Educational simulation, not a clinical tool.
MorePatients and responses are simplified teaching cases. Drug treatments are named at protocol level without doses; in practice follow current Kenya Ministry of Health protocols (e.g. Basic Paediatric Protocols, obstetric and malaria guidelines), your facility's charts and your supervisors.
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Key facts to remember

  • Adult at rest: HR 60–100/min, RR 12–20/min, BP below 120/80 mmHg is optimal (≥ 140/90 on repeated readings = hypertension), SpO₂ 95–100% on air (target 94–98% when on oxygen), temperature about 36.1–37.2 °C (fever ≥ 38.0 °C).
  • Fast breathing in a child (WHO IMCI, Kenya BPP): ≥ 60/min under 2 months, ≥ 50/min at 2–11 months, ≥ 40/min at 12–59 months. Count for a full 60 seconds while the child is calm.
  • Hypotension in a child aged 1–10 years: systolic BP below 70 + (2 × age in years) mmHg. A falling BP is a late, pre-arrest sign in children; tachycardia, cold hands and capillary refill > 3 s come first.
  • Hypoglycaemia: treat a child if glucose < 3 mmol/L (Kenya BPP), or if AVPU is below A and glucose cannot be checked; an adult with diabetes if < 4.0 mmol/L.
  • NEWS2: adults ≥ 16 only, not in pregnancy. 5–6 = urgent review; ≥ 7 = emergency response; any single parameter scoring 3 = urgent ward review.
  • ETAT+ order: Emergency signs (A/B, C, Coma/Convulsion, Dehydration) → treat immediately; Priority signs (3TPR-MOB) → front of the queue; none → queue.
  • Shock index = HR ÷ SBP: above about 0.9 suggests significant blood loss (useful after delivery and trauma).
Age (typical weight)Heart rate /minResp. rate /minSystolic BP mmHg
Term newborn (3.5 kg)120–17025–6060–95
3–6 months (6–8 kg)110–17020–6060–105
1–2 years (10–12 kg)95–15020–4570–105
4 years (15 kg)80–15017–3075–110
6–8 years (20–25 kg)70–14016–3080–115
10–12 years (30–40 kg)60–13015–2585–120
14 years and over (50 kg +)60–11514–2590–135

Child ranges: Royal Children's Hospital Melbourne, "Acceptable ranges for physiological variables" (2023). Fast-breathing cut-offs: WHO IMCI and Kenya Basic Paediatric Protocols. Ranges vary between textbooks; the trend in one child matters more than a single number.

Reading a bedside monitor

  • ECG (green): usually lead II. Each beat shows a P wave (atrial depolarisation), QRS complex (ventricular depolarisation) and T wave (repolarisation). Heart rate is counted from R–R intervals. The ST segment should sit on the baseline; elevation in two contiguous leads with chest pain suggests ST-elevation myocardial infarction (STEMI).
  • SpO₂ plethysmograph (yellow): pulse oximetry compares red and infrared light absorption to estimate the percentage of haemoglobin carrying oxygen. A small, flat pleth means poor peripheral perfusion (cold, shocked patient) and an unreliable reading.
  • Arterial pressure (red): a sharp upstroke, a peak (systolic), a dicrotic notch (aortic valve closure) and a diastolic run-off.
  • Respiration (white): chest impedance changes with breathing. Rate and depth matter: a slow, shallow trace is a warning sign.

Three quick calculations link these numbers. SBP and DBP are the systolic (peak) and diastolic (lowest) blood pressures; MAP is the mean arterial pressure that actually perfuses organs; CO is cardiac output, the blood pumped per minute; HR is heart rate and SV the stroke volume (blood per beat).

$$\text{MAP}\approx \text{DBP}+\tfrac13(\text{SBP}-\text{DBP}),\qquad CO = HR\times SV,\qquad \text{Shock index}=\frac{HR}{SBP}$$

The body defends blood pressure: when stroke volume falls, heart rate and vascular resistance rise. That is why tachycardia and a rising respiratory rate often come before hypotension. A falling blood pressure is a late sign. A shock index above about 0.9–1.0 is concerning even when the SBP looks "normal".

Early-warning bands (adult NEWS2)

ParameterScores 0Scores 3 (red score)
Heart rate51–90 /min≤ 40 or ≥ 131
Respiratory rate12–20 /min≤ 8 or ≥ 25
Systolic BP111–219 mmHg≤ 90 or ≥ 220
SpO₂ (scale 1)≥ 96%≤ 91%
Temperature36.1–38.0 °C≤ 35.0 (≥ 39.1 scores 2)

These are early-warning bands, not diagnostic normal ranges. A resting systolic BP of 180 mmHg scores 0 but is markedly raised, and a normal resting adult heart rate is usually quoted as 60–100/min.

The ABCDE approach

Assess and treat in order of what kills first: Airway, Breathing, Circulation, Disability (consciousness, glucose, pupils), Exposure. Call for help early, treat problems as you find them, and reassess after every intervention.

NEWS2

The National Early Warning Score 2 adds points for each of seven parameters. Higher scores predict deterioration (cardiac arrest, ICU admission, death) and trigger a graded response.

Parameter3210123
Resp. rate /min≤89–1112–2021–24≥25
SpO₂ scale 1 (%)≤9192–9394–95≥96
SpO₂ scale 2 (%)≤8384–8586–8788–92, ≥93 on air93–94 on O₂95–96 on O₂≥97 on O₂
Air or oxygen?OxygenAir
Systolic BP (mmHg)≤9091–100101–110111–219≥220
Pulse /min≤4041–5051–9091–110111–130≥131
ConsciousnessAlertCVPU
Temperature (°C)≤35.035.1–36.036.1–38.038.1–39.0≥39.1
AggregateClinical riskResponse
0LowRoutine monitoring, at least 12-hourly
1–4LowRegistered nurse assesses and decides on frequency (at least 4–6-hourly)
3 in any single parameterLow–mediumUrgent ward-based review by a clinician; at least hourly
5–6MediumUrgent review by a clinician competent in acute illness; at least hourly
≥ 7HighEmergency assessment by a critical-care-competent team; continuous monitoring

"C" stands for new confusion (ACVPU). Scale 2 is used only for patients with confirmed hypercapnic respiratory failure (for example some COPD patients) who have a prescribed target saturation of 88–92%.

Triage

Triage sorts patients by urgency, not by order of arrival. The South African Triage Scale (SATS), widely used in African emergency centres, combines a physiological Triage Early Warning Score (TEWS) (mobility, respiratory rate, heart rate, systolic BP, temperature, AVPU, trauma) with clinical discriminators (for example chest pain, active seizure, low glucose) that can raise the category. Target times to be seen: red immediately, orange within 10 minutes, yellow within 60 minutes, green within 4 hours. Under-triage (too low a category) risks harm; over-triage clogs resuscitation areas.

TEWS (adult)3210123
MobilityWalkingWith helpStretcher / immobile
Resp. rate< 99–1415–2021–29> 29
Heart rate< 4141–5051–100101–110111–129> 129
Systolic BP< 7171–8081–100101–199> 199
Temperature (°C)< 3535–38.4> 38.4
AVPUAlertVoice (confused*)PainUnresponsive
TraumaNoYes

TEWS 0–2 green, 3–4 yellow, 5–6 orange, ≥ 7 red. *Published versions of the SATS chart differ on whether a patient who is alert but newly confused scores 1; this simulator scores new confusion as 1. Always follow the chart used in your own facility.

The triage tab is a simplified teaching adaptation, not a clinical tool. Real SATS training uses the official chart, paediatric versions and senior clinical judgement.

Paediatric triage: ETAT+ (Kenya)

Kenyan hospitals triage sick children with ETAT+ (Emergency Triage Assessment and Treatment plus admission care), from the WHO ETAT course and the Kenya Basic Paediatric Protocols (BPP). Triage takes seconds per child and is done on arrival, before registration or payment.

Wording varies slightly between charts: the Kenya BPP chart lists "diarrhoea with sunken eyes" under D, while the WHO chart asks for diarrhoea plus any two of lethargy, sunken eyes and a very slow skin pinch. The Kenya chart uses temperature > 39.5 °C as the priority sign. Always use the chart in your facility.

What happens next: an Emergency child goes straight to the resuscitation area: call for help, give oxygen, manage A–B–C–D in order, check glucose, weigh (or estimate weight) and give treatment per protocol. A Priority child is seen next by a clinician and should not wait in the queue; re-triage if anything changes. A child with neither (Non-urgent) waits in the queue for routine assessment.

Pregnant and postpartum women

Normal pregnancy changes the numbers: heart rate rises by 10–20/min, blood pressure falls in the second trimester and blood volume expands by up to about 50%. A young, fit mother can lose a large volume of blood before her blood pressure falls, so tachycardia and a shock index above about 0.9 are early warnings in postpartum haemorrhage. NEWS2 is not validated in pregnancy; maternity units use an obstetric early-warning chart (MEOWS or the facility's maternal chart). Severe pre-eclampsia: BP ≥ 160/110 mmHg with proteinuria or symptoms (headache, visual disturbance, epigastric pain).

Alarm fatigue

Monitors alarm often, and most alarms are not clinically important. Staff can become desensitised. Setting sensible, patient-specific limits and responding to trends, not single numbers, makes alarms meaningful.

1. NEWS2 for the sepsis patient at the start

RR 24, SpO₂ 93% on air, SBP 89, HR 121, new confusion, temperature 39.2 °C.

  1. RR 24 → 2. SpO₂ 93 (scale 1) → 2. Air → 0.
  2. SBP 89 → 3. HR 121 → 2. Confusion (C) → 3. Temp 39.2 → 2.
  3. Total = 2+2+0+3+2+3+2 = 14: high risk, emergency response.

2. Shock index in haemorrhage

  1. The motorcyclist starts with HR 106, SBP 120: shock index = 106/120 = 0.88.
  2. Ten minutes later, uncontrolled: HR 137, SBP 87: index = 1.57. The SBP fell late; the index rose early.
  3. MAP at 87/57 ≈ 57 + (87−57)/3 = 67 mmHg.

3. Opioid toxicity and oxygen

  1. RR 7, SpO₂ 86% on air, responds to voice: NEWS2 = 3 (RR) + 3 (SpO₂) + 0 + … + 3 (V) = at least 9.
  2. After high-flow oxygen, SpO₂ 95%, RR still 7. NEWS2: RR 3 + SpO₂ 1 + oxygen 2 + V 3 = still ≥ 9. The saturation looks better but ventilation (and CO₂ clearance) has not improved. Treat the cause.

4. TEWS in the triage tab

Woman, 70, febrile and confused, brought on a stretcher: RR 26, HR 124, SBP 86, T 39.0 °C, confused.

  1. Mobility stretcher 2; RR 21–29 → 2; HR 111–129 → 2; SBP 81–100 → 1; Temp > 38.4 → 2; new confusion → 1 (this simulator's convention; see the Theory tab); no trauma 0.
  2. TEWS = 10 ≥ 7 → red (immediate).

5. Shock in a child with diarrhoea (Kenya BPP)

Amani, 18 months, 10 kg: cold hands, capillary refill 4 s, weak fast pulse, lethargic, sunken eyes, very slow skin pinch. (Teaching example; follow the current protocol chart.)

  1. Shock bolus: 20 mL/kg Ringer's lactate = 20 × 10 = 200 mL over 15 minutes. Reassess; one repeat bolus is allowed if still shocked.
  2. Plan C step 1 (age ≥ 12 months): 30 mL/kg = 300 mL over 30 minutes = 600 mL/h. With a macro-drip set (20 drops/mL): 600 × 20 ÷ 60 = 200 drops/min.
  3. Plan C step 2: 70 mL/kg = 700 mL over 2½ hours = 280 mL/h, about 93 drops/min. Reassess at least hourly and start ORS as soon as she can drink.

6. Shock index after delivery

  1. Njeri, 10 minutes after giving birth: HR 98, BP 116/74 → shock index 98/116 = 0.84.
  2. Ten minutes later without treatment: HR 125, BP 94/60 → 125/94 = 1.33. Well above 0.9: significant haemorrhage even though the systolic BP is still above 90.
  3. MAP = 60 + (94 − 60)/3 ≈ 71 mmHg.

7. Child fast breathing

A 9-month-old breathes 54 times in 60 seconds. The cut-off at 2–11 months is ≥ 50/min, so this is fast breathing. The same rate in a 3-year-old (cut-off 40) is also fast; in a 6-week-old (cut-off 60) it is not.

8. Pulse oximeter pitch

Many monitors lower the pitch of the pulse "beep" as SpO₂ falls, so you can hear desaturation without looking. In this simulator the tone is 300 Hz + 12 Hz per % above 70%: 98% → 636 Hz, 85% → 480 Hz.

Your best results are kept in this browser. For each scenario: press Load scenario, then Start scenario in the lab, treat the patient using the Interventions panel (work through ABCDE, following the protocol for the condition), and press End & debrief. A debrief score of at least 80% ticks it off; the debrief lists the protocol steps and explains anything you missed. Child and maternity cases use the Kenya Basic Paediatric Protocols (ETAT+) and obstetric guidance, so NEWS2 is switched off for them.

Guided experiments

  1. Compensated shock. In free play, raise HR to 125 and keep SBP at 115. Note NEWS2 and the shock index. Now drop SBP to 88: what changes?
  2. Pleth and perfusion. Lower the SBP below 80 and watch the pleth trace shrink.
  3. Alarm limits. Set the SpO₂ low limit to 94 and the heart-rate high limit to 100. Turn on sound and push a value across a limit; compare the medium and high-priority alarm tones.
  4. STEMI. Set ST to +3 mm. Compare the shape with a normal ECG.
  5. AF. Select AF: no P waves and an irregularly irregular rhythm.