Pediatric Critical Care Division Child Health Department, Faculty of Medicine University of Indonesia
Emergency sign Priority sign Non Urgent Triage
Emergency sign CNS Respiratory Cardiovascular Gastrointestinal Endocrine Etc
PAT ABCDE
The PAT Appearance Work of Breathing Circulation to Skin
Appearance (“Tickles” =TICLS) Tonus Interactiveness Consolability Look/Gaze Speech/Cry Appearance
Work of Breathings Abnormal airway sounds Abnormal positioning Retractions Nasal flaring
Pallor Mottling Cyanosis Circulation to Skin
Respiratory distress N N N Cardiopulmonary failure // Shock NN NN Primary CNS dysfunction/ metabolic abnormality NN NN N N NN
The ABCDEs Airway Breathing Circulation Disability Exposure
Airway Assessment Clear Maintainable Unmaintainable without intubation Obstructed
Breathing Assessment Rate Effort / mechanics Air entry Skin color
Respiratory Rate by Age Age (years) Respiratory rate (breaths per minute) < >
Circulation Assessment Heart rate Systematic perfusion Peripheral pulses Skin perfusion Appearance (Urine output) Blood pressure
Heart Rate by Age AgeRange Newborn – 3 mos 85 – 200 bpm 3 mos – 2 yrs100 – 190 bpm 2 – 10 yrs 60 – 140 bpm
Skin Perfusion Extremity temperature Capillary refill Color Pink Mottled Pale Blue
Minimal Systolic Blood Pressure by Age Age Fifth percentile mmHg Systolic BP 0 – 1 Mo60 > 1 mo – 1 yr70 > 1 yr70 + (2 x age in years)
Disability (neurologic status) Cerebral cortex Brain Stem Motor activity
Level of Consciousness A = Awake V = Responsive to voice P = Responsive to pain U = Unresponsive
Brain Stem Posture Central respiration Pupil response Cranial nerve
Motor Activity Symmetrical movements Seizures Posturing Flaccidity
Exposure Skin rashes Bruises Excoriation etc.
Stable Respiratory dysfunction Potential respiratory failure Probable respiratory failure Shock Compensated Decompensated Cardiopulmonary failure Classification of Physiologic status
Case Scenario 1 15-month-old child History Diarrhea, vomitting for 3 days Refused bottle this morning Sleepy, lethargic today
Physical Examination PAT: A : Very lethargic child in mother’s lap WB: Normal CS : mottled ABC A : clear B : RR 45/min, breath sounds clear bilaterally C : HR 178 regular, BP 90 mmHG systolic, CRT : > 4 sec, Temp 38 o C Weak peripheral pulses Cool, mottled extremities,dry mucous membranes CNS: V
What would be your approach to this patient?
UKKPGD IDAI 27 Initial Approach to the Patient in Shock Evaluate the ABCs Deliver high concentration of oxygen Monitor oxygenation and heart rate Achieve vascular access
UKKPGD IDAI 28 Case Scenario 1: progression The patient receives oxygen and is placed on a monitor; attempts at peripheral vascular access fail What would you do now?
UKKPGD IDAI 29 What fluid would you give? How much and how fast?
Treatment of Shock Initial rapid fluid administration of 20 mL/Kg of: Crystalloid Colloid Blood