Triage and the “ABCD” Concept

ETAT Module 1

Adapted from Emergency Triage Assessment and Treatment (ETAT):

Manual for Participants, World Health Organization, 2005
 Learning Objectives
• Understand the importance of continually
assessing the medical needs of all children from
arrival at the healthcare facility until discharge
• Recognize emergency (ABCD) and priority signs
• Assign children triage categories, based on
emergency and priority signs
• Identify the appropriate immediate response for
children in each triage category
 Target Audience

• All centre staff who have contact with

patients
• Assessment and immediate response to
emergency and priority patients will vary
depending on whether or not you are a
healthcare provider
 Overview
• What is triage?
• Performing a rapid
assessment
• The ETAT tool
• Emergency signs
• Priority signs
 Triage: what and why

• What: Sorting patients into priority groups

according to their needs and the resources
available
• Why: Identify and treat seriously ill children
as soon as possible to prevent
deterioration in their conditions
 Triage process
• When: as soon as the child arrives at the
healthcare facility and periodically throughout the
visit
• Where: at various locations, depending on the
facility (outpatient queue, waiting room,
designated triage area)
• Who: all clinical staff
• How: rapid assessment performed within 15-20
seconds, without using equipment or taking vital
signs
 How to perform a rapid
assessment
• Look and listen
• What is the overall appearance of the
child?
– Is he playful and interactive?
– Is she quiet or poorly responsive?
• For children who are ill appearing,
systematically look for the presence of
emergency and priority signs
 ETAT: Emergency Triage Assessment
Treatment Tool

• Reliably sorts children into

the following treatment
categories:
– immediate emergency
treatment (E)
– rapid assessment and
treatment (P)
– with non-urgent conditions
(N)

Adapted from ETAT manual for participants, Chart 2 page 67

 Emergency Signs Priority Signs

Airway 3TPR
Breathing (severe) T: tiny baby,
Circulation temperature, trauma
Coma P: pallor, poisoning, pain
Convulsion R: respiratory distress,
Dehydration (severe) restless, referral
MOB
M: malnutrition
O: oedema
B: burn
 Emergency signs
• Airway
• Breathing
• Circulation
• Coma
• Convulsion
• Dehydration (severe)
 Airway

• Is the airway obstructed?

• Signs of airway obstruction
– Complete obstruction: no air movement
– Partial airway obstruction: noisy breathing
during inspiration
 Case # 1

You are at the registration desk. You notice

a child with a small toy in her mouth.
Suddenly, she begins to choke.

What should you do?

She is in severe distress and choking
but she is not making any sound.

What is her triage category?

What should you do next?
Emergency

Call the triage nurse.

 Breathing (1)

• What is the child’s color?

– Pink
– Pale
– Grey
– Blue
• Is the child breathing? Does the chest wall
move with inspiration and expiration?
 Breathing (2)
• Is there increased work of breathing?
– Can the child nurse or talk?
– Is there severe indrawing of the chest?
• What is the rate and pattern of breathing?
– Too fast
– Too slow
– Agonal breathing: irregular, slow
– Abnormal patterns
• Deep, slow (as with acidosis)
• Irregular (as with brain abnormalities)
 Increased Work of Breathing

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

PALS: Rapid Cardiopulmonary Assessment, American Heart Association 2001

 Case # 2
A caretaker calls you to the waiting room
because she is concerned about the child
sitting next to her. The infant is pale and
appears anxious and uncomfortable.

Is this baby sick or well?

He is sick.

What should you do next?

Assess airway and breathing.

There is no noisy breathing. The

respiratory rate is rapid and there is
marked indrawing of the chest.

Describe his respiratory status.

The airway is patent. He has increased
work of breathing.

What is his triage status?

What should you do?

Emergency (respiratory distress)

Call for help.

 Circulation

• If the child’s hands are warm, circulation is

OK.
• For children with cold hands, assess the
capillary refill
 Prolonged Capillary Refill
• Press an area on the
patient’s extremity
with your finger until
it is pale.
• Color should return to
the skin within 3
seconds after you
remove your finger.

PALS: Rapid Cardiopulmonary Assessment, American Heart Association 2001

 Coma (mental status)

• A (alert)
• V (responds to voice): lethargic
• P (responds to pain): coma
• U (unresponsive): coma
 Coma (mental status)

• A
• V
• P (responds to pain): coma
• U (unresponsive): coma
 Case # 3
A mother comes to the registration
desk with her infant wrapped in a
blanket.

What should you do in order to assess

the baby?
Ask the mother to unwrap the baby.

She is limp and unresponsive.

What is her triage category?

What should you do?
Emergency (U = coma)

Call for help.

 Convulsions

• Sudden loss of
consciousness
• Uncontrolled jerking
of arms and/or legs
• Twitching of face
and/or eyes
www.nlm.nih.gov,accessed 2/9/08
 Dehydration (with severe diarrhea)

• Lethargy
• Sunken eyes
• Skin pinch goes back
very slowly (longer than
2 seconds)

Accessed through Google images, 2/9/08

 Case # 4
As you walk through the waiting room, you
notice a lethargic small child lying in his
mother’s lap. His eyes are sunken. His
mother says that he has had diarrhea for 3
days.

What is his triage category?

Emergency (Severe dehydration)

Call for help.

 Triage process to identify emergency signs

Triage steps Response

Assess Airway Positive: Stop. Call for help

Negative: assess Breathing
Assess Breathing Positive: Stop. Call for help
Negative: assess Circulation
Assess Circulation Positive: Stop. Call for help
(coma, convulsions) Negative: assess Dehydration
Assess Dehydration Positive: Stop. Call for help
Negative: assess Priority signs
Adapted from ETAT manual for participants, page 8
 Assess Airway
Positive Negative

Stop. Call for help Assess Breathing

Positive Negative

Assess Circulation, Coma,

Stop. Call for help
and Convulsion
Positive Negative

Stop. Call for help Assess Dehydration

(with diarrhea)
Positive Negative

Stop. Call for help Assess for Priority Signs

If any sign is positive, call for help!!

Adapted from ETAT manual for participants, Chart 2 page 67

 Priority Signs
• 3TPR
– T: tiny baby, temperature, trauma
– P: pallor, poisoning, pain
– R: respiratory distress, restless, referral
• MOB
– M: malnutrition
– O: oedema
– B: burn
 Priority signs: 3TPR
• T
– Tiny baby
– Temperature
– Trauma (or other surgical condition)
• P
– Pallor (severe)
– Poisoning
– Pain (severe)
• R
– Respiratory distress
– Restless, continuously irritable, or lethargic
– Referral (urgent)
 Tiny Baby: under two months of age

• More difficult to assess properly

• More likely to get serious infections
• More likely to deteriorate quickly
 Temperature

• Hot to touch: fever is a sign of infection

• Cold to touch: may be a sign of poor
circulation or serious infection
 Trauma
(or other urgent surgical condition)

• Head injury
• Fracture
• Acute abdomen
Poisoning

• Ask caretaker if this is

the reason for visit
• Child’s condition can
deteriorate rapidly
• Specific treatments
may be required
 Pain

• Pain may be due to serious conditions

(meningitis, acute abdomen, sickle cell
painful crisis)
• Patient should receive treatment for pain
relief
 Pallor

• Unusual paleness
of skin
• Compare the
child’s palm to your
palm
ETAT provider manual, page 7

• Indication of
anemia
 Respiratory Distress

• Signs of respiratory distress that are not severe

• Rapid breathing
• Indrawing of chest
• Noisy breathing
– inspiratory: stridor (upper airway obstruction)
– expiratory: wheezing (lower airway obstruction)
 Restlessness

• Restlessness, continuous irritability, and/or

lethargy may be due to serious conditions
(meningitis, acute abdomen, sickle cell
painful crisis)
 Referral (from another centre)
• Look carefully at patients who are referred
from another centre. The patient has
already been evaluated by another
healthcare provider who has determined
that he is very sick.
• Use information from the referring centre
and your assessment to determine if the
child has an urgent condition.
 Priority signs: MOB

• Malnutrition (visible wasting)

• Oedema of both feet
• Burn (major)
 When management resources are limited

• Use guidelines from Integrated Management

of Childhood Illness (IMCI).
• IMCI chartbook uses the same assessment
and classification principles as ETAT.
• Management recommendations emphasize
recognizing patients that should be stabilized
and transferred.
 Assessment and classification: IMCI under 2 months

ABCD Positive sign Manage

• Not feeding well OR
• Severe • Convulsion OR • Keep patient warm
(skin to skin)
disease OR • Rapid breathing OR
• Give first dose of
• Severe chest
• Local indrawing OR
antibiotic
bacterial • Refer urgently to
• Fever OR low
hospital
infection temperature
• Poorly responsive
 IMCI Danger signs for >2 months-5 years

Danger signs Severe Manage

• Any positive pneumonia • Keep patient warm
sign OR OR (skin to skin)
• Chest • Give first dose of
indrawing OR Very severe antibiotic
• Refer urgently to
• Stridor in a disease hospital
calm child OR
 IMCI: Temperature >2 months-5 years

Manage
Any general Very severe
• Keep patient warm (skin to
skin)

danger sign febrile

• In areas endemic for malaria,
give first dose of quinine for
severe malaria

OR disease • Give first dose of antibiotic

• Treat to prevent low blood
sugar
Stiff neck • Give one dose of
paracetamol for high fever (>
38.5)
• Refer urgently to hospital
IMCI: Malnutrition for >2 months-5years

Manage
Severe • Keep patient warm
Visible (skin to skin)
wasting OR malnutrition • Treat to prevent
low blood sugar
edema of • Refer urgently to
both feet hospital
 IMCI: Severe anemia >2 months-5 years

Severe Manage
Severe anemia Refer urgently
palmar pallor to hospital
 Summary

Emergency Signs Priority Signs

Airway 3TPR
Breathing (severe) T: tiny baby,
Circulation temperature, trauma
Coma P: pallor, poisoning, pain
Convulsion R: respiratory distress,
Dehydration (severe) restless, referral
MOB
M: malnutrition
O: oedema
B: burn
 ETAT categories: Emergency

• Rapid assessment performed within 15-20

seconds
• Identify emergency signs (ABCCCD)
• Call for help
• Initiate appropriate emergency treatment
Adapted from ETAT manual for participants, Chart 2 page 67
 ETAT categories: Priority

• No emergency signs
• Identify priority signs (3 TPR-MOB)
• Child needs prompt, but not emergency
assessment and treatment
• Notify triage nurse who will complete
triage evaluation
• Move to front of queue
ETAT categories: Non-urgent

• No emergency signs
• No priority signs
• Child may be seen in queue