Guía de valoración pediátrica de urgencias en Cuba / Guide of pediatric emergency assessment in Cuba

La valoración pediátrica de urgencias tiene características especiales respecto al resto de la atención pediátrica. El diagnóstico final será una prioridad secundaria. Es una evaluación clínica, cuyo intento principal es la identificación de aspectos anatómicos y fisiológicos anormales, la estimación de la gravedad de la enfermedad o lesión y la determinación de la necesidad de tratamiento urgente. El objetivo de esta colaboración es brindar una sistemática clara, con una secuencia de valoraciones y acciones que sirvan de base para la toma de decisiones clínicas orientadas a la estabilización del paciente y a evitar situaciones que pueden amenazar la vida en poco tiempo. El triángulo de evaluación pediátrica, la secuencia ABCDE, una breve anamnesis y examen enfocado que identifique el motivo de consulta de mayor prioridad, signos de alarma que pueden cambiar la prioridad y las reevaluaciones frecuentes serán los pilares de la actuación médica. Con el propósito de respetar el derecho del niño al disfrute del más alto nivel posible de salud, de garantizar la calidad asistencial y la seguridad de los pacientes pediátricos con entidades agudas o traumatismos, el grupo nacional de pediatría desarrolló y aprobó la guía de valoración pediátrica de urgencias en Cuba. Mediante la aplicación de esta guía se puede optimizar el proceso de valoración pediátrica de urgencias de forma que los pacientes de este segmento de edad reciban el nivel de cuidados médicos más apropiado para su situación clínica(AU)

The pediatric emergency assessment has special characteristics with respect to the rest of pediatric care. The final diagnosis will be a secondary priority. It is a clinical evaluation, and the main purpose of it is the identification of abnormal anatomical and physiological aspects, the estimation of the severity of the disease or injury and the determination of the need for urgent treatment. The objective of this collaboration is to provide a clear system, with a sequence of assessments and actions that serve as a basis for clinical decision-making aimed at stabilizing the patient and avoiding life-threatening situations in a short time. The pediatric assessment triangle, the ABCDE sequence, a brief history and focused examination that identifies the highest priority reason for consultation, warning signs that may change priority and frequent re-evaluations will be the pillars of medical action. To respect the right of the child to have access to the highest possible level of health, to guarantee the quality of care and its safety in the face of acute conditions or trauma, the National Group of Pediatrics developed and approved the guide for pediatric emergency assessment in Cuba. Through its application, the pediatric emergency evaluation process can be optimized so that patients of this age segment receive the most appropriate level of medical care for their clinical situation(AU)

Utilidad del triángulo de evaluación pediátrica en un servicio de emergencia pediátrica / Usefulness of the pediatric assessment triangle in an emergency pediatric service

En el servicio de emergencia pediátrica es fundamental reconocer de forma precoz los signos clínicos que indican amenaza para la vida del paciente. Con el objetivo de establecer la utilidad del Triángulo de Evaluación Pediátrica (TEP) en pacientes que asistieron al Servicio de Emergencia Pediátrica del Servicio Desconcentrado Hospital Pediátrico Dr. Agustín Zubillaga durante el lapso marzo-abril 2018, se realizó un estudio descriptivo, transversal, con una muestra de 216 pacientes, reportando un promedio de edad de 2,98 ± 3,06 años, de los cuales 36,11% eran lactantes menores de un año y 22,69% lactantes mayores, con ligero predominio del sexo masculino (53,7%). Al desglosar cada componente del TEP, se encontraron alterados la apariencia, lenguaje (61,54%), estado de conciencia (53,85%) y tono (50%); en la respiración predominó el tiraje subcostal (86,21%), tiraje intercostal (34,48%), quejido espiratorio (24,14%) y dificultad para hablar (17,24%). Para la circulación se registró palidez en membranas mucosas (91,89%) y piel (54,05%). El 68,98% de los pacientes tenían una situación estable, 9,26% dificultad respiratoria y 9,72% shock compensado. El 86,11% de los pacientes se manejaron de forma ambulatoria. Este estudio aporta información relevante sobre el TEP como herramienta útil para identificar y clasificar la gravedad de una emergencia pediátrica en nuestro hospital(AU)

In the pediatric emergency room it is essential to recognize the clinical signs that indicate the threat of the patient's condition on time. In order to establish the usefulness of the Pediatric Assessment Triangle (PET) in pediatric patients who attended the Emergency Service of the Servicio Desconcentrado Hospital Pediátrico Dr. Agustin Zubillaga during the period March-April 2018, a cross-sectional descriptive study was conducted with a total of 216 patients, with an average age of 2,98 ± 3,06 years, of which 36,11% were under one year old and 22,69% infants were one to two years old, with a slight predominance of males (53,70%). According to each component of the PET, 61,54% of patients had alterations in their appearance and general state, language (61,54%), state of consciousness (53,85%) and tone (50%). With respect to the work of breathing, subcostal retractions prevailed (86,21) as well as intercostal retractions (34,48%), expiratory moans (24,14%) and difficulty in speaking (17,24%). For the circulation part of the PET, pallor was register in mucous membranes (91,86%) and skin (54,05%). The physiopathological diagnoses were stability in 68,98% of cases, 9,26% had respiratory difficulty and 9,72% had compensated shock. The decision of admission was made in 13,89% of cases while 86,11% of cases were managed in an ambulatory manner. This study provides relevant information of the Pediatric Assessment Triangle as a useful tool to identify and classify the severity of a pediatric emergency in our hospital(AU)

Is this child sick? Usefulness of the Pediatric Assessment Triangle in emergency settings / Esta criança está doente? Utilidade do Triângulo de Avaliação Pediátrica nas configurações de emergência

Abstract Objective: The Pediatric Assessment Triangle is a rapid assessment tool that uses only visual and auditory clues, requires no equipment, and takes 30-60 s to perform. It's being used internationally in different emergency settings, but few studies have assessed its performance. The aim of this narrative biomedical review is to summarize the literature available regarding the usefulness of the Pediatric Assessment Triangle in clinical practice. Sources: The authors carried out a non-systematic review in the PubMed®, MEDLINE®, and EMBASE® databases, searching for articles published between 1999-2016 using the keywords "pediatric assessment triangle," "pediatric triage," "pediatric assessment tools," and "pediatric emergency department." Summary of the findings: The Pediatric Assessment Triangle has demonstrated itself to be useful to assess sick children in the prehospital setting and make transport decisions. It has been incorporated, as an essential instrument for assessing sick children, into different life support courses, although little has been written about the effectiveness of teaching it. Little has been published about the performance of this tool in the initial evaluation in the emergency department. In the emergency department, the Pediatric Assessment Triangle is useful to identify the children at triage who require more urgent care. Recent studies have assessed and proved its efficacy to also identify those patients having more serious health conditions who are eventually admitted to the hospital. Conclusions: The Pediatric Assessment Triangle is quickly spreading internationally and its clinical applicability is very promising. Nevertheless, it is imperative to promote research for clinical validation, especially for clinical use by emergency pediatricians and physicians.

Resumo Objetivo: O Triângulo de Avaliação Pediátrica é uma ferramenta de avaliação rápida que usa apenas pistas visuais e auditivas, não necessita de equipamentos e leva de 30-60 segundos. Tem sido usado internacionalmente em diferentes configurações de emergência, porém poucos estudos avaliaram seu desempenho. O objetivo desta análise biomédica narrativa é resumir a literatura disponível com relação à utilidade do Triângulo de Avaliação Pediátrica na prática clínica. Fontes: Fizemos uma análise não sistemática nas bases de dados do PubMed®, Medline® e Embase® em busca de artigos publicados entre 1999-2016 com as palavras-chave "triângulo de avaliação pediátrica", "triângulo pediátrico", "ferramentas de avaliação pediátrica" e "departamento de emergência pediátrica". Resumo dos achados: O Triângulo de Avaliação Pediátrica demonstrou ser útil na avaliação de crianças doentes na configuração pré-hospitalar e na tomada de decisões de transporte. Ele foi incorporado, como um instrumento essencial na avaliação de crianças doentes, em diferentes cursos de apoio de vida, apesar de pouco ter sido escrito sobre a eficácia de ensino do Triângulo de Avaliação Pediátrica. Pouco foi publicado sobre o desempenho do Triângulo de Avaliação Pediátrica na avaliação inicial no departamento de emergência (DE). No DE, o Triângulo de Avaliação Pediátrica é útil para identificar, na triagem, crianças que exigem cuidado mais urgente. Estudos recentes avaliaram e provaram a eficácia do Triângulo de Avaliação Pediátrica também na identificação dos pacientes com doenças de saúde mais graves e, eventualmente, são internados no hospital. Conclusões: O Triângulo de Avaliação Pediátrica se difunde rapidamente de forma internacional e sua aplicabilidade clínica é muito promissora. Contudo, é essencial promover pesquisa para validação clínica, principalmente para o uso clínico por pediatras e médicos de emergência.

Aplicación del Triángulo de Evaluación Pediátrica al sistema de clasificación de triaje en un Servicio de Urgencias / Application of the Pediatric Assessment Triangle to the Triage Classification System in an Emergency Department

Objetivos: Evaluar la validez del triángulo de evaluación pediátrica (TEP) como nuevo discriminante aplicado al sistema de clasificación de triaje. Determinar los factores de confusión al aplicar el triángulo de evaluación pediátrica. Evaluar si existe correlación entre el diagnóstico fisiopatologico y la clasificación del triaje y determinar si el personal de RAC aplica las prioridades de atención. Métodos: Estudio prospectivo, observacional y comparativo. Los datos fueron recogidos por un único observador entrenado mientras la enfermera clasificadora asignaba la priori dad de atención. Resultados: 157 niños fueron seleccionados, con una media de edad 4,3 años. Al aplicar el TEP, obtuvimos los siguientes diagnósticos fisiopatológicos: 138 (87,9%) fueron estables, 8 (5,1%) tenían dificultad respiratoria, 6 (3,8%) tenían shock compensado, 3 (1,9%) con disfunción del sistema nervioso central, 1 (0,6%) falla respiratoria, y 1 con shock descompensado. En 150 hubo concordancia en el diagnóstico entre el observador entrenado y la enfermera, en 7 discordancia (IC 0,91, k: 0,90). Respecto a la palidez como factor de confusión se detectaron 2 errores. En 2/13 niños con polipnea, hubo errores. 54 niños estaban irritables, sean consolables o no consolables, no hubo errores diagnósticos. Al correlacionar los diagnósticos del TEP y la clasificación de riesgo hubo concordancia: entre pacientes estables y clasificación no urgente (IC: 0,85 k: 0,83), estables y semi-urgencias (IC: 0,96 k: 0,95), dificultad respiratoria y shock compensado con urgencias (IC: 0,81 k: 0,79), emergencias y falla respiratoria o shock descompensado (IC: 0,6 k: 0,5). Según prioridades: 18/18 niños con fiebre recibieron antitérmicos, 8/13 niños que estaban con dolor recibieron analgesia. 6/9 niños con vómitos recibieron antieméticos, 4 fueron hidratados antes de la atención médica y 2/9 niños con broncoespasmo recibieron broncodilatores inhalados. 2/9 con dificultad respiratoria recibieron oxígeno, 117 no requirieron intervención. Conclusiones: Existió una alta concordancia inter-observador en la aplicación del TEP. La polipnea, la palidez previa y la irritabilidad, no se asociaron a errores en la aplicación del TEP. Las prioridades de tratamiento se cumplieron en los niños con fiebre, y en menor proporción para las variables dolor, dificultad respiratoria, necesidad de oxígeno. Es necesario capacitar al personal en triaje avanzado.

Objectives: To assess the validity of the pediatric assessment triangle (PAT) as a new discriminator when applied to the triage classification system. To identify factors that could cause confusion during application of the pediatric assessment triangle. To assess whether correlation is found between pathophysiological diagnosis and triage classification, and determine whether reception, attention, and classification (RAC) personnel apply the care priorities. Methods: We conducted a prospective, observational, and comparative study. Data were collected by a single trained observer while the nurse in charge of classification assigned care priorities. Results: The study selected 157 children with a mean age of 4.3 years for inclusion. Pathophysiological diagnoses obtained applying PAT were: 138 patients (87.9%) were stable, 8 (5.1%) experienced respiratory distress, 6 (3.8%) experienced compensated shock, 3 (1.9%) showed central nervous system dysfunction, 1 (0.6%) presented respiratory failure, and 1 (0.6%) decompensated shock. In 150 cases agreement was found between the diagnoses of the trained observer and the nurse; in 7 cases there was disagreement (CI: 0.91, Ê: 0.90). As a confounding factor, pallor was associated with 2 errors. Errors were seen in 2 of 13 children with polypnea. Irritability, consolable or nonconsolable, was seen in 54 children, but not associated with diagnostic error. Correlating PAT diagnosis and risk classification showed concordance between patients classified as stable and nonurgent (CI: 0.85 K: 0.83), stable and semiurgent (CI: 0.96 K: 0.95), between respiratory distress and compensated shock with urgencies (CI: 0.81 K: 0.79), and emergency and respiratory failure or decompensated shock (CI: 0.6 K: 0.5).In regard to priorities, 18 of 18 children with fever received antipyretics, 8 of 13 experiencing pain received analgesics, 6 of 9 with vomiting received antiemetics, 4 were hydrated prior to medical attention, 2 of 9 with bronchial spasms received inhaled bronchodilators, 2 of 9 with respiratory distress received oxygen, and 117 did not require intervention. Conclusions: High interobserver agreement was found in the application of PAT. Polypnea, pre-existing pallor, and irritability were not associated with errors in the application of PAT. Treatment priorities were met in children with fever, and to a lesser degree for the variables of pain, respiratory distress and need for oxygen. Training of personnel in advance triage is needed.

Evaluación inicial del paciente pediátrico: ¿cómo se debe realizar? / Initial Assessment of the Pediatric Patient: How to Perform?

En el servicio de urgencias de pediatría es fundamental reconocer de forma precoz lossignos clínicos que indican amenaza para la vida del paciente y que se deben manejarágil y oportunamente. Ello se constituye en un reto para el personal de salud que loasiste, pues se requiere una valoración inicial rápida enfocada en un punto de vistafisiopatológico que analice la afectación hemodinámica y la insuficiencia respiratoria,a fin de prevenir un paro cardiorrespiratorio. Esta primera aproximación que sepropone se denomina triángulo de evaluación pediátrica (TEP), basado en apariencia(aspecto general), respiración y circulación, a partir del cual se realiza un examenvisual y uno auditivo en los primeros segundos de la llegada del paciente pediátrico alservicio de urgencias. Este permite una categorización del estado clínico y tomar unadecisión adecuada...

In the pediatric emergency department, it is essentialto recognize early clinical signs that indicatethreat to the patient’s life and should behandled quickly, becoming a challenge for themedical team assisting. It requires a quick initialassessment of the critically ill patient, approachingit from a physiological point of viewby analyzing the hemodynamic and respiratorycompromise, preventing cardiac arrest. Thisfirst approach is called the Pediatric AssessmentTriangle based on general appearance, breathingand circulation, in which visual and auditoryexamination is performed in the first seconds ofthe arrival of the pediatric patient to the emergencyroom allowing categorization of the clinicalstatus to make the right decision...