PEDIATRIC ASSESSMENT

TRIANGLE
11-01-2023
Appearance
Appearance
● By six months of age, nearly all children should be able to sit up and support
their own heads
● If children do not appear to be interested in what is going on in the world
around them, it is time to be a little concerned
● If children cannot be consoled, despite the best efforts of their mother, then
something is wrong
● Not normal for young children to stare off into the distance, may be normal for
teen
Work of breathing
Circulation to skin
Appearance Work of breathing Circulation to skin Presentation

Normal Normal Normal Stable

Appearance Work of breathing Circulation to skin Presentation

Normal Abnormal Normal Respiratory

distress
Appearance Work of breathing Circulation to skin Presentation

Abnormal Abnormal Normal Respiratory failure

Appearance Work of breathing Circulation to skin Presentation

Normal Normal Abnormal Shock

Appearance Work of breathing Circulation to skin Presentation

Abnormal Normal or Abnormal Abnormal Shock

Appearance Work of breathing Circulation to skin Presentation

Abnormal Normal Normal CNS/ Metabolic

Appearance Work of breathing Circulation to skin Presentation

Abnormal Abnormal Abnormal Cardiopulmonary

arrest
Initial Physiological Categorization
● Stable
● Unstable
○ Not life threatening
○ Life threatening
Limitations
● Less useful in children with developmental delay, those with congenital
abnormalities or those who rely on technology.
Evidence
● Study in 2014 - 1552 PAT forms - 1168 patients included - Exluded patients
who were not transported to hospital and children with special care needs -
Investigators (blinded) reviewed hospital charts and assessed category of
illness - 77.4% Sensitive and 90% specific *

● 528 children - Triage nurses vs blinded investigators - LR of 10 *

Scenarios
A 3-year-old boy is brought to the ED with complaints of trouble breathing. The
PAT reveals an alert and interactive toddler who cries vigorously when his mother
puts him on the examination table and actively resists examination. He has
subcostal and intercostal retractions and stridor when agitated, and his skin is
pink.

The nurse calls you to the ED examination room of a 4-month-old girl. The infant is
limp and unresponsive and has gasping respiratory effort and pale skin
References
https://aliemcards.com/cards/pediatric-assessment-triangle/

https://dontforgetthebubbles.com/the-paediatric-assessment-triangle/

https://pubmed.ncbi.nlm.nih.gov/20386420/

PALS textbook