1. Systematic Approach to Pediatric Assessment

2. Learning 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

3. Respiratory Distress Respiratory Failure Shock Cardiopulmonary Failure Cardiac Arrest Precipitating Conditions RespiratoryCirculatorySudden Cardiac (Arrhythmia)

4. Survival Following Respiratory Arrest vs Cardiopulmonary Arrest in Children 100% 50% 0% Respiratory arrest Cardiopulmonary arrest Survival rate

5. Approach to Pediatric Assessment Approach to Pediatric Assessment CATEGORIZE DECIDEACT ASSESS At any point life-threatening problem life-saving interventions

6. ASSESSMENT Clinical Assessment Description General Assessment (Pediatric Assessment Triangle) Visual & auditory assessment of Appearance, Work of Breathing & Circulation (within 1 st few seconds of seeing patient) Primary Assessment Hands on A-B-C-D-E approach to evaluate (includes vital signs & pulse oximetry) Secondary Assessment Focused Medical History (S-A-M-P-L-E) Thorough Physical exam Tertiary AssessmentInvestigations

7. RespiratoryCirculatory Type Upper airway obstruction Lower airway obstruction Lung tissue disease Disordered control of breathing Hypovolemic shock Distributive shock Cardiogenic shock Obstructive shock Severity Respiratory distress Respiratory failure Compensated Shock Hypovolemic shock Respiratory + Circulatory Including cardiopulmonary failure CATEGORIZE

8. DECIDE  Action based on initial assessment & categorization of clinical condition  Decisions based on scope of practice ACT  Actions appropriate for clinical condition & severity

9. REASSESSMENT  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?

10. REMEMBER At any time during Assessment and Categorization process if a life threatening condition is identified initiate life saving interventions

11. GENERAL ASSESSMENT

12. PAT (Pediatric Assessment Triangle) Using Visual & Auditory clues APPEARANCE WORK OF BREATHING CIRCULATION Pediatric Assessment Triangle General Assessment Appearance Muscle tone, Interaction, Consolability, Look/gaze or Speech/cry Work of breathing Work of breathing or absent respiratory effort, Abnormal sounds CirculationAbnormal skin color, Bleeding

13. PRIMARY ASSESSMENT

14. Primary Assessment  Hands-on evaluation (in contrast to PAT) -Airway -Breathing -Circulation -Disability -Exposure AB C D E

15. AIRWAY  For Airway Patency, use look, listen, feel StatusDescription ClearOpen & unobstructed MaintainableMaintained by simple measures Not maintainableNeeds advanced measures A

16. BREATHING Evaluation of: Respiratory rate Respiratory effort Tidal volume Airway & lung sounds Pulse oximetry B

18. CIRCULATION Assessment includes evaluation of: Cardiovascular functionEnd-organ function  Heart rate  Blood pressure  Skin color, temperature  Capillary refill time (CRT)  Peripheral & central pulses  Brain perfusion (Mental status)  Skin perfusion  Renal perfusion (urine output) C

19. Cardiovascular function Normal Heart Rate by Age

20. Blood Pressure Definition by Systolic BP & Age (< 5 th centile) AgeSystolic 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

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

22. 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 Perfusion

23. Evaluate  Pallor  Mottling  Central cyanosis  Petechiae  Purpura Skin perfusion

24.  Normal urine output: AgeNormal Urine Output Infants & young children1.5 – 2 ml / kg / hr Older children & adolescents1 ml / kg / hr Renal perfusion

25. DISABILITY  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

26. AVPU Scale  For rapid evaluation of cerebral cortical function A - Alert V - Responsive to Voice P - Responds to Painful stimulus U - Unresponsive

28. EXPOSURE  Undress child to facilitate focused physical examination - look for evidence of trauma - unusual markings suggestive of abuse  Warm the child, if hypothermia detected E

29. LIFE-THREATENING CONDITIONS warranting immediate life-saving measures Signs include: AirwayComplete / severe airway obstruction BreathingApnea / significant work of breathing / bradypnea Circulation No detectable pulse / poor perfusion / hypotension / bradycardia DisabilityUnresponsiveness / depressed consciousness Exposure Hypothermia / bleeding / petechiae / purpura / abdominal distension

30. Categorization by Severity RESPIRATORY DISTRESSFAILURE 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

31. Categorization by Severity SHOCK COMPENSATEDHYPOTENSIVE 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

32. SECONDARY ASSESSMENT

33. Components  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

34. TERTIARY ASSESSMENT

35.  Investigations to detect & identify presence & severity of respiratory & circulatory abnormalities  Tertiary does not mean 3 rd in order – dictated by clinical situation. e.g. RBS may be done early

36. SUMMARY

37. 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

38. RespiratoryCirculatory Type Upper airway obstruction Lower airway obstruction Lung tissue disease Disordered control of breathing Hypovolemic shock Distributive shock Cardiogenic shock Obstructive shock Severity Respiratory distress Respiratory failure Compensated Shock Hypovolemic shock Respiratory + Circulatory Including cardiopulmonary failure Categorize illness by type & severity