Systematic Approach to Pediatric Assessment

Learning ObjectivesLearning Objectives

Master “Assess – Categorize – Decide – Act ” approach at every

stage of assessment

Purpose & components of General Assessment

Summarize ABCDE of Primary Assessment

Evaluate problems- respiratory / circulatory

Categorize clinical condition by type & severity

Summarize life-saving interventions to be instituted if life-threatening

condition identified

Recall components of Secondary & Tertiary assessments

Respiratory Distress

Respiratory Failure Shock

Cardiopulmonary Failure

Cardiac Arrest

Precipitating Conditions

Respiratory Circulatory Sudden Cardiac(Arrhythmia)

Survival Following Respiratory Arrest vs Cardiopulmonary Arrest in Children

100%

50%

0%Respiratory

arrestCardiopulmonary

arrest

Survivalrate

Approach to Pediatric AssessmentApproach to Pediatric Assessment

At any point life-threatening problem life-saving interventions

ASSESSMENTASSESSMENT

Clinical Assessment Description

General Assessment(Pediatric Assessment Triangle)

Visual & auditory assessment of Appearance, Work of Breathing & Circulation (within 1st few seconds of seeing patient)

Primary AssessmentHands on A-B-C-D-E approach to evaluate (includes vital signs & pulse oximetry)

Secondary AssessmentFocused Medical History (S-A-M-P-L-E) Thorough Physical exam

Tertiary Assessment Investigations

Respiratory Circulatory

Type

Upper airway obstructionLower airway obstructionLung tissue diseaseDisordered control of breathing

Hypovolemic shockDistributive shockCardiogenic shockObstructive shock

Severity Respiratory distressRespiratory failure

Compensated ShockHypovolemic shock

Respiratory + CirculatoryIncluding cardiopulmonary failure

CATEGORIZECATEGORIZE

DECIDE Action based on initial assessment & categorization of clinical condition

Decisions based on scope of practice

ACTACT Actions appropriate for clinical condition & severity

REASSESSMENTREASSESSMENT

Process of A - C - D - A is ongoing Reassess after interventions

Ex: Is patient’s breathing better after oxygen?Is child’s perfusion better after IV bolus?

REMEMBERREMEMBER

At any time during Assessment and Categorization process

if a life threatening condition is identified

initiate life saving interventions

GENERAL ASSESSMENTGENERAL ASSESSMENT

PAT (Pediatric Assessment Triangle) Using Visual & Auditory clues

APPEARANCE WORK OF

BREATHING

CIRCULATION

Pediatric Assessment Triangle General Assessment

AppearanceMuscle tone, Interaction, Consolability, Look/gaze or Speech/cry

Work of breathing Work of breathing or absent respiratory effort, Abnormal sounds

Circulation Abnormal skin color, Bleeding

PRIMARY ASSESSMENTPRIMARY ASSESSMENT

Primary AssessmentPrimary Assessment

Hands-on evaluation (in contrast to PAT)

- Airway- Breathing- Circulation- Disability- Exposure

A B

C

D

E

AIRWAYAIRWAY

For Airway Patency, use look, listen, feel

Status Description

Clear Open & unobstructed

Maintainable Maintained by simple measures

Not maintainable Needs advanced measures

A

BREATHINGBREATHING

Evaluation of:• Respiratory rate• Respiratory effort• Tidal volume• Airway & lung sounds• Pulse oximetry

B

CIRCULATIONCIRCULATION

Assessment includes evaluation of:

Cardiovascular function End-organ function

Heart rateBlood pressureSkin color, temperatureCapillary refill time (CRT)Peripheral & central pulses

Brain perfusion (Mental status) Skin perfusion Renal perfusion (urine output)

C

Cardiovascular functionCardiovascular function

Normal Heart Rate by AgeNormal Heart Rate by Age

Blood PressureBlood Pressure

Definition by Systolic BP & Age (< 5th centile)

Age Systolic BP (mm Hg)

Term Neonates (0-28 days) < 60

Infants (1-12 months) < 70

Children 1-10 yrs 70 + (age x 2)

Children > 10 yrs < 90

Hypotension with hemorrhage: > 20-25% acute blood loss

Capillary RefillCapillary RefillCapillary RefillCapillary Refill

Prolonged capillary refill (10 seconds) in a 3-month-old with cardiogenic shock

Brain perfusion (Mental status)Brain perfusion (Mental status)

S/S in sudden, severe cerebral hypoxia: loss of muscle tone, gen. seizures,

dilated pupils, unconsciousness

S/S in gradual development of hypoxia: altered consciousness with

confusion, irritability, lethargy, agitation

Pupillary response & AVPU scale used to characterize neurologic condition

Drugs, metabolic conditions & raised ICP can also cause neurologic s/s

End Organ PerfusionEnd Organ Perfusion

Evaluate

Pallor

Mottling

Central cyanosis

Petechiae

Purpura

Skin perfusionSkin perfusion

Normal urine output:

Age Normal Urine Output

Infants & young children 1.5 – 2 ml / kg / hr

Older children & adolescents 1 ml / kg / hr

Renal perfusionRenal perfusion

DISABILITYDISABILITY

Quick evaluation of cerebral cortex & brainstem Evaluate during Primary as well as Secondary Assessment

– to monitor changes in neurologic status: AVPU GCS Pupillary response to light

D

AVPU ScaleAVPU Scale For rapid evaluation of cerebral cortical function

A - Alert V - Responsive to Voice P - Responds to Painful stimulus U - Unresponsive

EXPOSUREEXPOSURE

Undress child to facilitate focused physical examination - look for evidence of trauma - unusual markings suggestive of abuse

Warm the child, if hypothermia detected

E

LIFE-THREATENING CONDITIONSLIFE-THREATENING CONDITIONSwarranting immediate life-saving measureswarranting immediate life-saving measures

Signs include:

Airway Complete / severe airway obstruction

Breathing Apnea / significant work of breathing / bradypnea

Circulation No detectable pulse / poor perfusion / hypotension / bradycardia

Disability Unresponsiveness / depressed consciousness

Exposure Hypothermia / bleeding / petechiae / purpura / abdominal distension

Categorization by Severity

RESPIRATORY

DISTRESS FAILURE

Tachypnoea

Tachycardia

Increased respiratory effort

Abnormal airway sounds

Pale cool skin

Changes in mental status

(Early) Marked tachypnoea/Tachycardia

(Late) Bradypnea, Apnea/ Bradycardia

Increased / decreased / no respiratory effort

Cyanosis

Stupor / coma

Categorization by Severity

SHOCK

COMPENSATED HYPOTENSIVE

Tachycardia

Cool pale diaphoretic skin

Delayed CRT

Weak peripheral pulses

Narrow pulse pressure

Oliguria

In addition:

BP BELOW THE 5th percentile

Change in mental status

SECONDARY ASSESSMENTSECONDARY ASSESSMENT

ComponentsComponents Focused History Focused physical examination

S

A

MP

L

E

Aim: to gain information that explains impaired respiratory, cardiovascular or neurologic function

Signs & symptoms

Allergies

Medications

Past medical history

Last meal

Events

TERTIARY ASSESSMENTTERTIARY ASSESSMENT

Investigations to detect & identify presence & severity of

respiratory & circulatory abnormalities

Tertiary does not mean 3rd in order – dictated by clinical

situation. e.g. RBS may be done early

SUMMARY SUMMARY

General Assessment

Appearance - Work of Breathing - Circulation

Primary Assessment

Airway Breathing Circulation Disability Exposure

Secondary Assessment

(SAMPLE History, Focused Physical Exam, glucose)

Tertiary Assessment

(Lab studies, x-rays, other tests)

Pediatric Assessment Flowchart

Respiratory Circulatory

Type

Upper airway obstructionLower airway obstruction

Lung tissue diseaseDisordered control of breathing

Hypovolemic shockDistributive shockCardiogenic shockObstructive shock

Severity Respiratory distressRespiratory failure

Compensated ShockHypovolemic shock

Respiratory + CirculatoryIncluding cardiopulmonary failure

Categorize illness by type & severityCategorize illness by type & severity