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PEP Course Lecture 3. PEDIATRIC ASSESSMENT TRIANGLE. Lecture Objectives. 1. Understand the elements of the Pediatric Assessment Triangle. 2. Distinguish the Triangle from the Pediatric Primary Survey.

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pep course lecture 3
PEP CourseLecture 3
lecture objectives
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.
case 1
Case 1
  • A babysitter calls 911 for a 14 month old girl who is having trouble breathing.
  • • 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.
key question
Key Question
  • What are the elements of the assessment that are most useful?
pediatric assessment triangle3
Pediatric Assessment Triangle


Work of


Circulation to Skin

pediatric assessment triangle4
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 ...






pediatric assessment triangle5
Pediatric Assessment Triangle
  • The Triangle is a rapid way to determine physiologic stability.
key question1
Key Question
  • How can you assess physiologic stability just by looking at the child?
  • • alertness • speech or cry
  • • distractibility • motor activity
  • • consolability • color
  • • eye contact
  • The child’s overall appearance
  • reflects the adequacy of oxygenation,
  • ventilation and perfusion.
  • • 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).
  • • 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.
key question2
Key Question
  • How do you recognize respiratory distress and failure by looking at the child?
work of breathing
Work of Breathing
  • • Abnormal audible breath sounds (e.g. stridor, wheezing or grunting)
  • • Retractions (suprasternal, intercostal, subcostal)
  • • Nasal flaring
triangle respiratory distress




Work of Breathing


Triangle: Respiratory Distress
triangle respiratory failure
Triangle: Respiratory Failure
  • Abnormal

Increased or

Decreased Work

of Breathing



key question3
Key Question:
  • What is the most reliable way to rapidly assess adequacy of perfusion?
circulation to skin
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.
key question4
Key Question
  • How do you assess circulation to the skin?
circulation to skin1
Circulation to Skin
  • • Skin temperature
  • • Pulse strength
  • • CRT (capillary refill time)
triangle shock



Poor Circulation to Skin


Triangle: Shock



Poor Circulation to Skin


circulation to skin other causes of vasoconstriction mottling crt
Circulation to SkinOther causes of vasoconstriction(mottling,  CRT)
  • Fever
  • Hypothermia
  • Medications
  • Normal vasomotor lability in infants

Pearl: Triangle

  • The Triangle can also help identify the child with CNS or systemic problems who has normal oxygenation, ventilation and perfusion.
triangle brain dysfunction

Normal Work

of Breathing



Normal Circulation to Skin


Triangle: Brain Dysfunction


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.
case continues
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.
pediatric primary survey
Pediatric Primary Survey
  • After completing the Triangle, begin a more complete pediatric primary survey.
key question5
Key Question
  • What is the difference between the Triangle and the pediatric primary survey?
key points
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.
case continues1
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.
pediatric primary survey1
Pediatric Primary Survey
  • Assess adjunctive signs:
  • • Respiratory rate (RR)
  • • Tidal volume ausculation
  • • Lung sounds (crackles, wheezes)
  • • Pulse oximetry (SaO2)

Pediatric Primary Survey

  • Assess adjunctive signs:
  • • Heart Rate (HR)
  • • Blood Pressure (BP): in children <3 yrs, attempt only once

Pediatric Primary Survey

  • • AVPU
  • • Pupils
  • • Abnormal movement
pearl disability vs appearance
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.
abnormal appearance on avpu



worsening severity

Abnormal Appearance on AVPU
  • A V P U
summary of triangle
Summary of Triangle
  • • Playful and vigorous.
  • • Stridor at rest.
  • • Suprasternal and intercostal retractions.
  • • Extremities warm. CRT <2 secs.
summary of primary survey
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.
key question6
Key Question
  • How would you describe this child when giving radio report to the base hospital?
radio report
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.
case 2
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.
key question7
Key Question
  • What features of this infant’s general appearance will help you to assess his physiologic stability?
case continues appearance
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.
key question8
Key Question
  • What are the key features of work of breathing?
case continues work of breathing
Case continues:Work of Breathing
  • • No abnormal audible breath sounds
  • • No retractions
  • • No flaring
key question9
Key Question
  • What are the key features of circulation to skin?
case continues circulation to skin
Case continues:Circulation to Skin
  • • Skin cool at kneecap
  • • Brachial pulse weak
  • • CRT 5 secs
key question10
Key Question
  • Based upon the Triangle, how sick is this child and how urgent is treatment?
pediatric primary survey2
Pediatric Primary Survey

A/B: Airway clear

RR 10/min; clear BS; poor air entry;

SaO2 not obtainable

C: HR 190/min; BP not obtainable on one attempt

D: Responds only to pain on AVPU;

PERRL; no spontaneous movement

  • An abnormally slow respiratory rate (< 20/min) in an ill-appearing child is a sign of respiratory failure and imminent respiratory arrest.


  • Attempt BP once only in children <3 years of age. BP has limited value for accurate assessment of circulation.
key question11
Key Question
  • How would you describe this baby in your radio report?
radio report1
Radio Report

This is a 6 month old male in respiratory failure and shock. He is responsive only to pain. The baby is breathing spontaneously at a slow rate of 10 breaths per minute, with unlabored respirations. His heart rate is 190/min. He is mottled, with weak central pulses, and cool extremities. We are initiating intubation and a rapid isotonic fluid bolus.

key question12
Key Question
  • How would you estimate ETT size and IV fluid rate for this baby?
resuscitation tape
Resuscitation Tape
  • The resuscitation tape is a proven method for rapid equipment sizing and drug dosing based upon
  • the child’s measured length. It avoids estimations of weight.
lecture summary
Lecture Summary
  • 1. The Pediatric Assessment Triangle is useful in every first contact with an ill or injured child.
  • 2. The pediatric primary survey helps identify potentially life-threatening problems, and directs initial resuscitation in a stepwise fashion.

Lecture Summary - cont’d.

  • 3. Interpretation of vital signs in children may be difficult.
  • 4. The resuscitation tape improves accuracy of equipment sizing and drug dosing.