As of this posting, it is November of 2022. We are seeing huge numbers of RSV cases, and they seem to be arriving earlier in the year than is typical. The flu and COVID are still lurking as well. This has resulted in huge numbers of Pediatric hospitalizations, pushing children's hospitals to the limit. Emergency departments always see a spike in pediatric patients in the late fall through the winter. The increased severity of the situation this year brings pediatric emergency topics to mind.

Pediatric patients, particularly at the younger ages, can be difficult to accurately triage. On the one hand, they can be overly dramatic. I'm thinking about my 11 year old who was convinced he broke a bone in his leg even though I promised him it was just a bruise. That kid limped all day, until he forgot he was supposed to be hurt. When I pointed out that he was walking normally he started limping again...

The more important consideration regarding pediatric triage is catching problems the child cannot communicate clearly to you. Some aren't old enough to speak, and the ones that can may not have the vocabulary to accurately describe what they are experiencing. Feeling "yucky" might mean burning or sharp pain, nausea or dizziness. Attempts to clarify can be hit-and-miss and may confuse the child more.

Pediatric vital signs are particularly difficult to interpret. Everyone learned in school that normal values vary by age, and just a few weeks can place a child in a new "normal range." Blood pressures are unreliable in infants, heartrates can fluctuate by a large degree if the child is crying or has a fever and respiratory rates can be difficult to accurately count quickly.

All of this is to say that ER nurses, whether working in a hospital with a pediatric department or not, need to know how to immediately identify a child that needs rapid intervention. Normally, gut feelings are not reliable enough to base medical decisions on. The American Academy of Pediatrics came up with the Pediatric Assessment Triangle as a way to quickly identify children that will need immediate intervention. When you understand the components of the triangle it becomes clear that it basically just identifies the different criteria that could trigger someone's "gut feeling."

The Pediatric Assessment Triangle (PAT)

Being a triangle, it predictably is composed of three main parts.

See the image to the right. This is my preferred version, without a lot of other information. This is because some versions include individual factors under each of the three main topics. I think all those factors turn this into a rather long checklist if it's not understood correctly.

A Pediatric Assessment has two steps (hence the rapid assessment):

1. Expose the child, at least to the diaper. If the child is in a car seat or some other type of holder, get them out and uncovered.
2. Apply all three components of the PAT at once (appearance, circulation, work of breathing)

Appearance

Ask yourself: is the child behaving as expected for a child of their age? It doesn't take a lot of pediatric exposure to know that a baby usually cries when you try to take them from mom, that a toddler should be capable of walking or standing if set down and a child should be alert and able to answer simple questions. Some specific things to note (but remember, this isn't a checklist) are:

• Is the child awake? If not, wake them up and make them cry. A "calm" or quiet child should raise alarms
• The cry - does the child cry when you expect them to? Is the cry high pitched and shrieking or weak and pitiful?
• When they're crying, do they wave their arms, curl up in a ball, shake their head or kick their feet? These are good signs, since the absence may indicate weakness. A flaccid child is a sick child.
• Can they be consoled? Let the family member take them and see if they calm down.

Work of Breathing

In my experience, this is by far the most likely place that you will have positive findings. Kids have small airways and small lungs and are very susceptible to anything that can narrow or clog the airways. They also react more severely to certain infections (think RSV). Increased work of breathing also tends to wear them out faster. Look/listen for the following to evaluate the work of breathing in pediatrics:

• Any respiratory sounds. If you can hear the patients respiratory sounds without a stethoscope you should investigate further. Grunting, wheezing, and gurgling are all signs of different types of respiratory concerns.
• Look at the stomach/chest. Stomach breathing and retractions around the ribs are signs that the child is working harder than normal to move air.
• Look at the face and neck. Again, nasal flaring and accessory muscle movement around the neck are signed of increased effort that need further immediate evaluation.

Again, these are all to be completed at the same time as each other and simultaneous to the other two PAT components.

Circulation

Most organizations point out skin color and capillary refill in the circulatory assessment. I add one more: tears.

• Look at the legs, arms and trunk. Are they pale or mottled? Mottling in particular is an especially bad sign that blood flow to the skin is inadequate. Because skin color can be difficult depending on skin type, looking at the gums can be a useful alternative to check for paleness.
• Since we know a good strong cry is the sign of a healthy child, eliciting this response also give the chance to check for tears. If the child is crying hard but producing no tears, you might consider if the child is dehydrated.
• As stated before, blood pressure is relatively unreliable in very young children. This makes capillary refills especially valuable for this population. Pro tip: since their toes and fingers are so small they can be hard to assess. If you push your thumb on their chest, you can get just as valid of a finding that is easier to see. A prolonged capillary refill is a huge red flag.

Putting the Assessment Together

All ED nurses should become familiar with the primary survey used in trauma patients: ABCDE. If you are unaware, this stands for Airway, Breathing, Circulation, Disability and Exposure. Its used to identify immediate risks to your patient's life as quickly as possible. We can look at the Pediatric Assessment Triangle as another form of the primary survey. Work of Breathing corresponds to the Airway and Breathing: Is there a respiratory problem? Circulation obviously corresponds to Circulation: Is there a problem moving blood around the body? Appearance corresponds to Disability: Is there a neurological or alertness problem?

The comparison to a primary survey does not stop there. Just like a primary survey, the PAT is only a starting point. It is meant to identify problems that need to be addressed immediately. The patient still needs vital signs and a proper assessment. Just because the PAT doesn't trigger any red flags doesn't mean there isn't anything wrong with the patient. There could even still be life threatening conditions, so don't skimp on your investigation.

A problem in any of the three components of the PAT warrant immediate intervention. These are the patients that require you to at least get a physicians eyes on them ASAP if not placing them in your last open bed. Children can compensate for a long time and that compensation can mask a problem very thoroughly. When they to start to crash though, they crash fast. Being able to rapidly assess a patient for a life threatening problem is key to intervening quickly enough to prevent a bad outcome.

Conclusion

The PAT has been well validated for quickly assessing pediatric patients. Practice applying it to your patients whenever possible. Apply it to as many (relatively) healthy children as you can. Knowing what a child should look, sound and act like makes it much easier to identify a sick child when you see one. I know kids in the emergency department can be scary to care for, but be bold, get in there and become an awesome and more versatile ED nurse. Lets hear some pediatric assessment tricks in the comments below.

External Links

https://wikem.org/w/index.php?title=Pediatric_assessment_triangle&modqueued=1