Pediatric Assessment Triangle

Katherine Remick, MD, FAAP

Associate Medical Director
Austin Travis County EMS
Pediatric Emergency Medicine
Dell Children’s Medical Center
 Objectives
1. Discuss why the Pediatric Assessment
Triangle might be a useful tool in the
prehospital setting
2. Discuss the 3 components of the Pediatric
Assessment Triangle
3. Explore how the Pediatric Assessment
Triangle can be used to recognize an ill child
and guide management
4. Sample cases
 Pediatric Emergency Care:
The Experience Gap
• Children account for 5 to 10% of all
EMS patients
- Only 0.5 -1% are critically ill/injured
- Limited experience for paramedics
• Children make 25-30 million ED visits
per year
- Less than 5% require 30 care
- Nearly 90% of children are cared for in
general hospital EDs
- Many of these EDs see few children
• 50% of EDs care for < 10 kids/day
• Limited experience with sick kids
 Pediatric Care and Patient Safety
• Children have unique needs:
– Equipment
– Policies and procedures
– Weight-based dosing
• Communication Challenges
– Developmental stage
– Children with special healthcare needs
• Deficiencies:
– Pediatric readiness
– Provider experience and competencies
• Low frequency of critically ill or injured children
– Failure to recognize a critically ill or injured child
 Age-Specific Vital Signs
Respiratory Systolic BP
Age Group Tachycardia Bradycardia
Rate mmHg

Newborn >180 <100 >50 <65

Neonate >180 <100 >40 <75

Infant >180 <90 >34 <100

Toddler >140 NA >22 <94

Child >130 NA >18 <105

Adolescent >110 NA >14 <117

 Pediatric Emergency Care
• Children at increased risk for safety events
• Providers have limited experience with
pediatric patients
• Low frequency of critically ill and injured
children
• May be a failure to recognize a critically ill or
injured child and subsequent failure to act
 Pediatric Assessment Triangle
• A tool to rapidly assess children
• Uses visual and auditory clues
• Does not require equipment
 Pediatric Assessment Triangle
• The PAT is intended to allow the EMT and
Paramedic to:
– Establish the child’s severity of illness
• Sick or not sick
– Recognize the general category of
pathophysiology
• Basically - what is going on with the child
– Determine the urgency of interventions
– Begin emergent management priorities
Pediatric Assessment Triangle

Appearance Work of Breathing

Circulation to the Skin

 Appearance
• Is the child alert?
• Is the child consolable?
– Irritability or restlessness may be a sign of
poor oxygenation
• Is the child responding to you?
• Are they able to speak?
 Appearance

• Tone
• Interactiveness
• Consolability
• Look/Gaze
• Speech/Cry
 Work of Breathing
• Is there evidence of increased work of
breathing?
• Are there abnormal airway sounds?
• Are they apneic or gasping?
Work of Breathing
• Abnormal airway sounds
– Stridor
– Wheezing
– Grunting
• Abnormal positioning
• Retractions
• Flaring
• Apnea/Gasping
Work of Breathing
Work of Breathing
 Head Bobbing and Tripod Position
• Head and neck extension • Tripod positioning is
to open airway followed common in older adults
by relaxation and children in
• Neck extensor muscles respiratory distress
are not strong enough to
stabilize the head
 Circulation

• How is the child’s color?

• Is the child mottled?
• Is the child cyanotic?
• Is the child pale?
Circulation to the Skin
• Pallor
• Mottling
• Cyanosis
Circulation to the Skin
 The Pediatric Assessment Triangle

APPEARANCE BREATHING
Abnormal Tone Abnormal Sounds
 Interactiveness Abnormal Position
 Consolability Retractions
Abnl. Look/Gaze Flaring
Abnl. Speech/Cry Apnea/Gasping

CIRCULATION
Pallor
Mottling
Cyanosis
 General Category of Pathophysiology:
General Impression
• PAT assessment can be used to determine the
general impression:
– Stable
– Respiratory distress
– Respiratory failure
– Shock
– CNS/Metabolic disorder
– Cardiopulmonary failure
 Components of the PAT and the General Impression
Cardio-
Resp. Resp. CNS/
Component Stable Shock pulmonary
Distress Failure Metabolic
failure

Normal/
Appearance Normal Normal Abnormal Abnormal Abnormal
Abnormal

Work of
Normal Abnormal Abnormal Normal Normal Abnormal
Breathing

Circulation Normal/
Normal Normal Abnormal Normal Abnormal
to the Skin Abnormal

What is going on with the patient?

 General Impression

= STABLE = SHOCK

= RESPIRATORY = CNS / METABOLIC

DISTRESS

= RESPIRATORY
= CARDIO-
FAILURE
PULMONARY
FAILURE
 General
Management Priorities
Impression
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,
diphenhydramine, 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
Consider EKG, IV fluids
Cardiopulmonary Position the head and open the airway
Failure/Arrest Initiate bag-mask ventilation with 100% oxygen
Begin chest compressions as needed
Specific therapy as based on possible etiologies (defibrillation,
Let’s see some examples…
 Case 1: 9 year-old boy
• You receive a call for a 9
year-old boy with shortness
of breath
• He has asthma and became
SOB after developing a fever
and cough today
• No allergies
• Medications: Albuterol as
needed, ran out yesterday
• What is your assessment?
– Appearance?
– Breathing?
– Circulation?
 Case 1: 9 year-old boy

APPEARANCE BREATHING
Abnormal Tone Abnormal Sounds*
 Interactiveness Abnormal
 Consolability
Position*
Abnl. Look/Gaze
Abnl. Speech/Cry Retractions*
Flaring*
CIRCULATION Apnea/Gasping
Pallor
Mottling
Cyanosis
 General Impression

= STABLE = SHOCK

= RESPIRATORY = CNS / METABOLIC

DISTRESS

= RESPIRATORY
= CARDIO-
FAILURE
PULMONARY
FAILURE
 Management Priorities:
Pediatric Respiratory Distress

• Position of comfort
• Maintain airway
• Supplemental oxygen as needed
• Administer albuterol nebulized for wheezing,
consider atrovent, steroids, benadryl,
magnesium sulfate, Epi, CPAP, and NS bolus
• Monitor en route to ED
 Case 2: 4 month-old infant

• You are dispatched to the

home of a 4-month-old
girl with trouble breathing
• He has a history of fever
and cough and was just
started on an antibiotic for
pneumonia
• What is your assessment?
– Appearance?
– Breathing?
– Circulation?
 Case 2: 4 month-old infant

APPEARANCE BREATHING
Abnormal Tone* Abnormal Sounds
Abnormal Position
 Interactiveness*
 Consolability Retractions*
Flaring
Abnl. Look/Gaze*
Apnea/Gasping
Abnl. Speech/Cry

CIRCULATION
Pallor
Mottling
Cyanosis
 General Impression

= STABLE = SHOCK

= RESPIRATORY = CNS / METABOLIC

DISTRESS

= RESPIRATORY
= CARDIO-
FAILURE
PULMONARY
FAILURE
 Management Priorities:
Respiratory Failure

• Position the head and open the airway

• Suction the airway
• Provide supplemental oxygen
• Initiate bag-mask ventilation, advanced airway
as needed
• Consider albuterol, epinephrine neb
• Consider checking glucose, vascular access
and fluid bolus, antipyretics
 Case 3 : 9 month-old infant

• You respond to the home of a 9 month-old

girl
• She has vomited 8 times today and cannot
keep any fluids down
• What is your assessment?
– Appearance?
– Breathing?
– Circulation?
 Case 3: 9 month-old infant

APPEARANCE BREATHING
Abnormal Tone* Abnormal Sounds
Abnormal Position
 Interactiveness*
Retractions
 Consolability
Flaring
Abnl. Look/Gaze*
Apnea/Gasping
Abnl. Speech/Cry

CIRCULATION
Pallor*
Mottling
Cyanosis
 General Impression

= STABLE = SHOCK

= RESPIRATORY = CNS / METABOLIC

DISTRESS

= RESPIRATORY
= CARDIO-
FAILURE
PULMONARY
FAILURE
 Management Priorities:
Shock

• Maintain airway, consider supplemental

oxygen as needed
• Check glucose
• Consider IV access and fluid resuscitation
• Consider pressors if hypotensive
• Consider EKG/cardiac monitor
• Monitor and reassess en route to ED
 Case 4: 6 month-old infant
• EMS is called to an apartment for a 6 month-old
infant who is “not acting right”
• Mother returned from shopping 3 hours ago and
found the baby difficult to arouse.
• She called a neighbor who told her to call 9-1-1
• What is your assessment?
– Appearance?
– Breathing?
– Circulation?
 Case 4: 6-month-old infant

APPEARANCE BREATHING
Abnormal Tone* Abnormal Sounds
 Interactiveness* Abnormal Position
 Consolability Retractions
Abnl. Look/Gaze* Flaring
Abnl. Speech/Cry
Apnea/Gasping
CIRCULATION
Pallor
Mottling
Cyanosis
 General Impression

= STABLE = SHOCK

= RESPIRATORY = CNS / METABOLIC

DISTRESS

= RESPIRATORY
= CARDIO-
FAILURE
PULMONARY
FAILURE
 Management Priorities: CNS/Metabolic

• Maintain airway, assess pulse oximetry

• Provide supplemental oxygen as needed
• Obtain rapid glucose
• Consider EKG/cardiac monitor
• Obtain vascular access – fluid resuscitation as
needed
• Consider non-accidental trauma
 Case 5: 12-year-old adolescent

• You respond to a call for a

12-year-old who was out
on a “joy ride” in his ATV
when he rolled
• Patient ambulatory at
scene, no LOC
• What is your assessment?
– Appearance?
– Breathing?
– Circulation?
 Case 5: 12-year-old adolescent

APPEARANCE
BREATHING
Abnormal Tone
Abnormal Sounds
 Interactiveness
Abnormal Position
 Consolability
Retractions
Abnl. Look/Gaze
Flaring
Abnl. Speech/Cry
Apnea/Gasping

CIRCULATION
Pallor
Mottling
Cyanosis
 General Impression

= STABLE = SHOCK

= RESPIRATORY = CNS / METABOLIC

DISTRESS

= RESPIRATORY
= CARDIO-
FAILURE
PULMONARY
FAILURE
 Management Priorities: Stable
• Monitor en route – transport
• Provide specific therapy based on further
assessment
 Case 6: 2-month-old boy

• EMS is called to the home of a 2 month-old

boy found unresponsive by parents.
• The infant is unresponsive, cyanotic, and
apneic
• What is you assessment?
– Appearance?
– Breathing?
– Circulation?
 Case 6: 2-month-old boy
BREATHING
APPEARANCE
Abnormal Tone* Abnormal Sounds
 Interactiveness* Abnormal
 Consolability Position
Abnl. Look/Gaze* Retractions
Abnl. Speech/Cry* Flaring
Apnea/Gasping*

CIRCULATION
Pallor
Mottling
Cyanosis*
 General Impression

= STABLE = SHOCK

= RESPIRATORY = CNS / METABOLIC

DISTRESS

= RESPIRATORY
= CARDIO-
FAILURE
PULMONARY
FAILURE
 Management Priorities:
Cardiopulmonary Failure
• Position the head and open the airway
• Initiate bag-mask ventilation with 100%
oxygen
• Monitor
• Begin chest compressions/CPR
• Obtain vascular access
 Summary
• Pediatric patients at high risk for medical errors
due to developmental stage and specific
management needs
• Providers have limited experience with critically ill
pediatric patients
• The PAT is a rapid assessment tool to help you
recognize and evaluate a sick child
• When evaluating a child use appearance,
breathing, and circulation to help guide your
management