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PREM Protocol: Triage & resuscitate using Pediatric Resuscitation and Emergency (PREM) Triangles

NORMAL PHYSIOLOGICAL STATUS PREM Terminology & Definitions:

v Breathing Normal = Normal RR + normal work of breathing DISABILITY AIRWAY Stable (vocalizes) v Respiratory distress = Increased RR + retractions LOC: A lert ; v Impending respiratory failure = Grunt+ respiratory distress T&P: N; BREATHING RR N; No grunt, v Relative bradycardia = Heart rate within normal range for age - whilst Eyes: EOM N; PERL stridor, retractions, thoracic other sides of the triangle are abnormal respiration; bilateral air - entry+, v Wide pressure = SBP-DBP > 40 mm Hg no added sounds; SaO2 > 94% v Vasodilatory shock = DBP <50% SBP + wide PP with or without low MAP v Mean Arterial Pressure = Normal MAP is DBP +1/3rd pulse pressure CIRCULATION HR: N (for age); no muffling or gallop; P&C: Warm, pink v Liver span = Mark lower border along right costal margin, percuss & mark sole of foot; * +++/++; CRT< 2 secs; Liver span: N; Blood Pressure: upper border for liver dullness. Measure span (cms) in the mid-clavicular SBP N, Diastolic BP > 50% SBP, Pulse Pressure 30-40 mm Hg, MAP N line. Check lower border & remeasure span after every intervention.

v Non -Convulsive Status Epilepticus = LOC: Responsive to pain or *Pulses: Femoral (F) & Dorsalis Pedis (DP) +++/++ means both normal volume Note: +++/+++ F = DP ; ++/+ both weak; ++/0 or +/0 weak Femoral palpable but no DP unresponsive + 1 or more abn EOM: Conjugate deviation, nystagmus, lid twitch

RESPIRATORY DISTRESS CARDIAC FAILURE VASODILATORY CARDIOGENIC SHOCK (MAP N)

DISABILITY AIRWAY Stable DISABILITY AIRWAY Stable DISABILITY AIRWAY Stable LOC: Alert; BREATHING ↑RR; LOC: Incessant cry±/ not BREATHING ↑RR, BREATHING ↑RR; LOC: Alert; T&P: N; No grunt, stridor± usual self±/ grunt±, stridor ± no grunt, stridor±, T&P: N; Eyes: EOM N; retractions+, thoracic lethargic±/sleepy± retractions+, Eyes: EOM N; retractions+, thoracic PERL respiration; bilateral T&P: N; abdom. respiration±; PERL respiration; bilateral air-entry+, added Eyes: EOM N; bilateral air-entry+, air-entry +, added sounds±; SaO > 94% PERL added sounds±; sounds ±; SaO > 94% 2 2 Exception: CCHD SaO ±< 94% 2

CIRCULATION CIRCULATION CIRCULATION HR: ↑/ N; HS: N; P&C: Warm, pink; Pulses +++/++; HR: Tachycardia; HS: N; P&C: warm, pink or dusky; Pulses +++/++; CRT< 2 secs; No shock; HR: Tachycardia; HS: Muffling±, gallop ±; P&C: Very CRT< 2 secs; No shock; No hepatomegaly; warm, very pink; Pulses: +++/+++; CRT instant; Shock; BP: SBP N, DBP N, PP N, MAP N +; BP: SBP N, DBP low, wide PP (shunt lesion ), MAP N Hepatomegaly ±; BP: SBP↑, DBP ↓, wide PP, MAP N

RESPIRATORY FAILURE (RESPIRATORY VASODILATORY CARDIOGENIC LOW SBP SHOCK EMERGENCIES) LOW MAP SHOCK DISABILITY LOC: AIRWAY Stable/ AIRWAY AIRWAY Stable/ Responds to pain; unstable DISABILITY LOC: DISABILITY LOC: Stable/unstable unstable T&P abnormal: BREATHING RR↑↓, Responds to pain; Responds to pain; BREATHING RR↑↓, BREATHING RR↑↓, Thirsty, agitated, grunt+, stridor± , T&P abnormal: T&P abnormal: grunt+, stridor±, grunt+, stridor± , combative, retractions+, Agitated, Thirsty, agitated, retractions+, retractions+, fighting mask abdominal combative, combative, abdominal abdominal or floppy, respiration; bilateral fighting mask fighting mask respiration; bilateral respiration; bilateral ± posturing; air-entry+, added or floppy, or floppy, air - entry ± , a dded air - entry +, a dded EOM ± abN , PERL; sounds ±; SaO2 <94% ± posturing; EOM ± abN, ± posturing; EOM ± abN , sound ±; SaO2 < 94% sounds±; SaO2 <94% NCSE± PERL; NCSE± PERL; NCSE± CIRCULATION CIRCULATION CIRCULATION HR: Tachycardia/relative bradycardia; HS: Muffling±, HR: Tachycardia; HS: N; P&C: Warm, pink; HR: Tachycardia/relative bradycardia; HS: Muffling±, gallop±; P&C: Cool, dusky; Pulses: ++/+, ++/0 or +/0; Pulses: +++/++ +; CRT <2sec; Shock+; Liver span gallop±; P&C: Very warm, very pink; Pulses: +++/+++; CRT >2sec; Shock; Hepatomegaly±; N; BP: SBP N, DBP ↓, wide PP, MAP N CRT instant; Shock; Hepatomegaly±; BP: SBP ↓, DBP ↓, PP N, wide or narrow, MAP↓ BP: SBP N, DBP ↓, wide PP, MAP N

RR: IMMINENT ARREST HR: Heart Rate HS: P&C: Peripheries (warmth) & Colour (foot-sole) DISABILITY AIRWAY Unstable LOC: Level of Consciousness LOC: Unresponsive; BREATHING T&P: Tone & Posture T&P abnormal: Bradypnea or apnea; EOM: Extra Ocular Movements Posturing, GTCS±; Little/no respiratory PERL: Pupils Equal, Reacting to Light EOM abn, pupils effort; Reduced or Note: All Normal (N), Increased (↑), SBP: Systolic sluggish; NCSE± absent breath DBP: Diastolic Blood Pressure relative (N) or Decreased (↓) values – sounds; SaO <<94% 2 PP: Pulse Pressure are interpreted with respect to normal CIRCULATION MAP: Mean Arterial Pressure ranges for age and the other parts of HR: Bradycardia; HS: Muffled, gallop; P&C: Cool, dusky; NCSE: Non-Convulsive Status Epilepticus the PREM triangle. Pulses: ++/0 or +/0; CRT >>2sec; Shock; Hepatomegaly; GTCS: Generalised Tonic Clonic Seizures BP: SBP ↓, DBP ↓, PP N, wide or narrow, MAP↓ CCHD: Cyanotic Congenital Heart Disease

National Health Mission-Strengthening of Pediatric Emergency Care System in Tamil Nadu-Establishment of Pediatric Resuscitation and emergency Units under Tamil Nadu Accidents and Emergency Care Initiative under the name of PREM G.O(D)No. 539, Department of Health and Family Welfare, dated 30.11.19

Santhanam I, et al. Arch Dis Child Educ Pract Ed 2021;0:1–6. doi: 10.1136/archdischild-2021-321981