Assessment of the Critically Ill Child

Objectives
 Describe the 3 components of the Pediatric
Assessment Triangle (PAT)
 Use PAT to determine sick vs. not sick
 Integrate findings to form general impression
 Identify pediatric-specific features of the initial
assessment
 Describe a focused history and physical exam
 Review techniques in evaluating children of different
ages
Pediatric Assessment Triangle

Appearance Work of Breathing

Circulation
Appearance
 Tone
 Interactiveness
 Consolability
 Look/Gaze
 Speech/Cry
Work of Breathing
 Abnormal airway sounds
 Abnormal positioning
 Retractions
 Nasal flaring
 Head bobbing
Circulation
 Pallor
 Mottling
 Cyanosis
Rapid Cardiopulmonary Assessment
 Organized approach to the pediatric patient
 Initial impression of child
 Sick or not sick
 Determine severity, physiologic abnormality &
urgency of treatment
 30-60 seconds
 From across the room
 What do you see, hear & feel?
Rapid Cardiopulmonary Assessment
 Airway (see)  Circulation (see/feel)
 Patency  Color/ temp of skin
 Peripheral & central pulses
 Breathing (see/hear)  Cap refill
 Rate
 Effort  Level of consciousness (see)
 Cyanosis  Aware of environment
 Audible sounds  Reaction to providers
Sick or Not Sick?

Why?
What do you see? Alert &
responding to
environment
Airway is
patent and Minimal
maintained work of
breathing

Activity is
spontaneous Skin is pink
What do you hear?
Good air
No audible movement
wheeze or
grunting
What do you feel?

Peripheral & central Skin is warm and

pulses are strong & dry to touch
equal

Cap refill is brisk

(< 2 seconds)
Pediatric Assessment Triangle

Appearance Work of Breathing

Normal Normal

Circulation
Normal
General Impression
 Well child (not critically ill)
 Respiratory distress
 Respiratory failure
 Shock
 Central nervous system / metabolic
dysfunction
“Cough, Difficulty Breathing”
 1 y/o boy
 Nasal congestion & low grade fever x 2 days
 Cough & noisy breathing since 2 am
 PMH unremarkable
Videos 1-4
 Video 1
Pediatric Assessment Triangle
General Impression?

Respiratory Distress
Case Progression
 Initial assessment: respiratory distress with upper airway
obstruction

 Initial treatment priorities

 Leave in position of comfort
 Obtain oxygen saturation
 Provide oxygen as needed
 Begin specific therapy (ie: racemic epinephrine)
 Consider imaging
Videos 1-4
 Video 1
 Video 2
“Severe Difficulty Breathing”
 3 month old girl
 Seen in ED 2 days earlier; sent home with
diagnosis of bronchiolitis
 Work of breathing has increased
 Decreased po intake
 No uop in 10 hrs
 What Do You See? No Eye
Contact

Nasal Flaring

Skin is Pale and

Cyanotic Accessory Muscle
Use

Increased Respiratory Rate

What Do You Hear?
Audible
Grunting Wheezing
 What Do You Feel?

Cool Extremities

Weak Peripheral
Pulses
Pediatric Assessment Triangle
 What information does the PAT give you about
this patient?
General Impression?

Respiratory Failure
Case Progression
 General Impression: Respiratory failure/ cardiopulmonary
failure

 Management priorities:
 Support oxygenation & ventilation with BVM
 Obtain vascular access
 Provide ivf
 Prepare for positive pressure/ endotracheal intubation
 Continually reassess after each intervention
Videos 1-4
 Video 3
 Video 4
“Vomiting”
 15 month male with 36 hours of vomiting & diarrhea
 Watery diarrhea
 Attempts at oral rehydration were unsuccessful
 Called ambulance when child became listless
Pediatric Assessment Triangle
General Impression

Shock
Case Progression
 Initial impression: Shock

 Management priorities
 Provide oxygen
 Obtain quick vascular access
 Administer volume (crystalloid: NS or LR) in 20mL/kg
increments
 Continuous reassessments
PAT: Shock
“Lethargic”
 3 month female
 Brought by mom after falling off her bed onto carpeted
floor
 Infant is sleepy, not herself
 Occurred 8 hrs ago
 Not improving, so brought in for evaluation
Pediatric Assessment Triangle
General Impression

CNS/ Metabolic Dysfunction

Case Progression
 General impression: CNS or metabolic dysfunction

 Management priorities
 Provide oxygen, closely monitor ventilation
 Obtain vascular access
 Rapid glucose screen
 Obtain labs, cultures, metabolic studies
 Obtain CT of head, radiographs
 Social work
 The ABCDEs
Pediatric specific differences
Airway
 Manual airway opening maneuvers
 Head tilt – chin lift, jaw thrust

 Suctioning
 Can result in dramatic improvement in infants

 Obstructed airway management

 < 1 year: back blows/ chest thrusts
 > 1 year: abdominal thrusts
Breathing: Respiratory Rate
Age Respiratory Rate
Infant 30 – 60
Toddler 24 – 60
Preschooler 22 – 34
School- aged child 18 – 30
Adolescent 12 - 16

Both slow and fast respirations can be worrisome.

Breathing: Auscultation
 Listen over mid-axillary line & above sternal notch

 Stridor: upper airway obstruction

 Wheezing: lower airway obstruction
 Grunting: pneumonia, drowning, pulmonary contusion
 Poor oxygenation
Circulation: Heart Rate
Age Normal Heart Rate
Infant 100 – 160
Toddler 90 – 150
Preschooler 80 – 140
School-aged child 70 – 120
Adolescent 60 - 100
Circulation
 Tachycardia – early indicator of shock
 Pulse quality: palpate central and peripheral pulses
 Capillary refill
 Blood pressure
 Minimum BP = 70 + (2 X age in years)
Disability
 Quick neurologic exam
 AVPU scale
 Alert
 Verbal: responds to verbal commands
 Painful: responds to painful stimulus
 Unresponsive
Exposure
 Necessary to evaluate physiologic function & identify
anatomic abnormalities
 Maintain warm, ambient environment
 Minimize heat loss
 Monitor temperature
Focused History
 Complete history including mechanism of injury and
circumstances of illness
 SAMPLE mnemonic:
 Signs/ Symptoms
 Allergies
 Medications
 Past medical history
 Last food/ drink
 Events leading to illness or injury
Detailed Physical Exam
 Again . . . Remember to undress patient fully
 Remember vital signs
 Make use of parents/ caretakers

 With history, helps establish clinical diagnosis

Ongoing Assessments
 Systematic review of assessment points
 Pediatric Assessment Triangle
 ABCDEs
 Repeat vital signs
 Reassessment of positive anatomic findings, and
physiologic derangements
 Review effectiveness and safety of treatments
Age appropriate norms and assessment
techniques
Assessment: < 2 months
 Limited behavioral repertoire
 Brief wake periods
 Do not recognize parents / strangers

 Consoled when held, gently rocked

 WARM hands/ stethoscope
 Anterior fontanelle
 Acrocyanosis
Assessment: 2-6 Month Old
 Social smile
 Recognizes caregivers
 Track light, faces
 Increasing vocalization
 Roll over, sit with support

 When possible, do much of the exam in caretaker’s

lap
Assessment: 6-12 Month Old
 Socially interactive
 Sit without support, increased
mobility
 Everything goes in mouth
 Stranger/ separation anxiety
 Sit or squat to get at eye level
when examining
 Use “toe-to-head” approach
Assessment: 1-3 Year Old
 “Terrible Twos”
 Increased mobility
 Curious about everything, no fear
 Egocentric, very strong opinions
 Not swayed by logic
 Language comprehension is greater than expression
 Watch what you say
Assessment: 4-10 Year Old
 Analytical, understand cause and effect
 Cooperative, “age of reason”
 But:
 Many misconceptions about the body
 May overestimate implications of illness/ injury
 May misinterpret information
Assessment: Adolescent
 Similar to toddlers
 Risk-takers, no fear of danger
 Don’t anticipate consequences
 Not swayed by common sense
 Dependence shifts from family to peers

 Assessment techniques
 Respect privacy
 Talk to teen, not the parents
 Private social history
 Provide concrete explanations
The Bottom Line
 Begin with PAT followed by ABCDEs
 Formulate your general impression
 Obtain a focused history and detailed physical exam
 Treat respiratory distress, failure and shock as soon as
it is recognized
 Perform ongoing assessments throughout ED stay