Table 4

 Recognition and pre-transportation treatment of the decompensating primary survey positive patient

ProblemFindingsPre-transportation treatment
Respiratory failure▸ Noisy upper airway becoming quiet without improvement in condition▸ Secure airway using simple manoeuvres if possible: use advanced interventions (for example, intubation) only if simple manoeuvres fail
▸ Very rapid and shallow or slow weak respirations▸ Give high concentration oxygen via non-rebreathing mask
▸ Decreasing evidence of increased work of breathing because of exhaustion▸ Consider assisting ventilation with bag valve mask if respiratory rate is very fast or slow
▸ Significantly decreased air entry on auscultation▸ Consider nebulised adrenaline in the presence of suspected croup (5 ml of 1:1000 once only)
▸ Limited chest expansion▸ In the presence of wheeze consider nebulisation with β2 agonist and anticholinergic (for example, salbutamol and ipratropium)
▸ Loss of wheeze without improvement in condition▸ Decompress tension pneumothorax
▸ SpO2 less than 90% on high concentration oxygen▸ Consider intravenous/intraosseous 10% dextrose 5 ml/kg
▸ Cyanosis
▸ Reduced AVPU score
▸ Flaccid or increased muscle tone
▸ No interaction with carers or responders
▸ Glazed, unfocused gaze
▸ Abnormal, weak, or absent cry
▸ Hypoglycaemia
Circulatory failure▸ Increased respiratory rate in the absence of increased work of breathing▸ Secure airway using simple manoeuvres if possible: use advanced interventions (for example, intubation) only if simple manoeuvres fail
▸ Central pallor, mottling, or cyanosis▸ Give high concentration oxygen via non-rebreathing mask
▸ Cool skin centrally▸ Consider intravenous/intraosseous fluid challenge of 20 ml/kg
▸ Bradycardia or falling heart rate in the absence of improvement in condition▸ Consider intravenous/intraosseous 10% dextrose 5 ml/kg
▸ Central capillary refill time >5 seconds or absent▸ Consider benzylpenicillin 300 mg/kg IV
▸ Reduced AVPU score
▸ Flaccid muscle tone
▸ No interaction with carers or responders
▸ Glazed, unfocused gaze
▸ Weak or absent cry
▸ Non-blanching rash and history of flu-like illness
Central nervous system failure▸ Reduced AVPU scoreConsider the presence of undiagnosed respiratory or circulatory failure and treat accordingly. Otherwise:
▸ Flaccid muscle tone▸ Secure airway using simple manoeuvres if possible: use advanced interventions (for example, intubation) only if simple manoeuvres fail
▸ No interaction with carers or responders▸ Give high concentration oxygen via non-rebreathing mask
▸ Glazed, unfocused gaze▸ Consider assisting ventilation with bag valve mask if respiratory rate is very fast or slow
▸ Weak or absent cry▸ Consider rectal diazepam (0 to 1 yr 2.5 mg, 1 to 3 years 5 mg, 4 to 12 years 10 mg) or IV diazepam 250 to 400 μg/kg
▸ Continuous fits, or failure to regain consciousness between fits▸ Consider intravenous/intraosseous 10% glucose (5 ml/kg)
▸ Hypoglycaemia