PEP Course Lecture 3 PEDIATRIC ASSESSMENT TRIANGLE

Lecture Objectives

1. Understand the elements of the Pediatric Assessment Triangle.

2. Distinguish the Triangle from the Pediatric Primary Survey.

3. Highlight the differences between adult and pediatric assessment.

Case 1

A babysitter calls 911 for a 14 month old girl who is having trouble breathing.

Assessment

• The child is in her babysitter’s arms and appears fatigued, with loud inspiratory stridor with each breath.

• She takes one look at you and starts to wail. Her stridor gets worse as she becomes agitated.

Key Question

What are the elements of the assessment that are most useful?

Pediatric Assessment Triangle Appearance

Pediatric Assessment Triangle Work of Breathing

Pediatric Assessment Triangle Circulation to Skin

Pediatric Assessment Triangle Appearance Work of Breathing Circulation to Skin

Pediatric Assessment Triangle

The Triangle focuses on three interdependent aspects of physical assessment that reflect: 1. Severity of illness or injury 2. Urgency of intervention

In other words ...

How sick?

How quick?

Pediatric Assessment Triangle

The Triangle is a rapid way to determine physiologic stability.

Key Question

How can you assess physiologic stability just by looking at the child?

Appearance

• alertness • distractibility • consolability • eye contact • speech or cry • motor activity • color

Appearance

The child’s overall appearance reflects the adequacy of oxygenation, ventilation and perfusion.

Pearl

• Appearance is the single most important factor in assessment.

• There are very few false negatives (very few truly sick or injured children that have normal appearance).

Pearl

• A child can have a chronic or acute illness or injury with visible abnormalities, but not be physiologically sick.

•A physiologically sick child will look sick.

Key Question

How do you recognize respiratory distress and failure by looking at the child?

Work of Breathing

• Abnormal audible breath sounds (e.g. stridor, wheezing or grunting) • Retractions (suprasternal, intercostal, subcostal) • Nasal flaring

Triangle: Respiratory Distress

Normal Appearance Increased Work of Breathing

MEANS RESPIRATORY DISTRESS

Triangle: Respiratory Failure

Abnormal Appearance Increased or Decreased Work of Breathing

MEANS RESPIRATORY FAILURE

Key Question:

What is the most reliable way to rapidly assess adequacy of perfusion?

Circulation to Skin

• Inadequate perfusion of vital organs leads to compensatory vasoconstriction in non-essential anatomic areas, especially the skin.

• Therefore circulation to skin reflects overall adequacy of perfusion.

Key Question

How do you assess circulation to the skin?

Circulation to Skin

• Skin temperature • Pulse strength • CRT (capillary refill time)

Triangle: Shock

Abnormal Appearance Poor Circulation to Skin

MEANS SHOCK

Triangle:

Normal Appearance Poor Circulation to Skin

MEANS OBSERVE

Circulation to Skin

Other causes of vasoconstriction (mottling,



CRT)

• Fever • Hypothermia • Medications • Normal vasomotor lability in infants

Pearl: Triangle

The Triangle can also help identify the child with CNS or systemic problems who has normal oxygenation, ventilation and perfusion.

Triangle: Brain Dysfunction

Abnormal Appearance Normal Work of Breathing Normal Circulation to Skin

MEANS BRAIN DYSFUNCTION

Pearl: Sensitivity and Specificity

The Triangle provides sensitivity and specificity: • Appearance identifies almost every child with serious illness or injury, and offers sensitivity.

• Work of Breathing and Circulation to Skin help distinguish between organ systems that are likely sources of distress. These elements offer specificity.

Case continues

You perform the triangle: • The child is alert, makes good eye contact, has a strong cry and is consolable.

• She has stridor. No grunting or wheezing. No flaring. Suprasternal and intercostal retractions present.

• Circulation to skin is normal.

Pediatric Primary Survey

After completing the Triangle, begin a more complete

pediatric primary

survey.

Key Question

What is the difference between the Triangle and the pediatric primary survey?

Key Points

1. The Triangle is a “quick look” of overall severity and urgency of treatment.

2. The primary survey is a rapid ordered, stepwise evaluation of cardiopulmonary and neurologic function to prioritize treatment.

3. Begin resuscitation immediately when you identify a life-threatening problem in the primary survey.

Case continues

You approach the child, who is now calm in her babysitter’s arms. You offer her your penlight which she plays with while you perform your “hands-on” assessment, or primary survey.

Pediatric Primary Survey AIRWAY & BREATHING

Assess adjunctive signs: • Respiratory rate (RR) • Tidal volume ausculation • Lung sounds (crackles, wheezes) • Pulse oximetry (SaO 2 )

Pediatric Primary Survey CIRCULATION

Assess adjunctive signs: • Heart Rate (HR) • Blood Pressure (BP): in children <3 yrs, attempt only once

Pediatric Primary Survey DISABILITY

• AVPU • Pupils • Abnormal movement

Pearl: Disability vs. Appearance

• “Disability” evaluates altered level of consciousness. It is not very useful unless illness or injury is moderate-critical.

• Abnormal “appearance” reflects mild-moderate severity and is much more useful as an assessment tool.

Abnormal Appearance on AVPU

Abnormal

A V P U

worsening severity

Summary of Triangle

• Playful and vigorous.

• Stridor at rest.

• Suprasternal and intercostal retractions.

• Extremities warm. CRT <2 secs.

Summary of Primary Survey

• RR 50/min.

• Fair inspiratory volume.

• Breath sounds clear.

• SaO 2 = 93% on room air.

• HR 140/min. BP not obtained.

• Alert, PERRL, normal motor exam.

Key Question

How would you describe this child when giving radio report to the base hospital?

Radio Report

This is a 14 month old female in moderate respiratory distress with partial upper airway obstruction. She is alert and interactive but has inspiratory stridor at rest and is retracting. She is pink and well perfused. We will transport with blow-by oxygen.

Case 2

A frantic young mother calls 911 because her infant had a fever last night, and she could not awaken him this morning. She is waiting for the ambulance on the street, while holding her 6 month old baby in her arms.

Key Question

What features of this infant’s general appearance will help you to assess his physiologic stability?

Case continues: Appearance

• Child is lethargic.

• Eyes are open, but he does not focus on his mother’s face.

• Cries weakly with painful stimulus, but does not pull away.

• Limp, with no spontaneous movement.

• Pale and mottled.

Key Question

What are the key features of work of breathing?

Case continues: Work of Breathing

• No abnormal audible breath sounds • No retractions • No flaring

Key Question

What are the key features of circulation to skin?

Case continues: Circulation to Skin

• Skin cool at kneecap • Brachial pulse weak • CRT 5 secs

Key Question

Based upon the Triangle, how sick is this child and how urgent is treatment?

Pediatric Primary Survey A/B :

Airway clear RR 10/min; clear BS; poor air entry; SaO 2 not obtainable

C :

HR 190/min; BP not obtainable on one attempt

D :

Responds only to pain on AVPU; PERRL; no spontaneous movement

Pearl

An abnormally slow respiratory rate (< 20/min) in an ill-appearing child is a sign of respiratory failure and imminent respiratory arrest.

Pearl

Attempt BP once only in children <3 years of age. BP has limited value for accurate assessment of circulation.

Key Question

How would you describe this baby in your radio report?

Radio Report

This is a 6 month old male in respiratory failure and shock. He is responsive only to pain. The baby is breathing spontaneously at a slow rate of 10 breaths per minute, with unlabored respirations. His heart rate is 190/min. He is mottled, with weak central pulses, and cool extremities. We are initiating intubation and a rapid isotonic fluid bolus.

Key Question

How would you estimate ETT size and IV fluid rate for this baby?

Resuscitation Tape

The resuscitation tape is a proven method for rapid equipment sizing and drug dosing based upon the child’s measured length. It avoids estimations of weight.

Lecture Summary

1. The Pediatric Assessment Triangle is useful in every first contact with an ill or injured child.

2. The pediatric primary survey helps identify potentially life-threatening problems, and directs initial resuscitation in a stepwise fashion.

Lecture Summary cont’d.

3. Interpretation of vital signs in children may be difficult.

4. The resuscitation tape improves accuracy of equipment sizing and drug dosing.