PEP Course Lecture 3

1. PEP CourseLecture 3 • PEDIATRIC • ASSESSMENT • TRIANGLE

2. Lecture Objectives • 1. Understand the elements of the • Pediatric Assessment Triangle. • 2. Distinguish the Triangle from the • PediatricPrimary Survey. • 3. Highlight the differences between adult and pediatric assessment.

3. Case 1 • A babysitter calls 911 for a 14 month old girl who is having trouble breathing.

4. Assessment • • The child is in her babysitter’s arms and appears fatigued, with loud inspiratory stridor with each breath. • • She takes one look at you and starts to wail. Her stridor gets worse as she becomes agitated.

5. Key Question • What are the elements of the assessment that are most useful?

6. Pediatric Assessment Triangle Appearance

7. Work of Breathing Pediatric Assessment Triangle

8. Pediatric Assessment Triangle Circulation to Skin

9. Pediatric Assessment Triangle Appearance Work of Breathing Circulation to Skin

10. Pediatric Assessment Triangle • The Triangle focuses on three interdependent aspects of physical assessment that reflect: • 1. Severity of illness or injury • 2. Urgency of intervention In other words ...

11. How sick? How quick?

12. Pediatric Assessment Triangle • The Triangle is a rapid way to determine physiologic stability.

13. Key Question • How can you assess physiologic stability just by looking at the child?

14. Appearance • • alertness • speech or cry • • distractibility • motor activity • • consolability • color • • eye contact

15. Appearance • The child’s overall appearance • reflects the adequacy of oxygenation, • ventilation and perfusion.

16. Pearl • • Appearance is the single most important factor in assessment. • • There are very few false negatives (very few truly sick or injured children that have normal appearance).

17. Pearl • • A child can have a chronic or acute illness or injury with visible abnormalities, but not be physiologically sick. • •A physiologically sick child will look sick.

18. Key Question • How do you recognize respiratory distress and failure by looking at the child?

19. Work of Breathing • • Abnormal audible breath sounds (e.g. stridor, wheezing or grunting) • • Retractions (suprasternal, intercostal, subcostal) • • Nasal flaring

20. Normal Appearance Increased Work of Breathing MEANS RESPIRATORY DISTRESS Triangle: Respiratory Distress

21. Triangle: Respiratory Failure • Abnormal Increased or Decreased Work of Breathing Appearance MEANS RESPIRATORY FAILURE

22. Key Question: • What is the most reliable way to rapidly assess adequacy of perfusion?

23. Circulation to Skin • • Inadequate perfusion of vital organs leads to compensatory vasoconstriction in non-essential anatomic areas, especially the skin. • • Therefore circulation to skin reflects overall adequacy of perfusion.

24. Key Question • How do you assess circulation to the skin?

25. Circulation to Skin • • Skin temperature • • Pulse strength • • CRT (capillary refill time)

26. Abnormal Appearance Poor Circulation to Skin MEANS SHOCK Triangle: Shock

27. Normal Appearance Poor Circulation to Skin MEANS OBSERVE Triangle:

28. Circulation to SkinOther causes of vasoconstriction(mottling,  CRT) • Fever • Hypothermia • Medications • Normal vasomotor lability in infants

29. Pearl: Triangle • The Triangle can also help identify the child with CNS or systemic problems who has normal oxygenation, ventilation and perfusion.

30. Normal Work of Breathing Abnormal Appearance Normal Circulation to Skin MEANS BRAIN DYSFUNCTION Triangle: Brain Dysfunction

31. Pearl: Sensitivity and Specificity • The Triangle provides sensitivity and specificity: • • Appearance identifies almost every child with serious illness or injury, and offers sensitivity. • • Work of Breathing and Circulation to Skin help distinguish between organ systems that are likely sources of distress. These elements offer specificity.

32. Case continues • You perform the triangle: • • The child is alert, makes good eye contact, has a strong cry and is consolable. • • She has stridor. No grunting or wheezing. No flaring. Suprasternal and intercostal retractions present. • • Circulation to skin is normal.

33. Pediatric Primary Survey • After completing the Triangle, begin a more complete pediatric primary survey.

34. Key Question • What is the difference between the Triangle and the pediatric primary survey?

35. Key Points • 1. The Triangle is a “quick look” of overall severity and urgency of treatment. • 2. The primary survey is a rapid ordered, stepwise evaluation of cardiopulmonary and neurologic function to prioritize treatment. • 3. Begin resuscitation immediately when you identify a life-threatening problem in the primary survey.

36. Case continues • You approach the child, who is now calm in her babysitter’s arms. You offer her your penlight which she plays with while you perform your “hands-on” assessment, or primary survey.

37. Pediatric Primary Survey • AIRWAY & BREATHING • Assess adjunctive signs: • • Respiratory rate (RR) • • Tidal volume ausculation • • Lung sounds (crackles, wheezes) • • Pulse oximetry (SaO2)

38. Pediatric Primary Survey • CIRCULATION • Assess adjunctive signs: • • Heart Rate (HR) • • Blood Pressure (BP): in children <3 yrs, attempt only once

39. Pediatric Primary Survey • DISABILITY • • AVPU • • Pupils • • Abnormal movement

40. Pearl: Disability vs. Appearance • • “Disability” evaluates altered level of consciousness. It is not very useful unless illness or injury is moderate-critical. • • Abnormal “appearance” reflects mild-moderate severity and is much more useful as an assessment tool.

41. Abnormal Appearance worsening severity Abnormal Appearance on AVPU • A V P U

42. Summary of Triangle • • Playful and vigorous. • • Stridor at rest. • • Suprasternal and intercostal retractions. • • Extremities warm. CRT <2 secs.

43. Summary of Primary Survey • • RR 50/min. • • Fair inspiratory volume. • • Breath sounds clear. • • SaO2 = 93% on room air. • • HR 140/min. BP not obtained. • • Alert, PERRL, normal motor exam.

44. Key Question • How would you describe this child when giving radio report to the base hospital?

45. Radio Report • This is a 14 month old female in moderate respiratory distress with partial upper airway obstruction. She is alert and interactive but has inspiratory stridor at rest and is retracting. She is pink and well perfused. We will transport with blow-by oxygen.

46. Case 2 • A frantic young mother calls 911 because her infant had a fever last night, and she could not awaken him this morning. She is waiting for the ambulance on the street, while holding her 6 month old baby in her arms.

47. Key Question • What features of this infant’s general appearance will help you to assess his physiologic stability?

48. Case continues:Appearance • • Child is lethargic. • • Eyes are open, but he does not focus on his mother’s face. • • Cries weakly with painful stimulus, but does not pull away. • • Limp, with no spontaneous movement. • • Pale and mottled.

49. Key Question • What are the key features of work of breathing?

50. Case continues:Work of Breathing • • No abnormal audible breath sounds • • No retractions • • No flaring