Basic emergency care for first-level facilities
Many deaths from injury, infection, pregnancy complications and acute illness happen in the first hours, often at a facility that has no doctor. A systematic approach lets any trained health worker find and treat the immediate threats to life with a few skills and medicines, then hand over safely. This course follows the WHO-ICRC Basic Emergency Care approach.
- Use the ABCDE approach to find and treat immediate threats to life, and take a SAMPLE history.
- Explain how facility triage sorts patients into red, yellow and green.
- Give first-line treatment for airway obstruction, severe wheeze, anaphylaxis, shock, hypoglycaemia and seizures.
- Carry out a trauma primary survey and control life-threatening bleeding.
- Assess and manage burns, including fluid needs, and give first care for poisoning.
- Recognise emergency signs in children and adapt ABCDE treatment for them.
- Protect the injured patient, prepare for transfer and hand over with SBAR.
The ABCDE approach, SAMPLE history and triage
- Describe the ABCDE sequence and why you treat as you find.
- Take a SAMPLE history and place a patient in a triage category.
Emergency patients often need treatment long before anyone knows the diagnosis. The ABCDE approach puts the threats to life in the order in which they kill: a blocked airway kills faster than poor breathing, and poor breathing faster than blood loss.
| Letter | Ask yourself | Examples of immediate action |
|---|---|---|
| A: Airway | Is the airway open? Can the person talk normally? | Head-tilt and chin-lift (jaw thrust if trauma is possible); clear secretions; manage choking |
| B: Breathing | Is breathing adequate? Fast, slow, noisy, low oxygen? | Oxygen; bag-valve-mask if not breathing adequately; salbutamol for wheeze |
| C: Circulation | Signs of poor perfusion or bleeding? | Stop bleeding; IV fluids for shock |
| D: Disability | Level of consciousness (AVPU), glucose, pupils, seizures? | Recovery position; glucose if low; benzodiazepine for seizures |
| E: Exposure | Hidden injuries, rashes, bites, temperature? | Look at the whole body; cover to prevent hypothermia; immobilise a bitten limb |
AVPU
A quick measure of consciousness: Alert, responds to Voice, responds only to Pain, or Unresponsive. Anything other than Alert is a warning sign. In trauma the Glasgow Coma Scale may be used.
The SAMPLE history
Once immediate threats are treated, take a focused history: Signs and symptoms; Allergies; Medications; Past medical history (and pregnancy); Last oral intake; Events surrounding the illness or injury.
Triage: who is seen first
Triage sorts patients by how urgently they need care so the sickest are seen first. The Interagency Integrated Triage Tool (WHO, ICRC and MSF) uses three categories: red (high acuity: needs to be seen immediately), yellow (moderate acuity: needs to be seen soon) and green (low acuity: can wait). There are versions for people aged 12 and over and for children under 12, and a mass casualty version. It updates earlier WHO emergency triage guidance.
| Category | Meaning | Example |
|---|---|---|
| Red | Seen immediately | Blocked airway, severe breathing difficulty, signs of shock, unconscious, convulsing |
| Yellow | Seen soon | Abnormal vital signs or high-risk symptoms without an immediate threat |
| Green | Can wait | Stable, normal vital signs, minor problem |
Worked case 2: A busy morning queue
At 8 in the morning, 40 people are waiting. A triage nurse sees a man sitting quietly, sweating and grey, holding his chest; a toddler with fever who is playing; and a woman with a 3-day cough who is talking normally.
- Who goes first?
- Answer: The man with chest pain, sweating and a grey colour: possible heart attack or shock, a red category. He needs ABCDE now, not a place in the queue.
- Why triage at the door?
- Answer: The sickest people are often quiet. Triage on arrival finds them before they deteriorate in the waiting area; the toddler and the woman can be seen soon or wait, depending on their vital signs.
At a rural health centre: a man who fell from a ladder and is talking but holding his wrist; a woman who is breathing fast, cannot finish a sentence and has a wheeze; and a teenager with a cut finger that has stopped bleeding.
Who do you see first, and why?
The woman with breathing difficulty: a Breathing problem threatens life soonest. She is red. The man needs to be seen soon, with attention to a possible spinal or other hidden injury; the teenager can wait (green).
What does 'treat as you find' mean for her?
Check her airway, then while assessing breathing give oxygen if available and salbutamol for the wheeze straight away, then continue to C, D and E and reassess.
- ABCDE: Airway, Breathing, Circulation, Disability, Exposure. Treat as you find; reassess often.
- AVPU: anything other than Alert is a warning sign.
- SAMPLE: Signs and symptoms, Allergies, Medications, Past history, Last oral intake, Events.
- Triage: red seen immediately, yellow soon, green can wait.
Airway and breathing
- Open and protect the airway, including in suspected trauma and choking.
- Give first-line treatment for severe wheeze, anaphylaxis and inadequate breathing.
Airway
- If the person can talk normally, the airway is open.
- Noisy breathing (stridor, snoring, gurgling) or a hoarse voice suggests partial obstruction. Look for blood, vomit, a foreign body or swelling.
- Unconscious and not breathing normally: open the airway with head-tilt and chin-lift. If trauma is possible, keep the neck still and use the jaw thrust instead.
- Secretions or vomit: suction or wipe clean. If ABCDE is otherwise normal and there is no trauma, use the recovery position.
- Choking but coughing: keep calm and encourage coughing. Unable to cough or make a sound: back blows and chest or abdominal thrusts appropriate to age. If they become unconscious, start CPR.
Anaphylaxis
Stridor, swelling, wheeze or hives after a trigger suggest a severe allergic reaction. Give intramuscular adrenaline 1 mg/mL (1:1000): adults 50 kg or more 0.5 mg (0.5 mL), repeat every 5 minutes as needed; children 0.15 mg (0.15 mL), repeat every 5 to 15 minutes as needed. Give oxygen and IV fluids if in shock, and plan transfer.
Breathing
- Look at the rate and depth, work of breathing (indrawing, nasal flaring, accessory muscles), and listen for wheeze or crackles. Check oxygen saturation if a pulse oximeter is available.
- Breathing too slow or too shallow: bag-valve-mask ventilation; start straight away, even if oxygen is not yet ready.
- Breathing fast or low oxygen: give oxygen.
- Wheeze: salbutamol. By inhaler (100 micrograms per puff) and spacer, adults 2 puffs every 2 minutes until improved; or nebulised 5 mg (adult) or 2.5 mg (child). Repeat as needed.
- No breath sounds on one side with low blood pressure, a shifted trachea or distended neck veins: think tension pneumothorax. This needs immediate needle decompression by a trained provider and urgent transfer.
Source: Doses from the WHO-ICRC Basic Emergency Care participant workbook (2018). Follow your national protocol.
A 40-year-old farmer (about 70 kg) is brought in 15 minutes after a bee sting. His lips and tongue are swollen, he has hives, a hoarse voice and wheeze, and his pulse is fast and weak.
What is the most likely diagnosis and the first medicine?
Anaphylaxis. Give adrenaline 0.5 mg IM (0.5 mL of 1 mg/mL) into the thigh straight away, and repeat every 5 minutes if needed.
What else do you do?
Let him sit in a position of comfort, give oxygen, treat wheeze with salbutamol, put in an IV line and give fluids for shock, reassess ABCDE often, and arrange transfer to a facility that can manage the airway.
- Head-tilt and chin-lift; jaw thrust if trauma is possible.
- Inadequate breathing: bag-valve-mask now, oxygen when ready.
- Anaphylaxis: IM adrenaline 1 mg/mL, adults 0.5 mg, children 0.15 mg; repeat as needed.
- Wheeze: salbutamol by spacer or nebuliser, repeated.
Circulation and shock
- Recognise poor perfusion and look for bleeding.
- Give IV fluids safely to adults and children, adjusting for malnutrition, anaemia and heart problems.
Shock means the tissues are not getting enough blood and oxygen. Causes include bleeding, dehydration (for example from diarrhoea), severe infection, anaphylaxis, heart attack and tension pneumothorax.
Signs of poor perfusion
- Cool, moist hands and feet; capillary refill longer than 3 seconds.
- Fast pulse, fast breathing; low blood pressure (a late sign); weak or absent pulses.
- Confusion or drowsiness; little or no urine.
- Look for external bleeding and for hidden bleeding into the chest, abdomen, gut, pelvis or thigh.
What to do
- Give oxygen. Stop external bleeding with direct pressure.
- Put in one or two IV lines and give fluid (normal saline or Ringer's lactate).
- Bind a suspected pelvic fracture and splint a femur fracture to reduce bleeding.
- Suspected internal bleeding: refer rapidly to a facility that can operate.
| Patient | IV fluid for shock |
|---|---|
| Adult | 1 litre over less than 30 minutes, then reassess. If still in shock and no fluid overload, another 1 litre. Still in shock after 2 litres: look again for bleeding and call for advanced help |
| Adult with severe malnutrition, severe anaemia or fluid overload | 500 mL, reassess, then another 500 mL if no signs of overload |
| Child, no severe anaemia, malnutrition or overload | 10 to 20 mL/kg bolus, then reassess |
| Child with malnutrition or severe anaemia | 10 to 15 mL/kg of dextrose-containing fluid over 1 hour; check for overload every 5 minutes |
| Suspected heart attack with shock | Smaller boluses and close watch for overload |
After each bolus, reassess: the pulse should slow, blood pressure rise, capillary refill improve and the person become more alert. Monitor urine output.
Types of shock, and why the cause matters
| Type | Clues | Extra action |
|---|---|---|
| Bleeding (haemorrhagic) | Injury, vomiting blood, black stools, bleeding in pregnancy | Stop bleeding; transfer for blood and surgery |
| Dehydration | Diarrhoea, vomiting, high glucose (DKA) | IV fluids; oral fluids when able |
| Infection (septic) | Fever or low temperature, a source of infection | Antibiotics early per protocol; malaria test where relevant |
| Anaphylaxis | Trigger, hives, swelling, wheeze | IM adrenaline first (lesson 2) |
| Heart (cardiogenic) | Chest pain, crackles, swollen legs, distended neck veins | Small fluid boluses only; watch for overload |
| Tension pneumothorax | Chest injury, absent breath sounds one side, distended neck veins | Needle decompression by a trained provider (lesson 6) |
Worked case 2: Fever, confusion and low blood pressure
A 45-year-old woman has had fever and burning urine for 3 days. Today she is confused. Temperature 39.2 °C, pulse 120, BP 82/50, capillary refill 4 seconds. No fluid overload signs.
- What type of shock is likely?
- Answer: Septic shock from a urinary infection (consider malaria too where it occurs).
- What do you give?
- Answer: Oxygen, IV line, 1 litre of crystalloid over less than 30 minutes and reassess; the first dose of antibiotics per protocol; check glucose; refer. Repeat fluid once if still in shock and no overload.
A 25-year-old motorcyclist is brought in after a crash. He is talking but confused. Pulse 128 per minute, blood pressure 84/50, capillary refill 4 seconds, cold hands. His left thigh is swollen and deformed. No external bleeding.
What is happening and what do you give?
Shock, most likely from bleeding into the thigh (femur fracture), possibly elsewhere. Give oxygen, two large IV lines, and 1 litre of normal saline or Ringer's lactate over less than 30 minutes, then reassess.
What else reduces blood loss, and what is the plan?
Splint the femur fracture (and bind the pelvis if a pelvic fracture is possible). Keep him warm. If still in shock after 2 litres, suspect ongoing internal bleeding and transfer urgently to a facility that can operate.
- Shock: cool extremities, capillary refill over 3 seconds, fast pulse, confusion; low BP is late.
- Stop bleeding, oxygen, IV fluid. Adults 1 litre, then reassess.
- Children 10 to 20 mL/kg; malnutrition or severe anaemia 10 to 15 mL/kg over 1 hour.
- Reassess after every bolus and watch for overload.
Altered mental status, the unconscious patient, seizures and overdose
- Assess disability with AVPU, glucose and pupils.
- Treat hypoglycaemia, seizures, eclampsia and opioid overdose.
A confused or unconscious person may have a problem with A, B or C first, so always complete those. Then look for the treatable causes: low glucose, seizures, poisoning, infection, head injury, stroke and eclampsia.
Always check glucose
If the glucose is below 3.5 mmol/L, or you cannot test and the person has altered mental status, give glucose:
- Adults and children over 40 kg: 25 to 50 mL of 50% dextrose IV, or 125 to 250 mL of 10% dextrose IV.
- Children up to 40 kg: 5 mL/kg of 10% dextrose IV (preferred).
- No IV access: 2 to 5 mL of 50% dextrose or sugar solution in the cheek (buccal).
Seizures
- Protect from injury; place on the side once the seizure stops; nothing in the mouth.
- Active seizure: give a benzodiazepine. Diazepam for adults: 10 mg slow IV; second dose after 10 minutes if still seizing. Children: 0.2 mg/kg slow IV. Rectal or other routes per national protocol when there is no IV access.
- Watch breathing closely after any benzodiazepine.
- Pregnant (or recently delivered) and seizing: give magnesium sulfate per your obstetric protocol (BEC: 4 g IV over 5 minutes plus 10 g IM, 5 g in each buttock) and transfer.
Other causes
- Small pupils and slow breathing: suspect opioid overdose and give naloxone (BEC: 100 micrograms IV or 400 micrograms IM, repeat every 5 minutes as needed).
- Unequal pupils: think raised pressure in the head; raise the head of the bed 30 degrees if no spinal injury and transfer to neurosurgical care.
- Unconscious, no trauma, ABC stable: recovery position to protect the airway.
- Fever with confusion: treat for sepsis, and malaria where it occurs, per national protocol.
The unconscious patient: a checklist
- Safety, then ABC: open and protect the airway; recovery position if no trauma.
- Glucose: check, or give if you cannot check.
- AVPU (or GCS), pupils, any weakness of one side, neck stiffness, rash.
- Look for injury, especially to the head, and for needle marks, tablets or chemicals.
- SAMPLE from family or bystanders: what happened, when, any illness, medicines in the house.
- Reassess the airway often: someone responding only to pain (P) or unresponsive (U) may not be able to protect it.
Worked case 2: A young man found drowsy
Friends bring in a 22-year-old man who is hard to wake. Breathing 6 per minute, pupils very small, glucose 5.4 mmol/L. There are needle marks on his arm.
- What is likely and what do you do?
- Answer: Opioid overdose. Support breathing with bag-valve-mask and oxygen, and give naloxone (100 micrograms IV or 400 micrograms IM, repeat every 5 minutes as needed).
- He wakes and wants to leave. What is the risk?
- Answer: Many opioids last longer than naloxone, so he may become drowsy again. Observe him, explain why, and repeat naloxone if needed. Ask about self-harm and offer support.
A 58-year-old woman is carried in by her neighbours. She responds only to pain. Airway open, breathing 16 per minute, pulse 100, BP 130/80. Her glucose is 2.1 mmol/L. Her neighbour says she takes 'tablets for sugar'.
What is her AVPU score and what do you give?
P (responds to pain only). Give 25 to 50 mL of 50% dextrose IV (or 125 to 250 mL of 10% dextrose), then recheck glucose and AVPU.
She wakes. What next?
Give food when she can swallow safely, recheck glucose regularly because sulfonylurea lows can recur, take a SAMPLE history, and transfer or observe per protocol. Review her diabetes medicines.
- Always check glucose in a confused or unconscious person; below 3.5 mmol/L or untestable: give glucose.
- Seizure: benzodiazepine (diazepam 10 mg IV adult); watch breathing.
- Seizure in pregnancy: magnesium sulfate and transfer.
- Small pupils and slow breathing: naloxone.
Exposure, trauma basics, transfer and handover
- Protect the injured patient's spine and prevent hypothermia.
- Prepare a safe transfer and hand over with SBAR.
Exposure
- Examine the whole body for hidden injuries, rashes and bites, while protecting dignity.
- Remove wet clothes, dry the person and cover them: acutely ill people lose heat quickly.
- Remove rings and tight clothing near injuries.
- Snakebite: immobilise the bitten limb. Do not risk more bites trying to catch the snake; a photograph taken from a distance can help.
Trauma basics
- Injured and unconscious, or conscious with neck pain, neck tenderness, numbness or weakness: immobilise the spine. Keep the neck still (rolled sheet or collar), open the airway with the jaw thrust, and log-roll to examine the back.
- Control external bleeding with direct pressure and wound packing.
- Splint fractures; bind a suspected pelvic fracture.
- Give tetanus vaccine for wounds if not up to date.
Before transfer
- Check the receiving facility has what the patient needs, and speak to the accepting provider before leaving.
- Send a short written record with the patient: name, age, what happened, findings and every treatment given.
- Take airway equipment and suction, enough oxygen, a bag-valve-mask, secured IV lines and extra doses of medicines and fluids.
- Position: recovery position if no trauma; pregnant over 20 weeks, tilt to the left.
- During transfer reassess ABCDE at least every 15 minutes, with glucose checks if the person was hypoglycaemic.
Handover with SBAR
| Step | Say |
|---|---|
| S: Situation | Who you are; the patient's name, age and sex; the main problem |
| B: Background | Why you are transferring; relevant history (SAMPLE) |
| A: Assessment | ABCDE findings, vital signs and treatments given, and the response |
| R: Recommendation | What you think the patient needs next and what to watch for |
We need to take you to the hospital because you need care that we cannot give here. A nurse will travel with you and we have told the hospital you are coming.
The motorcyclist from lesson 3 has had 1.5 litres of fluid, his thigh is splinted and his BP is 98/60. The district hospital is 90 minutes away by ambulance.
What do you check before he leaves?
The hospital can operate and has blood, the accepting clinician knows he is coming, IV lines are secure, there are extra fluids, oxygen and airway equipment, his spine is protected if needed, and a written record goes with him.
Give a brief SBAR handover.
S: I am the clinical officer at X; 25-year-old man, road crash, shock. B: motorcyclist, no known illness, no allergies. A: confused, pulse 128 and BP 84/50 on arrival, deformed left thigh; 1.5 litres saline and splint, now BP 98/60, pulse 110. R: likely femur fracture with blood loss; needs blood and surgical review; watch for further bleeding.
- Expose fully, then cover: prevent hypothermia.
- Possible spinal injury: neck still, jaw thrust, log-roll.
- Call ahead, send a written record, take equipment, reassess every 15 minutes.
- Hand over with SBAR: Situation, Background, Assessment, Recommendation.
The trauma primary survey
- Carry out ABCDE in the injured patient, protecting the cervical spine.
- Recognise and treat the injuries that kill in minutes: airway obstruction, tension pneumothorax, open chest wound and major bleeding.
Injuries kill in a predictable order. The primary survey uses ABCDE to find and treat the immediate threats; the full head-to-toe examination (secondary survey) comes after. Check scene safety first, and use gloves.
| Step | Look for | Do |
|---|---|---|
| A with spine protection | Blood, vomit, teeth or objects in the mouth; burns or soot at nose or mouth; neck swelling; noisy breathing | Keep the neck still; jaw thrust, not head-tilt; suction; oral airway (avoid a nasal airway with facial injury). Expanding neck swelling or airway burns: early transfer for advanced airway care |
| B | Increased work of breathing; chest wall moving abnormally (flail chest); tracheal shift; sucking chest wound; absent breath sounds; cyanosis | Oxygen. Tension pneumothorax: immediate needle decompression by a trained provider. Sucking wound: three-sided dressing. Bag-valve-mask if breathing is inadequate |
| C | Capillary refill over 3 seconds, cold pale hands, fast weak pulse; external and hidden bleeding into chest, abdomen, pelvis and thighs | Direct pressure or deep wound packing; tourniquet for uncontrolled limb bleeding (write the time); two large IV lines and fluid; splint femur, bind pelvis; leave penetrating objects in place |
| D | AVPU or GCS, pupils, movement and feeling in all limbs, glucose if confused | GCS under 9 (child: AVPU P or U): plan transfer for airway care. Give glucose if low or untestable. Benzodiazepine for seizures |
| E | Hidden wounds, burns, deformities; the back (log-roll) | Cover and keep warm; tetanus vaccine if not up to date; pain relief |
Head injury
- Brain injury is made worse by low oxygen and low blood pressure: treat A, B and C first.
- Any injured person with altered mental status may also have a spine injury.
- Unequal pupils or falling consciousness: raise the head of the bed 30 degrees if there is no spinal injury, and transfer to neurosurgical care.
- Reassess AVPU or GCS and pupils often, and write each result down with the time.
Many casualties at once
When injured people outnumber staff, use the mass casualty version of your triage tool, call for help early, and give each person only the life-saving steps (open airway, stop bleeding) before moving on.
Source: WHO-ICRC Basic emergency care (2018); WHO, ICRC and MSF Interagency Integrated Triage Tool.
Worked case 2: A stab wound to the chest
A man is brought in with a stab wound to the right chest. He is very breathless. There is no breath sound on the right, the trachea is pushed to the left, his neck veins are distended and BP is 78/40.
- What is the likely problem?
- Answer: Tension pneumothorax: air trapped under pressure in the right chest, pushing the heart and great vessels across.
- What do you do?
- Answer: Oxygen and immediate needle decompression on the injured side by a trained provider, then IV fluids and urgent transfer for a chest drain. If you are not trained to decompress, give oxygen and transfer immediately with a provider who is, if at all possible.
A 35-year-old builder fell 4 metres. He responds to voice, says his neck hurts, breathing 26 per minute, pulse 118, BP 96/60, capillary refill 4 seconds. His pelvis is painful when gently pressed and there is a large cut on his scalp that is bleeding.
What are your first actions in order?
A: keep the neck still (manual hold, then rolled sheet or collar), jaw thrust if needed. B: oxygen, look and listen to the chest. C: firm pressure on the scalp wound; two large IV lines and 1 litre of fluid; bind the pelvis with a sheet at the level of the hips. D: AVPU and glucose. E: log-roll to check the back, then cover to keep warm.
Where is he probably bleeding, and what is the plan?
From a pelvic fracture, and the scalp. Binding the pelvis reduces bleeding. Reassess after the fluid; if still in shock, he needs urgent transfer to a facility with blood and surgery, with his spine protected and an SBAR handover (lesson 5).
- Primary survey: ABCDE with spine protection; treat as you find.
- Tension pneumothorax: needle decompression; sucking wound: three-sided dressing.
- Bleeding: pressure, packing, tourniquet (note the time), splint femur, bind pelvis.
- Head injury: prevent low oxygen and low BP; GCS under 9 needs airway care.
- Log-roll to examine the back, then keep warm.
Burns and poisoning
- Stop the burning process, assess burn size and depth, and calculate fluids.
- Know which burns need transfer.
- Give first care for poisoning, including decontamination and protecting yourself.
Burns: first actions
- Make the scene safe. Stop the burning: remove burning or hot clothing and all jewellery. With chemicals, protect yourself first and remove the chemical.
- If the burn is less than 3 hours old and no first aid was given, wash it with clean water to stop the burning process.
- ABCDE. Soot around the nose or mouth, singed nasal hairs, swollen lips or a change in voice suggest an airway burn: the airway can swell shut quickly, so transfer early.
- Burns that go all the way round the chest or a limb (circumferential) can restrict breathing or blood flow and may need escharotomy at a surgical unit.
- Give pain relief and tetanus vaccine if not up to date; elevate burned limbs.
Size and depth
| Depth | What you see |
|---|---|
| Superficial | Red or pink, painful, no blisters, quick capillary refill |
| Partial thickness | Red or mottled, blisters, wet, painful; blanches then refills |
| Full thickness | White or black, leathery and dry, no feeling, no change when pressed |
Estimate the burned area with the rule of nines in adults (head 9%, each arm 9%, front of trunk 18%, back of trunk 18%, each leg 18%, genitals 1%). Children have bigger heads and smaller legs, so use the paediatric chart.
Fluids
Start IV fluid for partial or full thickness burns of 15% or more in adults or 10% or more in children. BEC uses the Parkland formula for the first 24 hours: 4 mL x weight in kg x % burned area. Give half in the first 8 hours from the time of the burn (not from arrival), and the rest over the next 16 hours. Adults: normal saline or Ringer's lactate. Children: a dextrose-containing fluid, plus their usual maintenance fluid.
Clean with saline, remove loose dead skin, and cover the whole burn with a non-adherent dressing. Clean plastic film can be used for a short time before transfer.
Poisoning
- Protect yourself: pesticides and some chemicals contaminate skin and clothes. Wear protection, remove the person's clothes and wash the skin as your local decontamination protocol says.
- ABCDE and glucose in every case. Organophosphate pesticides cause small pupils, sweating, vomiting, diarrhoea and copious secretions that can block the airway: suction, oxygen, and an advanced provider for atropine and other antidotes per protocol.
- Small pupils and slow breathing after drugs: naloxone (lesson 4).
- Several people from one place with headache or confusion, especially with indoor fires or heaters: think of carbon monoxide; move them to fresh air and give oxygen.
- Find out what, how much and when. Keep the container or take a photograph, and talk to an advanced provider or poisons service for the specific antidote.
- Do not make the person vomit. Children with stridor or burns in or around the mouth after swallowing a chemical need airway care and transfer.
Worked case 2: A farmer who drank pesticide
A 30-year-old farmer is brought in an hour after drinking an insecticide. He is drowsy, drooling, sweating and has very small pupils. His clothes smell of chemical.
- What do you do first?
- Answer: Put on gloves and protection, remove his clothes and wash his skin to decontaminate. Then ABCDE: suction the secretions, recovery position if not injured, oxygen, IV line, glucose check.
- What next?
- Answer: Treat as organophosphate poisoning: urgent advanced care for atropine and monitoring of the airway, with the container or a photograph. When he is able, ask about self-harm and plan follow-up.
A 3-year-old (14 kg) pulled a pot of boiling water over her chest and both arms 1 hour ago. No first aid. She is crying, airway clear, breathing 32, pulse 150. The burns are red, blistered and wet: the front of the trunk and both arms, about 20% in all.
What first care does she need?
Wash the burns with clean water (under 3 hours, no first aid), keep her warm, pain relief, ABCDE. Cover with a non-adherent dressing or clean plastic film.
Does she need IV fluid, and how much?
Yes: partial thickness burns of 10% or more in a child. Parkland: 4 x 14 x 20 = 1120 mL in the first 24 hours, half (560 mL) in the first 8 hours from the time of the burn, using a dextrose-containing fluid, plus maintenance fluid. She is very young with a large burn, so arrange transfer.
- Burns: stop the burning, wash with clean water if under 3 hours, look for airway burns.
- Fluids for partial or full thickness burns of 15% or more (adults) or 10% or more (children): 4 mL x kg x % burn, half in the first 8 hours from the burn.
- Transfer burns over 15%, of the face, hands, groin or joints, circumferential or with inhalation injury.
- Poisoning: protect yourself, decontaminate, ABCDE and glucose, identify the poison, ask about self-harm.
Children in emergencies
- Recognise emergency and priority signs in children at triage.
- Adapt airway, fluid, glucose and seizure treatment for children.
Children become very sick quickly and often die within the first 24 hours of arriving at a facility. WHO Emergency Triage Assessment and Treatment (ETAT) teaches health workers to check every sick child for emergency signs as soon as they arrive, before any paperwork.
Emergency signs: treat now
- Obstructed or absent breathing.
- Severe respiratory distress; central cyanosis.
- Signs of shock: cold hands with capillary refill over 3 seconds and a weak, fast pulse.
- Coma (or AVPU P or U), or convulsing now.
- Severe dehydration in a child with diarrhoea: lethargy, sunken eyes, skin pinch goes back very slowly.
Priority signs: assess first in the queue
A tiny baby (under 2 months); very high temperature; trauma or another urgent surgical problem; severe pallor; poisoning; severe pain; restless, irritable or lethargic; respiratory distress; an urgent referral; visible severe wasting or swelling of both feet; major burns.
How children are different
| Area | In children |
|---|---|
| Airway | Bigger tongue and head, soft airway. Use the sniffing position, padding under the shoulders of small infants; avoid over-extending the neck. Jaw thrust if the airway is not open. Choking: back blows and chest thrusts in infants, abdominal thrusts in older children |
| Shock fluids | 10 to 20 mL/kg isotonic fluid, then reassess. Severe malnutrition or severe anaemia: 10 to 15 mL/kg of dextrose-containing fluid over 1 hour (lesson 3). Children overload easily: watch breathing and the liver |
| Low glucose | Common in sick young children. 5 mL/kg of 10% dextrose IV, or sugar solution by mouth or nasogastric tube if no IV |
| Seizures | Diazepam 0.5 mg/kg rectally, or 0.2 mg/kg slow IV; half the first dose again after 10 minutes if still fitting. Do not give a second dose if breathing is under 10 a minute. Not IM |
| Temperature | Avoid hypothermia: keep babies skin-to-skin with the mother, cover the head, uncover one part at a time |
| Poisoning | Think of unwitnessed swallowing in children under 6 (especially 1 to 3 years): ask about medicines and chemicals at home |
After emergency treatment, use the IMCI or sick young infant protocols to classify the illness, and refer children with any emergency sign once they are stable enough to travel.
Worked case 2: A baby who will not stop fitting
A 9-month-old (8 kg) has been fitting for 10 minutes with fever. There is no IV access. Glucose 2.4 mmol/L.
- What do you give?
- Answer: Diazepam 4 mg rectally (0.5 mg/kg), and treat the low glucose: sugar solution by nasogastric tube, or 10% dextrose 40 mL IV (5 mL/kg) once access is obtained.
- What else?
- Answer: Recovery position, airway and oxygen, watch breathing after diazepam, cool if very hot, malaria test where relevant, first antibiotic dose if meningitis or sepsis is possible, and urgent referral.
A 2-year-old (10 kg) is carried in after 2 days of watery diarrhoea. She is lethargic, her hands are cold, capillary refill is 4 seconds and the pulse is weak and fast. She is not severely malnourished and has no severe pallor.
Which emergency signs does she have?
Signs of shock (cold hands, capillary refill over 3 seconds, weak fast pulse) and lethargy. She is red: treat now.
What fluid do you give?
Oxygen, IV or intraosseous access by a trained provider, and an isotonic fluid bolus of 10 to 20 mL/kg (100 to 200 mL), then reassess; check glucose. Watch for overload after each bolus. Continue rehydration per IMCI plan C and refer.
- Check every sick child for emergency signs on arrival: airway, breathing, shock, coma or convulsions, severe dehydration.
- Priority signs move a child to the front of the queue.
- Children: sniffing position; fluids 10 to 20 mL/kg (less and slower with severe malnutrition or anaemia); 10% dextrose 5 mL/kg.
- Seizure: diazepam 0.5 mg/kg rectally or 0.2 mg/kg IV; watch breathing.
Quiz and CPD certificate
Answer all 15 questions, then press Mark. You need 12 or more to pass. You can look back at the lessons: the aim is learning. A pass gives a printable certificate of completion for 5 hours of self-directed learning; you need a free account, signed in, to issue it.
Sources
- World Health Organization and International Committee of the Red Cross. Basic emergency care: approach to the acutely ill and injured (participant workbook and quick cards). 2018 (ISBN 9789241513081).
- World Health Organization. Basic emergency care course: slide sets on ABCDE, breathing, shock, altered mental status, trauma, and transfer and handover. 2018.
- World Health Organization, International Committee of the Red Cross and Médecins Sans Frontières. Interagency Integrated Triage Tool (web page and tools). 2020. Initially released in 2020; year of the current version not stated on the WHO page.
- World Health Organization. mhGAP Intervention Guide, version 2.0 (epilepsy emergency management). 2016.
- World Health Organization. Updated guideline: paediatric emergency triage, assessment and treatment (ETAT). 2016.
- World Health Organization. Pocket book of hospital care for children: guidelines for the management of common childhood illnesses, 2nd edition. 2013.
- World Health Organization. Clinical management of acute pesticide intoxication: prevention of suicidal behaviours. 2008.