The ABCDE Approach – Triage and Treatment

 

The importance of triage is well recognized and the benefits of the ABCDE approach are well documented.  It is particularly important to ensure that the limited health resources in South Sudan are directed to those patients who need them most.

Many patients die within the first few hours of presenting at the hospital often from hypoxia, dehydration or sepsis and early intervention can save lives. The charts on pages 51 and 52 are adapted from the World Health Organization (WHO) Emergency Triage and Treatment (ETAT) course and UK teaching (1, 2), and are suitable for patients of all ages (3). They aim to give South Sudanese doctors and nurses wherever they work the information they need to recognize, and then treat, patients who need urgent intervention. The charts can be printed, laminated and displayed in any area where patients are at risk of deterioration, such as wards, theatres and outpatient departments. They can be used as a teaching guide and as a reminder of key patient management actions. Laminated copies are on the wall of the out-patient department at Wau Teaching Hospital.

The ABCDE Approach Triage Chart (Chart 1)

This chart lists the signs that identify the three categories of patients (of all ages) seen in the outpatient departments. The same signs may be used on the ward when nurses need to decide whether to call a doctor in an emergency. Ideally the nurse will recognise when a patient starts to deteriorate and will give the necessary treatment before the patient’s condition becomes too serious - using the graded response helps nurses to prioritise.

3 categories of out-patients

These categories are used in WHO’s ETAT course (1). This course covers triage and treatment of children in more detail, but requires 3½ days to fully cover.

1. Emergency – patients showing signs indicating a severe condition. Chart 1 outlines each physiological parameter to measure using the ABCDE approach.  These patients need immediate treatment.
2. Priority – patients at risk of sudden deterioration who should not be left to wait in the clinic; they may be breathing rapidly, have a higher than normal heart rate and a high temperature.  They may be drowsy or dehydrated.  They need not show all these signs at the same time,   as any one may indicate a worsening condition.
3. Queue – well patients who are able to wait, and need to be encouraged to wait, so allowing the sicker patients to get priority.

 

In Wau we have started to introduce triage by stamping the notes of out-patients; other countries have used coloured discs or a stamp onto the patient’s hand.  Whatever is used, nurses have shown that they are able to identify which patients should be given emergency or priority status.  At Wau we showed nurses how to periodically review all waiting out-patients so that they can upgrade anyone who deteriorates. This leaves the doctors to manage their workload more effectively, knowing that there are unlikely to be very unwell patients waiting to be seen.

It is important that doctors appreciate the importance of triage, support the nurses working with them and work as a team.

The ABCDE Approach Treatment Chart (Chart 2)

This gives practical advice on emergency management of unwell patients.

Using the ABCDE approach

• Airway assessment is always the first as it is imperative that the airway is not obstructed.   For detailed advice on management of the airway see the WHO ETAT course (1).
• Breathing should be adequate; if breathing assistance is required use a bag valve mask device or give oxygen if available. Only when problems with airway and breathing are addressed should the clinician move onto circulation.
• Circulation.  The chart gives guidance on the use of fluids.  It is important to recognise malnutrition at this stage, as rapid infusion of intravenous fluids to a malnourished child can be very dangerous.  Depending upon measurement of capillary refill, heart rate and blood pressure, give fluids: rapidly IV, slowly IV, or orally.
• Disability.  If the patient shows signs of disability (either coma or convulsion) airway and breathing management are top priority. It is then appropriate to insert an IV cannual and measure the blood sugar if possible.  These patients are at risk of low blood sugar and often it is safer to give glucose as soon as possible.
• Dehydration - is so common in tropical countries that checking for signs of dehydration should be routine.  The signs of shock have already been looked for while assessing circulation but specific examination for loose skin, lethargy and sunken eyes should occur. 
• Exposure.  Finally it is important to look at the whole patient, to look for signs of a rash, trauma or swollen abdomen.

References

1. WHO. 2005. Emergency Triage and Treatment (ETAT) course. Manual for participants and Facilitator guide. Geneva, WHO. http://www.who.int/child_adolescent_health/documents/9241546875/en/index.html
2. Greater Manchester Critical Care Skills Institute. Acute Illness Management (AIM) course www.gmcriticalcareinstitute.org.uk
3. Acute Life Threatening Events, Recognition and Treatment (ALERT) course. Based at Portsmouth Hospital in UK.  www.alert-course.com

 

We thank WHO for permission to adapt their charts from the Emergency Triage and Treatment (ETAT) course (1).

 

Chart 1. The ABCDE Approach – Triage

Treat First what kills first

 

Identification of Emergency, Priority and Queue patients

	Emergency	Priority		Queue
Airway	Obstructed	At risk		Clear
Breathing Rate	>40 or <10	30 -40	10-30
Breathing Colour	Blue (Cyanosis)	Pink or Pale	Pink
Breathing Effort	Distressed using accessory muscles	Mild distress	No distress
Circulation Capillary Refill	>3 second (shock)	>2 seconds	<2 seconds
Circulation Pulse rate	>150 (<40)	>130 (<60)	60-100
Circulation Temperature	Low (Shock)	Normal or High	Normal or High
Disability Coma	Unresponsive Pain response	Voice Response	Alert
Disability Blood sugar	<2	2-3	>3
Dehydration	Skin pinch >2 seconds Lethargic	Skin pinch <2 seconds,  Alert Malnourished	Mild Alert and well nourished
Exposure	Major Trauma Florid  total skin rash	Minor injury Mild total skin rash	Nothing evident or limited rash

 

Produced by Frankie Dormon and team for Wau Teaching Hospital  [email protected].

 

Chart 2. The ABCDE Approach - Treatment

Emergency Treatment of Children and Adults

 

Airway – (Care with Cervical Spine in Trauma)

• Clear airway
• Suction – If necessary

Breathing        

• Give assisted ventilation if not breathing adequately
• Use oxygen if available

 

Circulation – Child

	Malnourished	Well Nourished
Capillary Refill  >3 seconds	Fluids IV Slowly	Fluids IV rapidly
Capillary Refill 2-3 seconds	Oral Fluids	Fluids IV
HR >150	Fluids IV Slowly	Fluids IV Rapidly
HR 130-150	Oral Fluids	Fluids IV
Low Blood Pressure	Fluids IV Slowly	Fluids IV Rapidly

 

Circulation – Adult – Unwell.

If Blood pressure <100 and Pulse > 100 give Normal Saline 500 mls.

Reasses and Repeat if still abnormal and patient unwell

 

Disability

	A	B	C	D
Coma	Clear/support	Recovery Position	IV Cannula	Blood sugar
Convulsion	Clear/support	Recovery Position	IV Cannula	Blood sugar/Drugs

 

Dehydration

	Malnourished	Well nourished
Signs of Shock	Fluids IV Slowly	Fluids IV Rapidly
Skin Pinch >2 seconds	Fluids IV Slowly	Fluids IV Rapidly
Lethargic	Try oral fluids first	IV Fluids
Sunken Eyes	Try oral fluids first	IV Fluids

See Chart on Fluid Administration (to be published later)

 

Exposure

Check the whole patient for other signs.   Rash, Trauma, Abdominal Distention.

 

Produced  by Frankie Dormon and team for Wau Teaching Hospital  [email protected]

More from the May 2012 issue