1. PEP Course Lecture 3 PEDIATRIC PEDIATRICASSESSMENT TRIANGLE TRIANGLE

2. Lecture Objectives 1. Understand the elements of the Pediatric Assessment Triangle. Pediatric Assessment Triangle. 2. Distinguish the Triangle from the Pediatric Primary Survey. Pediatric Primary Survey. 3. Highlight the differences between adult and pediatric assessment.

3. Case 1 A babysitter calls 911 for a 14 month old girl who is having trouble breathing. A babysitter calls 911 for a 14 month old girl who is having trouble breathing.

4. The child is in her babysitters arms and appears fatigued, with loud inspiratory stridor with each breath. The child is in her babysitters 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. She takes one look at you and starts to wail. Her stridor gets worse as she becomes agitated. Assessment Assessment

5. Key Question What are the elements of the assessment that are most useful? What are the elements of the assessment that are most useful?

6. Pediatric Assessment Triangle Appearance

7. Work of Breathing Breathing

8. Pediatric Assessment Triangle Circulation to Skin

9. Pediatric Assessment Triangle Circulation to Skin Appearance Work of Breathing Breathing

10. The Triangle focuses on three interdependent aspects of physical assessment that reflect: The Triangle focuses on three interdependent aspects of physical assessment that reflect: 1. Severity of illness or injury 1. Severity of illness or injury 2. Urgency of intervention 2. Urgency of intervention Pediatric Assessment Triangle In other words...

11. Howsick? How quick? quick?

12. Pediatric Assessment Triangle The Triangle is a rapid way to determine physiologic stability. The Triangle is a rapid way to determine physiologic stability.

13. Key Question How can you assess physiologic stability just by looking at the child? How can you assess physiologic stability just by looking at the child?

14. Appearance Appearance alertness speech or cry alertness speech or cry distractibility motor activity distractibility motor activity consolability color consolability color eye contact eye contact

15. Appearance Appearance The childs overall appearance reflects the adequacy of oxygenation, ventilation and perfusion.

16. Appearance is the single most important factor in assessment. 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). There are very few false negatives (very few truly sick or injured children that have normal appearance). Pearl Pearl

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

18. Key Question Key Question How do you recognize respiratory distress and failure by looking at the child? How do you recognize respiratory distress and failure by looking at the child?

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

20. Triangle: Respiratory Distress NormalAppearanceIncreased Work of Breathing MEANS RESPIRATORY DISTRESS

21. Triangle: Respiratory Failure MEANS RESPIRATORY FAILURE Increased or Decreased Work of Breathing of Breathing Abnormal Appearance

22. Key Question: Key Question: What is the most reliable way to rapidly assess adequacy of perfusion? What is the most reliable way to rapidly assess adequacy of perfusion?

23. Circulation to Skin Inadequate perfusion of vital organs leads to compensatory vasoconstriction in non-essential anatomic areas, especially the 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. Therefore circulation to skin reflects overall adequacy of perfusion.

24. Key Question How do you assess circulation to the skin? How do you assess circulation to the skin?

25. Circulation to Skin Skin temperature Skin temperature Pulse strength Pulse strength CRT (capillary refill time) CRT (capillary refill time)

26. Triangle: Shock Poor Circulation to Skin MEANS SHOCK MEANS SHOCK AbnormalAppearance

27. Triangle: Poor Circulation to Skin MEANS OBSERVE MEANS OBSERVE NormalAppearance

28. Circulation to Skin Other causes of vasoconstriction (mottling, CRT) FeverFever HypothermiaHypothermia MedicationsMedications Normal vasomotor lability in infantsNormal vasomotor lability in infants

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

30. Triangle: Brain Dysfunction Normal Circulation to Skin Normal Circulation to Skin MEANS BRAIN DYSFUNCTION AbnormalAppearance Normal Work of Breathing of Breathing

31. The Triangle provides sensitivity and specificity: Appearance identifies almost every child with serious illness or injury, and offers sensitivity. 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. Work of Breathing and Circulation to Skin help distinguish between organ systems that are likely sources of distress. These elements offer specificity. Pearl: Sensitivity and Specificity

32. Case continues You perform the triangle: The child is alert, makes good eye contact, has a strong cry and is consolable. 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. She has stridor. No grunting or wheezing. No flaring. Suprasternal and intercostal retractions present. Circulation to skin is normal. Circulation to skin is normal.

33. Pediatric Primary Survey Pediatric Primary Survey After completing the Triangle, begin a more complete pediatric primary survey. After completing the Triangle, begin a more complete pediatric primary survey.

34. Key Question Key Question What is the difference between the Triangle and the pediatric primary survey? What is the difference between the Triangle and the pediatric primary survey?

35. Key Points 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.

36. You approach the child, who is now calm in her babysitters arms. You offer her your penlight which she plays with while you perform your hands-on assessment, or primary survey. You approach the child, who is now calm in her babysitters arms. You offer her your penlight which she plays with while you perform your hands-on assessment, or primary survey. Case continues

37. Pediatric Primary Survey AIRWAY & BREATHING AIRWAY & BREATHING Assess adjunctive signs: Assess adjunctive signs: Respiratory rate (RR) Respiratory rate (RR) Tidal volume ausculation Tidal volume ausculation Lung sounds (crackles, wheezes) Lung sounds (crackles, wheezes) Pulse oximetry (SaO 2 ) Pulse oximetry (SaO 2 )

38. CIRCULATION CIRCULATION Assess adjunctive signs: Assess adjunctive signs: Heart Rate (HR) Heart Rate (HR) Blood Pressure (BP): in children <3 yrs, attempt only once Blood Pressure (BP): in children <3 yrs, attempt only once Pediatric Primary Survey

39. DISABILITY DISABILITY AVPU AVPU Pupils Pupils Abnormal movement Abnormal movement Pediatric Primary Survey

40. Pearl: Disability vs. Appearance Pearl: Disability vs. Appearance Disability evaluates altered level of consciousness. It is not very useful unless illness or injury is moderate-critical. 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 reflects mild-moderate severity and is much more useful as an assessment tool.

41. Abnormal Appearance on AVPU A V P U AbnormalAppearance worsening severity

42. Summary of Triangle Playful and vigorous. Playful and vigorous. Stridor at rest. Stridor at rest. Suprasternal and intercostal retractions. Suprasternal and intercostal retractions. Extremities warm. CRT <2 secs. Extremities warm. CRT <2 secs.

43. Summary of Primary Survey Summary of Primary Survey RR 50/min. RR 50/min. Fair inspiratory volume. Fair inspiratory volume. Breath sounds clear. Breath sounds clear. SaO 2 = 93% on room air. SaO 2 = 93% on room air. HR 140/min. BP not obtained. HR 140/min. BP not obtained. Alert, PERRL, normal motor exam. Alert, PERRL, normal motor exam.

44. Key Question Key Question How would you describe this child when giving radio report to the base hospital? How would you describe this child when giving radio report to the base hospital?

45. 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. 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.

46. Case 2 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. 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.

47. Key Question What features of this infants general appearance will help you to assess his physiologic stability? What features of this infants general appearance will help you to assess his physiologic stability?

48. Appearance Alertness Alertness Distractability Distractability Consolability Consolability Eye contact Eye contact Quality of cry Quality of cry Spontaneous movement (tone, responsiveness) Spontaneous movement (tone, responsiveness) Color Color

49. Case continues: Appearance Child is lethargic. Child is lethargic. Eyes are open, but he does not focus on his mothers face. Eyes are open, but he does not focus on his mothers face. Cries weakly with painful stimulus, but does not pull away. Cries weakly with painful stimulus, but does not pull away. Limp, with no spontaneous movement. Limp, with no spontaneous movement. Pale and mottled. Pale and mottled.

50. Key Question What are the key features of work of breathing? What are the key features of work of breathing?

51. Work of Breathing Abnormal audible breath sounds Abnormal audible breath sounds Retractions Retractions Flaring Flaring

52. Case continues: Work of Breathing No abnormal audible breath sounds No abnormal audible breath sounds No retractions No retractions No flaring No flaring

53. Key Question Key Question What are the key features of circulation to skin? What are the key features of circulation to skin?

54. Circulation to Skin Skin temperature Skin temperature Pulse strength Pulse strength CRT CRT

55. Case continues: Circulation to Skin Skin cool at kneecap Skin cool at kneecap Brachial pulse weak Brachial pulse weak CRT 5 secs CRT 5 secs

56. Key Question Key Question Based upon the Triangle, how sick is this child and how urgent is treatment? Based upon the Triangle, how sick is this child and how urgent is treatment?

57. Key Point The child is critically ill and needs immediate resuscitation. The child is critically ill and needs immediate resuscitation. Perform the pediatric primary survey quickly and simultaneously begin treatment. Perform the pediatric primary survey quickly and simultaneously begin treatment.

58. Pediatric Primary Survey A/B : Airway clear RR 10/min; clear BS; poor air entry; RR 10/min; clear BS; poor air entry; SaO 2 not obtainable 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 PERRL; no spontaneous movement

59. Key Question Key Question What do you think about these vital signs? What do you think about these vital signs?

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

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

62. Key Question Key Question How would you describe this baby in your radio report? How would you describe this baby in your radio report?

63. 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.

64. Key Question How would you estimate ETT size and IV fluid rate for this baby? How would you estimate ETT size and IV fluid rate for this baby?

65. Resuscitation Tape The resuscitation tape is a proven method for rapid equipment sizing and drug dosing based upon The resuscitation tape is a proven method for rapid equipment sizing and drug dosing based upon the childs measured length. It avoids estimations of weight. the childs measured length. It avoids estimations of weight.

66. Lecture Summary 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.

67. 3. Interpretation of vital signs in children may be difficult. 4. The resuscitation tape improves accuracy of equipment sizing and drug dosing. Lecture Summary - contd. Lecture Summary - contd.