This document provides an overview of physical assessment for sick children. It outlines the pediatric assessment triangle (PAT) as an initial evaluation of appearance, work of breathing, and circulation. The PAT determines if a child appears well, sick, or needs immediate lifesaving intervention. For sick children, a primary survey assesses the airway, breathing, circulation, disability, and exposure (ABCDE). Specific respiratory, circulatory, and neurological emergencies are discussed along with management strategies. Case examples demonstrate application of the assessment and identification of conditions like asthma, sepsis, and dehydration.

1. Physical assessement of a sick child
Dr. Shafini Beryl

2. Disclaimer
• This presentation covers only a snapshot of
the subjects presented- each topic could be
lecture of its own!
• You are encouraged to do further research
into each topic.
• Not all pediatric emergencies are covered in
this presentation

3. Pediatric emergencies
1. Respiratory emergencies
– Upper airway obstruction(croup, epiglottis,
foreign body obstruction)
– Lower airway obstruction(Asthma)
– Pneumonia
2. Circulatory emergencies- shock
3. Cardiac emergencies- SVT, Cardiac failure
4. CNS- Coma, seizures
5. Infections- Sepsis, meningitis, encephalitis
6. Trauma
7. Poisoning.....and so on ....

4. Aim of the presentation
• Recognize and manage life threats based on simple assessment findings
for a child while awaiting additional emergency response.

5. Important considerations
• Differs from adult assessment
• Have age-appropriate equipment, review age-appropriate vital signs
• Sudden illness and medical emergencies are common in children and
infants.
• Anatomical differences exist between adults and children.

6. • Managing a pediatric emergency can be one of the most
stressful situations you face as an EMR.
– Calm and professional.
– Unless you are prepared, your anxiety and fear may interfere with your
ability to deliver proper care.
– The parents can be either allies or a potential problem.
– Talk to both the parents and the child as much as possible.
– Try to develop a rapport with the child.

7. ASSESSMENT

8. Steps in structured assessement

9. The pediatric assessment triangle
• The PAT helps you quickly form a general impression of the child
using only your senses of sight and hearing.
• Can be used to assess a child from a distance

10. INITIAL IMPRESSION: A-B-C

11. Appearance
Lethargic
Active
Decreased interactiveness
Interactive child

12. Appearance
Gaze abnormality- strabismus
Inconsolable cry

13. PAT-Work of breathing

14. Work of breathing
Intercostal retraction
subcostal retraction
substernal retraction

15. PAT-Circulation

16. Circulation
Pallor Mottling Cyanosis

17. Initial impression- Pediatric assessement triangle(PAT)
UNRESPONSIVE
APNEA/GASPING
CYANOSIS
Life threatening conditions

18. If Life-threatening on initial impression
• Activate the Emergency response system
• Initiate life-saving measures based on the scope of practice
￭ Open The Airway and provide oxygen
￭ Attach monitor and AED
￭ Check for pulse
￭ Provide CPR if needed (central pulse absent/<60)
￭ I.V. / IO Access, Fluids, and medications
•Proceed for further evaluation after initial stabilization/ all parameters
normal

19. MANAGEMENT

20. How to proceed?

21. Initial impression
PAT

22. SICK or NOT SICK
• The ‘PAT’ functions as a rapid initial
assessement to determine, “sick” or
“not sick” and should be
immediately followed by the
ABCDE’s

23. Further evaluation- Primary assessement

24. Pediatric anatomy- Children are not small
adults
• A child’s airway is
smaller in relation to
the rest of the body
compared to an
adult’s airway.
• A child’s tongue is
relatively larger than
an adult’s.

25. AIRWAY- Assessement

26. AIRWAY- Assessement

27. Airway- Intervention

28. Airway Intervention- simple measures

29. Airway intervention- advanced

30. BREATHING- Assessement
1. Respiratory rate
2. Work of breathing
3. Chest wall expansion
4. Auscultation- added sounds
5. Pulse oximetry

31. BREATHING-RR
WHO-IMCI

32. BREATHING-WOB, Additional sounds
• Nasal flaring
• Retractions
• Grunting
• Head nodding
• See saw respiration

33. Pulse oximetry
• Detects before apparent cycnosis
• SpO2 >94% in room air
• Limited in poor perfusion

34. BREATHING-Identification
• Severity
• Anatomical site

35. BREATHING- Severity

36. BREATHING- Anatomical site
• Upper airway obstruction
• Lower airway obstruction
• Lung parenchymal disorders
• Disorder of breathing

37. BREATHING- Anatomical site

38. Upper airway obstruction

39. Respiratory emergencies- fundamental of
management
• Keep the child in the position of comfort and minimize agitation.
• Suctioning of nose or mouth if secretions are present.
• Provide humidified oxygen, preferably with high concentration delivery
device e.g., Head box (for infants less than 6 mo), Oxymask or non-
rebreathing mask (for older children).
• Monitor heart rate, respiratory rate, blood pressure and SpO2.
• Establish vascular access

40. Croup- Mx

41. Foreign body

42. Anaphylaxis
• Acute onset of an illness (minutes
to several hours) involving the
skin, mucosal tissue, or both and
at least one of the following:
1.Respiratory compromise
2.Reduced blood pressure
3.Persistent GI symptoms
GIVE Adrenaline (The wonder drug):
• 0.01 ml/kg (1:1000) IM
(maximum dose 0.5 ml).

43. Lower airway obstruction

44. Bronchiolitis- Mx

45. Asthma - Mx

47. Respiration-Intervention

48. Circulation- assessment
1. Heart rate and rhythm
2. Peripheral and central pulses
3. Capillary refill time
4. Skin and peripheries
5. Blood pressure
6. Urine output

49. Circulation- HR

50. Circulation- Pulses
• Central pulses- Carotid in older
children. Femoral and axillary in
infants
• Peripheral - radial, temporal,
posterior tibial
• Pulses become weak in shock

51. Circulation - CRT
• Normal: 2-3 seconds

52. Skin perfusion- colour and temperature
• Decreased cardiac output results in decreased perfusion and oxygenation
to the extremities
• Look for
– cold extremities
– mottling
– cyanosis
– pallor

53. Blood pressure

54. Blood pressure
• use appropriate size cuff

55. Urine output
• Indirect indicator of adequate circulation
• Indicates kidney perfusion and function
• Infants: 1.5-2ml/kg/hr
• Children : 1ml/kg/ hr

56. Circulatory insufficiency- categorization by
severity
Compensated
• Tachycardia
• Cool peripheries
• Delayed CRT
• Weak peripheral pulses
• Narrow pulse pressure
• Oliguria
• NORMAL BP
Hypotensive
• All the above plus
• BP below 5th centile
• Change in mental status

57. Shock- Fundamentals of management
• Allow the child to remain in the most comfortable position.
• Start high flow oxygen
• Support ventilation: CPAP or invasive mechanical ventilation.
• Establish vascular access for fluid resuscitation and administration of
medications.
• Give rapid fluid bolus(NS or RL) of 20 ml/kg over 5 to 10 min

58. Shock- Fundamentals of management
• Monitor vitals and perform frequent assessment to determine the
response to therapy.
• Take initial blood samples. Identify and correct hypoglycemia and
hypocalcemia early.
• Give medications e.g., vasoactive agents (dopamine, epinephrine),
dextrose, calcium, antibiotics, analgesic. Give 1st dose of antibiotic in
septic shock preferably within 1st hour of presentation.
• Refer to pediatric facility with intensive care monitoring for further
management.

59. Based on etiology
• Hypotensive shock
• Distributive shock
• Cardiogenic shock
• Obstructive shock

60. Shock-Interventions

61. Disability
• Quick evaluation of the neurological function - AVPU
• Assess the third vital organ- the brain
• Brain injury may be primary(direct-trauma, meningitis, seizures) or
secondary (hypoxia, shock)
• Severity and duration of hypoxia will give rise to different signs
• Bedside glucose estimation is a must

62. Disability

63. Seizure- Management

64. Seizure- Management

65. Seizure- Management

66. Exposure
• Undress as appropriate, avoid exposure to cold
• Look for deformities/ bruises/ bleeds
• Take care of cervical spine in case of emergencies
• Record temperature and correct hypo and hyperthermia

67. Revision-Primary survey

68. Secondary survey
• Focussed history- SAMPLE
• Physical examination

69. CASE DISCUSSION

70. CASE 1
• 8 year old child
– Cough x 1 day
– Breathing difficulty since
evening and rapidly worsening,
even has difficulty in speaking
– Past history of nebulisations ,
not on any regular MDI
• Mother having history of asthma

71. Primary assessment

72. Identify and treat
• Respiratory failure
• Lower airway disease
• Status asthmaticus

73. Case 2
• 3 year old boy child
– Fever x 3 day high grade
– No rashes
– Decrease activity 1 day
– No past significant history

74. Primary assessement

75. Identiify and treat
• Hypotensive shock
• Probable Sepsis

76. Case 3
• 1 year old male child
– Diarrhea x 3 day , 8- 10
episodes/day
– Vomiting x 4 episodes non
bilious
– Decrease activity 1 day
– On bottle feeding
– No past significant history

77. Primary assessement

78. • Hypotensive shock
• AGE with severe dehydration

79. Left out- Pediatric trauma and poisoning

81. Do you have any questions?
THANK YOU FOR YOUR ATTENTION