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微信编辑器 构思编辑器
微信编辑器 构思编辑器
微信编辑器 构思编辑器
付尧
吉林大学第一医院重症医学科，医师
Paediatric emergency triage, assessment and treatment Care of critically ill children UPDATED GUIDELINE
World Health Organization
概要及背景/
Executive Summary and Background
Deaths of children in hospital often occur within the first 24 h of admission. Many of these deaths could be prevented if very sick children were identified soon after their arrival in the health facility and appropriate treatment started immediately. This can be facilitated by rapid triage of all children arriving at a hospital to determine whether emergency or priority signs are present.
住院患儿的死亡常发生于入院第一个24小时内。若在到达医疗保健机构后能立即识别出危重患儿并立刻开始适当的治疗，则可以避免这样的死亡。对所有到达医院的儿童进行快速分诊，确定其是否存在紧急或需优先处置的临床表现，有助于降低患儿死亡率。
WHO therefore published guidelines for paediatric ETAT and supportive training materials in 2005 (WHO, 2005a). The guidelines and materials were developed mainly for low-resource settings and were adapted from the guidelines for Advanced Paediatric Life Support that are used in high-income countries (European Resuscitation Council, 2005). An abbreviated version was included in the first edition of the Pocket book of hospital care for children (WHO, 2005b).
因此，世界卫生组织（WHO）在2005年发表了儿科急诊分诊、评估和管理（ETAT，emergency triage, assessment and treatment）指南以及相关培训材料（WHO，2005a）。2005版指南以及培训材料主要用于低资源医疗保健机构。另外，2005版指南由用于高收入国家（欧洲复苏委员会，European Resuscitation Council，2005）的高级儿科生命支持指南改编而来。2005版指南的精简版已被收入《儿童医院护理口袋书》的第一版中（WHO，2005b）。
In 2013, a WHO guideline development scoping group reviewed the paediatric ETAT guidelines and identified areas of care and specific recommendations that should be updated in light of the new evidence and international consensus (WHO, 2013a).
2013年，WHO 指南更新小组修订了2005版儿科ETAT指南，进一步确定了医疗护理范围，并依据新出现的医学证据及国际共识更新了具体推荐意见（WHO, 2013a）。
The recommendations in this publication complement or update guidance in published WHO ETAT materials. This guideline does not, therefore, reflect all WHO recommendations on paediatric ETAT but only those identified by the WHO guideline development group in 2013.
此次2016版指南的推荐意见是对此前已发表的WHO ETAT指南材料的补充及更新。因此，本版指南内容并不包括WHO对于儿科ETAT的全部推荐意见，仅包括2013年WHO指南更新小组已经提到的部分。
This guideline is intended for use in low-resource settings where infants and children are likely to be managed by non-specialists. The aim is to provide clinical guidance to these health workers on managing infants and children presenting with signs of severe illness.
本指南主要用于低资源医疗机构（无儿科专科医师的机构），为这些医务人员提供临床指导，管理存在严重疾病表现的婴幼儿。
目的/
Objective of the guidelines
In order to reduce mortality among infants and children presenting with critical danger signs that require immediate management, WHO reviewed the guidelines on emergency triage, assessment and treatment to provide updated guidance in three areas of clinical care: oxygen therapy for critically ill children, fluid management in critically ill infants and children and management of children presenting with seizures and altered consciousness.
为降低存在需紧急处置的、伴有危重表现的婴幼儿及儿童的死亡率，WHO修订了ETAT指南，更新了三个方面的临床护理推荐意见：危重患儿氧疗方案、危重婴幼儿液体管理和伴抽搐及意识改变的患儿管理。
受益人群/
Population of interest
The guideline addresses the management of critically ill infants and children presenting to health facilities in low-resource settings with emergency signs, namely:
· airway or breathing problems, defined as obstructed or absent breathing, central cyanosis or severe respiratory distress: Is the child breathing? Is the airway obstructed? Is the child blue (central cyanosis)? Does the child have severe respiratory distress?
· signs of circulation impairment, defined as cold hands or capillary refill > 3 s or weak with rapid pulse
· signs of seizure or coma, defined as not alert, does not respond to voice or painful stimulus (AVPU) or is convulsing now
· signs of severe dehydration, defined as the presence of diarrhoea or another dehydrating condition such as vomiting or insufficient fluid intake due to e.g. malaise and fever, with any of the three signs: lethargic or unconscious, sunken eyes, pinched skin returns very slowly (> 2 s).
该指南用于就诊于低资源医疗保健机构的、存在危急表现的危重婴幼儿及儿童的诊治管理。
危急表现（emergency signs）指：
·气道或呼吸问题，定义为患儿存在阻塞性呼吸困难或呼吸暂停，中枢性紫绀或重度呼吸窘迫：是否存在呼吸？是否存在气道梗阻？皮肤是否发蓝（中枢性紫绀）？是否存在严重的呼吸窘迫？
·循环障碍的表现，定义为患儿手足冰冷，或毛细血管再充盈时间> 3秒，或脉搏细速
·抽搐或昏迷的表现，定义为无觉醒，对声音或疼痛刺激无反应（AVPU），或抽搐发作
·重度脱水的表现，定义为患儿存在腹泻或其他脱水情况（如呕吐，或由于精神萎靡和发热等原因导致的液体摄入不足），并伴有以下3种症状其中之一：昏睡或昏迷、双眼凹陷、皮肤的回弹速度慢（>2秒）。
指南推荐意见
DETECTION OF HYPOXAEMIA AND USE OF OXYGEN THERAPY
低氧血症的诊断及氧疗
When to start and stop oxygen therapy for severely ill children with emergency signs
何时开始及终止存在危急表现的重症患儿的氧气治疗
1.1 Pulse oximetry is recommended to determine the presence of hypoxaemia in all children with ETAT emergency signs. When the child has only respiratory distress, oxygen supplementation is recommended at SpO2 < 90%. Children presenting with other ETAT emergency signs with or without respiratory distress should receive oxygen therapy if their SpO2 is < 94%. (Strength of recommendations: Strong, Quality of evidence: Very low)
1.1推荐应用指尖血氧饱和度来判断所有伴有ETAT危急表现的患儿是否存在低氧血症。对仅存在呼吸窘迫的患儿，SpO2＜90%时给予氧疗。若患儿存在其他ETAT危急表现，无论是否伴有呼吸窘迫，SpO2＜94%时则给予氧疗。（推荐强度：强，证据质量：极低）
1.2 Oxygen therapy can be stopped when the child no longer has ETAT emergency signs and maintains an oxygen saturation of SpO2 ≥ 90% in room air. (Strength of recommendations: Conditional, Quality of evidence: Very low)
1.2患儿无ETAT危急表现，且不额外吸氧条件下可维持SpO2≥90%，给予终止氧疗。（推荐强度：弱，证据质量：极低）
Oxygen flow rate and humidification in severely ill children with emergency signs
伴危急表现的重症患儿氧流量及湿度的选择
1.3 Severely ill children with signs of obstructed breathing, central cyanosis, severe respiratory distress, signs of shock or who are unconsciousness should receive oxygen initially by nasal prongs at a standard flow rate (0.5–1 L/min for neonates, 1–2 L/min for infants and 2–4 L/min for older children) or through an appropriately sized face mask (> 4 L/min) to reach an SpO2 of ≥ 94%. (Strength of recommendations: Strong, Quality of evidence: Very low)
1.3危重患儿出现阻塞性呼吸困难、中枢性紫绀或重度呼吸窘迫的表现；或出现休克的表现；或出现昏迷时，应维持SpO2≥94%，首先经鼻导管给予标准氧流量的吸氧（标准氧流量指新生儿0.5–1 L/min，婴儿1–2 L/min，幼儿2–4 L/min），或选择大小适中的面罩给予面罩吸氧（氧流量> 4 L/min）。（推荐强度：强，证据质量：极低）
微信编辑器 构思编辑器
微信编辑器 构思编辑器
1.4 For standard flow oxygen therapy, humidification is not needed. (Strength of recommendations: Strong, Quality of evidence: Very low)
1.4采用标准氧流量进行吸氧治疗时不需额外加湿。（推荐强度：强，证据质量：极低）
1.5 In an emergency setting, when a flow of > 4 L/min through nasal cannulae is required for more than 1–2 h, effective heated humidification should be added. (Strength of recommendations: Strong, Quality of evidence: Very low)
1.5当经鼻导管吸氧的氧流量> 4 L/min、吸氧时间大于1-2h时，应予以有效的加温加湿。（推荐强度：强，证据质量：极低）
FLUID MANAGEMENT IN CHILDREN WITH SIGNS OF IMPAIRED CIRCULATION
循环障碍患儿的液体管理
Children who are not in shock but have signs of circulatory impairment
无休克，但存在循环障碍表现的患儿
2.1 Children with only one or two signs of impaired circulation – cold extremities or capillary refill > 3 s or a weak and fast pulse – but who do not have the full clinical features of shock, i.e. all three signs present together, should not receive any rapid infusion of fluids but should still receive maintenance fluids appropriate for their age and weight. (Strength of recommendations: Strong, Quality of evidence: High)
2.1患儿仅有1-2个循环障碍的表现——四肢冰冷或毛细血管再充盈时间> 3秒或脉搏细速——但没有充分的休克表现（以上3个症状同时出现），不应给予快速补液，但应予以补充与其年龄和体重相适应的维持液体量。（推荐强度：强，证据质量：高）
2.2 In the absence of shock, rapid IV infusion of fluids may be particularly harmful to children who have severe febrile illness, severe pneumonia, severe malaria, meningitis, severe acute malnutrition, severe anaemia, congestive heart failure with pulmonary oedema, congenital heart disease, renal failure or diabetic ketoacidosis. (Strength of recommendations: Strong, Quality of evidence: High)
2.2无休克患儿快速静脉补液，对患有以下疾病的患儿可能尤其有害：严重发热性疾病、重症肺炎、重症疟疾、脑膜炎、重度急性营养不良、重度贫血、伴有肺水肿的充血性心力衰竭、先天性心脏病、肾衰竭、糖尿病酮症酸中毒。（推荐强度：强，证据质量：高）
2.3Children with any sign of impaired circulation, i.e. cold extremities or prolonged capillary refill or weak, fast pulse, should be prioritized for full assessment and treatment and reassessed within 1 h. (Strength of recommendations: Strong, Quality of evidence: High)
2.3应优先给予存在循环障碍表现（即四肢冰冷，或毛细血管再充盈时间延长，或脉搏细速）的患儿充分评估病情并治疗，并应于1 h内再次评估病情。（推荐强度：强，证据质量：高）
Children who are in shock
休克患儿
2.4 Children who are in shock, i.e. who have all the following signs: cold extremities with capillary refill > 3 s and a weak and fast pulse, should receive IV fluids.
· They should be given 10–20 mL/kg body weight (bw) of isotonic crystalloid fluids over 30–60 min.
· They should be fully assessed, an underlying diagnosis made, receive other relevant treatment and their condition monitored.
· The child should be reassessed at the completion of infusion and during subsequent hours to check for any deterioration:
——If the child is still in shock, consider giving a further infusion of 10 mL/kg bw over 30 min.
——If shock has resolved, provide fluids to maintain normal hydration status only (maintenance fluids).
· If, at any time, there are signs of fluid overload, cardiac failure or neurological deterioration, the infusion of fluids should be stopped, and no further IV infusion of fluids should be given until the signs resolve. (Strength of recommendations: Conditional, Quality of evidence: Low)
2.4休克患儿（即同时存在以下3种表现：四肢冰冷、毛细血管再充盈时间> 3秒、脉搏细速）应给予静脉补液。
·30–60min内应输注10–20 ml/公斤体重的等渗晶体液。
·应充分评估病情，明确初步诊断，给予其他相关治疗并监测病情变化。
·补液结束后应再次评估病情，并继续观察病情是否恶化：
——如果仍存在休克，可继续补液，30min输注10 ml/公斤体重液体。
——如果休克已纠正，仅补充可供维持正常水合状态的液体量（即维持液体量）。
·如果出现液体过多的表现（心衰或神经功能恶化），应立即停止所有静脉输液直到完全纠正上述症状。（推荐强度：弱，证据质量：低）
2.5 Children in shock and with severe anaemia [erythrocyte volume fraction (haematocrit) < 15 or haemoglobin < 5 g/dL as defined by WHO] should receive a blood transfusion as early as possible and receive other IV fluids only to maintain normal hydration. (Strength of recommendations: Strong, uality of evidence: Low)
2.5重度贫血（WHO重度贫血定义：红细胞体积分数（红细胞压积）< 15或血红蛋白< 5 g/dl）的患儿出现休克时，应尽早输血治疗，其他静脉输液仅用于补充维持液体量。（推荐强度：强，证据质量：低）
2.6 Children with severe acute malnutrition who are in shock should receive 10–15 mL/kg bw of IV fluids over the first hour. Children who improve after the initial infusion should receive only oral or nasogastric maintenance fluids. Any child who does not improve after 1 h should be given a blood transfusion (10 mL/kg bw slowly over at least 3 h) (WHO, 2013b). (Strength of recommendations: Strong, Quality of evidence: Low)
2.6重度急性营养不良的患儿出现休克时，第1h内静脉输液10–15 ml/公斤体重。首次补液后病情好转的患儿，改为仅经口或鼻饲补充维持液体量。输液1h时后病情无改善的患儿应行输血治疗（10ml/公斤体重，缓慢输注，至少持续3小时）（WHO, 2013b）。（推荐强度：强，证据质量：低）
MANAGEMENT OF SEIZURES
抽搐患儿的管理
Choice of anticonvulsant medicines for children with acute seizures when IV access is not available
急性抽搐患儿无静脉通路时，止惊药物的选择
3.1 When IV access is not available for the control of acute seizures in children, non-parenteral routes of administration of benzodiazepines should be used. Options include rectal diazepam, oral or intranasal midazolam and rectal or intranasal lorazepam. Some benzodiazepines (lorazepam and midazolam) may be given intramuscularly; this requires additional expertise and expense. The preference may be guided by availability, expertise and social preference. (Strength of recommendations: Strong, Quality of evidence: Low)
3.1当急性抽搐患儿无静脉通路时，选择可经非静脉注射途径给药的苯二氮卓类药物，包括经直肠给予地西泮、经口或鼻腔给予咪达唑、经直肠或鼻腔给予劳拉西泮。一些苯二氮卓类药物（如劳拉西泮和咪达唑仑）可肌肉注射，这需要额外的专业知识并产生相关费用。具体给药途径应根据可操作性、专业能力及社会偏好进行选择。（推荐强度：强，证据质量：低）
Choice of anticonvulsant medicines for children with acute seizures when IV access is available
急性抽搐患儿已开放静脉通路时，止惊药物的选择
3.2 For children presenting with acute seizures where IV administration is available, IV diazepam or IV lorazepam should be used to terminate the seizure. (Strength of recommendations: Conditional, Quality of evidence: Very low)
3.2已开放静脉通路的急性抽搐患儿，应静脉注射地西泮或劳拉西泮，终止抽搐发作。（推荐强度：弱，证据质量：极低）
Choice of second-line anticonvulsant medicines for children with established status epilepticus resistant to first-line benzodiazepines
一线止惊药物疗效不佳时，确定性癫痫持续状态患儿二线止惊药物的选择
3.3 In children with established status epilepticus, i.e. seizures persisting after two doses of benzodiazepines, IV valproate, IV phenobarbital or IV phenytoin can be used, with appropriate monitoring.
The choice of drug depends on local resources, including availability and facilities for monitoring. IV valproate is preferred to IV phenobarbital or IV phenytoin because of its superior benefit–risk profile.
When IV infusion or monitoring is not feasible, intramuscular (IM) phenobarbital remains an option. Phenytoin and valproate must not be given intramuscularly. (Strength of recommendations: Conditional, Quality of evidence: Low)
3.3确定性癫痫持续状态（如应用2次苯二氮卓药物后仍持续抽搐）的患儿，在充分监测下可继续静脉注射丙戊酸钠、苯巴比妥或苯妥英钠。
具体药物选择取决于当地资源配给，包括监测病情的可操作性和监测设备的配给。静脉注射首选丙戊酸钠，因其与苯巴比妥、苯妥英钠相比具有更高的效益–风险比。
如果不能进行静脉输液或病情监测，可选择肌注苯巴比妥。禁止肌注苯妥英钠和丙戊酸钠。（推荐强度：弱，证据质量：低）
Pharmacological interventions for prophylaxis of recurrence of febrile seizures
预防热性惊厥复发的药物干预措施
3.4 Prophylactic treatment with intermittent antipyretics, intermittent anticonvulsant medications (diazepam or clobazam) or continuous anticonvulsant medications (phenobarbital or valproate) should not be used for febrile seizures. (Strength of recommendations: Strong, Quality of evidence: Low)
3.4不推荐以下方法用于预防高热惊厥：间断应用退热药、间断应用抗惊厥药物（地西泮、氧异安定）或连续应用抗惊厥药物（苯巴比妥、丙戊酸钠）。（推荐强度：强，证据质量：低）
Role of diagnostic tests in the management of seizures with altered consciousness, particularly when used by non-specialists in low- and middle-income countries
抽搐伴意识改变时的诊断性检查（尤其适用于低中收入国家的非专科医师）
3.5 The following diagnostic tests should be performed in children with acute seizures or altered consciousness:
· blood glucose
· blood sodium (in children with severe dehydration or diarrhoea)
· lumbar puncture in febrile children with signs of meningitis (Strength of recommendations: Strong, Quality of evidence: Very low)
3.5急性抽搐或意识改变的患儿应进行以下诊断性检查：
·血糖
·血钠（严重脱水或腹泻时）
·可疑脑膜炎的发热患儿应进行腰椎穿刺（推荐强度：强，证据质量：极低）
3.6 Lumbar puncture should be considered for any infant or child who appears severely ill (e.g. high fever with altered consciousness or seizure) and with any of the following:
· age < 18 months (especially < 6 months);
· complex febrile seizures (prolonged, focal or recurrent during the same febrile illness);
· antimicrobials were given before assessment;
· not vaccinated against Haemophilus influenza type b or Streptococcus pneumoniae or with unknown immunization status. (Strength of recommendations: Strong, Quality of evidence: Very low)
3.6任何病情危重的婴幼儿都应考虑腰椎穿刺（如高热伴意识改变或抽搐），同时需满足以下任意1项条件：
·年龄小于18个月（尤其＜6个月）；
·复杂性热性惊厥（相同的发热性疾病，复杂性热性惊厥持续时间更长，或呈局灶性发作，或反复发作）；
·病情评估前已应用抗生素；
·未接种乙型流感嗜血杆菌疫苗或肺炎链球菌疫苗或免疫状况未知。（推荐强度：强，证据质量：极低）
3.7 Lumbar puncture should be performed in infants and children only after all of the following clinical signs have been resolved:
· unresponsive or in coma (based on ETAT AVPU scale)
· focal neurological signs
· signs of brainstem herniation
· signs of raised intracranial pressure
· signs of respiratory compromise
· ETAT signs of shock
· infections in the skin overlying the site of the proposed lumbar puncture
· evidence of a bleeding disorder (Strength of recommendations: Strong, Quality of evidence: Very low)
3.7婴幼儿及儿童腰椎穿刺术禁忌症：
·无反应或昏迷（依据ETAT AVPU量表评估）
·局灶性神经系统异常
·脑疝
·颅内压增高
·呼吸障碍
·休克的ETAT表现
·腰椎穿刺部位皮肤感染
·出血倾向（推荐强度：强，证据质量：极低）
3.8 Neuroimaging [ultrasound in young infants, computerized tomography (CT) or magnetic resonance imaging (MRI)] should be considered for children with altered consciousness or a new focal neurological deficit. (Strength of recommendations: Strong, Quality of evidence: Very low)
3.8患儿存在意识改变或新发局灶性神经功能异常的，应考虑行神经系统影像学检查（小婴儿超声，CT或MRI）。（推荐强度：强，证据质量：极低）
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