EMERGENCY

ASSESSMENT IN
Swapna KG
Asst. Professor (Child Health
Nursing)

PEDIATRIC ADVANCED Govt.College of Nursing

Thiruvananthapuram
LIFE SUPPORT
SYSTEMATIC ASSESSMENT

ID
EN
SS

TI
SE

FY
AS

INTERVENE
SYSTEMATIC ASSESSMENT
Initial Impression
Primary Assessment
Secondary Assessment
INITIAL IMPRESSION

To identify a life threatening condition

Life threatening problem

Not Life threatening problem
INITIAL IMPRESSION
PAT (pediatric assessment triangle)
INITIAL IMPRESSION-
APPEARANCE
T
I
C
L
S
INITIAL IMPRESSION-WORK
OF BREATHING
Normal Abnormal

Respiratory Effort •Regular breathing, no •Nasal flaring

increased effort •Retractions or use of
•Passive expiration accessory muscles
•Increased, inadequate or
absent respiratory effort
Lung Sounds No abnormal breath Noisy breathing
sounds
INITIAL IMPRESSION-
CIRCULATION

Normal Abnormal
Skin colour Appears normal •Pallor
•Mottling
•Cyanosis
Petechiae/ Purpura/ Not normal •Obvious significant
visible bleeding bleeding
wound •Bleeding within the
skin
 IDENTIFICATION-TYPE AND
SEVERITY OF PROBLEM
Type Severity
Respiratory •Upper airway obstruction •Respiratory distress
•Lower airway obstruction •Respiratory failure
•Lung tissue disease
•Disordered control of
breathing
Cardiac •Hypovolemic shock •Compensated shock
•Distributive shock •Decompensated shock
•Cardiogenic shock
•Obstructive shock
Cardiopulmonary failure
Cardiac arrest
INTERVENTION
Sick (Life threatening)- Begin life saving
interventions
Not sick- continue with systematic assessment
LIFE SAVING INTERVENTIONS
oPositioning to maintain patent airway
oActivate EMS
oStart CPR
oObtain crash cart and monitor
oPlacing the child on monitor
oAdminister oxygen
oSupporting ventilation
oStarting medications and fluids
PRIMARY ASSESSMENT
A rapid hands on
ABCDE approach to
A B
evaluate respiratory
cardiac and
C neurologic function
E

including vital signs

D
and pulse oxymetry
AIRWAY- ASSESS
Look for movement of chest/abdomen
Listen for air movement and breath sounds
Feel for air movement at the nose and mouth

ASSESS FOR NOT MORE THAN 10 SECONDS

AIRWAY-FINDINGS
STATUS DESCRIPTION
Clear Unobstructed clear airway
Maintainable Obstructed but can maintain
open by simple measures
Non-maintainable Obstructed and cannot maintain
without advanced interventions
AIRWAY- FINDINGS

1. Upper Air way obstruction

Increased effort with retractions

Inspiratory stridor
Snoring
Absence of breath sounds
AIRWAY-SIMPLE
INTERVENTIONS
Positioning-Responsive child/ unresponsive child
Head tilt chin lift/ jaw thrust
Suction
Back slap and chest thrust
Heimlich maneuver
Airway adjuncts – OPA/NPA
OPA/NPA
AIRWAY- ADVANCED
INTERVENTIONS
ET intubation/ LMA
Non invasive ventilation/ continuous positive
pressure ventilation
Foreign body removal- direct laryngoscopy
cricothyrotomy
LMA
NORMAL RESPIRATORY RATES
BY AGE
Age Breaths / minute
Infant 30-53
Toddler 22-37
Preschooler 20-28
School age child 18-25
adolescent 12-20
BREATHING- ASSESS
Rate Tachypnea, bradypnea, apnea*

Effort Nasal flaring, chest retractions, head bobbing, grunting,

wheezing,
Expansion Bilaterally equal or not

SPo2 <94% (room air) - hypoxia

Airway sounds Wheeze, crackles, rhonchi

RETRACTIONS AND LEVEL
OF BREATHING DIFFICULTY
Level of breathing difficulty Location of retraction
Mild to moderate Subcostal
Substernal
Intercostal
Severe Supraclavicular
Suprasternal
Sternal
BREATHING- IDENTIFY

2. Lower air way obstruction

3. Lung tissue disease
BREATHING- INTERVENE
Supplemental oxygen
Nebulized medications
Bag and mask ventilation
Endotracheal intubation
CIRCULATION- ASSESS
CIRCULATION- ASSESS
Pulse Characteristics
Rate Absent, Tachycardia, bradycardia

Rhythm Arrhythmic, regular

Volume Central vs peripheral

Characteristics Regular, irregular

NORMAL HEART RATES
Age Awake rate(/min) Sleeping rate (/min)
Neonate 100-205 90-160
Infant 100-180 90-160
Toddler 98-140 80-120
Preschooler 80-120 65-100
School age 75-118 58-90
adolescent 60-100 50-90
HEART RATE CLASSIFICATION
Slow- bradycardia
Fast- tachycardia
Absent- cardiac arrest
PULSES
Central pulses Peripheral pulses
•Femoral •Radial
•Brachial •Dorsalis pedis
•Carotid •Posterior tibial
•axillary
CIRCULATION- ASSESS
Blood pressure Hypotension
Systolic BP
Term neonate <60
Infant <70
1-10 years 70 + (2 X age of child)
>10 years 90+ (2 X age of child)
CIRCULATION- ASSESS
NORMAL BLOOD PRESSURE
Age SBP (mm Hg) DBP (mm Hg) MAP (MM Hg)
Birth (12 hrs, <1000gm) 39-59 16-36 28-42
Birth (12 hrs 1-3 kg) 60-76 31-45 48-57
Neonate (96 hrs) 67-84 35-53 45-60
Infant 72-104 37-56 50-62
Toddler 86-106 42-63 49-62
Pre schooler 89-112 46-72 58-69
School age 97-115 57-76 66-72
Pre adolescent 102-120 61-80 71-79
Adolescent 110-131 64-83 73-84
CIRCULATION- IDENTIFY
Tissue perfusion- normal or decreased
CIRCULATION- INTERVENE
Chest compression
Fluid resuscitation
Vasopressors
Inotropes
DISABILITY (NEUROLOGICAL)-
ASSESS
Level of consciousness
A - Alert
V - Response to verbal command
P - Response to painful stimulus
U - Unresponsive
Pupillary response
Blood glucose level
AVPU SCORING
Response GCS eqivalent
Alert Awake, active, appropriately 15
responding
Voice Responds to 13
voice only
Painful Responds to painful stimulus 8
only
Unresponsive Not responding to any stimuli 3
DISABILITY (NEUROLOGICAL)-
IDENTIFY
Neurologically stable or not
Hypoglycemic or not
DISABILITY (NEUROLOGICAL)-
INTERVENE
Chest compression and ventilation
Glucose administration
EXPOSURE
To facilitate focused physical examination
To find out unidentified evidences of trauma
SECONDARY ASSESSMENT
43