a Positive pressure ventilation should be initiated with air for infants with gestation > 32 weeks. For very preterm infants, it is preferable to start with 30% oxygen if possible. A and B are basic resuscitation steps Chart 12. Neonatal resuscitation: Flow chart No Yes Breathing Breathing well Not breathing, or gasping After 30-60 s If HR  60/min If HR < 60/min Dry the infant immediately with a clean cloth. Keep warm by skin-to-skin contact and covered. Look for  Breathing or crying  Good muscle tone or vigorous movements Stimulate by rubbing the back 2 to 3 times. Suction only if had meconium stained liquor or the mouth or nose is full of secretions.Transfer to newborn resuscitation area. Position the head/neck slightly extended.  Start positive pressure ventilation with mask and self-infl ating bag within 1 min of birth. a Make sure the chest is moving adequately. Check the heart rate (HR) with a stethoscope.Triage of all sick children EMERGENCY SIGNS: If any sign is positive, call for help, assess and resuscitate, give treatment(s), draw blood for emergency laboratory investigations (glucose, malaria smear, Hb) TREAT Do not move neck if a cervical spine injury is possible, but open the airway.#
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
The mention of specifi c companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.

# TRIAGE AND EMERGENCY CONDITIONS 1
- 1 Triage 2 1.2 Summary of steps in emergency triage assessment and treatment 3 1.3 Assessment of emergency and priority signs 4 Triage of all sick children 5 How to manage a choking infant or child 7 How to manage the airway in a child with obstructed breathing 9 How to give oxygen How to position the unconscious child Give IV fl uids for shock in a child without severe acute malnutrition Give IV fl uids for shock in a child with severe acute malnutrition Give diazepam rectally Give IV glucose Treat severe dehydration in an emergency setting 1.4 Emergency treatment for a child with severe malnutrition 1.5 Diagnostic considerations for children with emergency conditions 1.5.1 Child presenting with an airway or severe breathing problem 1.5.2 Child presenting with shock 1.5.3 Child presenting with lethargy, unconsciousness or convulsions 1.6 Common poisoning 1.6.1 Principles for ingested poisons 1.6.2 Principles for poisons in contact with skin or eyes TABLES Table 1. Differential diagnosis in a child presenting with an airways or severe breathing problem Table 2. Differential diagnosis in a child presenting with shock Table 3. Differential diagnosis in a child presenting with lethargy, unconsciousness or convulsions Table 4.
Differential diagnosis in a young infant (< 2 months) presenting with lethargy, unconsciousness or convulsions Table 5.
Poisoning: amount of activated charcoal per dose Table 6. Differential diagnosis in a child presenting with cough or diffi culty in breathing Table 7.
Classifi cation of the severity of pneumonia Table 8. Differential diagnosis in a child presenting with wheeze Table 9.
Differential diagnosis in a child presenting with stridor Table 10. Differential diagnosis in a child presenting with chronic cough Table 11. Differential diagnosis in a child presenting with diarrhoea Table 12.
Classifi cation of the severity of dehydration in children with diarrhoea Table 13.
Administration of intravenous fl uids to a severely dehydrated child Table 14.
First diet for persistent diarrhoea: a starch-based, reduced-milk (low-lactose) diet Table 15.
Second diet for persistent diarrhoea: a reduced-starch (cereal) no-milk (lactose-free) diet Table 16.
Differential diagnosis of fever without localizing signs Table 17.
Differential diagnosis of fever with localized signs Table 18.
Differential diagnosis of fever with rash Table 19.
Additional differential diagnosis of fever lasting longer than 7 days Table 20 WHO criteria for the diagnosis of rheumatic fever (based on the revised Jones criteria) Table 21.
Time frame for the management of a child with severe acute malnutrition Table 22.
Volumes of F-75 per feed for malnourished children (approximately 130 ml/kg per day) Table 23.
WHO paediatric clinical staging system for HIV infection Table 24.
Classes of antiretroviral drugs recommended for use in children CO NTENTS xiv Table 25. First-line treatment regimens for children Table 26.
Common side-effects of antiretroviral drugs Table 27.
Recommended second-line treatment regimens for children Table 28.
Endotracheal tube size by age Table 29.
Blood volume of children by age Table 30.
Normal pulse rate and blood pressure in children Table 31.
Examples of local adaptations of feeding recommendations on the mother's card in Bolivia, Indonesia, Nepal, South Africa and the United Republic of Tanzania Table 32.
Maintenance fl uid requirements Table 33.
Primary vaccination schedule for infants recommended in the Expanded Programme on Immunization Table A2.1 Drug dosage by surface area (m 2 of the child Table A5.1.1 Weight-for-age from birth to 5 years: Boys Table A5.1.2 Weight-for-age from birth to 5 years: Girls Table A5.2.1 Weight-for-length from birth to 2 years: Boys Table A5.2.2 Weight-for-length from birth to 2 years: Girls Table A5.2.3 Weight-for-height from 2 to 5 years: Boys Table A5.2.4 Weight-for-height from 2 to 5 years: Girls Preface This is the second edition of the World Health Organization (WHO) Pocket book of hospital care for children, which was fi rst published in 2005. It is a compilation of the updated WHO guidelines for the management of common childhood illnesses at the fi rst-referral level in low-resource countries. It presents relevant, up-to-date, evidence-based clinical guidelines that can be used by clinicians in their daily work in hospitals with basic laboratory facilities and inexpensive medicines. The guidelines focus on inpatient management of children who are severely ill with conditions that are major causes of childhood mortality, such as neonatal illness, pneumonia, diarrhoea, fever (mainly malaria, meningitis and septicaemia), severe acute malnutrition and HIV/AIDS. It also includes guidance on common surgical problems, appropriate supportive care and monitoring of patients on the ward.
The Pocket book is part of a series of tools for improving the quality of care for severely ill children and is consistent with the Integrated Management of Childhood Illness (IMCI) guidelines for outpatient management of sick children. It is for use by doctors, senior nurses and other senior health workers who are responsible for the care of young children at the fi rst referral level in developing countries.
The fi rst edition of the Pocket book was reviewed by a WHO guidelines steering committee, which identifi ed those chapters that required updating, comprising:
- revisions to align the Pocket book with recently published, WHO-approved guidelines; and
- priorities for which new information had become available, which was collated, analysed and synthesized before updating.
In the fi rst category, recommendations approved by the WHO Guidelines Review Committee were incorporated. The second category required synthesis of evidence and updates consistent with new recommendations. The changes made are therefore based on published WHO guidelines and recommendations as of 2012, which are listed in the bibliography on p. 329; in addition, certain subsections were added or removed, others reorganized and some editorial changes made on the basis of feedback from Pocket book users. In response to users' feedback and the popularity of the fi rst edition, the presentation is similar.
All the changes were reviewed by external clinical experts and were approved by the WHO Guidelines Review Committee. A web version of the Pocket book will be updated regularly as new evidence with clinical implications emerges. Printed editions will be published every 5 years if there are substantial new changes. Users are therefore advised to check the WHO web site regularly for Pocket book updates (/).
The main changes in the second edition are listed below.

# Chapters unchanged from the fi rst edition of the Pocket book (2005):
Chapters with only editorial changes or reorganization but with no major update of previous information: xvii Additional sections or subsections in this second edition Several sections of some chapters were added or substantially expanded in response to demand from users:
- Chapter 1, section 1.10. Trauma and injuries
- Chapter 3, section 3.7. Convulsions or fi ts
- Chapter 3, section 3.11.3. Respiratory distress syndrome
- Chapter 4, section 4.6.3. Epiglottitis
- Chapter 4, section 4.6.4. Anaphylaxis
- Chapter 4, section 4.9. Rheumatic heart disease
- Chapter 6, section 6.11. Rheumatic fever
- Chapter 8, section 8.5. Prevention of mother to child HIV transmission, and infant feeding
The Pocket book is presented in a format that could be carried by doctors, nurses and other health workers during their daily work and be available to help guide the management of sick children. Although some new topics have been added, standard textbooks of paediatrics should be consulted for rarer conditions not covered in the Pocket book. These guidelines are applicable in most areas of the world and may be adapted by countries to suit their specifi c circumstances.
WHO recommends that countries should locally adapt the Pocket book to include important conditions not covered and believes its widespread adoption would improve the care of children in hospital and lead to lower case fatality rates.

# T riage and emergency conditions
- 1 Triage 1.2 Summary of steps in emergency triage assessment and treatment 1.3 Assessment of emergency and priority signs Triage of all sick children How to manage a choking infant or child How to manage the airway in a child with obstructed breathing How to give oxygen How to position the unconscious child Give IV fl uids for shock in a child without severe acute malnutrition Give IV fl uids for shock in a child with severe acute malnutrition Give diazepam rectally Give IV glucose Treat severe dehydration in an emergency setting 1.4 Emergency treatment for a child with severe malnutrition 1.5 Diagnostic considerations for children with emergency conditions 20 1.5.1 Child presenting with an airway or severe breathing problem 1.5.2 Child presenting with shock 1.5.3 Child presenting with lethargy, unconsciousness or convulsions 1.6 Common poisoning 1.6.1 Principles for ingested poisons 1.6.2 Principles for poisons in contact with skin or eyes 1.6.3 Principles for inhaled poisons 1.6.
Triage is the process of rapidly screening sick children soon after their arrival in hospital, in order to identify:
-those with emergency signs, who require immediate emergency treatment;
-those with priority signs, who should be given priority in the queue so that they can be assessed and treated without delay; and -non-urgent cases, who have neither emergency nor priority signs.

# Emergency signs include:
 obstructed or absent breathing  severe respiratory distress  central cyanosis  signs of shock (cold hands, capillary refi ll time longer than 3 s, high heart rate with weak pulse, and low or unmeasurable blood pressure)
 coma (or seriously reduced level of consciousness)
 convulsions  signs of severe dehydration in a child with diarrhoea (lethargy, sunken eyes, very slow return after pinching the skin or any two of these).
Children with these signs require immediate emergency treatment to avert death.
The priority signs (see p. 6) identify children who are at higher risk of dying. These children should be assessed without unnecessary delay. If a child has one or more emergency signs, don't spend time looking for priority signs. TRIAGE 1.

# Summary of steps in emergency triage assessment and treatment
Steps in emergency triage assessment and treatment are summarized in the charts on pp. 5-17.
First check for emergency signs in three steps:
- Step 1. Check whether there is any airway or breathing problem; start immediate treatment to restore breathing. Manage the airway and give oxygen. - Step 2. Quickly check whether the child is in shock or has diarrhoea with severe dehydration. Give oxygen and start IV fl uid resuscitation. In trauma, if there is external bleeding, compress the wound to stop further blood loss. - Step 3. Quickly determine whether the child is unconscious or convulsing.
Give IV glucose for hypoglycaemia and/or an anti-convulsant for convulsing.
If emergency signs are found:
- Call for help from an experienced health professional if available, but do not delay starting treatment. Stay calm and work with other health workers who may be required to give the treatment, because a very sick child may need several treatments at once. The most experienced health professional should continue assessing the child (see Chapter 2, p. 41), to identify all underlying problems and prepare a treatment plan.
- Carry out emergency investigations (blood glucose, blood smear, haemoglobin. Send blood for typing and cross-matching if the child is in shock, appears to be severely anaemic or is bleeding signifi cantly.
- After giving emergency treatment, proceed immediately to assessing, diagnosing and treating the underlying problem.
Tables of common differential diagnoses for emergency signs are provided from p. 21 onwards.
If no emergency signs are found, check for priority signs:
 Tiny infant: any sick child aged < 2 months The above can be remembered from the mnemonic 3TPR MOB.
These children need prompt assessment (no waiting in the queue) to determine what further treatment is needed. Move a child with any priority sign to the front of the queue to be assessed next. If a child has trauma or other surgical problems, get surgical help where available.

# Assessment of emergency and priority signs  Assess the airway and breathing (A, B)
Does the child's breathing appear to be obstructed? Look at the chest wall movement, and listen to breath sounds to determine whether there is poor air movement during breathing. Stridor indicates obstruction.
Is there central cyanosis? Determine whether there is bluish or purplish discoloration of the tongue and the inside of the mouth.
Is the child breathing? Look and listen to determine whether the child is breathing.
Is there severe respiratory distress? The breathing is very laboured, fast or gasping, with chest indrawing, nasal fl aring, grunting or the use of auxiliary muscles for breathing (head nodding). Child is unable to feed because of respiratory distress and tires easily.

#  Assess circulation (for shock) (C)
Children in shock who require bolus fl uid resuscitation are lethargic and have cold skin, prolonged capillary refi ll, fast weak pulse and hypotension.
Check whether the child's hand is cold. If so, determine whether the child is in shock.
Check whether the capillary refi ll time is longer than 3 s. Apply pressure to whiten the nail of the thumb or the big toe for 5 s. Determine the time from the moment of release until total recovery of the pink colour.
If capillary refi ll is longer than 3 s, check the pulse. Is it weak and fast? If the radial pulse is strong and not obviously fast, the child is not in shock. If you cannot feel the radial pulse of an infant (< 1 year old), feel the brachial pulse or, if the infant is lying down, the femoral pulse. If you cannot feel the radial pulse of a child, feel the carotid. Position the unconscious child (if head or neck trauma is suspected, stabilize the neck fi rst) (Chart 6).

# Chart 2. Triage of all sick children
Give IV glucose (Chart 10).
Make sure the child is warm.
If no severe malnutrition: Insert an IV line and begin giving fl uids rapidly following Chart 11 and diarrhoea treatment plan C in hospital (Chart 13,p. 131).

# If severe malnutrition:
Do not insert an IV line. Proceed immediately to full assessment and treatment (see section 1.4, p. 19).

# IF COMA OR CONVULSION DIARRHOEA PLUS two signs positive

# Check for severe malnutrition
Severe dehydration (only in a child with diarrhoea) Diarrhoea plus any two of these signs:
 Lethargy  Sunken eyes  Very slow skin pinch  Unable to drink or drinks poorly  Tiny infant (< 2 months)  Temperature very high  Trauma or other urgent surgical condition  Pallor (severe)  Poisoning (history of)  Pain (severe)  Respiratory distress  Restless, continuously irritable, or lethargic  Referral (urgent)  Malnutrition: visible severe wasting  Oedema of both feet or face  Burns (major) Note: If a child has trauma or other surgical problems, get surgical help or follow surgical guidelines.
Proceed with assessment and further treatment according to the child's priority.

# TRIAGE CHART 3. HOW TO MANAGE A CHOKING INFANT

# Chart 3. How to manage a choking infant

# Chest thrusts
Lay the infant on your arm or thigh in a head-down position.
 Give fi ve blows to the middle of the infant's back with the heel of the hand.
If obstruction persists, turn the infant over and give fi ve chest thrusts with two fi ngers on the lower half of the sternum.
If obstruction persists, check infant's mouth for any obstruction that can be removed.
If necessary, repeat sequence with back slaps.

# Back slaps
- TRIAGE CHART 3. HOW TO MANAGE A CHOKING CHILD Chart 3. How to manage a choking child (> 1 year of age)

# Heimlich manoeuvre for a choking older child
Administer back blows to clear airway obstruction in a choking child.
Give fi ve blows to the middle of the child's back with the heel of the hand, with the child sitting, kneeling or lying.
If the obstruction persists, go behind the child and pass your arms around the child's body; form a fi st with one hand immediately below the child's sternum; place the other hand over the fi st and pull upwards into the abdomen (see diagram); repeat this Heimlich manoeuvre fi ve times.
If the obstruction persists, check the child's mouth for any obstruction that can be removed.
If necessary, repeat this sequence with back blows.

# Back blows to clear airway obstruction in a choking child
- TRIAGE CHART 4. HOW TO MANAGE THE AIRWAY IN A CHILD Chart 4. How to manage the airway in a child with obstructed breathing (or who has just stopped breathing)
A: When no neck trauma is suspected  OLDER CHILD

# Look, listen and feel for breathing

# Child conscious
- Inspect mouth and remove foreign body, if present.
- Clear secretions from the throat.
- Let child assume position of maximal comfort.

# Child unconscious
- Tilt the head as shown, keep it tilted and lift chin to open airway.
- Inspect mouth and remove foreign body if present and easily visible.
- Clear secretions from the throat.
- Check the airway by looking for chest movements, listening for breath sounds and feeling for breath (see diagram).

#  INFANT

# Neutral position to open the airway in an infant
Tilting position to open the airway in an older child 2. Inspect mouth and remove foreign body, if present.
- Clear secretions from throat under direct vision.
- Check the airway by looking for chest movements, listening for breath sounds and feeling for breath.

# If the child is still not breathing after the above, ventilate with bag and mask, ideally with a reservoir bag and oxygen
- TRIAGE Chart 5. How to give oxygen CHART 5. HOW TO GIVE OXYGEN Give oxygen through nasal prongs or a nasal catheter.

#  NASAL PRONGS
Place the prongs just inside the nostrils and secure with tape.
 NASAL CATHETER

# Use an 8 French gauge size tube
Measure the distance from the side of the nostril to the inner eyebrow margin with the catheter.
Insert the catheter as shown in the diagram.
Secure with tape.
Start oxygen fl ow at 1-2 litres/min to aim for an oxygen saturation > 90% (see section 10.7, p. 312).
- TRIAGE Chart 6. How to position an unconscious child CHART 6. HOW TO POSITION AN UNCONSCIOUS CHILD  If neck trauma is suspected:
Stabilize the child's neck and keep the child lying on the back.
Tape the child's forehead and chin to the sides of a fi rm board to secure this position.
Prevent the neck from moving by supporting the child's head (e.g. using litre bags of IV fl uid on each side).
If the child is vomiting, turn on the side, keeping the head in line with the body.
 If neck trauma is not suspected:
Turn the child on the side to reduce risk of aspiration.
Keep the neck slightly extended, and stabilize by placing cheek on one hand.
Bend one leg to stabilize the body position.

# Chart 7. How to give intravenous fl uids to a child in shock without severe malnutrition
Check that the child is not severely malnourished, as the fl uid volume and rate are different. (Shock with severe malnutrition, see Chart 8.) Insert an IV line (and draw blood for emergency laboratory investigations).  Attach Ringer's lactate or normal saline; make sure the infusion is running well.  Infuse 20 ml/kg as rapidly as possible.

# Chart 8. How to give intravenous fl uids to a child in shock with severe malnutrition
Give this treatment only if the child has signs of shock (usually there will also be a reduced level of consciousness, i.e. lethargy or loss of consciousness):
Insert an IV line (and draw blood for emergency laboratory investigations).
Weigh the child (or estimate the weight) to calculate the volume of fl uid to be given. Give IV fl uid at 15 ml/kg over 1 h. Use one of the following solutions according to availability: -Ringer's lactate with 5% glucose (dextrose); -Half-strength Darrow's solution with 5% glucose (dextrose); -0.45% NaCl plus 5% glucose (dextrose).
If there are signs of improvement (pulse rate falls, pulse volume increases or respiratory rate falls) and no evidence of pulmonary oedema -repeat IV infusion at 15 ml/kg over 1 h; then -switch to oral or nasogastric rehydration with ReSoMal at 10 ml/kg per h up to 10 h (see p. 204);
-initiate re-feeding with starter F-75 (see p. 209).
If the child fails to improve after two IV boluses of 15 ml/kg, -give maintenance IV fl uid (4 ml/kg per h) while waiting for blood; -when blood is available, transfuse fresh whole blood at 10 ml/kg slowly over 3 h (use packed cells if the child is in cardiac failure); then -initiate re-feeding with starter F-75 (see p. 209); -start IV antibiotic treatment (see p. 207).
If the child deteriorates during IV rehydration (breathing rate increases by 5/min and pulse rate increases by 15/min, liver enlarges, fi ne crackles throughout lung fi elds, jugular venous pressure increases, galloping heart rhythm develops), stop the infusion, because IV fl uid can worsen the child's condition by inducing pulmonary oedema.

# CHART 8. HOW TO GIVE INTRAVENOUS FLUIDS TO A CHILD IN SHOCK

# Chart 9. How to give diazepam rectally  Give diazepam rectally:
Draw up the dose from an ampoule of diazepam into a tuberculin (1-ml) syringe. Base the dose on the weight of the child, when possible. Then remove the needle. Insert the syringe 4-5 cm into the rectum, and inject the diazepam solution. Hold the buttocks together for a few minutes.

# Chart 10. How to give glucose intravenously
Insert an IV line, and draw blood for emergency laboratory investigations. Check blood glucose with a glucose monitoring stick. If the level is < 2.5 mmol/litre (45 mg/dl) in a well-nourished or < 3 mmol/litre (54 mg/dl) in a severely malnourished child or if blood glucose cannot be measured as no stick test is available, treat as for hypoglycaemia:  Give 5 ml/kg of 10% glucose solution rapidly by IV injection

# Age (weight)
Volume of 10% glucose solution as bolus (5 ml/kg) < 2 months (< 4 kg) 15 ml 2-< 4 months (4-< 6 kg) 25 ml 4-< 12 months (6-< 10 kg) 40 ml 1-< 3 years (10-< 14 kg) 60 ml 3-< 5 years (14-< 19 kg) 80 ml
Recheck the blood glucose in 30 min. If it is still low, repeat 5 ml/kg of 10% glucose solution.
Feed the child as soon as he or she is conscious.
If the child is unable to feed without danger of aspiration, give: -milk or sugar solution via a nasogastric tube (to make sugar solution, dissolve four level teaspoons of sugar (20 g) in a 200-ml cup of clean water), or -IV fl uids containing 5-10% glucose (dextrose) (see Annex 4,p. 377) Note: 50% glucose solution is the same as 50% dextrose solution. If only 50% glucose solution is available: dilute one part 50% glucose solution in four parts sterile water, or dilute one part 50% glucose solution in nine parts 5% glucose solution. For example, 10 ml 50% solution with 90 ml 5% solution gives 100 ml of approximately a 10% solution.
Note: To use blood glucose stick tests, refer to instructions on box. Generally, the strip must be stored in its box at 2-3 C, avoiding sunlight or high humidity. A drop of blood should be placed on the strip (it should cover all the reagent area). After 60 s, the blood should be washed off gently with drops of cold water and the colour compared with the key on the bottle or on the blood glucose reader. (The exact procedure varies for different strips.) Note: Sublingual sugar may be used as an immediate 'fi rst aid' measure in managing hypoglycaemia if IV access is impossible or delayed. Place one level teaspoonful of sugar moistened with water under the tongue every 10-20 min.
CHART 10. HOW TO GIVE GLUCOSE INTRAVENOUSLY

# Chart 11. How to treat severe dehydration in an emergency after initial management of shock
For children with severe dehydration but without shock, refer to diarrhoea treatment plan C, p. 131.
If the child is in shock, fi rst follow the instructions in Charts 7 and 8 (pp. 13 and 14). Switch to the chart below when the child's pulse becomes slower or capillary refi ll is faster.
Give 70 ml/kg of Ringer's lactate (Hartmann's) solution (or, if not available, normal saline) over 5 h to infants (aged < 12 months) and over 2.5 h to children (aged 12 months to 5 years).

# Total volume IV fl uid (volume per hour)
Weight Age < 12 months Give over 5 h Age 12 months to 5 years Give over 2.5 h < 4 kg 200 ml (40 ml/h) -4-6 kg 350 ml (70 ml/h) -6-10 kg 550 ml (110 ml/h) 550 ml (220 ml/h) 10-14 kg 850 ml (170 ml/h) 850 ml (340 ml/h) 14-19 kg -1200 ml (480 ml/h)
Reassess the child every 1-2 h. If the hydration status is not improving, give the IV drip more rapidly.
Also give oral rehydration salt (ORS) solution (about 5 ml/kg per h) as soon as the child can drink, usually after 3-4 h (in infants) or 1-2 h (in children).
If the room is very cold, rely on the pulse to determine whether the child is in shock.
Check whether the systolic blood pressure is low for the child's age (see Table below). Shock may be present with normal blood pressure, but very low blood pressure means the child is in shock. Is the child in coma? Check the level of consciousness on the 'AVPU' scale:

# Normal blood pressure ranges in infants and children
A alert, V responds to voice, P responds to pain, U unconscious.
If the child is not awake and alert, try to rouse the child by talking or shaking the arm. If the child is not alert but responds to voice, he or she is lethargic. If there is no response, ask the mother whether the child has been abnormally sleepy or diffi cult to wake. Determine whether the child responds to pain or is unresponsive to a painful stimulus. If this is the case, the child is in coma (unconscious) and needs emergency treatment.
Is the child convulsing? Are there spasmodic repeated movements in an unresponsive child?
 Assess the child for severe dehydration if he or she has diarrhoea Does the child have sunken eyes? Ask the mother if the child's eyes are more sunken than usual.
Does a skin pinch go back very slowly (longer than 2 s)? Pinch the skin of the abdomen halfway between the umbilicus and the side for 1 s, then release and observe.
 Assess for priority signs While assessing the child for emergency signs, you will have noted several possible priority signs:
Is there any respiratory distress (not severe)?
Is the child lethargic or continuously irritable or restless?
This was noted when you assessed for coma.
Note the other priority signs (see p. 6).

# Emergency treatment for a child with severe malnutrition
During triage, all children with severe malnutrition will be identifi ed as having priority signs, which means that they require prompt assessment and treatment.
A few children with severe malnutrition will be found during triage assessment to have emergency signs.
Those with emergency signs for 'airway and breathing' or 'coma or convulsions' should receive emergency treatment accordingly (see charts on pp. 5-17).
- Those with signs of severe dehydration but not in shock should not be rehydrated with IV fl uids, because severe dehydration is diffi cult to diagnose in severe malnutrition and is often misdiagnosed. Giving IV fl uids puts these children at risk of over-hydration and death from heart failure. Therefore, these children should be rehydrated orally with the special rehydration solution for severe malnutrition (ReSoMal). See Chapter 7 (p. 204).
- In severe malnutrition, individual emergency signs of shock may be present even when there is no shock. Malnourished children with many signs of shock: lethargy, reduced level of consciousness, cold skin, prolonged capillary refi ll and fast weak pulse, should receive additional fl uids for shock as above.
- Treatment of a malnourished child for shock differs from that for a wellnourished child, because shock from dehydration and sepsis are likely to coexist, and these are diffi cult to differentiate on clinical grounds alone, and because children with severe malnutrition may not cope with large amounts of water and salt. The amount of fl uid given should be guided by the child's response. Avoid over-hydration. Monitor the pulse and breathing at the start and every 5-10 min to check whether they are improving. Note that the type of IV fl uid differs for severe malnutrition, and the infusion rate is slower.
All severely malnourished children require prompt assessment and treatment to deal with serious problems such as hypoglycaemia, hypothermia, severe 1. TRIAGE infection, severe anaemia and potentially blinding eye problems. It is equally important to take prompt action to prevent some of these problems, if they were not present at the time of admission to hospital.

# Diagnostic considerations for children with emergency conditions
The following text provides guidance for approaches to the diagnosis and differential diagnosis of presenting conditions for which emergency treatment has been given. After you have stabilized the child and provided emergency treatment, determine the underlying cause of the problem, in order to provide specifi c curative treatment. The following lists and tables are complemented by the tables in the disease-specifi c chapters.
- 5.1 Child presenting with an airway or severe breathing problem History

# Table 2. Differential diagnosis in a child presenting with shock
Children with shock are lethargic, have fast breathing, cold skin, prolonged capillary refi ll, fast weak pulse and may have low blood pressure as a late sign. To help make a specifi c diagnosis of the cause of shock, look for the signs below.

# Diagnosis or underlying cause

# Child presenting with lethargy, unconsciousness or convulsions History
- Fever - Head injury - Drug overdose or toxin ingestion - Convulsions: How long do they last? Have there been previous febrile convulsions? Epilepsy?
In the case of an infant < 1 week old, consider history of:
- birth asphyxia - birth injury to the brain The coma scale score should be monitored regularly. In young infants < 1 week old, note the time between birth and the onset of unconsciousness. Other causes of lethargy, unconsciousness or convulsions in some regions of the world include malaria, Japanese encephalitis, dengue haemorrhagic fever, measles encephalitis, typhoid and relapsing fever.

# Laboratory investigations
- If meningitis is suspected and the child has no signs of raised intracranial pressure (unequal pupils, rigid posture, paralysis of limbs or trunk, irregular breathing), perform a lumbar puncture.  -Blood smear or rapid diagnostic test positive for malaria parasites -Jaundice -Anaemia -Convulsions -Hypoglycaemia Febrile convulsions (not likely to be the cause of unconsciousness)
-Prior episodes of short convulsions when febrile -Associated with fever -Age 6 months to 5 years -Blood smear normal Hypoglycaemia (always seek the cause, e.g. severe malaria, and treat the cause to prevent a recurrence) -Blood glucose low (< 2.5 mmol/litre (< 45 mg/dl) or < 3.0 mmol/litre (< 54 mg/dl) in a severely malnourished child); responds to glucose treatment Head injury -Signs or history of head trauma Poisoning -History of poison ingestion or drug overdose Shock (can cause lethargy or unconsciousness, but is unlikely to cause convulsions)
-Poor perfusion -Rapid, weak pulse
- In a malarious area, perform a rapid malaria diagnostic test and prepare a blood smear. - If the child is unconscious, check the blood glucose. If not possible, then treat as hypoglycaemia; if the level of consciousness improves, presume hypoglycaemia. - Carry out urine microscopy if possible.

# CHILD PRESENTING WITH LETHARGY, UNCONSCIOUSNESS OR CONVULSIONS

# Table 3. Continued

# Diagnosis or underlying cause
Acute glomerulonephritis with encephalopathy -Raised blood pressure -Peripheral or facial oedema -Blood and/or protein in urine -Decreased or no urine Diabetic ketoacidosis -High blood sugar -History of polydipsia and polyuria -Acidotic (deep, laboured) breathing a The differential diagnosis of meningitis may include encephalitis, cerebral abscess or tuberculous meningitis. Consult a standard textbook of paediatrics for further guidance. b A lumbar puncture should not be done if there are signs of raised intracranial pressure (see section 6.3, p. 167 and A1.4, p. 346). A positive lumbar puncture may show cloudy cerebrospinal fl uid (CSF) on direct visual inspection, or CSF examination shows an abnormal number of white cells (usually > 100 polymorphonuclear cells per ml in bacterial meningitis). Confi rmation is given by a low CSF glucose ( 0.4 g/litre), organisms identifi ed by Gram staining or a positive culture.

# Common poisoning
Suspect poisoning in any unexplained illness in a previously healthy child.
Consult standard textbook of paediatrics for management of exposure to specifi c poisons and/or any local sources of expertise in the management of poisoning, for example a poison centre. Only the principles for managing ingestion of few common poisons are given here. Note that traditional medicines can be a source of poisoning.
A diagnosis is based on a history from the child or carer, a clinical examination and the results of investigations, where appropriate.
 Obtain full details of the poisoning agent, the amount ingested and the time of ingestion. Attempt to identify the exact agent involved and ask to see the container, when relevant. Check that no other children were involved.
The symptoms and signs depend on the agent ingested and therefore vary widely -see below.
 Check for signs of burns in or around the mouth or of stridor (upper airway or laryngeal damage), which suggest ingestion of corrosives.
Admit all children who have deliberately ingested iron, pesticides, paracetamol or aspirin, narcotics or antidepressant drugs; and those who may have been given the drug or poison intentionally by another child or adult.
Children who have ingested corrosives or petroleum products should not be sent home without observation for at least 6 h. Corrosives can cause oesophageal burns, which may not be immediately apparent, and petroleum products, if aspirated, can cause pulmonary oedema, which may take some hours to develop.

# Principles for ingested poisons
All children who present as poisoning cases should quickly be assessed for emergency signs (airway, breathing, circulation and level of consciousness), as some poisons depress breathing, cause shock or induce coma. Ingested poisons must be removed from the stomach.
Gastric decontamination is most effective within 1 h of ingestion. After this time, there is usually little benefi t, except for agents that delay gastric emptying or in patients who are deeply unconscious. A decision to undertake gastric decontamination must weigh the likely benefi ts against the risks associated with each method. Gastric decontamination does not guarantee that all the substance has been removed, so the child may still be in danger.
Contraindications to gastric decontamination are:
-an unprotected airway in an unconscious child, except when the airway has been protected by intubation with an infl ated tube by the anaesthetist -ingestion of corrosives or petroleum products Check the child for emergency signs (see p. 2) and for hypoglycaemia; if blood glucose is not available and the child has a reduced level of consciousness, treat as if hypoglycaemia (p. 16).
Identify the specifi c agent and remove or adsorb it as soon as possible.
Treatment is most effective if given as quickly as possible after the poisoning event, ideally within 1 h.
- If the child swallowed kerosene, petrol or petrol-based products (note that most pesticides are in petrol-based solvents) or if the child's mouth and throat have been burnt (for example with bleach, toilet cleaner or battery acid), do not make the child vomit but give water or, if available, milk, orally.
Call an anaesthetist to assess the airway.
- If the child has swallowed other poisons, never use salt as an emetic, as this can be fatal.
Give activated charcoal, if available, and do not induce vomiting; give by mouth or nasogastric tube at the doses shown in Table 5. If a nasogastric tube is used, be particularly careful that the tube is in the stomach and not in the airway or lungs.

# Table 5. Poisoning: Amount of activated charcoal per dose
Children  1 year of age 1 g/kg Children 1-12 years of age 25-50 g Adolescents and adults 25-100 g
- Mix the charcoal in 8-10 volumes of water, e.g. 5 g in 40 ml of water.
- If possible, give the whole amount at once; if the child has diffi culty in tolerating it, the charcoal dose can be divided.
If charcoal is not available, then induce vomiting, but only if the child is conscious, and give an emetic such as paediatric ipecacuanha (10 ml for children aged 6 months to 2 years and 15 ml for those > 2 years). Note: Ipecacuanha can cause repeated vomiting, drowsiness and lethargy, which can confuse a diagnosis of poisoning. Never induce vomiting if a corrosive or petroleum-based poison has been ingested.

# Gastric lavage
Undertake gastric lavage only if staff have experience in the procedure, if ingestion was less than 1 h previously and is life-threatening and if the child did not ingest corrosives or petroleum derivatives. Make sure a suction apparatus is available in case the child vomits. Place the child in the left lateral head-down position. Measure the length of tube to be inserted. Pass a 24-28 French gauge tube through the mouth into the stomach, as a smaller nasogastric tube is not suffi cient to let particles such as tablets pass. Ensure the tube is in the stomach. Perform lavage with 10 ml/kg of normal saline (0.9%). The volume of lavage fl uid returned should approximate the amount of fl uid given. Lavage should be continued until the recovered lavage solution is clear of particulate matter.
Note that tracheal intubation by an anaesthetist may be required to reduce the risk of aspiration.
Give a specifi c antidote if this is indicated.
Give general care.
Keep the child under observation for 4-24 h, depending on the poison swallowed.
Keep unconscious children in the recovery position.
Consider transferring the child to next level referral hospital only when appropriate and when this can be done safely, if the child is unconscious or has a deteriorating level of consciousness, has burns to the mouth and throat, is in severe respiratory distress, is cyanosed or is in heart failure.
- TRIAGE 1.6.2 Principles for poisons in contact with skin or eyes Skin contamination Remove all clothing and personal effects, and thoroughly clean all exposed areas with copious amounts of tepid water. Use soap and water for oily substances. Attending staff should take care to protect themselves from secondary contamination by wearing gloves and aprons. Removed clothing and personal effects should be stored safely in a see-through plastic bag that can be sealed, for later cleansing or disposal.

# Eye contamination
Rinse the eye for 10-15 min with clean running water or normal saline, taking care that the run-off does not enter the other eye if the child is lying on the side, when it can run into the inner canthus and out the outer canthus. The use of anaesthetic eye drops will assist irrigation. Evert the eyelids and ensure that all surfaces are rinsed. When possible, the eye should be thoroughly examined under fl uorescein staining for signs of corneal damage.
If there is signifi cant conjunctival or corneal damage, the child should be seen urgently by an ophthalmologist.

# Principles for inhaled poisons
Remove the child from the source of exposure.
Urgently call for help.
Administer supplementary oxygen if the child has respiratory distress, is cyanosed or has oxygen saturation  90%.
Inhalation of irritant gases may cause swelling and upper airway obstruction, bronchospasm and delayed pneumonitis. Intubation, bronchodilators and ventilatory support may be required.

# Specifi c poisons

# Corrosive compounds
Examples: sodium hydroxide, potassium hydroxide, acids, bleaches or disinfectants Do not induce vomiting or use activated charcoal when corrosives have been ingested, as this may cause further damage to the mouth, throat, airway, lungs, oesophagus and stomach.
Give milk or water as soon as possible to dilute the corrosive agent.
Then give the child nothing by mouth and arrange for surgical review to check for oesophageal damage or rupture, if severe.

# Petroleum compounds
Examples: kerosene, turpentine substitutes, petrol Do not induce vomiting or give activated charcoal, as inhalation can cause respiratory distress with hypoxaemia due to pulmonary oedema and lipoid pneumonia. Ingestion can cause encephalopathy.
Specifi c treatment includes oxygen therapy if there is respiratory distress (see p. 312).

# Organophosphorus and carbamate compounds
Examples: organophosphorus compounds (malathion, parathion, tetra ethyl pyrophosphate, mevinphos (Phosdrin)); carbamates (methiocarb, carbaryl) These compounds can be absorbed through the skin, ingested or inhaled.
The child may complain of vomiting, diarrhoea, blurred vision or weakness.
The signs are those of excess parasympathetic activation: excessive bronchial secretion, salivation, sweating, lachrymation, slow pulse, small pupils, convulsions, muscle weakness or twitching, then paralysis and loss of bladder control, pulmonary oedema and respiratory depression.
Remove the poison by irrigating eye if in eye or washing skin if on skin.
Give activated charcoal within 4 h of ingestion if ingested.
Do not induce vomiting because most pesticides are in petrol-based solvents.
In a serious case of ingestion, when activated charcoal cannot be given, consider careful aspiration of stomach contents by nasogastric tube (the airway should be protected).
If the child has signs of excess parasympathetic activation (see above), one of the main risks is excessive bronchial secretion. Give atropine at 20 g/ kg (maximum dose, 2000 g or 2 mg) IM or IV every 5-10 min, depending on the severity of the poisoning, until there is no sign of secretions in the chest, the skin becomes fl ushed and dry, the pupils dilate and tachycardia develops. Doses may be repeated every 1-4 h for at least 24 h to maintain atropine effects. The main aim is to reduce bronchial secretions while avoiding atropine toxicity. Auscultate the chest for signs of respiratory secretions, and monitor respiratory rate, heart rate and coma score (if appropriate).
Check for hypoxaemia by pulse oximetry if atropine is given, as it can cause heart irregularities (ventricular arrhythmia) in hypoxic children. Give oxygen if the oxygen saturation is  90%
If there is muscle weakness, give pralidoxime (cholinesterase reactivator) at 25-50 mg/kg diluted in 15 ml water by IV infusion over 30 min, repeated once or twice or followed by IV infusion of 10-20 mg/kg per h, as necessary.
In paracetamol poisoning:
If within 4 h of ingestion, give activated charcoal, if available, or induce vomiting unless an oral or IV antidote is required (see below).
Decide whether an antidote is required to prevent liver damage: ingestion of 150 mg/kg or more or toxic 4-h paracetamol level when this is available.
An antidote is more often required for older children who deliberately ingest paracetamol or when parents overdose children by mistake.
If within 8 h of ingestion, give oral methionine or IV acetylcysteine. Methionine can be used if the child is conscious and not vomiting (< 6 years: 1 g every 4 h for four doses;  6 years: 2.5 g every 4 h for four doses).
If more than 8 h after ingestion, or the child cannot take oral treatment, give IV acetylcysteine. Note that the fl uid volumes used in the standard regimen are too large for young children.
- For children < 20 kg give the loading dose of 150 mg/kg in 3 ml/kg of 5% glucose over 15 min, followed by 50 mg/kg in 7 ml/kg of 5% glucose over 4 h, then 100 mg/kg IV in 14 ml/kg of 5% glucose over 16 h. The volume of glucose can be increased for larger children. Continue infusion of acetylcysteine beyond 20 h if presentation is late or there is evidence of liver toxicity. If liver enzymes can be measured and are elevated, continue IV infusion until enzyme levels fall.

# Aspirin and other salicylates
Ingestion of these compounds can be very serious in young children because they rapidly become acidotic and are consequently more likely to suffer the severe central nervous system effects of toxicity. Salicylate overdose can be complex to manage.
 These compounds cause acidotic-like breathing, vomiting and tinnitus.
Give activated charcoal if available. Note that salicylate tablets tend to form a concretion in the stomach, resulting in delayed absorption, so it is worthwhile giving several doses of charcoal. If charcoal is not available and a severely toxic dose has been ingested, perform gastric lavage or induce vomiting, as above.
Give IV sodium bicarbonate at 1 mmol/kg over 4 h to correct acidosis and to raise the pH of the urine above 7.5 so that salicylate excretion is increased. Give oral supplementary potassium too (2-5 mmol/kg per day in three or four divided doses). Monitor urine pH hourly.
Give IV fl uids at maintenance requirements unless the child shows signs of dehydration, in which case give adequate rehydration (see Chapter 5).
Monitor blood glucose every 6 h, and correct as necessary (see p. 350).
Give vitamin K at 10 mg IM or IV.
Check for clinical features of iron poisoning: nausea, vomiting, abdominal pain and diarrhoea. The vomit and stools are often grey or black. In severe poisoning, there may be gastrointestinal haemorrhage, hypotension, drowsiness, convulsions and metabolic acidosis. Gastrointestinal features usually appear within the fi rst 6 h, and a child who has remained asymptomatic for this time probably does not require an antidote.
Activated charcoal does not bind to iron salts; therefore, consider a gastric lavage if potentially toxic amounts of iron were taken. This also allows deferoxamine, the antidote, to remain in the stomach to counteract any remaining iron.
Decide whether to give the antidote. As this can have side-effects, it should be given only if there is clinical evidence of poisoning (see above).
Give deferoxamine, preferably by slow IV infusion: initially 15 mg/kg per h, reduced after 4-6 h so that the total dose does not exceed 80 mg/kg in 24 h. Maximum dose, 6 g/day.
If deferoxamine is given IM: 50 mg/kg every 6 h. Maximum dose, 6 g/day.
More than 24 h therapy for acute iron overdose is uncommon. Therapeutic end-points for ceasing infusion may be a clinically stable patient and serum iron < 60 mol/litre.

# Morphine and other opiates
Check for reduced consciousness, vomiting or nausea, respiratory depression (slowing or absence of breathing), slow response time and pin-point pupils.
Clear the airway; if necessary assist breathing with a bag-valve-mask and provide oxygen.
Give the specifi c antidote naloxone IV 10 g/kg; if no response, give another dose of 10 g/kg. Further doses may be required if respiratory function deteriorates. If the IV route is not feasible, give IM, but the action will be slower.

# Carbon monoxide
Give 100% oxygen to accelerate removal of carbon monoxide (Note: patient can look pink but still be hypoxaemic) until signs of hypoxia disappear.
Monitor with a pulse oximeter, but be aware that it can give falsely high readings. If in doubt, be guided by the presence or absence of clinical signs of hypoxaemia.

# Prevention of poisoning
Teach parents to keep drugs and poisons in proper containers and out of reach of children.
Advise parents on fi rst aid if poisoning occurs again.
- Do not induce vomiting if the child has swallowed kerosene, petrol or petrolbased products, if the child's mouth and throat have been burnt or if the child is drowsy. If the child swallowed bleach or another corrosive, give milk or water to drink as soon as possible.
- Take the child to a health facility as soon as possible, together with information about the substance concerned, e.g. the container, label, sample of tablets, berries.
Initial assessment should include ensuring adequate airway patency, breathing, circulation and consciousness (the 'ABCs'). Check if there are any injuries, especially after diving or an accidental fall. Facial, head and cervical spine injuries are common.
Give oxygen and ensure adequate oxygenation.
Remove all wet clothes.
Use a nasogastric tube to remove swallowed water and debris from the stomach, and when necessary bronchoscopy to remove foreign material, such as aspirated debris or vomitus plugs, from the airway.
Warm the child externally if the core temperature is > 32 C by using radiant heaters or warmed dry blankets; if the core temperature is < 32 C, use warmed IV fl uid (39 C) or conduct gastric lavage with warmed 0.9% saline.
Check for hypoglycaemia and electrolyte abnormalities, especially hyponatraemia, which increase the risk of cerebral oedema.
Give antibiotics for possible infection if there are pulmonary signs.
Provide emergency care by ensuring airway patency, breathing and circulatory support. Provide oxygen, especially for children with severe hypoxia, facial or oral burns, loss of consciousness or inability to protect the airway, or respiratory distress.
Assess for traumatic injuries such as pneumothorax, peritonitis or pelvic fractures.
Begin normal saline or Ringer's lactate fl uid resuscitation, and titrate to urine output of at least 2 ml/kg per h in any patient with signifi cant burns or myoglobinuria.
Consider furosemide or mannitol for further diuresis of myoglobin.
Give tetanus vaccine as indicated, and provide wound care. Treatment may include early fasciotomy when necessary.

# Common causes of envenoming
Accidents caused by venomous and poisonous animals may be relatively common in some countries. Management of these cases may be complex because of the variety of such animals, differences in the nature of the accidents and the course of envenoming or poisoning. It is important to have some knowledge of the common poisonous animals, early recognition of clinically relevant envenoming or poisoning, and symptomatic and specifi c forms of treatment available.

# Snake bite
Snake bite should be considered in any case of severe pain or swelling of a limb or in any unexplained illness presenting with bleeding or abnormal neurological signs. Some cobras spit venom into the eyes of victims, causing pain and infl ammation.
 General signs include shock, vomiting and headache. Examine bite for signs such as local necrosis, bleeding or tender local lymph node enlargement.
 Specifi c signs depend on the venom and its effects. These include:
-shock -local swelling that may gradually extend up the bitten limb -bleeding: external from gums, wounds or sores; internal, especially intracranial 1. TRIAGE -signs of neurotoxicity: respiratory diffi culty or paralysis, ptosis, bulbar palsy (diffi culty in swallowing and talking), limb weakness -signs of muscle breakdown: muscle pains and black urine  Check Hb (when possible, blood clotting should be assessed).
First aid Splint the limb to reduce movement and absorption of venom. If the bite is likely to have been by a snake with neurotoxic venom, apply a fi rm bandage to the affected limb, from fi ngers or toes to near the site of the bite.
Clean the wound.
If any of the above signs are present, transport the child to a hospital that has antivenom as soon as possible. If the snake has been killed, take it with the child to hospital.
Avoid cutting the wound or applying a tourniquet.

# Hospital care
Treatment of shock or respiratory arrest Treat shock, if present (see pp. 4, 13, 17).
Paralysis of respiratory muscles can last for days and requires intubation and mechanical ventilation or manual ventilation (with a mask or endotracheal tube and bag-valve system) by relays of staff and/or relatives until respiratory function returns. Attention to carefully securing the endotracheal tube is important. An alternative is to perform an elective tracheostomy.
 If there are systemic or severe local signs (swelling of more than half the limb or severe necrosis), give antivenom, if available.
Prepare IM adrenaline 0.15 ml of 1:1000 solution IM and IV chlorphenamine, and be ready to treat an allergic reaction (see below).
Give monovalent antivenom if the species of snake is known. Give polyvalent antivenom if the species is not known. Follow the directions given on preparation of the antivenom. The dose for children is the same as that for adults.
- Dilute the antivenom in two to three volumes of 0.9% saline and give intravenously over 1 h. Give more slowly initially, and monitor closely for anaphylaxis or other serious adverse reactions.
If itching or an urticarial rash, restlessness, fever, cough or diffi cult breathing develop, then stop antivenom and give adrenaline at 0.15 ml of 1:1000 IM (see anaphylaxis treatment, p. 109. Possible additional treatment includes bronchodilators, antihistamines (chlorphenamine at 0.25 mg/kg) and steroids. When the child is stable, re-start antivenom infusion slowly.
More antivenom should be given after 6 h if there is recurrence of blood clotting disorder or after 1-2 h if the patient is continuing to bleed briskly or has deteriorating neurotoxic or cardiovascular signs.
Blood transfusion should not be required if antivenom is given. Clotting function returns to normal only after clotting factors are produced by the liver. The response of abnormal neurological signs to antivenom is more variable and depends on the type of venom.
If there is no response to antivenom infusion, it should be repeated.
Anticholinesterases can reverse neurological signs in children bitten by some species of snake (see standard textbooks of paediatrics for further details).
Other treatment Surgical opinion: Seek a surgical opinion if there is severe swelling in a limb, it is pulseless or painful or there is local necrosis. Surgical care will include:
-excision of dead tissue from wound Elevate the limb if swollen.
Give antitetanus prophylaxis.
Antibiotic treatment is not required unless there is tissue necrosis at the wound site.
Avoid IM injections.
Monitor the patient very closely immediately after admission, then hourly for at least 24 h, as envenoming can develop rapidly.

# Scorpion sting
Scorpion stings can be very painful for days. Systemic effects of venom are much commoner in children than adults.
Signs of envenoming can develop within minutes and are due to autonomic nervous system activation. They include:
 shock  high or low blood pressure  fast and/or irregular pulse  nausea, vomiting, abdominal pain  breathing diffi culty (due to heart failure) or respiratory failure  muscle twitches and spasms.
Check for low blood pressure or raised blood pressure and treat if there are signs of heart failure (see p. 120).
First aid Transport to hospital as soon as possible.
Hospital care If there are signs of severe envenoming, give scorpion antivenom, if available (as above for snake antivenom infusion).
Other treatment Treat heart failure, if present (see p. 120).
Consider use of prazosin if there is pulmonary oedema (see standard textbooks of paediatrics).

# Supportive care
Give oral paracetamol or oral or IM morphine according to severity. If very severe, infi ltrate site with 1% lignocaine, without adrenaline.

# Other sources of envenoming
Follow the same principles of treatment as above. Give antivenom, when available, if there are severe local or any systemic effects.
In general, venomous spider bites can be painful but rarely result in systemic envenoming. Antivenom is available for some species such as widow and banana spiders. Venomous fi sh can give very severe local pain, but, again, systemic envenoming is rare. Box jellyfi sh stings are occasionally rapidly life-threatening. Apply vinegar on cotton-wool to denature the protein in the skin. Adherent tentacles should be carefully removed. Rubbing the sting may cause further discharge of venom. Antivenom may be available. The dose of antivenom to jellyfi sh and spider venoms should be determined by the amount of venom injected. Higher doses are required for multiple bites, severe symptoms or delayed presentation.

# Trauma and injuries
Severe multiple injuries or major trauma are life-threatening problems that children may present with to hospital. Multiple organs and limbs may be affected, and the cumulative effects of these injuries may cause rapid deterioration of the child's condition. Management requires urgent recognition of the life-threatening injuries.
Basic techniques of emergency triage and assessment are most critical in the fi rst hour of the patient's arrival at hospital. When there is more than one lifethreatening state, simultaneous treatment of injuries is essential and requires effective teamwork.

# Primary survey or initial assessment
The initial rapid assessment, also commonly referred to as 'the primary survey', should identify life-threatening injuries such as:
- airway obstruction - chest injuries with breathing diffi culty - severe external or internal haemorrhage - head and cervical spine injuries - abdominal injuries.
The primary survey should be systematic, as described in section 1.2. If there is a risk of neck injury, try to avoid moving the neck, and stabilize as appropriate (see p. 12).
During the primary survey, any deterioration in the patient's clinical condition should be managed by reassessment from the start of the protocol; as a previ-

# Secondary survey
Conduct a secondary survey only when the patient's airway patency, breathing, circulation and consciousness are stable.
Undertake a head-to-toe examination, noting particularly the following:
- Head: scalp and ocular abnormalities, external ears and periorbital soft tissue injuries - Neck: penetrating wounds, subcutaneous emphysema, tracheal deviation and neck vein appearance - Neurological: brain function (level of consciousness, AVPU), spinal cord motor activity and sensation and refl ex - Chest: clavicles and all ribs, breath sounds and heart sounds - Abdominal: penetrating abdominal wound requiring surgical exploration, blunt trauma and rectal examination when necessary - Pelvis and limbs: fractures, peripheral pulses, cuts, bruises and other minor injuries
After the child is stabilized and when indicated, investigations can be performed (see details in section 9.3, p. 269). In general, the following investigations may be useful, depending on the type of injury:
- X-rays: depending on the suspected injury (may include chest, lateral neck, pelvis, cervical spine, with all seven vertebrae, long bones and skull).
- Ultrasound scan: a scan of the abdomen may be useful in diagnosing internal haemorrhage or organ injury.
Once the child is stable, proceed with management, with emphasis on achieving and maintaining homeostasis, and, if necessary arrange transfer to an appropriate ward or referral hospital.
In the absence of head injury, give morphine 0.05-0.1 mg/kg IV for pain relief, followed by 0.01-0.02 mg/kg increments at 10-min intervals until an adequate response is achieved. Pain relief and patient reassurance should be provided during all stages of care.
If there are signs of shock, give 20 ml/kg of normal saline, and re-assess (see p. 13).
If blood is required after haemorrhage, give initially 20 ml/kg of whole blood or 10 ml/kg of packed red cells.
Manage hypoglycaemia (see p. 16).
For management of specifi c injuries, see section 9.3, p. 269.