PAEDIATRIC ASSESSMENT

:TRIAGE
RECOGNITION OF THE
CRITICALLY ILL CHILD
:OBJECTIVES AND GOALS

How to do rapid and accurate evaluation of cases in

ED to determine critically ill cases.
 Know the three components of the Pediatric
Assessment Triangle
Have systematic approach to sick child in ED
 Know the ED management of Common Pediatric
Emergencies
:REMEMBER THAT

o Children are not young adults

o Adults are big children but with chest pain
o Different age group
o Age specific norms
o Remember important differences between adult and
kids
 ILL CHILD COME TO ED
??HOW TO DEAL

ABCDE ASSESSMENT

VITAL SIGNS,DETAILED HISTORY,PHYISCAL

EXAM
PAEDIATRIC ASSESSMENT TRIANGLE
WHAT IS PAT???

It is a rapid, accurate and easily-

learned model for the initial
assessment of any child
It allows the clinician, using only
visual clues, to rapidly assess the
severity of the child’s illness or
injur y and urgency for treatment,
regardless of the underlying
diagnosis .
:PAT IS THE INITIAL STEP

door step” assessment.

 “PAT” is the tool.
 Some idea about – Respirator y /
Circulator y /Neurological.
 No touching baby
No stethoscope
 No pricking / inter vention.
 APPEARANCE

 Reflect the adequacy of :

Oxygenation
Ventilation
Brain per fusion
Cns function
 STAND BACK!!! - APPEARANCE

 MNEMONIC – TICLS
 Tone
 Interactiveness
 Consolability (overlaps with
irritability)
 Look / Gaze (“glassy eyed”
 Speech / Cry (high pitched, ‘cephalic’)
 Level of aler tness, somnolent, lethargic
MUSCLE TONE
INTERACTIVNESS,LOOK,GAZE,SPEECH,
CRY
ALERT
EYE
CONTACT

Inconsonable
crying
NORMAL:

• All of the above normal suggests at

least adequate ventilation, oxygenation
and brain per fusion
• Ask the parents!!! What is normal?
• Watching interaction with parent can
differentiate behaviour from illness
• Inconsolable versus irritable
• More dif ficult the younger the patient
(Neonates can ‘startle’ and cr y)
TRULY “INCONSOLABLE” CHILDREN

Corneal ulcer
Testicular torsion
Meningitis
colic and constipation
Airway & Breathing - assessment

?Is the child breathing•

? Is there central cyanosis•

Does the child have severe respiratory•

?distress
 ? IS THE CHILD BREATHING

Look: If active, talking, or crying, the child is obviously•

breathing. If none of these, look again to see whether
. the chest is moving
. Listen: Listen for any breath sounds•
.Feel: Feel the breath at the nose or mouth of the child •
Gasping is spasmodic open mouth breathing associated
with sudden contraction of diaphragm & retraction of
.hyoid apparatus. It is a manifestation of brain hypoxia
 ? IS THERE CENTRAL CYANOSIS

To assess for central cyanosis, look at the mouth and •

. tongue
A bluish or purplish discoloration of the tongue and the •
.inside of the mouth indicates central cyanosis
 DOES THE CHILD HAVE SEVERE
? RESPIRATORY DISTRESS
Respiratory rate ≥ 70/min•
Severe lower chest in-drawing•
Head nodding•
Apneic spells•
Unable to feed due to respiratory problem•
.( Stridor (A harsh noise on breathing in is called stridor•
Grunting (A short noise when breathing out in young infants•
.(is called grunting
 Airway & Breathing - management

Airway management
Manage airway•

Provide BLS - Basic Life Support•

Give Oxygen•

Make sure child is warm•

 Airway management

If there is history of foreign body aspiration or if the •

child is choking with increasing respiratory distress,
.suspect foreign body

.Clear any secretions in present•

MANAGEMENT OF CHOKING IN YOUNG
INFANT

 Lay the infant on arm or thigh in a head

. down position
 Give 5 blows to the infant’s back with heel of
( hand. (Back slaps
 If obstruction persists, turn infant over and
give 5 chest thrusts with 2 fingers, one
finger breadth below nipple level in midline.
( (Chest thursts
 If obstruction persists, check infant’s mouth
. for any obstruction which can be removed
 If necessary, repeat sequence with back
.slaps again
MANAGEMENT OF CHOKING IN OLDER CHILD

 Give 5 blows to the child’s back with heel of hand with

( child sitting, kneeling or lying. (Back slaps
 If the obstruction persists, go behind the child and pass
your arms around the child’s body; form a fist with one
hand immediately below the child’s sternum; place the
other hand over the fist and pull upwards into the
. abdomen; repeat this Heimlich maneuver 5 times
 If the obstruction persists, check the child’s mouth for
. any obstruction which can be removed
 If necessary, repeat this sequence with back slaps
.again
 NECK TRAUMA

Suspect when there is history of trauma to head and neck region or history
. of fall or external injuries to head and neck region on examination

Keep the child lying on the back•

. on a flat surface
Tape the child’s forehead to the•
sides of a firm board to secure
. this position
Prevent the neck from moving by•
. supporting the child’s head
.Place a strap over the chin•
OPENING THE AIRWAY IN AN INFANT & OLDER
CHILD
:CIRCULATION

o Goals
 Adequate cardiovascular function and tissue perfusion
 Effective circulating fluid volume
 Normal core body temperature

o Reflect adequacy of
 Cardiac output
 Perfusion of vital organs
:CIRCULATION

 Circulation assessed by evaluation of

• Heart rate and rhythm
• Pulse
• Capillary refill time
• Skin color and temp
• Blood pressure
Cardiovascular signs
 HEART RATE- 1

• HR with age
• In cardiac arrest
Early HR
Late HR

• Normal HR in presence of other signs of circulatory

insufficiency is a bad prognostic sign
( Age (years HR
1> 110-160
1-2 100-150
2-5 95-140
5-12 80-120
12< 60-100
CAPILLARY REFILL TIME-2

 Time takes for blood to return to

tissue blanched by pressure.
 Increase as skin per fusion decrease.
 Prolonged CFT(3-5seconds) indicate
low cardiac out put.
Normal CFT <= 2
To evaluate CFT lift extremity slightly
above the level of the heart, press on
the skin and rapidly release the
pressure
 PULSE VOLUME-3

Grade Description
4+ Full , NOT obliterated with pressure

3+ Normal easily palpated NOT easily obliterated with pressure

2+ Difficult to palpate obliterated with pressure

1+ Thready and weak difficult to palpate

 Compare
0 strength and quality of central Absent
and peripheral pulses
 Central pulse
infant > brachial or femoral
old child >carotid artery
 BLOOD PRESSURE-4
( Age (years ( SBP (mmHg
1> 70-90
1-2 80-95
2-5 80-100
5-12 90-110
12< 100-120

BP with age 
Y SBP =70+(2 X age in 2< 
(years
Hypotension is a late and pre 
terminal sign
Absence of hypotension NOT 
exclude shock
 SKIN AND TEMPERATURE- 5

 Mucous membrane, nail beds, palms and soles

should be pink.
 When perfusion deteriorates and O2 delivery to
tissue becomes inadequate the hands and feet
are typically affected 1st.
 They may become cool , pale, dusky or mottled.
 If perfusion become worst skin over the trunk
and extremities may under go similar changes
Pallor

mottled
EFFECTS OF CIRCULATORY INADEQUACY ON
OTHER ORGANS
 Respiratory system
tachypnea without recession
 Skin
mottled ,cold ,pale
 Mental
irritable then unresponsive
 Urinary output
UOP less than 1ml/kg/h in child indicate
inadequate renal perfusion
 THERE IS A CLEAR OVERLAP BETWEEN
RESPIRATORY AND CIRCULATORY FAILUER
THE FOLLOWING SIGN ARE MORE IN FAVOR OF
A CIRCULATORY CONDITION

1 . Cyanosis despite supplied

oxygen
2. Quite tachypnea ( tachypnea
without recession)
3. Raised jugular venous
pressure
4. Gallop rhythm / murmur
5. Enlarged liver
 DISABILITY

o Quick neurological examination:

o consciousness level:
 POSTURE

The posture at rest/without stimulation may be abnormal.  For

example the seriously ill child may be hypotonic (floppy),a painful
stimulus should be then applied.  This may elicit abnormal stiff
posturing:
Decorticate (flexed arms and extended legs)
Decerebrate (extended arms and legs). 
 PUPILS

When examining the pupils note the size, equality and reaction to light.
A fixed dilated pupil in the context of a brain injury indicates herniation of
the temporal lobe through the tentorial hiatus (‘coning’) as a result of 3rd
cranial nerve compression. Urgent discussion with a neurosurgical centre
is required.

Bilateral fixed dilated pupils are a sign of brain death but can occur in
hypothermia, severe hypoxia, during and post seizure, anticholinergic
overdose and in deep unconsciousness.
Small reactive pupils can be seen in metabolic disorders.
Pinpoint pupils are seen with an opioid overdose and organophosphate
ingestion.
 OTHER NEUROLOGICAL SIGNS

Tone
Interactivity (mental status)
Consolablity by parents
Look or Gaze
Speech or Cry
Abnormal reflexs
Motor activity
Eye contact (>2 months)
 BLOOD GLUCOSE

Both hypo and hyperglycemia can cause a change in level or

consciousness and neurological functioning. The blood
glucose should be measured as part of your assessment of D.
A rapid finger-prick bedside testing method can be used. 
 PEDIATRIC CUPS ASSESSMENT

Category Assessment Actions Example

Critical ,Absent airway Perform rapid initial Severe traumatic injury
breathing, or interventions and transport with respiratory arrest or
circulation simultaneously cardiac arrest

Unstable ,Compromised airway Perform rapid initial Significant injury with

breathing, or interventions and transport ,respiratory distress
circulation with simultaneously ;active bleeding, shock
altered mental status ;near-drowning
unresponsiveness
Potentially ,Normal airway Perform initial assessment ;Minor fractures
unstable ,breathing, circulation with interventions; transport pedestrian struck by car
and mental status BUT promptly; do focused history but with good appearance
significant mechanism and physical exam during and normal initial
of injury or illness transport if time allows assessment; infant
younger than three
months with fever

Stable ,Normal airway Perform initial assessment ,Small lacerations

,breathing, circulation with interventions; do abrasions, or
and mental status; no focused history and detailed ecchymoses; infant older
significant mechanism physical exam; routine than three months with
of injury or illness transport fever
CARDIOPULMONRY ARREST
 CAUSES OF CARDIOPULMONRY ARREST

 1) Hypoxia
 2) Hypotension
 3) Hypothermia
 4) Hypoglycemia
 5) Acidosis (H+)
 6) Hypokalemia (electrolyte disturbance)
 7) Cardiac Tamponade
 8) Tension pneumothorax
 9) Thromboembolism (pulmonary, coronary)
 10) Toxicity (eg. digoxin, local anesthetics, TCA, insecticides).
 RESPIRATORY CARDIAC ARREST TREATMENT

Infant Child Teen

1year > years 1-8 years 9-18

Ventilation min/20 min/20 min/12

CPR method finger 2 hand 1 hand 2

Chest depth 1/3-1/2 1/3-1/2 1/3-1/2

Compression rate min/100≤ min/100≤ min/100≤

ratio 5:1 5:1 5:1

CPR should be started for HR>60.

Only AEDs with pediatric capabilities should be
used on patients > 8 yrs. of age (approx. 25kg
or 55lb).