Assessing a child
The pediatric assessment triangle, the toe-to-head exam, caregivers and family-centered care
You learn more about a child in the first half minute, from across the room, than from any number you take later. A frightened child who is touched too soon cries, and crying hides the breathing, the heart rate and the behavior you needed to see. So the assessment of a child starts with your eyes and ears, before your hands.
The pediatric assessment triangle
The pediatric assessment triangle is a first impression with three sides: appearance, work of breathing, and circulation to the skin. It needs no equipment. One way to remember appearance's parts is TICLS.
- Tone: moving and resisting, or limp and floppy?
- Interactiveness: alert to you, reaching for a toy, or uninterested in everything?
- Consolability: does the caregiver's comfort settle the crying?
- Look or gaze: eyes that follow you, or a glassy stare past you?
- Speech or cry: strong and normal, or weak, muffled or hoarse?
For work of breathing, listen for stridor, wheeze or grunting, and look for retractions, nasal flaring, head bobbing and a tripod or sniffing posture. For circulation to the skin, look for pallor, mottling or cyanosis.
Reading the triangle
The sides combine into a general impression. Increased work of breathing with a normal appearance is respiratory distress. Add an abnormal appearance and it is respiratory failure. Poor skin color with a normal appearance suggests compensated shock, and with an abnormal appearance, decompensated shock. An abnormal appearance alone, with easy breathing and pink skin, points to a problem affecting the brain or the whole body, such as low blood sugar, poisoning, head injury or serious infection. The decision you make from it is simple: sick or not sick. A sick child gets a fast primary assessment, treatment and early transport, with ALS where it is available.
The hands-on exam
The primary assessment is the same order as always: airway, breathing, circulation. For an awake infant, toddler or preschool child who is not critical, take your time and let the child guide how you approach them. Let the caregiver help, and give the child something to hold, such as a toy. A critical child, or one with a serious mechanism of injury, gets a rapid head-to-toe exam without delay. Fear is not the priority when the airway is.
Count the breathing and the pulse long enough to see the pattern, since infants breathe irregularly. Use a cuff sized to the child's arm, since the wrong size gives a false reading. Normal vital signs change with age, so read them from a length-based tape or a reference card instead of memory.
The caregiver as historian
Ask the usual history questions, then the pediatric ones: how is this different from normal, is the child eating and drinking, how many wet diapers today, are the immunizations current, and for an infant, was the birth early or difficult? Take it seriously when a caregiver says the child is just not right. For a child with special health care needs, such as a tracheostomy, a feeding tube or a shunt, the caregiver knows the baseline and the equipment better than you do. Ask them.
Family-centered care
Keep the child and caregiver together unless it is unsafe. Have one crew member speak with the family, explain what you are doing. Be honest with the child. If something will hurt, say so just before it happens, and say it will be quick. Speak to an adolescent directly, protect privacy, and ask sensitive questions about pregnancy, drugs or self-harm.
Look before you touch. A child who is limp, quiet and does not care that a stranger is handling them is sick until proven otherwise. A child who fights you and cries loudly is showing you a normal appearance, which is reassuring.
These lessons are study material. On a real call your local protocols and your medical director decide what you do, which equipment you carry and when you call for ALS. Where this lesson and your protocol differ, follow your protocol.