Objectives. Initial Evaluation and Triage. of the. Acutely Ill or Injured Child 9/11/2012. Chapter 02. Patient Assessment
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1 Chapter 02 Patient Assessment Objectives Discuss the components of a pediatric assessment. Describe techniques for successful assessment of infants and children. Identify key anatomical and physiological characteristics of infants and children and their implications. Identify normal age group related vital signs. Discuss the appropriate equipment used to obtain pediatric vital signs. Identify the components of pediatric triage. 2 Initial Evaluation and Triage of the Acutely Ill or Injured Child 3 1
2 Scene Survey Hazards or possible hazards Relationship/interaction Determine need for additional resources 4 Components of a Pediatric Assessment Initial assessment Pediatric Assessment Triangle (general impression) Primary survey (ABCDE assessment) Secondary survey Vital signs Focused history Physical examination Reassessment 5 Initial Assessment 6 2
3 Pediatric Assessment Triangle General Impression Across-the-room assessment Can be completed in 60 seconds or less No equipment required Use your senses of sight and hearing to quickly determine if a life-threatening problem exists 7 Pediatric Assessment Triangle General Impression Purpose Establishes severity of illness or injury Sick or not sick Identifies general category of physiologic abnormality Cardiopulmonary Neurologic Metabolic Toxicologic Trauma Determines urgency of further assessment and intervention 8 Pediatric Assessment Triangle General Impression Components: Circulation 9 3
4 Pediatric Assessment Triangle General Impression Appearance Reflects the adequacy of: Oxygenation Ventilation Brain perfusion Homeostasis Central nervous system function Circulation 10 Pediatric Assessment Triangle General Impression Appearance Assessment areas (TICLS): Tone (muscle tone) Interactivity/mental status Consolability Look or gaze Speech or cry 11 Pediatric Assessment Triangle General Impression Work of breathing Reflects the adequacy of airway, oxygenation, and ventilation Circulation 12 4
5 Pediatric Assessment Triangle General Impression Work of breathing Assessment areas: Body position Visible movement (chest/abdomen) Ventilatory rate Ventilatory effort Audible airway sounds Circulation 13 Pediatric Assessment Triangle General Impression Sniffing position Circulation 14 Pediatric Assessment Triangle General Impression Tripod position Circulation 15 5
6 Pediatric Assessment Triangle General Impression Circulation Reflects the adequacy of cardiac output and perfusion of vital organs (i.e., core perfusion) Assessment areas: Skin color Circulation 16 Pediatric Assessment Triangle General Impression Mottling Circulation 17 PAT General Impression Summary Appearance Mental status Muscle tone Body position Breathing Body position Visible movement of chest/ abdomen Work of breathing (ventilatory rate/effort) Audible airway sounds Circulation Circulation Skin color 18 6
7 General Impression Decision Based on your first impression, is the child sick (unstable)? Or not sick (stable)? Sick Proceed immediately with rapid assessment of airway, breathing, and circulation If a problem is identified, perform necessary interventions Treat as you find Not Sick Proceed systematically: Primary survey (ABCDE) Secondary survey Vital signs Focused history Physical exam Reassessment 19 Primary Survey Focus: Basic Life Support Interventions 20 Primary Survey - ABCDE Hands-on assessment Purpose Determine if life-threatening conditions exist Components Airway, level of responsiveness, and cervical spine protection Breathing (ventilation) Circulation (perfusion) Disability (mini-neurologic exam) Expose/environment 21 7
8 Primary Survey Airway Assessment Goal determine if the airway is open, maintainable, or unmaintainable Open able to be maintained independently Maintainable with positioning, suctioning Unmaintainable requires assistance 22 Primary Survey Airway/Responsiveness Assessment AVPU: Alert Verbal stimuli Painful stimuli Unresponsive 23 Primary Survey Airway If cervical spine injury is suspected, manually stabilize the head and neck in a neutral, inline position If the child is responsive: And the airway is patent, move on to evaluation of breathing But cannot talk, cry, or cough forcefully, evaluate for possible airway obstruction 24 8
9 Primary Survey Airway If the child is unresponsive: Quickly check breathing If normal breathing is present, continue the primary survey If the child is not breathing (or only gasping), check for a pulse If there is no pulse or you are unsure if there is a pulse, begin chest compressions 25 Primary Survey Airway If the child is unresponsive and a pulse is present, use manual maneuvers to open the airway Head tilt-chin lift Jaw thrust without head tilt Use if trauma is suspected 26 Primary Survey Airway If the child is unresponsive and a pulse is present but the airway is not patent, assess for sounds of airway compromise Snoring Gurgling Stridor 27 9
10 Primary Survey Airway Look in the mouth Blood Broken teeth Gastric contents Foreign objects Loose teeth Gum Small toy 28 Primary Survey Airway Signs of distress may include: Preferred posture Drooling Difficulty swallowing Swelling of lips and/or tissues of the mouth Inadequate air movement Obstruction by tongue, blood, vomitus, foreign body Abnormal airway sounds 29 Primary Survey Airway Interventions Spinal stabilization as needed for trauma By history or physical exam Jaw thrust without head-tilt Head-tilt/chin-lift Suction Reposition Removal of foreign body Airway adjuncts 30 10
11 Primary Survey Breathing Assessment Goals Adequate gas exchange with no signs of hypoxia Awake and alert Maintain oxygen saturation of at least 94% Skin color normal; warm and dry Breathing is spontaneous, unlabored, and at a normal rate for age Chest expansion is equal bilaterally Breath sounds are present, clear, and equal bilaterally Absence of dyspnea, stridor, increased work of breathing 31 Primary Survey Breathing Confirm child is breathing Determine if breathing is adequate or inadequate If breathing adequate, move on to assessment of circulation 32 Primary Survey Breathing Assess chest and abdomen for ventilatory movement Evaluate depth and symmetry of movement with each breath 33 11
12 Primary Survey Breathing Assessment Determine ventilatory rate Normal Ventilatory Rates by Age Age Breaths/min (at rest) Infant (1 to 12 months) 30 to 60 Toddler (1 to 3 years) 24 to 40 Preschooler (4 to 5 years) 22 to 34 School-age (6 to 12 years) 18 to 30 Adolescent (13 to 18 years) 12 to Primary Survey Breathing Assess for the presence of respiratory distress/failure If respiratory distress is observed, potential respiratory failure is present 35 Primary Survey Breathing Note signs of increased work of breathing (ventilatory effort) Anxious appearance, concentration on breathing Use of accessory muscles Leaning forward to inhale Nasal flaring 36 12
13 Primary Survey Breathing Note signs of increased work of breathing (ventilatory effort) Retractions 37 Primary Survey Breathing Note signs of increased work of breathing Seesaw movement Note rhythm of breathing Regular Irregular Periodic 38 Primary Survey Breathing Respiratory Distress Nasal flaring Inspiratory retractions Increased breathing rate Increased depth of breathing Head-bobbing See-saw respirations Restlessness Tachycardia Grunting Stridor Location of retractions 39 13
14 Primary Survey Breathing Signs of Respiratory Distress and Respiratory Failure Respiratory Distress Respiratory Failure Nasal flaring Inspiratory retractions Increased breathing rate Increased depth of breathing Head-bobbing See-saw ventilations Restlessness Tachycardia Grunting Stridor Cyanosis Diminished breath sounds Decreased LOC or response to pain Poor skeletal muscle tone Inadequate ventilatory rate, effort, or chest excursion Tachycardia Use of accessory muscles 40 Primary Survey Breathing Listen for air movement at the nose and mouth Note if breathing is quiet, absent, or noisy Stridor Wheezing Snoring Crowing Gurgling Listen for presence and quality of breath sounds 41 Primary Survey Breathing If breathing is difficult and rate is too slow or too fast: Supplemental oxygen Positive-pressure ventilation if necessary Continue primary survey 42 14
15 Primary Survey Breathing If breathing is absent: Insert an airway adjunct Deliver two breaths Ensure chest rise with each ventilation Continue the primary survey 43 Primary Survey Breathing Interventions Suction Oxygen Airway adjuncts Positive-pressure ventilation 44 Primary Survey Circulation Goals Adequate cardiovascular function and tissue perfusion Effective circulating fluid volume Normal core body temperature 45 15
16 Primary Survey Circulation Assessment Control bleeding Look for visible external hemorrhage Control major bleeding, if present Consider possible areas of major internal hemorrhage 46 Primary Survey Circulation Assessment Compare strength and quality of central and peripheral pulses Central pulse Newly born Umbilical cord Infant Brachial artery Older child Carotid or femoral artery 47 Primary Survey Circulation Grading of Pulses Description Grade Full, bounding, not obliterated with pressure +4 Normal easily palpated, not easily obliterated with pressure +3 Difficult to palpate, obliterated with pressure +2 Weak, thready, difficult to palpate +1 Absent pulse
17 Primary Survey Circulation Normal Heart Rates by Age Age Beats/min* Infant (1 to 12 months) 100 to 160 Toddler (1 to 3 years) 90 to 150 Preschooler (4 to 5 years) 80 to 140 School-age (6 to 12 years) 70 to 120 Adolescent (13 to 18 years) 60 to 100 *Pulse rates for a sleeping child may be 10% lower than the low rate listed in age group. 49 Primary Survey Circulation Assessment Evaluate cardiac rhythm Skin color Pink Pale Blue/cyanotic Mottled 50 Primary Survey Circulation Acrocyanosis in a newborn 51 17
18 Primary Survey Circulation Assessment Skin temperature Skin moisture Skin turgor 52 Primary Survey Circulation Assessment Capillary refill Less than 2 seconds = normal 3 to 5 seconds = delayed Poor perfusion Exposure to cool ambient temperatures More than 5 seconds = markedly delayed Suggests shock 53 Primary Survey Circulation Assessment Capillary refill 54 18
19 Primary Survey Circulation Interventions Oxygen Position Chest compressions Bleeding control Defibrillation 55 Primary Survey Disability Glasgow Coma Scale Adult / Child Score Infant Eye Opening Spontaneous 4 Spontaneous To verbal 3 To verbal To pain 2 To pain No response 1 No response Best Verbal Response Best Motor Response Oriented 5 Coos, babbles Disoriented 4 Irritable cry Inappropriate words 3 Cries only to pain Incomprehensible sounds 2 Moans to pain No response 1 No response Obeys commands 6 Spontaneous Localizes pain 5 Withdraws from touch Withdraws from pain 4 Withdraws from pain Abnormal flexion 3 Abnormal flexion (decorticate) (decorticate) Abnormal extension 2 Abnormal extension (decerebrate) (decerebrate) No response 1 No response Total = E + V + M 3 to Primary Survey Disability Interventions Oxygen Ventilation Position Spinal stabilization 57 19
20 Primary Survey Expose / Environment Undress the patient Preserve patient modesty whenever possible Maintain appropriate temperature 58 The Secondary Survey Focus: Advanced Life Support Interventions 59 Secondary Survey Overview Vital signs, pulse oximeter, ECG, BP monitor Obtain focused SAMPLE or CIAMPEDS history (Advanced) Airway Breathing Circulation Detailed (or focused) examination, differential diagnosis, diagnostic procedures Evaluate interventions, pain management Facilitate family presence for invasive and resuscitative procedures 60 20
21 Vital Signs Temperature Obtain the child s temperature by an appropriate route considering the child s age and clinical condition Oral Axillary Rectal Tympanic 61 Vital Signs Blood Pressure (BP) Measure BP Only after assessing pulse and respiration In children older than 3 years Width of BP cuff should cover 1/2 to 2/3 the length of the upper arm or upper leg 62 Vital Signs Blood Pressure (BP) Age Term neonate (0 to 28 days) Infant (1 to 12 months) Child 1 to 10 years Child 10 years and older Lower Limit of Normal Systolic BP > 60 mm Hg or strong central pulse > 70 mm Hg or strong central pulse > 70 mm Hg + (2 x age in years) > 90 mm Hg 63 21
22 Vital Signs Pulse Pressure Pulse pressure Difference between systolic and diastolic blood pressure Indicator of stroke volume Narrowed pulse pressure suggests circulatory compromise 64 Weight Obtain a measured weight when possible If a measured weight is not possible: Length-based measuring tape Ask caregiver child s last weight Pediatric weight formula Weight in kg = 8 + (2 x age) 65 Focused History SAMPLE Signs and symptoms Allergies Medications Past medical history Last oral intake Events prior to illness or injury CIAMPEDS Chief complaint Immunizations/Isolation (communicable disease exposure) Allergies Medications Past medical history/parent s impression of child s condition Events surrounding illness/ injury Diet/diapers Symptoms 66 22
23 Focused History Onset Provocation Quality Region/Radiation Severity Time 67 Physical Examination Purpose Detect non-life-threatening conditions Provide care for those conditions/injuries 68 Detailed Physical Examination Inspect and palpate each major body area for: Deformities Contusions Abrasions Penetrations/Punctures Burns Lacerations Swelling/edema Tenderness Instability Crepitus 69 23
24 Detailed Physical Examination Scalp / Skull Inspect for DCAP-BLS Palpate DCAP-BLS-TIC Depressions, protrusions Fontanelles 70 Detailed Physical Examination Ears Inspect DCAP-BLS Battle s sign Blood or clear fluid in ears Palpate for tenderness or pain 71 Detailed Physical Examination Face Inspect DCAP-BLS Singed facial hair Symmetry of facial expression Palpate Orbital rims Zygoma Maxilla Mandible 72 24
25 Detailed Physical Examination Eyes Inspect DCAP-BLS Foreign body Hyphema Eyeglasses/contact lenses Raccoon eyes Color of sclera and conjunctiva Periorbital edema Pupils Eye movement Determine Pediatric Coma Scale score or Glasgow Coma Scale score 73 Detailed Physical Examination Nose Inspect DCAP-BLS Blood or fluid from the nose Singed nasal hairs Nasal flaring Palpate nasal bones 74 Detailed Physical Examination Mouth Inspect DCAP-BLS Blood, absent or broken teeth, gastric contents, foreign objects Injured or swollen tongue Color of the mucous membranes Note presence and character of fluids, vomitus Note sputum color, amount, and consistency Listen for hoarseness, inability to talk Note unusual odors 75 25
26 Detailed Physical Examination Neck Inspect DCAP-BLS Neck veins flat or distended Use of accessory muscles Presence of a stoma Presence of a medical identification device Palpate DCAP-BLS-TIC Tracheal position Subcutaneous emphysema 76 Detailed Physical Examination Chest Inspect Work of breathing Symmetry of movement Use of accessory muscles Retractions Note abnormal breathing patterns DCAP-BLS Vascular access devices 77 Detailed Physical Examination Chest Auscultate Equality of breath sounds Adventitious breath sounds Heart sounds Palpate DCAP-BLS-TIC Chest wall tenderness Symmetry of chest wall expansion Subcutaneous emphysema 78 26
27 Detailed Physical Examination Abdomen Inspect DCAP-BLS Distention, scars Use of abdominal muscles during respiration Signs of injury, discoloration Auscultate bowel sounds Palpate all four quadrants for: DCAP-BLS Guarding or distention Rigidity Masses 79 Detailed Physical Examination Pelvis / Genitalia Inspect DCAP-BLS Palpate DCAP-BLS-TIC Apply pressure to iliac crests and symphysis pubis Assess strength and quality of femoral pulses 80 Detailed Physical Examination Extremities Inspect DCAP-BLS Vascular access devices Purpura, petechiae Congenital anomalies Abnormal extremity position Medical identification bracelet Palpate DCAP-BLS-TIC Pulses, motor, sensory (PMS) Skin temperature 81 27
28 Detailed Physical Examination Posterior Body Inspect If trauma is suspected, ensure manual stabilization of head and spine during exam DCAP-BLS Purpura, petechiae, rashes, edema Auscultate posterior thorax Palpate posterior trunk for DCAP-BLS 82 Secondary Survey Differential diagnosis, diagnostic procedures Search for, find, and treat reversible causes Glucose check Laboratory and radiographic studies Evaluate Interventions Pain management Facilitate Family presence for invasive/resuscitative procedures 83 Reassessment Purpose Reevaluate the patient's condition Assess the effectiveness of emergency care interventions provided Identify any missed injuries or conditions Observe subtle changes or trends in the patient's condition Alter emergency care interventions as needed 84 28
29 Reassessment Reassessment should be: Performed on EVERY patient Performed after assuring completion of critical interventions Performed after the detailed physical exam, if one is performed Repeated and documented: Every 5 minutes for an unstable patient Every 15 minutes for a stable patient 85 Reassessment Components Repeat the primary survey Reassess and document vital signs Repeat the focused assessment regarding patient complaint or injuries Reevaluate emergency care interventions 86 Pediatric Triage in the Emergency Department 87 29
30 Goals of Triage Rapidly identify patients with life-threatening conditions Determine the most appropriate treatment area for patients presenting to the ED Optimize use of resources Decrease congestion in emergency treatment areas Provide ongoing assessment of patients Provide information to patients and families regarding services, expected care, and waiting times 88 Triage Guidelines Ability to triage patients effectively and accurately is based on: The Pediatric Assessment Triangle Physical assessment findings Patient s pertinent medical history Appropriate use of guidelines and triage protocols Practical knowledge gained through experience and training 89 5-level Triage Classification System Classification Definitive Care Resuscitation Emergent Urgent Semiurgent Nonurgent Immediate Within 10 min Within 30 to 60 min Within 1 to 2 hours Within 2 to 3 hours 90 30
31 Questions? 91 31
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