Medicine:Pediatric assessment triangle

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The Pediatric Assessment Triangle is a tool used in emergency medicine to form a general impression of a pediatric patient.[1] In emergency medicine, a general impression is formed the first time the medical professional views the patient, usually within seconds.[2] The Pediatric Assessment Triangle is used as a method of quickly determining the acuity of the child, and can determine whether the child is in respiratory distress, respiratory failure, or shock.

The Pediatric Assessment Triangle is taught, among other contexts, in Advanced Pediatric Life Support courses.

Components of the Triangle

Appearance

The "Appearance" portion of the Pediatric Assessment Triangle measures a variety of things, designed to determine whether the child is experiencing mental status changes (as these can be difficult to identify in an infant or young child). Components of the "Appearance" item also help to determine whether the child's airway is clear.

The acronym "TICLS" (pronounced "tickles") is sometimes used by emergency medical providers to recall the components of the "Appearance" item:[1][2]

  • Tone (muscle tone)
    • Abnormal: Limp, rigid, or absent muscle tone
    • Normal: Good muscle tone with good movement of the extremities. Infants should strongly resist attempts to straighten their limbs.
  • Irritability
    • Abnormal: Crying is absent, or abnormal. The child cannot be stimulated to cry. In addition to indicating an altered mental status, this may also be a sign of an occluded airway.
    • Normal: Strong, normal cry (this is a reliable sign of a clear airway)
  • Consolability
    • Abnormal: The child cannot be consoled or comforted by usual caregivers. The child does not respond normally to environmental stimuli, like preferred toys.
    • Normal: The child is able to be consoled by usual caregivers. The child responds in his or her usual way to environmental stimuli.
  • Look (gaze)
    • Abnormal: Vacant stare with lack of eye contact. The child may not seem to recognize normal caregivers.
    • Normal: Child is able to make eye contact
  • Speech
    • Abnormal: The child is unable to express himself or herself age-appropriately. Speech (or crying for babies) is absent or abnormal. As with lack of crying in infants, this can be a sign of an occluded airway.
    • Normal: The child expresses himself or herself age-appropriately. Speech (or crying) is normal (this is a reliable sign of a clear airway).

Work of Breathing

Signs of increased work of breathing include:[1][3]

  • Noisy breathing (including grunting in infants)
  • Retractions (the soft tissue between the ribs gets sucked inward because the child is trying so hard to breathe in)
  • Use of accessory muscles of respiration to breathe (the child is having so much difficulty breathing that he or she needs extra muscles, like the abdominal muscles, to lift the chest and inhale)
  • Nasal flaring in young children
  • Seesaw breathing in infants (where the chest and abdomen "seesaw" up and down; this is a sign of severe respiratory distress in an infant)

A child exhibiting decreased work of breathing may be bradypneic (breathing too slowly) or too weak to engage the muscles required for inhalation.

Circulation to Skin

"Circulation to Skin" is measured by skin color and obvious bleeding. Circulation, as measured by skin color and capillary refill, is an excellent indicator of perfusion in children.

A child with normal circulation will have his or her usual skin color. There will be no obvious bleeding.

Abnormal circulation to the skin may be indicated by:[2]

  • Pallor (generally an early sign of decreased circulation; pallor may also be an indication of blood loss)
  • Cyanosis
  • Mottling
  • Obvious blood loss

"Scoring" the Triangle

The Pediatric Assessment Triangle assigns no numerical scores, its goal being to help medical providers formulate a quick assessment of a pediatric patient's acuity. However, based on the results of the assessment, some initial conclusions can be drawn. These initial conclusions can help to guide medical decisions, such as whether to call for additional medical resources, but further assessment is always done, and repeated, following the quick usage of the Pediatric Assessment Triangle.[1]

Respiratory distress

A child who is exhibiting increased work of breathing, but has normal appearance and circulation to skin, can be initially assumed to be in respiratory distress.[3] While the child is having trouble breathing, he or she is getting enough oxygen to perfuse the body well (hence normal circulation) and to oxygenate the brain (preventing mental status changes).

Respiratory failure

Shock

In extremis

A child with abnormal appearance, work of breathing, and circulation to the skin is generally in extremis - for example, due to imminent respiratory collapse.[3]

References

  1. 1.0 1.1 1.2 1.3 "Pediatric Assessment". New York State Emergency Medical Services. http://www.health.ny.gov/professionals/ems/pdf/pediatricreferencecard-04.pdf. 
  2. 2.0 2.1 2.2 Deickmann, MD, Ronald. "Pediatric Emergencies". http://sfghed.ucsf.edu/Education/Lectures/Syllabus/PedEmergencies.pdf. 
  3. 3.0 3.1 3.2 Horeczko, MD, Timothy; Enriquez, MD, Brianna; McGrath, MN, RN, Nancy E.; Gausche-Hill, MD, Marianne; Lewis, MD, Ph.D., Roger J. (March 2013). "The Pediatric Assessment Triangle: Accuracy of its Application by Nurses in the Triae of Children". Journal of Emergency Nursing 39 (2): 182–189. doi:10.1016/j.jen.2011.12.020. PMID 22831826. 


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