Family health diploma
 Pediatric lecture
 On importance of to check general danger signs.
Dr .Shazia Memon
Associate Professor
Learning objectives
 Identify general danger signs.
 How to check the child for general danger signs
 Know the D/D of child with convulsion, lethargy or
coma.
 To give pre referral treatment.
 Base line investigations.
A general danger sign is present if:
 The child is not able to drink or breast feed
 The child vomits every thing
 The child has had convulsions during current illness
 The child is lethargic or unconscious
 The child is convulsing now.
Assess For General Danger Sign
CHECK FOR GENERAL DANGER SIGNS
Ask:
•Is the child
not able to
drink or
feed?
•Does the
child vomit
every thing ?
•Has the
child has
convulsions?
Look:
•See if the
child is
lethargic or
unconscious.
•See if the
child is
convulsing
now.
WHEN YOU CHECK FOR GENERAL
DANGER SIGNS
ASK:
 Is the child not able to drink or breast feed?
 A child has the sign “not able to drink or breast feed” if he child is not
able to suck or swallow when offered a drink or breast milk.
Causes:
 CNS infections .
 Acute gastroentritis with severe dehydration.
 Sepsis
 Throat abscess
DOES THE CHILD VOMITS EVERY THING?
 A CHILD WHO IS NOT ABLE TO HOLD ANY THING
DOWN AT ALL HAS THE SIGN ”VOMITS EVERY
THING”
CAUSES
 Lethargic/unconscious
 Acute gastroenteritis with severe dehydration
 Intestinal obstruction
 sepsis
HAS THE CHILD HAD CONVULSIONS
?
 CONVULSION: Paroxysmal, time limited change in
motor activity and/or behaviour that results from
abnormal electrical activity in the brain
 CAUSES:
Causes
In favour
Meningitis
•History of high grade fever
•Recurrent history of otitismedia
•Neck stiffness
•Signs of meningial irritation
•Petachial rashes (meningiococal
meningitis)
•Tense or bulging fontenelle
•Abnormal posture
Encephlitis
•Reccent history of gastroentritis
•Irritibility/behavioural changes
•Raised ICP
•Csf
T.B meningitis
•Hx of contact with t.b patient
•Hx of weight loss
•Low grade fever
•Loss of appetite
•Focal neurologicalsigns
•Cranial nerve palsy
•Labs: CXR ,Sputum AFB, montoux test,
Febrile convulsions
•Age 6 months to 5 years
•High grade fever
•No loss of consciousness
•Positive family Hx
Head trauma
Poisoning
•Hx of poison ingestion or drug over dose
Hypertensive Encephalopathy
•Hx of head ache
•Vomiting
•Irritibility
•Raised blood pressure
Diabetic ketoacidosis
•Hx of polydypsia, polyphagia, polyurea
•Hx of weight loss
•Acidotic breathing
•Labs:
High blood sugar
Urinary ketones
Dr. Shazia Memon
Assistant professor
Learning objectives
At end of session you become able to:
 Take relevant history.
 Know the D/D of child with convulsion or coma
 Know the out-patient management of child presenting
with convulsion /coma and identify the pre referral
treatment.
 know in-patient management of child presenting with
convulsion /coma.
Learning objectives
Following Skills you will learn during practical and
clinical session
 To Identify general danger signs (practical /clinical)
 To Assess the level of consciousness by AVPU scale.
 To examine the child for signs of meningeal irritation
 To perform the motor system examination .
Why convulsion is selected as
general danger sign.
 CONVULSION: Paroxysmal, time limited change in
motor activity and/or behaviour that results from
abnormal electrical activity in the brain.
 Convulsion is the presenting complaint in around 30%
of children admitted in pediatric emergency
 If occur with underlying disease increases the risk of
morbidity and mortality.
 If uncontrolled will lead to brain damage.
Common causes of convulsions
 CNS Infection
 Febrile convulsions
 Epileptic convulsions
 Metabolic. Hypoglycemia
 Head injury
 Intoxication (drug over dose)
 Hepatic encephalopathy
 DKA.
 AGN ( hypertensive encephalopathy.
 Most common causes are febrile convulsions and
CNS infections.
Assessment areas
 Out-patient/ community
 Inpatient management .
management.
 Patient flow high.
 Screen the patient for
any severe classification.
 Identify the pre-referral
treatment.
 Give pre-referral
treatment.
 Initially assess the child
in triage.
 Look for emergency
/priority signs.
 Give emergency
treatment.
 Admit the child.
Community or outpatient management
 History : check for general danger signs
 Ask for 5 main symptoms
 Fever with general danger or Stiff neck and enquire
about malaria risk.
 Classify the illness.
 Identify and give pre-referral treatment.
 Write down the referral note.
 Refer the child to inpatient department.
Assess For General Danger Sign
CHECK FOR GENERAL DANGER SIGNS
Ask:
•Is the child
not able to
drink or
feed?
•Does the
child vomit
every thing ?
•Has the
child has
convulsions?
Look:
•See if the
child is
lethargic or
unconscious.
•See if the
child is
convulsing
now.
WHEN YOU CHECK FOR GENERAL
DANGER SIGNS
ASK:
 Is The Child Not Able To Drink Or Breast Feed?
 A child has the sign “not able to drink or breast feed” if he child is not
able to suck or swallow when offered a drink or breast milk.
 DOES THE CHILD VOMITS EVERY THING?
 A CHILD WHO IS NOT ABLE TO HOLD ANY THING DOWN AT ALL
HAS THE SIGN ”VOMITS EVERY THING”
 HAS THE CHILD HAD CONVULSIONS ?
 History of convulsion during current illness
 CLASSIFY THE ILLNESS AS ?
IDENTIFY THE TREATMENT
 Treat convulsions if present now by giving
diazepam per-rectally.
 Complete assessment immediately.
 Give first dose of an appropriate antibiotic.
 Treat the child to prevent low blood sugar.
 Refer URGENTLY to hospital.
PRE-REFERRAL TREATMENT
 IMPORTANCE.
 CHARTBOOKLET: TREATMENT GIVEN IN CLINIC.
Practical session
video demonstration
Facility based management
 Initially assess the child in triage.
 Look for emergency /priority signs.
 Give emergency treatment in the triage.
 Admit the child.
Facility Based Management
 The first step is, to assess referred case in the
triage –where we screen the cases to decide to
which of the following group(s) a sick child
belongs:
 Those with emergency signs require immediate
emergency treatment .
 Those with priority signs should alert you to for
immediate assessment and treatment.
 Children with no emergency or priority signs are
treated as non-urgent cases.
Emergency signs:
 Obstructed breathing
 Severe respiratory
distress.
 Central cyanosis.
 Signs of shock
 Coma
 Convulsions
 Signs of severe
dehydration
priority signs:











Sick child < 2 months
Temprature : child very hot
Trauma or other urgent surgical
Pallor
Poisoning
Pain
Respiratory distress
Lethargic/ irrtibility
Severe malnutrition/visible wasting
Edema on both feet.
Burns.
Assessment of child with
convulsion or coma
 AVPU scale.
 Alert
 Response to vocal commands.
 Response to pain
 Un-concouscious .
Stabilize and investigate

CBC and MP
 CSF
 Blood glucose.
 Assessment of blood pressure
 Urine microscopy.
 Other investigations according to presentation
 ADMIT THE CHILD & MANAGE ACCORDINGLY
INPATIENT MANAGEMENT
 HISTORY FROM LOG BOOK FOR INPATIENTS
 DETAIL EXAMINATION & D/D
 FOLLOW INVESTIGATIONS
 NEED FOR FURTHER INVESTIGATION
 MANAGE ACCORDINGLY
Exercise question
 Salina is 15 months old weighs 8.5 kg with temp 38.5c.
 The mother said that Salina has been coughing for 4
days, and not eating well. This is her initial visit.
 Mother said that she does not want to breast feed. The
health worker gave some water to Salin but she was too
weak to lift her head. She was not able to drink.
Mother said that she has no vomiting or convulsions.
Salina was not lethargic or unconscious and not
convulsing now.
Question
 Classify the illness.
 What information is missing
 What pre-referral treatment will you give to Salina
Key of exercise question
 Very sever febrile disease
 Malaria risk
 Anti biotics
 Antimalarial
 Sugar water
 Oral paracetamol.
Exercise question
 Kareena, a 4-year-old child has been urgently referred
to you with classification of very severe febrile disease.
Not very low weight and anaemia. She is from a high
malaria risk area. She is in coma and has no signs of
shock. The child is not severely malnourished and has
some pallor. Her temperature is 39.2ºC.
Exercise question
 a) List the emergency signs. What emergency
treatment would you give?
 b) Enlist important points in history and physical
examination.
 c) What is your differential diagnosis?
 d) What investigations would you like to do?
key of Exercise question
 a. She has coma as emergency sign and high fever as
priority sign.
 Manage airway, position, check and correct
hypoglycaemia.
Key of Exercise question
 b. H/O skin rash, headache, ear pain.
 Look for stiff neck, skin rash, discharge from ear,
splenomegaly.
 c. Meningitis, cerebral malaria, viral
meningoencephalitis.
 d. LP, smear for MP and RDT, blood glucose, Hb and
complete blood counts.