Pediatric Initial assessment form Filled by

Date Time
Name sex Date of birth
Father's Name
Evaluate
Initial Impression
evaluation action
Consciousness alert proceed evaluation
agitated / irritable
start o2 / monitors / blood sugar
lethargic
unresponsive call for help /put on monitors /? CPR

Breathing normal
fast or labored
ensure oxygen
slow
gasping / not breathing Start Chest Compression if pulse < 60

Color pink proceed as appropriate

pale
ensure oxygenation
mottled / cyanosed
bleeding attempt controlling bleeds
Primary assessment
A Airway open clear support breathing
nasal block maintainable use saline nasal drops
secretions maintainable suction, < ten seconds continuously
stridor maintainable use positioning,
wheezing maintainable use positioning, nebulization
injured maintainable use positioning, OPA, NPA
unmaintainable tracheal tube placement

B Breathing normal
Respiratory Rate fast ensure appropriate oxygenation
slow call for help / BVM Ventilation

normal
Respiratory efforts increased
decreased call for help / BVM Ventilation

normal
chest wall expansion increased
decreased call for help

AEBE
air entry / auscultation crepts
rhonchi
bronchial breathing
absent air entry on any Right / Left side

>94% in RA
pulse oxymetery < 94% ensure oxygenation
<90% despite oxygen call for help / BVM Ventilation

c circulation normal
Heart Rate fast apply cardiac monitor and
 slow call for help / BVM Ventilation

HR < 220 (infants) or 180 in child p waves present,

Rhythm narrow QRS HR > 220 in infants
assess circulation, call ice packs, get vascular
HR > 180 in children
access, arrange synchronized cardio version
pulse present
broad complex
pulse absent start Chest compressions

normal volume
pulse peripheral / central decreased volume vascular access / blood gas /sampling
absent

CFT <2 seconds > 2 seconds

pink
skin color mottled
pale
cyanosed

normal
skin temperature warm
cool

>minimum acceptable
Blood Pressure <minimum acceptable call for help / vascular access gained?
1-10 y =70 + (age x 2)
>10 yr = > 90 mm Hg

D Disability >12
GCS score GCS 8 - 12
<8 arrange intubation

PEARL
Pupils non reacting
dilated
anisocoric arrange intubation / ventilation

E exposure above 100.3 paracetamol / hydrotherapy / monitor

core temperature below 97 ensure warmth / check RBS
below 96 initiate warming
deformities / swellings /
injuries / abdominal describe
distension
Respiratory Insufficiency
Identify I respiratory distress ensure 100% Oxygen
* respiratory failure arrange ventilation
upper airway obstruction position / adrenalin nebulization / I/M dexamethasone
lower airway obstruction salbutamol nebulization / systemic steroids
lung parenchymal disease oxygenate/ blood sampling / antimicrobials
disordered control of breathing manage under lying condition / support ventilation as needed

circulatory insufficiency
normotensive oxygen / vascular access / call for help /
hypotensive secondary assessment

cardiopulmonary failure bradycardia / bradypnea / cyanosis

initiate ventilation / IV bolus

Secondary Assessment
 S signs and symptoms

A allergies

M medications

P past medical history

L last meal

E events

head to toe and systemic examination

HEENT throat
CVS
PA
CNS meningeal signs FND reflexes
relevant local examination

Identify II * Respiratory insufficiency cause of respiratory insufficiency

Circulatory insufficiency
Birth history
cause of shock
Hypovolemic state h/o losses
distributive sepsis / neurogenic
anaphylactic skin / respiratory signs / shock
cardiogenic no specific history (shock with grunting)
start NS bolus: 10 ml / kg if suspect cardiogenic, plan / start inotropes, for
other shocks give 20 ml / kg and reassess,

Development history

Dietary history

Immunization history

Family history

Anthropometery wt Ht Head circumference

Provisional Diagnosis

Differential diagnosis

Investigations

Intervention (treatment)

Referals
signed Senior Resident Consultant date / time