PEP Course Lecture 3

1
PEP CourseLecture 3

• PEDIATRIC
• ASSESSMENT
• TRIANGLE

2
Lecture Objectives

• 1. Understand the elements of the
• Pediatric Assessment Triangle.
• 2. Distinguish the Triangle from the
• 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.

4
Assessment

• 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.

5
Key Question

• What are the elements of the assessment that
  are most useful?

6
Pediatric Assessment Triangle

Appearance
7
Pediatric Assessment Triangle

8
Pediatric Assessment Triangle

Circulation to Skin
9
Pediatric Assessment Triangle

Appearance
Work of Breathing
Circulation to Skin
10
Pediatric Assessment Triangle

• The Triangle focuses on three interdependent
  aspects of physical assessment that reflect
• 1. Severity of illness or injury
• 2. Urgency of intervention

In other words ...
11
How sick?
How quick?
12
Pediatric Assessment Triangle

• 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?

14
Appearance

• alertness speech or cry
• distractibility motor activity
• consolability color
• eye contact

15
Appearance

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

16
Pearl

• 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).

17
Pearl

• 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.

18
Key Question

• How do you recognize respiratory distress and
  failure by looking at the child?

19
Work of Breathing

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

20
Triangle Respiratory Distress

21
Triangle Respiratory Failure
Increased or Decreased Work of Breathing

• Abnormal

Appearance
MEANS RESPIRATORY FAILURE
22
Key Question

• 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.
• Therefore circulation to skin reflects overall
  adequacy of perfusion.

24
Key Question

• How do you assess circulation to the skin?

25
Circulation to Skin

• Skin temperature
• Pulse strength
• CRT (capillary refill
  time)

26
Triangle Shock
27
Triangle
28
Circulation to SkinOther causes of
vasoconstriction(mottling, ? CRT)

• Fever
• Hypothermia
• Medications
• Normal vasomotor lability in infants

29
Pearl Triangle

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

30
Triangle Brain Dysfunction

31
Pearl Sensitivity and Specificity

• The Triangle provides sensitivity and
  specificity
• 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.

32
Case continues

• You perform the triangle
• 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.
• Circulation to skin is normal.

33
Pediatric Primary Survey

• After completing the Triangle, begin a more
  complete pediatric primary survey.

34
Key Question

• What is the difference between the Triangle
  and the pediatric primary survey?

35
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
Case continues

• 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.

37
Pediatric Primary Survey

• AIRWAY BREATHING
• Assess adjunctive signs
• Respiratory rate (RR)
• Tidal volume ausculation
• Lung sounds (crackles,
  wheezes)
• Pulse oximetry (SaO2)

38

• CIRCULATION
• Assess adjunctive signs
• Heart Rate (HR)
• Blood Pressure (BP) in children lt3
  yrs, attempt only once

39

• DISABILITY
• AVPU
• Pupils
• Abnormal movement

40
Pearl Disability vs. Appearance

• 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.

41
Abnormal Appearance on AVPU

• A V P U

42
Summary of Triangle

• Playful and vigorous.
• Stridor at rest.
• Suprasternal and intercostal retractions.
• Extremities warm. CRT lt2 secs.

43
Summary of Primary Survey

• RR 50/min.
• Fair inspiratory volume.
• Breath sounds clear.
• SaO2 93 on room air.
• HR 140/min. BP not obtained.
• Alert, PERRL, normal motor exam.

44
Key Question

• 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.

46
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.

47
Key Question

• What features of this infants general
  appearance will help you to assess his
  physiologic stability?

48
Appearance

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

49
Case continuesAppearance

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

50
Key Question

• What are the key features of work of
  breathing?

51
Work of Breathing

• Abnormal audible breath sounds
• Retractions
• Flaring

52
Case continuesWork of Breathing

• No abnormal audible breath sounds
• No retractions
• No flaring

53
Key Question

• What are the key features of circulation to
  skin?

54
Circulation to Skin

• Skin temperature
• Pulse strength
• CRT

55
Case continuesCirculation to Skin

• Skin cool at kneecap
• Brachial pulse weak
• CRT 5 secs

56
Key Question

• 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.
• 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 SaO2 not obtainable C
HR 190/min BP not obtainable on one
attempt D Responds only to pain on AVPU
PERRL no spontaneous movement
59
Key Question
What do you think about these vital signs?
60
Pearl

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

61
Pearl

• Attempt BP once only in children lt3 years of
  age. BP has limited value for accurate assessment
  of circulation.

62
Key Question

• 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?

65
Resuscitation Tape

• 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.

66
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
Lecture Summary - contd.

• 3. Interpretation of vital signs in children may
  be difficult.
• 4. The resuscitation tape improves accuracy of
  equipment sizing and drug dosing.

68
The Pediatric Assessment Triangle