By: Steve Shotz
In pre-hospital care, pediatric patients usually represent only 10-20 percent of the patients treated, so one's gut sense about their conditions is usually not as well developed as it is for adults. Problems in children also often manifest differently than they do in adults. It can therefore be very useful to have a reliable assessment tool to help make good judgments. One such tool is the Pediatric Assessment Triangle (PAT), which has three parts.
Part 1: Appearance
This is the most important of the three parts. It refers to your general impression of how the child looks and responds to your presence. This impression reflects how the child's central nervous system is functioning and whether there is adequate blood and oxygen getting to the brain. When you compare a child who is crying loudly and forcefully to one who is quiet, unresponsive, and essentially limp, you can immediately deduce which one is in the worse condition.
To get a good sense of appearance, use the TICLS (tickles) checklist:
- Look (gaze)
- Speech (crying)
This method is more effective in children than the standard AVPU (Alert, Verbal, Pain, Unresponsive) measure of responsiveness commonly used for adults.
Part 2: Work of Breathing.
How much effort must the child exert to breathe? This may provide useful information about how well oxygenated the child is, in addition to his rate of respiration and presence/type of breath sounds. When a child must work hard to breathe, he is trying to overcome a problem. Strenuous effort may signal that a respiratory failure is about to occur.
Abnormal sounds to listen for include:
- Snoring, hoarseness, a muffled voice and/or trouble swallowing suggest the child has a problem in the upper airway. Stridor is a high pitched sound heard when the child inhales. Infection, swelling, foreign body obstruction or bleeding can cause problems in the upper airway.
- Wheezing, in the early stages, is typically heard only with a stethoscope when the child exhales, but as it worsens, may also be heard when she inhales, even without a stethoscope. Wheezing is the most common abnormal breath sound and may decrease as the child becomes exhausted and air flow decreases. This is a bad sign and may signal an imminent respiratory arrest.
- Grunting when exhaling is a sign that the patient is not exchanging lung gases adequately and is likely to lack adequate oxygenation. This sign may indicate the presence of pulmonary edema or pneumonia.
Abnormal signs to watch for:
- You may see a child who extends his/her neck forward and angles his/her head up and back in an attempt to open a partially blocked airway. This is called the sniffing position.
- Sometimes a child will sit straight up and extend her arms wide in front of her on her knees or other surface in a tripod position. This is an attempt to utilize chest and neck muscles to assist with breathing.
- Head bobbing is another sign of labored breathing.
Part 3: Circulation
How well is the heart working? Indications of problems include cyanosis - a bluish tint to the skin, lips and other mucus membranes that suggests there is not enough dissolved oxygen in the arterial blood.
In your role as a first responder, you need to recognize any of the above signs and symptoms in your patient. They may tip you off to the presence of a serious condition that can be life threatening. As with any problem with ABC's (airway, breathing, circulation), apply your Basic Life Support and first aid training, administer oxygen if you are properly training and authorized, and arrange for immediate evacuation and transportation by paramedics. Always work within your training and experience level.
Steve Shotz (sjshotz [at] sbcglobal [dot] net) is an Emergency Medical Technician and an Outdoor Emergency Care instructor for the National Ski Patrol. He welcomes your questions on first aid practices.