide your presentation to the clinical team and your hospital management.
Consider the following needs when preparing your action plan:
•
Advocacy (including identification of any major stakeholders who need to be involved in the
process of accepting new standards into hospital care)
•
Human resources and training needs
•
Material resources and management (supplies, equipment, medications)
•
Infrastructure
•
Patient flow
•
Monitoring and evaluation
Prepare a summary of your findings in the form of recommendations to the hospital
superintendent or the hospital management board.
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Participant training manual: Quick Check, triage and emergency treatments
Developing individual plans of actions
Planning framework
Goals
Activities
Time frame
J
F
M
Requirements
A
M
J
J
Participant training manual: Quick Check, triage and emergency treatments
A
S
O
N
Cost
Responsible
persons
Source of
funds
D
Chapter 8 – 89
Planning framework
Goals
Activities
Time frame
J
F
M
Requirements
A
M
Participant training manual: Quick Check, triage and emergency treatments
J
J
A
S
O
N
Cost
Responsible
persons
Source of
funds
D
Chapter 8 – 90