Pediatric Assessment Triangle

1. See Also
   1. Pediatric Resuscitation
2. Indications
   1. Establish the general appearance of an emergently presenting pediatric patient
3. Evaluation
   1. Appearance (Mnemonic: TICLS)
      1. Tone
         1. Vigorous to limp
         2. Normal children of all ages, including newborns should have muscle tone
      2. Interactiveness
         1. Engaged to unintererested
      3. Consolability
         1. Content to unconsolable
      4. Look or gaze
         1. Gaze follows to glassy eyed stare
      5. Speech or cry
         1. Spontaneous speech to wimper
   2. Work of breathing
      1. Abnormal airway sounds
         1. Grunting
         2. Stridor
         3. Wheezing
      2. Abnormal positioning
         1. Tripod position
         2. Sniffing
         3. Head Tilt (consider Retropharyngeal Abscess, Epiglottitis)
      3. Intercostal or neck retractions (or head bobbing in infants)
      4. Nasal Flaring
   3. Skin circulation
      1. Pallor
      2. Mottling
      3. Cyanosis
4. Protocol
   1. Perform PAT evaluation as above
      1. Determine based on PAT if the patient is stable or unstable (sick or not sick, toxic or non-toxic)
   2. Define status along a spectrum
      1. Stable
      2. Respiratory distress
      3. Respiratory Failure
      4. Shock
      5. CNS Dysfunction
      6. Cardiopulmonary Failure or Arrest
   3. Intervene with critical management
      1. Respiratory distress or respiratory failure
      2. Shock
      3. Cardiopulmonary failure
   4. Constantly reassess
      1. See Pediatric Resuscitation for ABC evaluation and management
5. Exam: Pearls
   1. Heart Rate
      1. Significant Sinus Tachycardia should warrant a thorough evaluation for cause
      2. Normal Heart Rate despite complaints of significant pain suggests Malingering
      3. Remember 3 Heart Rates in children
         1. Heart Rate should be above 60 bpm
         2. Newborn Resuscitation is triggered below a Heart Rate of 100 bpm
         3. Confirm Sinus Tachycardia if Heart Rate >160 bpm
   2. Blood Pressure
      1. Blood Pressure is an important vital sign in children and should be obtained on any patient considered unstable
      2. Hypotension is a late sign and signals decompensated shock and impending failure
      3. Initial stabilization room Blood Pressure often does not correlate with overall trend (obtain frequent recheck on Blood Pressure)
      4. Hypertension may signal renal dysfunction (especially in children with Urinary Tract Infections)
   3. Age appropriate activity
      1. Maintenance of normal activity for developmental age is a very reassuring sign
      2. Ask parents for their opinion on how their child appears
         1. Parents worried about their child's appearance suggests more significant illness
   4. Respiratory
      1. Observe from the doorway for retractions, grunting, Tachypnea and other signs of respiratory distress
   5. Documentation
      1. Triage note evaluation
         1. Investigate and explain any abnormal findings in the triage note
         2. Confirm accuracy of recorded vital signs
      2. Serial exams
         1. Document repeat exam with updated status prior to discharge
   6. Percussion
      1. Abdominal percussion may provoke Abdominal Pain
      2. Chest percussion may identify Pneumonia
      3. Bone percussion may identify Fracture sites
   7. Fever
      1. Antipyretics may dramatically improve a child's appearance (and will not mask a more significant underlying illness)
   8. Metabolic disorders
      1. Frequently overlooked as cause of Altered Mental Status
      2. Consider in children with abnormal appearance, but normal respiratory and circulatory assessment
6. Exam: Red Flags
   1. Grunting
      1. Suggests auto-PEEP, CNS disorder or airway obstruction
   2. Neurologic
      1. Lethargy
      2. Head Trauma (e.g. hematoma, Otorrhea, Rhinorrhea, battle's sign, racoon's eyes)
      3. Bulging Fontanelle
   3. Respiratory
      1. Drooling
      2. Stridor
   4. Gastrointestinal
      1. Poor feeding
      2. Bilious Vomiting or Vomiting without Diarrhea
      3. Constipation
         1. Associated with higher risk of Urinary Tract Infections and possibly Appendicitis
   5. Musculoskeletal
      1. Pediatric Limp
   6. Skin
      1. Bruising or Burn Injury
      2. Petechiae
7. Labs: High yield tests
   1. Serum Glucose or finger stick Blood Sugar
      1. Indicated in lethargic or ill appearing children
      2. Ill children have poor glycogen stores
   2. Urinalysis
8. References
   1. Fuchs and Yamamoto (2011) APLS, Jones & Bartlett, Burlington, MA
   2. Cantor and Claudius (2012) EM:RAP 12(7): 7-8
   3. Dieckmann (2010) Pediatr Emerg Care 26:312-5