Lou Romig MD, FAAP, FACEPPediatric Emergency Medicine

Miami Children’s HospitalMedical Advisor, FL DOH EMS for Children Program

ObjectivesObjectives

Recognize how much information children can give you without saying a word

Learn the Pediatric Assessment Triangle and its applications

Goals for the Acute Early Goals for the Acute Early Assessment PhaseAssessment Phase

Filter and focus

Access knowledge and experience

Control the emotional environment

Problems with the Problems with the Assessment of ChildrenAssessment of Children

Physical and cognitive immaturity

Normal vs. abnormal

Dependence on information from caregivers

Dealing with caregivers

Problems with the Problems with the Assessment of ChildrenAssessment of Children

They can’t talk to me!They can’t talk to me!

Children speak with their bodies.Children speak with their bodies.

We must listen with our eyes.We must listen with our eyes.

The Pediatric Assessment Triangle (PAT)The Pediatric Assessment Triangle (PAT)

From the AAP’s Pediatric Education for Prehospital Professionals(PEPP) course. www.PEPPsite.com

The PATThe PAT

Quick physiological gestalt

Often best done from a distance

Takes seconds

Can be repeated as needed

Answers two questions

How sick?

How quick?

The PATThe PAT

General Appearance

Work of Breathing

Circulation to the Skin

The Pediatric Assessment Triangle (PAT)The Pediatric Assessment Triangle (PAT)

General AppearanceGeneral Appearance

T Tone

IInteractiveness

C Consolability

L Look/gaze

S Speech/cry

General AppearanceGeneral Appearance

Assesses higher brain function by looking mostly at interaction with the environment

Higher brain function depends on good oxygenation, ventilation and perfusion to the brain

Don’t be fooled by chronic features or dramatic physical findings that don’t affect vital functions

Good general appearanceGood general appearance

Normal to well-compensated Normal to well-compensated physiologyphysiology

“Not sick”“Not sick”“Not quick”“Not quick”

Poor general appearancePoor general appearance

Inadequate physiologic Inadequate physiologic compensationcompensation

““Sick!Sick!””““Quick!Quick!””

Sick or not sick?Sick or not sick?

Sick or not sick?Sick or not sick?

Sick or not sick?Sick or not sick?

Sick or not sick?Sick or not sick?

Sick or not sick?Sick or not sick?

The Pediatric Assessment Triangle (PAT)The Pediatric Assessment Triangle (PAT)

Work of BreathingWork of Breathing

More important than respiratory rate

Reflects unique anatomy

Increased WOB is good

Decreased WOB is bad

Small airways

Weak intercostals

Dependence on diaphragm

The Pediatric Assessment Triangle (PAT)The Pediatric Assessment Triangle (PAT)

Circulation to the SkinCirculation to the Skin

Decreased circulation to the skin is an early sign of compensation for a circulatory problem in kids (not always true in adults)

Capillary refill is a good measure in kids, especially when done in a serial fashion in a normothermic environment

You don’t need a blood pressure…You don’t need a blood pressure…

Remember these eyesRemember these eyes

Putting the PAT togetherPutting the PAT together

A B C PhysiologicCategory

Sick?

GoodRespiratory Distress

Poor Respiratory Failure

RespiratoryRespiratory

A B C PhysiologicCategory

Sick?

GoodNonspecific Peripheral

Vasoconstriction

Poor Shock

CirculatoryCirculatory

A B C PhysiologicCategory

Sick?

Poor Good GoodCNS

Dysfunction

Central Nervous SystemCentral Nervous System

Seizure/Post-ictal Head injuryIntoxication/Drug effect MetabolicMeningitis/Encephalitis Chronic disability

A B C PhysiologicCategory

Sick?

Cardiopulmonary Failure

The Last ChanceThe Last Chance

Hear Hear herehere

!!

Child with a cold and a raised red Child with a cold and a raised red rashrash

Sick?

o Alert

o Interacts with toy

o Good spontaneous movement

o Good coordination and strength

Another Another blotchy blotchy

kidkid

Sick?

Not sickNot sick

MottlingMottling

Sick?Sick?

Cutis MarmorataCutis Marmorata

Child with fever and petechiaeChild with fever and petechiae

Small red dotsDo not blanchNot palpable

More fever and petechiaeMore fever and petechiae

Purpura fulminans:Purpura fulminans:MeningococcemiaMeningococcemia

Purpura fulminans:Purpura fulminans:MeningococcemiaMeningococcemia

Vomiting and diarrhea x 3 daysVomiting and diarrhea x 3 days

Dry, sunken eyes

Dry oral membranes

But is he sick?

Vomiting and diarrhea x 3 daysVomiting and diarrhea x 3 days

Watching passively

Since when does a kid this age stay still?

Is he sick?

CompareCompare

Which would you treat first?

Before and AfterBefore and After

Distress or failure?Distress or failure?

Distress or failure?Distress or failure?

Kussmaul breathingKussmaul breathing

Respiratory distressRespiratory distress

A known asthmaticA known asthmatic

Respiratory distressRespiratory distress

Two hours laterTwo hours later

Respiratory failureRespiratory failure

The Pediatric Assessment Triangle (PAT)The Pediatric Assessment Triangle (PAT)

From the AAP’s Pediatric Education for Prehospital Professionals(PEPP) course. www.PEPPsite.com

Can you hear them now?Can you hear them now?

Louromig@bellsouth.netLouromig@bellsouth.net

www.jumpstarttriage.comwww.jumpstarttriage.com