SECTION OUTLINE
- Identification of “At Risk” Newborn and Admission to SCNU/NICU
- Hypothermia
- Respiratory Distress
- Neonatal Shock
- Suspected Infection
- Neonatal Seizures
- Jaundice
- Suspected Congenital Heart Defect
- Fluid and Electrolyte Therapy
- Hypoglycemia
- Hypocalcemia
- Polycythemia
- Feed Intolerance: Gastric Residues
- Bleeding Newborn
- Thrombocytopenia
- Anemia
- Neonatal Encephalopathy
- Floppy Infant
- Suspected Inborn Errors of Metabolism
- Disorder of Sex Development
- Neonatal Transport
- Abdominal Distension
- Apnea
- Blistering Skin Disorders
- Systemic Fungal Infections
WHAT IS TRIAGE?
Triage is a process of rapidly examining all sick newborn when they arrive in hospital in order to place them in one of the following categories with the help of TABC concept. The basic purpose of triage is to ensure that sickest newborn gets earliest treatment.
Concept of TABC
When sick newborn arrives in emergency department of a hospital the assessment is done based on TABC concept where:
- T stands for temperature
- A stands for airways
- B stands for breathing
- C stands for circulation, consciousness/coma and/or presence of convulsion.
EMERGENCY SIGNS
If any of the following are present (alone or in combination):
- T: Moderate or severe hypothermia (Temperature <35.9°C).
- A: No chest movement or no air entry in lungs/obstructed airways and/or central cyanosis.
- B: Not breathing/severe respiratory distress with increased work of breathing as evidenced by respiratory rate >60/minute with nasal flaring and/or chest retractions and/or grunting/gasping/head bobbing.
- C: Capillary refill time >3 seconds and/or poor pulse and/or decreased urine output.
- Color of baby mottled or pale with or without cyanosis.
- Presence of unconsciousness as evidenced by no response or minimal response.
- Presence of convulsion.
PRIORITY SIGNS
If any of the following are present (alone or in combination):
- T: Mild-hypothermia (temperature ~ 36.0–37.4°C) or fever (temperature >37.5°C)
- A: Decreased air entry in either lungs ± chest signs by auscultation, e.g. crackles or wheezing.
- B: Fast breathing respiratory rate >60/minute ± retractions.
- C: Capillary refill time <3 seconds but decreased urine output.
Apart from above signs presence of the following features also classifies the newborn as having priority signs:
- Low-birth weight (weight <1,800 g)
- Irritability/restlessness/jitteriness
- Refusal to feed
- Abdominal distension
- Severe jaundice
- Severe pallor
- Bleeding from any site (apart from physiological vaginal bleed in female)
- Major congenital anomaly
- Large baby (weight >4 kg)
- Redness around umbilical area with or without pus discharge.
NON URGENT SIGNS
Newborns with nonurgent signs are mostly well and can wait for their turn to be addressed. TABC assessment in newborn with nonurgent sign is normal and usually newborns present with following features:
- Physiological jaundice
- Transitional stools
- Developmental peculiarity
- Minor malformations
- Rashes.
When and Where to Triage?
The process should begin as soon as the newborn arrives in the emergency department of the treatment facility or hospital or outpatient department of the hospital.
Time for Triaging
The process to triage newborns in having three above listed signs should take minimum time. The staff nurse on duty should complete the triage stratification at the earliest. It is important that they should know how to look for several signs at the same time for rapid assessment.
Who should Triage?
Triaging should be done by experienced clinical staff nurse with involvement of the junior nurses.
How to Triage?
Triaging of newborns shall be a rapid assessment with focus on TABC concept. After completing TABC assessment the various other features as mentioned above should be taken into account. The basic purpose of triage is to ensure that sickest newborn gets earliest treatment.
Keep in mind the concept of TABC. First assess temperature, then airway, breathing, circulation and lastly consciousness level/coma/convulsion.
Temperature assessment (Flowchart 1): To assess the temperature one should feel the newborn's soles and abdomen.
- If abdomen and soles both are warm, the newborn has normal temperature.
- If soles are cold and abdomen is warm, the newborn is suffering from mild hypothermia/cold stress.
- If the soles and abdomen are cold, the newborn has moderate/severe hypothermia.
Axillary thermometer should be used to record the newborn's temperature. Any other positive finding should be noted.
Newborn having hypothermia needs warming. The method of warming depends on the actual temperature.
Airway and breathing assessment (Flowchart 2): Airways and breathing pattern is assessed simultaneously for the sake of saving time. The following points should be looked for:
- Is the newborn breathing/gasping/grunting/having head bobbing or nasal flaring?
- Is the airway obstructed?
- Is the newborn blue?
- Does newborn have severe respiratory distress with or without retractions?
Any positive finding should be addressed on urgent basis and airways should be made patent. Oxygen is usually started before a definite diagnosis is made.
Circulation assessment (Flowchart 3): To assess if the newborn has circulatory problems one should:
- Look for cold and clammy skin.
- Look for capillary refill time (CRT) and note if it is more than or less than 3 seconds.
- Look for weak and fast pulse rate.
Prolonged CRT (>3 sec) is a surrogate marker of poor peripheral perfusion. Fast and weak pulse with decreased urine output in this setting may herald a shock like state. Such newborns need warmth and oxygen. An intravenous (IV) line should be inserted and bolus 20 mL/kg of normal saline/Ringer's lactate (NS/RL) initiated over 15–20 minutes. Color of skin of the newborn may be an early catch to an experienced eye. Pallor, mottling, and cyanosis are key visual indicators of reduced circulation to skin.
Flowchart 2: Assessment of circulation.Note: Normal breathing appears regular without excessive respiratory muscle effort or audible respiratory sound. While in abnormal breathing there is increased or excessive nasal flaring or abnormal muscle use or decreased or absent respiratory effort or noisy breathing.
Pallor signifies white skin coloration from lack of peripheral blood flow. Mottling/patchy skin discoloration, with patches of cyanosis is due to vascular instability or cold. Cyanosis can be a sign of shock or respiratory failure.
Assessment of consciousness level in newborns (Flowchart 4): AVPU scale (“alert, pain, unres ponsive”) can be used to rapidly assess the newborn. AVPU in comparison with GCS scale is read as: A = 15, V = 12, P = 8, U = 3.
- A: Is the newborn alert?
- V: Is the newborn responding to voice?
- P: Is the newborn responding to pain?
- U: Is the newborn not responding? (Unresponsive).
Any unresponsive newborn or newborn with convulsion needs immediate attention.
After placing the newborn under radiant warmer airways/breathing should be assessed and addressed. Peripheral IV line should be established at the earliest, RBS infused checked and injection phenobarbitone 20 mg/kg slowly over 20 minutes in a convulsing baby.
Flowchart 3: Assessment of airway and breathing.(CRT: capillary refill time)Note: Normal warm child is usually suggestive of normal circulation whereas cyanosis, mottling, paleness/pallor or obvious bleeding suggests abnormal circulation.
Flowchart 4: Assessment of consciousness.(AVPU: Alert, voice, pain, unresponsive)Note: A normal conscious child has normal cry and responds to parents or to environmental stimuli such as light, etc. and has good muscle tone and moves extremity well whereas abnormal or decreased cry and poor response to parents/environment suggests abnormal conscious level.
CRITERIA FOR ADMISSION TO SCNU/LEVEL II NICU
All newborns with emergency/priority signs and some babies with nonurgent signs will require admission in hospital for further management or for observational purpose. Other indications that may require admission into special care neonatal unit/neonatal intensive care unit (SCNU/NICU) may be enumerated as:
- Birth weight ≤1,800 g.
- Low-birth weight: Babies between 2,500 g and 1,800 g; if the clinical examination shows the baby needs supervised treatment should be shifted to SCNU and not postnatal ward.
- Prematurity <34 weeks of gestation and any baby >34 weeks if is not sucking well.
- Suspicion of infection
- Clinical concern of respiratory problems like: (1) Apnea or cyanotic episodes, (2) Any respiratory distress causing concern.
- Clinical concern of gastrointestinal problems, e.g. feeding problems severe enough to cause clinical concern and bile stained vomiting or signs suggestive of bowel obstruction.
- Clinical concern of metabolic disorder, e.g. low serum glucose level and acidotic breathing.
- Clinical concern of neurological disorder. (1) Convulsion (2) Perinatal asphyxia.
- Congenital anomalies including surgically correctable lesions.
- Any clinical condition which may require initial period of observation.
SUGGESTED READING
- Children and Infant—Recognition of a sick baby or child in the emergency department—NSW Policy Guidelines; 2011.
- Emergency Triage Assessment and Treatment — World Health Organization Publication.