Emergency assessment of a critically ill or injured infant or young child is often difficult, even for the experienced provider (Hohenhaus, 2006). History, when available, is usually gained through a third-party filter—the child's caregiver. The child may be too young, frightened, or disabled to respond to questions (Adirim and Smith, 2006). Vital signs—the cornerstones of adult assessment—may be difficult to interpret because of age-based variation, lack of sensitivity (blood pressure) or poor specificity (heart rate, respiratory rate) (McCarthy et al, 1985; Dieckmann et al. 2000; Dieckmann et al. 2010). In addition, any individual prehospital provider may have relatively infrequent encounters with critically ill or injured children, which limits opportunities to reinforce both cognitive and psychomotor skills (Gausche et al. 1990; Gausche et al, 1998a; Gausche et al, 1998b; Gausche, 2000).
In 2000, the American Academy of Pediatrics (AAP) published Pediatric Education for Prehospital Providers (PEPP)—the first national course of its kind (Dieckmann et al. 2000a; Dieckmann et al. 2000b). The curriculum introduced a new rapid assessment tool, called the paediatric assessment triangle (PAT), to determine a child's clinical status and category of illness.
The use of the PAT in the emergency department was supported subsequently by the American College of Emergency Physicians (ACEP) and the American Academy of Pediatrics in the course, Advanced Pediatric Life Support (APLS); and has been included in the American Heart Association's paediatric advanced life support (PALS) course, the Emergency Nurses Association's emergency nursing paediatric course, and the teaching resource for instructors in prehospital paediatrics (Gausche-Hill et al. 2003; American Academy of Pediatrics, 2005; American Academy of Pediatrics, 2006; Center for Pediatric Emergency Medicine, 2009; Emergency Nurses Association, 2009). Since its inception, the PAT has been taught to hundreds of thousands of medical providers in the US and abroad (Dieckmann et al. 2010).
Paediatric emergency assessment
For children of all ages, emergency assessment includes four distinct, sequential steps: (1) the general observational assessment—the PAT; (2) the ‘primary’ hands-on physiological assessment with the ABCDEs; (3) the ‘secondary’ anatomical assessment; and (4) the ‘tertiary’ or diagnostic assessment. The paediatric primary and secondary assessments (sometimes called the ‘initial’ and ‘additional; assessments) have well-defined components that mirror the tools used in adult practice. The tertiary assessment or diagnostic assessment involves use of bedside diagnostic testing such as pulse oximeter readings, ECG or glucose testing to aid the provider in further clarifying the clinical condition of the patient. These steps (initial, secondary, and tertiary) are well described in other texts and will not be discussed further here. Implicit in an emergency assessment of a patient of any age is the mandate to treat life-threatening problems at the time that they are identified in sequence, prior to moving on to the next step in the algorithm.
Paediatric assessment triangle (PAT)
The paediatric assessment triangle (PAT) is a rapid assessment tool using only visual and auditory clues; it requires no equipment, and takes seconds to perform. The PAT enables the provider to articulate formally a general impression of the child, establish the severity of the presentation and category of pathophysiology, and determine the type and urgency of intervention.
Using the paediatric assessment triangle, the provider makes observations of three components (or ‘arms’ of the triangle): appearance, work of breathing, and circulation to the skin. Any observed abnormality within an arm of the triangle qualifies the entire component (arm) as abnormal. The combination of abnormal arms in the triangle determines the child's category of illness and helps to identify the immediate intervention.
Appearance is illustrated by the ‘TICLS’ mnemonic (Table 1): Tone, Interactiveness, Consolability, Look or Gaze, and Speech or Cry. This arm of the triangle is based on a child's age and stage of development. For example, a newborn has a relatively limited repertoire of behavior and is unable to fix his gaze or track objects (which is normal for a newborn), in contrast to an older child who should be able to fix a gaze and track a light or objects; thus if unable to do so, the child's appearance is abnormal. Other important clues such as the infant's tone, response to variations in environmental stimuli (e.g., cold), and cry can inform the provider of the child's appearance as normal or abnormal (for age and development).
Paediatric assessment triangle and its application in determining General Impression.
| Characteristic | Normal Features |
|---|---|
| Tone | Moves spontaneously |
| Resists exam | |
| Sits or stands (age appropriate) | |
| Interactiveness | Appears alert and engaged with clinician or caregiver |
| Interacts with people, environment | |
| Reaches for toys, objects (e.g. penlight) | |
| Consolability | Stops crying with holding and comforting by caregiver |
| Has differential response to caregiver versus examiner | |
| Look/Gaze | Makes eye contact with provider |
| Tracks visually | |
| Speech/Cry | Has strong cry |
| Uses age-appropriate speech. |
Work of breathing describes the child's respiratory status, especially the degree to which the child must work in order to oxygenate and ventilate (Table 2). Clinical signs such as abnormal airway sounds, abnormal positioning, retractions (indentations of the skin against the chest wall during labored breathing), or flaring of the nostrils on inspiration determine an abnormal work of breathing.
| Characteristic | Abnormal features |
|---|---|
| Abnormal airway sounds | Snoring |
| Muffled or hoarse speech | |
| Stridor | |
| Grunting | |
| Wheezing | |
| Abnormal positioning | Sniffing position |
| Tripoding | |
| Preference for seated posture | |
| Retractions | Supraclavicular, intercostals, or substernal retractions |
| Head bobbing (infants) | |
| Flaring | Flaring of the nares on inspiration. |
Circulation to the skin reflects the general perfusion of blood throughout the body (Table 3). The prehospital provider notes the colour and colour pattern of the skin and mucous membranes. In the context of blood/fluid loss or changes in venous tone, compensatory mechanisms shunt blood to vital organs such as the heart and brain, and away from the skin and periphery. By noting changes in skin color and temperature, the provider may recognize early signs of shock.
| Characteristic | Abnormal features |
|---|---|
| Pallor | White or pale skin or mucous membrane coloration |
| Mottling | Patchy skin discoloration of skin due to vasoconstriction/vasodilation |
| Cyanosis | Bluish discoloration of skin and mucous membranes. |
The general impression
Combining the three PAT components forms a general impression. The general impression is the provider's overall evaluation of the child's physiologic state.
This general impression in its simplest form distinguishes acuity: ‘stable’ vs ‘unstable’; or ‘sick’ vs ‘not sick’. Furthermore, the PAT helps identify the category of physiologic abnormality (respiratory, perfusion, metabolic or CNS).
Once acuity is established, the PAT informs the provider of the patient's clinical severity and category of pathophysiology.
There are six major assessment categories: stable, respiratory distress, respiratory failure, shock, central nervous system (CNS) dysfunction/metabolic disorder, and cardiopulmonary failure (Table 4). Hence, the PAT defines the urgency of treatment based on the assessment category, which in turn drives life-saving management, e.g. the delivery of oxygen, support of ventilation, establishment of intravenous access and fluid resuscitation, emergency drug delivery, and the initiation of chest compressions (Table 5).
| Appearance | Work of breathing | Circulation to skin | ||
|---|---|---|---|---|
| Stable | Normal | Normal | Normal | |
| Respiratory distress | Normal | Abnormal | Normal | |
| Respiratory failure | Abnormal | Abnormal | Normal/Abnormal | |
| Shock | Normal/Abnormal | Normal/Abnormal | Abnormal | |
| CNS/metabolic | Abnormal | Normal | Normal | |
| Cardiopulmonary failure | Abnormal | Abnormal | Abnormal. |
| General impression | Management priorities |
|---|---|
| Stable | Monitor and transport |
| Specific therapy based on possible etiologies | |
| Respiratory distress | Position of comfort |
| Supplemental oxygen/suction as needed | |
| Specific therapy based on possible etiologies: (albuterol/salbutamol, diphenhydramine, adrenaline/epinephrine) | |
| Respiratory failure | Position the head and open the airway |
| Provide 100% oxygen | |
| Initiate bag-mask ventilation as needed | |
| Initiate foreign body removal as needed | |
| Advanced airway as needed | |
| Shock | Provide oxygen as needed |
| Obtain vascular access | |
| Begin fluid resuscitation | |
| Specific therapy based on possible etiologies (epinephrine, spinal stabilization, cardioversion) | |
| CNS/Metabolic | Provide oxygen as needed |
| Obtain rapid glucose as needed | |
| Cardiopulmonary failure/arrest | Position the head and open the airway |
| Initiate bag-mask ventilation with 100% oxygen | |
| Begin chest compressions as needed | |
| Specific therapy as based on possible etiologies (defibrillation, epinephrine, amiodarone). |
In other words, using the PAT at the point of first contact with the patient helps to establish a level of severity, determine urgency for treatment, and identify the general type of physiologic problem. Serial applications of the PAT provide a way to track response to therapy and determine timing of subsequent interventions. The PAT promotes consistent communication among medical professionals about the child's physiologic status and goals for therapy.
‘The paediatric assessment triangle provides a rapid, global assessment and determines the category of illness, thereby clarifying the initial management.’
Application of the paediatric assessment triangle in the field
Case one
You receive a call for a 9-year-old boy with shortness of breath. He has a history of asthma and has had increased symptoms after developing a fever and a cough today. He has no allergies. He uses albuterol (salbutamol) as needed, but ran out yesterday. On arrival you find the boy sitting up in a chair, supporting his torso with his hands on his knees.
You apply the PAT—his appearance assessment reveals no abnormalities in tone, interactiveness, look/gaze, or speech/cry. His work of breathing reveals intercostal retractions and auditory wheezes. His circulation to the skin is normal. Within seconds, you realize that a normal appearance, abnormal work of breathing, and normal circulation to the skin together constitute respiratory distress.
Now that the category of illness is established, the plan of action is clear: you supply supplemental oxygen and provide beta-agonist therapy while you continue your assessment and prepare to transport. In the hospital, he is diagnosed with an asthma exacerbation. After continued aggressive treatment in hospital, he improves sufficiently to be discharged home.
Case two
You are dispatched to the home of a four-month-old girl with trouble breathing. The baby has a history of fever and cough, and began an antibiotic today for pneumonia. You enter the home to find a young infant in her mother's arms. Knowing that delineating young children's respiratory status is vital, you apply the PAT. Her appearance shows decreased interactiveness, abnormal gaze, and a weak cry. Her work of breathing reveals grunting, substernal retractions with rapid shallow breaths. The circulation to the skin is normal. An abnormal appearance, abnormal work of breathing and a normal circulation to the skin alert you that this child is not just in distress - she is in respiratory failure. That is, her respiratory status has crossed the threshold from impaired (as in distress) to insufficient (as in failure) due to its generalized effect on her appearance.
After recognizing the severity of her respiratory status, you place her head in the sniffing position, give supplemental oxygen, suction secretions, and prepare for potential respiratory decompensation. You are thinking steps ahead now and are ready to provide positive pressure ventilation with bag-mask device if needed. In the emergency department (ED), a chest radiograph shows right lower lobe pneumonia; she is admitted for intravenous antibiotics and fluids. Your rapid recognition of the severity of her respiratory status prevented her further decompensation and safe arrival to definitive care.
Case three
You respond to a call from a tired, frustrated mother of a 9-month-old girl who has vomited eight times today, and ‘can't keep anything down’. You find a listless child lying on her side.
This is an obviously sick infant. To focus your approach, you ask yourself: ‘what is her primary category of illness and how can I best help this child?’. You follow the PAT step-by-step: appearance is abnormal in tone, interactiveness, and look/gaze. Her work of breathing is normal. Her circulation to the skin shows patchy discoloration: she is mottled.
You remember that any abnormal skin sign is shock until proven otherwise. In addition, her abnormal appearance is likely due to her severe volume depletion. In this case, rapid intravenous access with volume resuscitation with 20 mL/kg of normal saline is indicated. You continue your assessment and look for other causes of shock that you can address, such as dysrhythmia, trauma, and anaphylaxis. Her listless appearance also triggers diagnostic testing: pulse oximetry reading is 98% (normal) and you check her glucose level, which is 75 mg/dL (normal). She becomes more interactive during your fluid therapy on your way to the hospital. Your description of her initial clinical status aids the hospital staff in recognizing the severity of her illness and in her ongoing treatment and reassessment.
Case four
You are called to a private residence for a six-month-old infant who is ‘not acting right’. Her mother returned from shopping three hours ago and found the baby difficult to arouse. She called a neighbour who told her to call an ambulance. On arrival you find the infant lying in her crib, lethargic. Her appearance is notable for decreased interactiveness and an abnormal look/gaze; she makes no eye contact. Her work of breathing seems comfortable. Her circulation to the skin is normal.
An abnormal appearance in the absence of any other findings is consistent with the category of CNS/ metabolic disorder: this child is altered for no other apparent reason. The differential diagnosis for an altered level of consciousness comes to mind using the mnemonic ‘AEIOU TIPS’:
Although the etiology of this child's altered mental status may not be completely clear in the prehospital setting, a thorough report will assist hospital staff in further investigation. Regardless of cause, the paramedic's focus should remain on the immediate intervention for a CNS/metabolic disorder: giving oxygen if needed, obtaining a rapid finger-stick glucose, placing the infant in cervical spine precautions, and rapid transport. With every pediatric patent, one must consider the possibility of child abuse. In this case, the delay in care and obvious neurologic devastation portends nonaccidental injury.
Case five
You respond to a traffic collision. A 12-year-old was out for a ‘joy ride’ in his parents’ jeep and rolled the car while turning a corner. He is ambulatory on scene and bystanders report no loss of consciousness or abnormal behavior prior to arrival. You find a young man with multiple abrasions to the face and extremities, scared and crying for his parents. His appearance shows normal tone, interactiveness, consolability, look/gaze, and speech/cry. His work of breathing is normal. His circulation to the skin is normal.
Although the child is visibly upset with superficial abrasions, his normal appearance, work of breathing, and circulation to the skin typify a stable patient. He may be monitored during transport, and specific therapy is based on further assessment. This may include spinal precautions, wound/burn care, and splinting extremity deformities.
Case Six
You are called in the early morning to the home of a two-month-old boy who was found unresponsive by parents after waking. You arrive to find frantic parents hovering over an unconscious, apneic, and cyanotic infant in the crib. Seconds count; you immediately recognize that his appearance, work of breathing, and circulation to the skin are all grossly abnormal. He is in cardiopulmonary failure.
Without hesitation, you position the head and open the airway. You initiate bag-mask ventilation with 100% oxygen and begin chest compressions. Your partner obtains vascular access and you continue with Pediatric Advanced Life Support (PALS) protocol. Your rapid evaluation of his acuity and pathophysiology help you to remain focused on the management priorities in a stressful situation.
Conclusion
Each of these six cases demonstrates the utility of the PAT, which optimizes the first few seconds of the EMS provider patient contact. The PAT provides a rapid, global assessment and determines the category of illness, thereby clarifying the initial management. Furthermore, it serves as a common language among providers and serves as a consistent metric in reassessment of the acutely ill or injured child.