QUICK CHECK TRIAGE ASSESSMENT AND EMERGENCY TREATMENTS FOR ADOLESCENTS AND ADULTS

Page and Section numbers refer to Nepal IMAI District Clinician Manual. IMAI = Integrated Management of Adolescent and Adult Illness. IMPAC= Integrated egrated Management of Pregnancy and Childbirth; IMEESC = Integrated Management of Essential and Emergency Surgical Care
draft updated for SEARO
17 March 2020

SAFETY FIRST PERSONAL PROTECTIVE EQUIPMENT (PPE)

If a dangerous pathogen with human-to human transmission (COVID-19, Nipah, MERS-CoV, human avian influenza, Ebola, or CCHF) is occurring At first, you may not know the cause of illness or injury and may expose yourself to diseases, chemicals or poisons without appropriate PPE.
in your province or patient has traveled to area with outbreak: do screening and complete only a visual assessment Always protect yourself from any exposure to a patient’s bodily fl uids.
 call for help in appropriate PPE if positive screening or if cannot determine contact status. Use standard precautions when performing the Quick Check triage assessment of any patient including PPE according to risk assessment for each
 If screening negative, continue with assessment and management using standard PPE patient:
If cough, sneezing or other signs of respiratory illness, use droplet precautions and source control for the patient- tissues, handkerchiefs or medical masks and  add droplet precautions if acute respiratory infection; add droplet plus contact if COVID19 or other ARI of concern (gown, gloves, mask, goggles or face shield)
accommodate patient at least 1 meter away from other patients or in a room; evaluate as soon as possible.  add aerosol precautions if airway management or intubation- use particulate respirator such as N95 or FFP2.

EMERGENCY SIGNS FIRST LINE EMERGENCY TREATMENT IF TRAUMA ALSO CONTINUE WITH URGENT MANAGEMENT
All staff should be able to assess these signs. If any sign is present, patient
is severely ill. Call for help. Clinical staff should immediately give emergency
If any emergency sign is present, nurse and others on clinical team should give
the treatments, call for help, and establish IV access. After the Quick Check, test
The trauma guidelines are applicable for all ages.*
For further management of trauma, use the IMEESC package for surgical or
OF PATIENTS WITH EMERGENCY SIGNS
treatment(s). blood for glucose, malaria RDT, haemoglobin. Make sure a full set of vital signs trauma related conditions.
and pulse oximetry are obtained from all patients with emergency signs and these Also use the treatment guidelines in the IMPAC PCPNC and MCPC when
If not breathing or unresponsive,check pulse and follow BLS/ACLS. findings are acted on. managing Women of Childbearing Age who may be pregnant.
* Use the IMCI ETAT for Children Less than 5 Years of Age (rather than these guidelines).

THEN ASSESS:

A IRWAY AND B REATHING Do not move neck if cervical spine injury possible – immobilize spine
If head or neck trauma, manage airway
and immobilize spine Finish remainder of Quick Check then:

If obstructed airway: Look for:  Count pulse, RR; measure SBP, SpO2
 Respiratory distress  Titrate oxygen to SpO2 94 if airway, breathing or ciculation
 If foreign body aspiration, treat choking patient.
 Trachea deviated Treat tension pneumothorax emergency sign or pregnant
 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.  Decreased breath sounds with emergency needle  Give antibiotics if fever and RR >30 (see Section 3.2)
Check for obstruction  Low SBP decompression.
 Appears obstructed (noisy breathing, gurgling, neck
or swelling), slow breathing, wheezing, For all patients:  Give oxygen 5 litres.  If suspect COVID-19 or influenza-Send swabs for both (or respiratory .
 Central cyanosis choking, not able to speak.  If wound to chest wall which sucks air in when patient breathes panel). Isolate.See Section...
or  Manage airway.
Check pupils in --> treat sucking chest wound  Insert IV and start fluidsat1ml/kg/hour
 Severe respiratory distress  Give oxygen 5 litres. Then...
Check oxygen saturation  Treat pain- see palliative care guidelines
 If inadequate breathing, assist ventilation with bag valve mask.
 If slow breathing with small pupils, give naloxone for opiate overdose  If chest trauma, call for help for possible surgical intervention.
Severely ill patient See Section 3.2.
 If pinpoint pupils, excessive respiratory secretions, muscle weakness with difficult breathing: Consider silent
If airway and and other signs of organophosphate poisoning, give atropine IV/IM chest with bronchospasm Give salbutamol (another dose)
0.05 mg/kg bolus (for 60 kg, 3 mg = 6 ampules ) then continue and ipratropium).
breathing atropinization. If moderate – severe wheeze continues See Section 3.2 for other causes wheezing.
clear, go to  Help patient assume position of comfort. Continue atropinization and add
circulation. If suspect organophosphate intoxication
 If wheezing, give salbutamol. pralidoxime. See flowchart in Section 3.8.
If suspect opioid intoxication See p. 26 and Section 3.6.
Suspect other poisoning or snakebite
See Sections 3.8 and 3.9.
Suspect inhalation burn See Sections 3.2 and 3.10.
If signs of pericardial tamponade (poor
perfusion, distended neck veins, and muffled Give IV fluids
heart sounds): Rapid handover to surgical provider
THEN ASSESS:

CIRCULATION (SHOCK OR HEAVY BLEEDING)

Caution with IV fluids, monitor breathing
If decreased breath sounds , crackles, dullness Consider heart failure/ pleural effusion (see
to percussion, bilateral leg swelling Section 3.2.5)

If trauma and patient in shock (SBP <90, pulse >110) or suspect

Do not move neck if cervical spine injury possible – immobilize spine significant internal or external bleeding Decide on type of shock and treat accordingly
 Weak or fast pulse
or If SBP <90 mmHg or pulse >110 per minute or heavy bleeding:  Give oxygen 5 litres if SpO2 <94 or respiratory distress.
 Capillary refill longer than three seconds
or  Give rapid IV fluids. If... Then...
Check SBP, pulse  Give oxygen 5 litres if respiratory distress or SpO2 <94 (10-15 litres if critically ill)
 Heavy bleeding from any site  Keep warm.
Is she pregnant? Fever, consider septic shock and malaria, scrub Give empirical antibiotics and glucose (if
or Insert IV, give 1 litre bolus crystalloid (LR or NS) then reassess (see give fluids  Urgently send blood for type and cross match. typhus, dengue, enteric fever, kala-azar, blood glucose is low or unknown). Send
 Severe trauma  rapidly). Japanese encephalitis blood culture if feasible before starting
antibiotics. Do RDT for malaria; treat with
 Keep warm (cover). If external bleeding: antimalarials if positive.

 If > 20 weeks pregnant, place on left side.  Apply pressure immediately to stop bleeding. Suspect heart failure, cardiogenic shock or Be cautious with giving fluids.
severe anaemia See Section 3.2.
 If anaphylaxis, give 1:1000 epinephrine (adrenaline) IM – If suspect internal bleeding:
0.5 ml if 50 kg or above, 0.4 ml if 40 kg, 0.3 if 30 kg. Diarrhoea Classify dehydration. If severe, give rapid fluids
If circulation for shock and follow Fluid Plan C.
clear, go to Uncontrolled, noncompressible haemorrhage (abdomen, chest, pelvis or around See Sections 3.1.2 and 10.7.
disability. long bone fractures) requires emergency surgical intervention.
Vaginal bleeding Assess pregnancy status and amount of
 If possible femur fracture – splint (see Section 4). bleeding and treat.
 If possible pelvic fracture – apply pelvic binder. Large nosebleed See Quick Check emergency treatments.
 Call for help and plan emergency surgical intervention (see Section 4).
Vomiting blood See Quick Check emergency treatments.
 If patient remains in shock after 2 litres of IV fluids – transfuse (see Section 4).

IF VAGINAL BLEEDING, FOLLOW GUIDELINES ON MANAGEMENT OF VAGINAL BLEEDING.

DISABILITY
Check pupils Do not move neck if cervical spine injury possible Check for signs of serious head and spine trauma
 Altered level consciousness Check AVPU (or GCS in
or trauma) For all:  Immobilize spine. If... Then...
 Convulsing Check serum glucose  Give oxygen 5 litres.
or  Protect from fall or injury. Altered consciousness See Section 3.4.
Check for head trauma  Log-roll patient when moving.
 New loss of function (stroke) Is she pregnant?  Manage airway and assist into recovery position. Convulsions See Section 3.5.
 Expose patient fully.
 Give oxygen 5 litres.
 Look/feel for deformity of skull. Fever Give empirical antibiotics. If in a malaria
 Call for help but do not leave patient alone. endemic area or travel history, do RDT and
 Look for: give antimalarial if posiive. See Section 11.23.
 If slow breathing with small pupils, give naloxone for opiate overdose
• pupils not equal or not reactive to light;
If disability  Give glucose (if blood glucose is low or unknown). • blood/fluid from ear or nose; Pinpoint pupils and suspect organophosphate Give atropine. See flowchart in Section 3.8.
 If suspect chronic alcoholic give thiamine and glucose. intoxication
clear, go to • associated traumatic injuries (spine, chest,pelvis) (see Section 4).
expose.  Check (then monitor and record) level of consciousness on AVPU scale.  Call for help from district clinician/surgeon. Alcohol intoxication or withdrawal See Section 3.7.
Poisoning See Section 3.8.
If convulsing:
If elevated blood glucose, suspect diabetic Give IV normal saline.
 Give diazepam IV or rectally. ketoacidosis. See Section 3.4.3 for further management.

 If convulsing in second half of pregnancy or post-partum up to one week,

give magnesium sulfate rather than diazepam.

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 (see Section 3.5).

EXPOSE AND EVALUATE FOR LIFE THREATS

EXAMINE ENTIRE BODY FOR INJURY, RASH, BITES, AND LIFE THREATS. DOES PATIENT FEEL VERY COLD OR VERY HOT?
IF PRESENT CHECK SBP, PULSE, RR, TEMPERATURE. COVER AFTER EXAM TO PRESERVE DIGNITY AND PREVENT HYPOTHERMIA..
 Nothing by mouth (NPO). Do not move neck if cervical spine injury
 IV fluids.
 Severe abdominal pain  Give oxygen if respiratory distress or SpO2 <90; < 94 if ABC emergency sign or pregnant If trauma with abdominal pain: If... Then...
and Is she pregnant? 
Empirical antibiotics IV/IM.  Consider possible spleen or liver injury. Trauma See Section 4.
 Abdomen hard on palpation  Treat pain.  If penetrating injuries to abdomen or distended or painful abdomen: Pregnant with abdominal pain or severe Decide if severe pre-eclampsia.
headache with elevated BP See IMPAC MCPC guidelines.
 Suspect surgical abdomen – call for help (see Section 4); send blood for type and cross match. • check Hb;
Severe headache See Section 10.10b.
• send type and cross match;
If early pregnancy possible, consider ectopic and check rapid pregnancy test. Suspect acute myocardial infarction Follow national guidelines.
If late pregnancy, consider abruption or ruptured uterus (see emergency obstetrical • consider diagnostic peritoneal lavage or ultrasound to check for internal See Section 3.3 for DDx.
guidelines). bleeding. Major burn See Section 3.10.
If prolonged labour, see emergency obstetrical guidelines. Snakebite See Section 3.9.

 Severe headache If current/recent pregnancy, elevated BP and headache, consider severe pre-eclampsia; If trauma with neck pain or possible cervical spine injury:
or dipstick urine for protein. Give magnesium sulfate if diastolic >110 mmHg with
Is she pregnant? proteinuria.
 Stiff neck DO NOT MOVE NECK —> immobilize the neck.
or If severe headache with stiff neck and fever, consider meningitis:
 Trauma to head/ neck  Give IV antibiotics (call clinician to do LP first if can do within 15 minutes).  If severe headache, manage as possible head injury.
 Give IV or IM antimalarials if in malaria endemic area or travel and RDT or blood smear
positive

 New onset chest pain If crushing, retrosternal pain, cardiovascular risk factors, and no history of trauma, suspect acute If trauma with chest pain:
myocardial infarction:

 Give aspirin (300 mg, chewed).  Palpate chest for rib fractures.
 Give oxygen if respiratory distress or SpO2 <90 or <94 if ABC emergency sign or pregnant • if present, consider pneumothorax.
 Insert IV – if no signs of shock, give fluids slowly at a keep-open rate.
 Give morphine for pain.
 Do ECG. Call district clinician for help.

 Major burn  Manage airway.

 Consider inhalational burn.
 Give oxygen if respiratory distress or SpO2 <90 or <94 if ABC emergency sign or pregnant
 Insert IV; give fluids rapidly.
 Treat pain.
 Apply clean sterile bandages – see Section 3.10.

 Snake-bite  Immobilize extremity.

 Give oxygen if respiratory distress or SpO2 <90 or <94 if ABC emergency sign or pregnant.
 Insert IV; give fluids rapidly.
 Treat pain .
 See Section 3.9 for antivenom guidelines.
After completing ABCDE, check for priority signs.

PRIORITY SIGNS AND SYMPTOMS

AFTER SCREENING FOR DANGEROUS PATHOGENS AND EMERGENCY SIGNS, SCREEN ALL PATIENTS FOR PRIORITY SIGNS

PRIORITY SIGNS FOR URGENT CARE – THESE PATIENTS SHOULD NOT WAIT IN QUEUE: IN ALL CASES OF TRAUMA, CONSIDER:
CIRCULATORY
Very pale, weak, or recent fainting. Measure haemoglobin if any bleeding, pale, weak, fainting, abdominal pain.
 Was alcohol a contributor? If yes, counsel on harmful
Bleeding:
alcohol use. See mhGAP.
• Large haemoptysis;
• GI bleeding (vomiting or in stools);
If melena or vomiting blood, manage as on QC34 and admit. If large haemoptysis see QC34.  Was drug use a contributor? If yes, counsel and
• External bleeding (if major, see Circulation). arrange for treatment. See mhGAP.
Frequent diarrhoea >5 times per day Assess for dehydration.
or vomiting everything Use fluid plan A, B or C – see Section 8.3.  Was this a suicide attempt? If possible, ask the
RESPIRATORY patient, were you trying to harm yourself?
Any respiratory distress/complaint of difficulty If any respiratory distress/complaint of difficulty breathing – measure SpO2; give oxygen 5 litres if SpO2 <90 or <94 if pregnant (see Sections 3.2 and 8.2)
(See Section 10.10 or mhGAP.)
breathing (without emergency signs)** use appropriate IPC if screen positive for possible COVID-19 If wheezing, give salbutamol (see QC23 and Section 3.2.4). Consider COVID-19, influenza, other causes.
 Was abuse or sexual violence involved?
NEUROLOGICAL/PSYCHOLOGICAL
(See Section 4.4.)
Acute visual changes. See Section 10.11.3.
Violent behaviour toward self or others or very agitated. If violent behaviour or very agitated, protect, calm, and sedate the patient as appropriate (see QC38). Protect patient from harming self or others.  Was interpersonal violence a contributor? Is there a
Check glucose, temperature and SpO2, consider causes (acute psychiatric decompensation, substance use, intracranial bleed (see Section 3.4). risk of further violence in retaliation? If yes, get help
Hyperventilation/ panic attack Reassure and calm patient, encourage to breathe at normal rate and volume; if unsuccessful, give small dose rapidly-acting benzodiazepine. to interrupt this and prevent further violence.
INJURY/POISONING
Fractures or dislocations. If visible deformity, assess and treat possible fractures/dislocations (see Section 4). Consider nerve or vessel injury.
Burns (not major). Manage burns (see Section 3.10).
Bite (or lick or scratch) from suspected rabid animal. Wound care- scrub with soap and water, flush for 15 minutes then povidone-iodine or benzalkonium
chloride. Post-exposure vaccination and immunoglobulin depending on contact type. See Section 11.27
Poisoning. Try to identify the toxin and treat with the appropriate antidote if available and supportive care. (see Section 3.8).
OTHER
Rape/abuse (maintain a high index of suspicion). If suspect rape or abuse (see Section 4).
New extensive rash with peeling and mucous membrane involvement (Stevens-Johnson). Give IV fluids.
Keep wounds clean.
Discontinue any suspected causal agent.
Refer to specialty care or burn centre.
Acute pain, cough or dyspnea, priapism, or fever in patient with sickle-cell disease. If painful vaso-occlusive crisis from sickle-cell disease – control pain, hydrate and give oxygen if SpO2 <90; <94 if pregnant (see Section 10.14.)

If priority sign is present the patient needs urgent clinical evaluation and should not wait in the general queue. Repeat Quick Check if in line more than 20 minutes.

IF NO EMERGENCY SIGNS AND NO PRIORITY SIGNS: NON URGENT IF FAMILY IS ANXIOUS:

■ Listen to their concern

■ Communicate well, talk kindly with them.

■ Patient can wait in queue. ■ Reassure them that patient has already been screened

for dangerous emergency signs and has none.

■ Provide routine care and use the appropriate sections. ■ Patient is receiving close monitoring and will get the best care.

■ Do not get aggressive

■ Repeat Quick Check if condition changes.

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