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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
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?
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
Nasal Flaring
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
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
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