PEP Course Lecture 3 PEDIATRIC PEDIATRICASSESSMENT TRIANGLE TRIANGLE

PEP CoursePEP CourseLecture 3Lecture 3

PEDIATRICPEDIATRIC

ASSESSMENTASSESSMENT

TRIANGLETRIANGLE

Lecture ObjectivesLecture Objectives

1. Understand the elements of the1. Understand the elements of the

Pediatric Assessment Triangle.Pediatric Assessment Triangle.

2. Distinguish the Triangle from the 2. Distinguish the Triangle from the

PediatricPediatric Primary Survey.Primary Survey.

3. Highlight the differences between 3. Highlight the differences between adult and pediatric adult and pediatric assessment.assessment.

Case 1Case 1

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

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

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

AssessmentAssessment

Key QuestionKey Question

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

Pediatric Assessment TrianglePediatric Assessment Triangle

AppearanceAppearance


Work ofWork of BreathingBreathing


Circulation to SkinCirculation to Skin



AppearanceAppearance Work ofWork of BreathingBreathing

The Triangle focuses on three The Triangle focuses on three interdependent aspects of physical interdependent aspects of physical assessment that reflect:assessment that reflect:

1. Severity of illness or injury1. Severity of illness or injury

2. Urgency of intervention2. Urgency of intervention


In other words ...In other words ...

HowHowsick?sick?

HowHow quick?quick?


The Triangle is a The Triangle is a rapidrapid way to way to determine physiologic stability. determine physiologic stability.


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

AppearanceAppearance

• • alertnessalertness • speech or cry • speech or cry

• • distractibilitydistractibility • motor activity • motor activity

• • consolabilityconsolability • color • color

• • eye contacteye contact

AppearanceAppearanceThe child’s overall appearanceThe child’s overall appearance

reflects the adequacy of oxygenation,reflects the adequacy of oxygenation,

ventilation and perfusion.ventilation and perfusion.

• • Appearance is the single most important Appearance is the single most important factor in assessment.factor in assessment.

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

PearlPearl

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

••A physiologically sick child will look sick.A physiologically sick child will look sick.

PearlPearl


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

Work of BreathingWork of Breathing

• • Abnormal audible breath sounds Abnormal audible breath sounds (e.g. stridor, wheezing (e.g. stridor, wheezing or grunting)or grunting)

• • Retractions (suprasternal, Retractions (suprasternal, intercostal, subcostal)intercostal, subcostal)

• • Nasal flaringNasal flaring

Triangle: Respiratory DistressTriangle: Respiratory Distress

NormalNormalAppearanceAppearance

IncreasedIncreasedWork of BreathingWork of Breathing

MEANS RESPIRATORY DISTRESSMEANS RESPIRATORY DISTRESS

Triangle: Respiratory FailureTriangle: Respiratory Failure

MEANS RESPIRATORY FAILUREMEANS RESPIRATORY FAILURE

Increased orIncreased orDecreased WorkDecreased Work of Breathingof Breathing

AbnormalAbnormalAppearanceAppearance

Key Question: Key Question:

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


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

• • Therefore circulation to skin reflects Therefore circulation to skin reflects overall adequacy of perfusion.overall adequacy of perfusion.


How do you assess circulation How do you assess circulation to the skin?to the skin?


• • Skin temperatureSkin temperature

• • Pulse strengthPulse strength

• • CRT (capillary refill CRT (capillary refill time)time)

Triangle: ShockTriangle: Shock

Poor Circulation to SkinPoor Circulation to Skin

MEANS SHOCKMEANS SHOCK


Triangle: Triangle:

Poor Circulation to SkinPoor Circulation to Skin

MEANS OBSERVEMEANS OBSERVE

NormalNormalAppearanceAppearance

Circulation to SkinCirculation to SkinOther causes of vasoconstrictionOther causes of vasoconstriction

(mottling, (mottling, CRT) CRT)

• FeverFever• HypothermiaHypothermia• MedicationsMedications• Normal vasomotor lability in infantsNormal vasomotor lability in infants

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

Pearl: TrianglePearl: Triangle

Triangle: Brain DysfunctionTriangle: Brain Dysfunction

Normal Circulation to SkinNormal Circulation to Skin

MEANS BRAIN DYSFUNCTIONMEANS BRAIN DYSFUNCTION


Normal WorkNormal Work of Breathingof Breathing

The Triangle provides sensitivity and specificity:The Triangle provides sensitivity and specificity:

• • Appearance identifies almost every child with Appearance identifies almost every child with serious illness or injury, and offers serious illness or injury, and offers sensitivitysensitivity..

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

Pearl:Pearl:SensitivitySensitivity and Specificity and Specificity

Case continuesCase continuesYou perform the triangleYou perform the triangle::

• • The child is alert, makes good eye The child is alert, makes good eye contact, has a strong cry and is contact, has a strong cry and is consolable.consolable.

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

• • Circulation to skin is normal.Circulation to skin is normal.

Pediatric Primary SurveyPediatric Primary Survey

After completing the Triangle, begin a After completing the Triangle, begin a more complete more complete pediatric primary pediatric primary surveysurvey..


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

Key PointsKey Points1. The Triangle is a “quick look” of overall 1. The Triangle is a “quick look” of overall

severity and urgency of treatment.severity and urgency of treatment.

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

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

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

Case continuesCase continues


AIRWAY & BREATHINGAIRWAY & BREATHING

Assess adjunctive signs:Assess adjunctive signs:

• • Respiratory rate (RR)Respiratory rate (RR)

• • Tidal volume ausculationTidal volume ausculation

• • Lung sounds (crackles, Lung sounds (crackles, wheezes) wheezes)

• • Pulse oximetry (SaOPulse oximetry (SaO22))

CIRCULATIONCIRCULATION

Assess adjunctive signs:Assess adjunctive signs:

• • Heart Rate (HR)Heart Rate (HR)

• • Blood Pressure (BP): in Blood Pressure (BP): in children <3 yrs, attempt only children <3 yrs, attempt only onceonce


DISABILITYDISABILITY

• • AVPUAVPU

• • PupilsPupils

• • Abnormal movementAbnormal movement


Pearl:Pearl: Disability vs. Appearance Disability vs. Appearance

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

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

Abnormal Appearance Abnormal Appearance on AVPU on AVPU

A V P UA V P U


worsening severityworsening severity

Summary of TriangleSummary of Triangle

• • Playful and vigorous.Playful and vigorous.

• • Stridor at rest.Stridor at rest.

• • Suprasternal and intercostal Suprasternal and intercostal retractions.retractions.

• • Extremities warm. CRT <2 secs.Extremities warm. CRT <2 secs.

Summary of Primary SurveySummary of Primary Survey

• • RR 50/min.RR 50/min.

• • Fair inspiratory volume.Fair inspiratory volume.

• • Breath sounds clear.Breath sounds clear.

• • SaOSaO2 2 = 93% on room air.= 93% on room air.

• • HR 140/min. BP not obtained.HR 140/min. BP not obtained.

• • Alert, PERRL, normal motor Alert, PERRL, normal motor exam.exam.


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

Radio ReportRadio Report

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

Case 2Case 2

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


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

Case continues:Case continues:AppearanceAppearance

• • Child is lethargic.Child is lethargic.

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

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

• • Limp, with no spontaneous Limp, with no spontaneous movement.movement.

• • Pale and mottled.Pale and mottled.


What are the key features of What are the key features of work of breathing? work of breathing?

Case continues:Case continues:Work of BreathingWork of Breathing

• • No abnormal audible breath No abnormal audible breath soundssounds

• • No retractionsNo retractions

• • No flaringNo flaring


What are the key features of What are the key features of circulation to skin?circulation to skin?

Case continues:Case continues:Circulation to SkinCirculation to Skin

• • Skin cool at kneecapSkin cool at kneecap

• • Brachial pulse weakBrachial pulse weak

• • CRT 5 secsCRT 5 secs


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


A/BA/B: : Airway clearAirway clear

RR 10/min; clear BS; poor air RR 10/min; clear BS; poor air entry;entry;

SaOSaO22 not obtainable not obtainable

CC: : HR 190/min; BP not obtainable on HR 190/min; BP not obtainable on one attempt one attempt

DD: : Responds only to pain on AVPU; Responds only to pain on AVPU;

PERRL; no spontaneous movementPERRL; no spontaneous movement

PearlPearl

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

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

PearlPearl


How would you describe How would you describe this baby in your radio this baby in your radio report?report?

Radio ReportRadio Report

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


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

Resuscitation TapeResuscitation Tape

The resuscitation tape The resuscitation tape is a proven method is a proven method for rapid equipment for rapid equipment sizing and drug sizing and drug dosing based upondosing based upon

the child’s measured the child’s measured length. It avoids length. It avoids estimations of weight.estimations of weight.

Lecture SummaryLecture Summary

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

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

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

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

Lecture Summary - cont’d.Lecture Summary - cont’d.

Documents

PEP Course Lecture 3 PEDIATRIC PEDIATRICASSESSMENT TRIANGLE TRIANGLE