This document provides guidance on systematically assessing and treating critically ill or injured children. It begins by outlining the objectives of utilizing appropriate assessment techniques to rapidly identify treatment priorities. It then describes the Pediatric Assessment Triangle (PAT) framework, which uses appearance, work of breathing, and skin circulation to evaluate a child's condition within seconds. The document emphasizes that any abnormality in the PAT denotes an unstable child requiring intervention. It provides details on evaluating each component of the PAT and categorizing the child's condition to dictate the type and urgency of treatment needed. Finally, it stresses intervening immediately for life-threatening problems by following ABC protocols, activating emergency response, and focusing on stabilization over detailed diagnosis in critically ill children.

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Systematic approach to the seriously ill
or injured child
Dr. Mahmoud Khedr ( PICU Specialist)

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Objectives & Goal
 Utilize the Appropriate Assessment Technique to Rapidly Identify
Treatment priorities for the critically injured and ill child
 Know the three components of the Pediatric Assessment Triangle
 Have systematic approach to sick child in Hospital.
 Discuss General Management of the Pediatric Patient

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Introduction:

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• Critical illness is any disease process which causes physiological instability leading to
disability or death within minutes or hours.
• The severity of illness must be recognized early and appropriate measures taken to
assess, diagnose and manage the illness.
• For children hospitalized in acute care settings, the rates of clinical deterioration
vary from 2 to 19% (Berg, 2008). Up to 16% of clinical deterioration events can be
attributed to suboptimal care such as delays in recognition or escalation (Hayes et
al., 2012).

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• Essential aspects of nursing practice are to detect changes in patient condition,
anticipate deterioration prior to confirming diagnostic signs, and assess the
patient's response to treatment. Benner (1984)
• Education about the indicators of deterioration, clinical experience, situation
awareness, and use of a standard assessment tool such as the PEWS enhanced
nurses' ability to evaluate instability (Martin et al., 2016).
• Trusting one's intuition about abnormal assessments also aided identification of
deterioration (Gawronski et al., 2018).

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• Under specific conditions, nurses made decisions about monitoring intensity, how
to intervene, and whether to call for help (Lobos et al., 2015).
• Surveillance intensity and escalating care increased when acuity of conditions was
higher and staffing lower (Lobos et al., 2015).

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Systematic approach to the seriously
ill or injured child
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One of the biggest challenges is identifying the difference between sick and not sick.

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Response of our body Depends on ( Receptor,
center, and action)

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We try to mimic body response (making receptor,Eye
monitor, Labs) , center (Nurse, Doctor), make priority and
action and then re-access)
We are trying to help compensatory mechanism that already turned on

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Steps for management of critical ill child

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Initial impression: how to spot the sick child?
pediatric assessment triangle (PAT)
• Initial impression to identify a life threatening
condition
• The initial impression is your first quick (from the
doorway) observation of the child’s appearance,
breathing, and color
• It’s accomplished within the first few seconds of
encountering the child
• The pediatric assessment triangle (PAT) is the tool
used to make the initial impression
• Helps to identify general type of physiological
problem (respiratory, circulatory or neurological)
and urgency for treatment and transport
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Appearance
• Delineated by the “TICLS” mnemonic: Tone,
Inter-activeness, Consolability, Look or Gaze,
and Speech or Cry.
• This arm of the PAT reflects a child’s age, stage
of development, and ability to interact with the
environment.
• Important clues such as the infant’s tone,
consolability, interaction with caregivers and
others, and strength of cry can inform the
provider of the child’s appearance as normal or
abnormal (for age and development).
Listen and Look

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Work of breathing
Listen and Look
Describes the child’s respiratory status,
especially the degree to which the child must
work in order to oxygenate and ventilate.
Clinical signs such as abnormal airway sounds
(eg, stridor, grunting, and wheezing), abnormal
positioning, retractions, or flaring of the
nostrils on inspiration determine an
abnormal/increased work of breathing.

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Circulation to the skin
Circulation to the skin reflects the general perfusion of
blood throughout the body.
The Nurses notes the colour and colour pattern of the
skin and mucous membranes.
In the context of blood loss/fluid loss or changes in
venous tone, compensatory mechanisms shunt blood to
vital organs such as the heart and brain and away from
the skin and periphery of the body.
By noting changes in skin colour and skin perfusion
(such as pallor, cyanosis, or mottling), the provider may
recognize early signs of shock.

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An abnormality noted in any of the arms of the PAT denotes an unstable child, that is, a child who will require
some immediate clinical intervention.
The pattern of affected arms within the PAT further categorizes the child into 1 of 5 categories: respiratory
distress, respiratory failure, shock, central nervous system or metabolic disorder, and cardiopulmonary failure
(Table 1). The specific category then dictates the type and urgency of intervention.

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Does the Paediatric Assessment Triangle framework
actually work in real life?
One group from UCLA examined how accurate triage nurses were at using the tool. In their
prospective observational cohort they provided a multimedia training package then asked nurses to
fill in a PAT card for every child that came through the door that met inclusion criteria. The
investigators then performed a structured chart review to assess just how good the PAT was. They
found that it did a great job of identifying stable patients (LR 0.12) but an even better job of
determining their pathophysiology.
A similar study was done with EMS providers and had similar results.

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Evaluate -Identify -
intervene sequence
If at any time you identify a life
threatening problem, immediately
begin appropriate intervention m
activate the emergency response
system as indicated in your practice
setting

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Intervene
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Set your Goals and Intervene:
when child is in need of stabilization , Do not waste time in detailed history and investigation for establishing
diagnosis: Do the following regardless of diagnosis (PALS intervention) :
• initiate stabilization measures and follow ABC (D=Dextrostick) protocol.
• Activating the emergency response system
• Placing the child on cardiac monitor and pulse oximeter
• Positioning the child to maintain an open/patent airway / suction saves lives
• Administrating O2 / Supporting ventilation / in respiratory failure: Bag and mask ventilation and endotracheal
intubation
• Always obtain a bedside glucose in any ill infant or child: any serious illness , any gastroentritis (esp. rotavirus) ,
any odd neurological presentation , any child with syncope.
• Starting medication and fluids (eg. Nebilizer treatment, IV/IO fluid bolus)
• Intravenous access • Larger is better than smaller, but 2-24G IVs are better than nothing : For volume expansion /
vasoactive drug

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Management of respiratory emergency

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“
• Regardless of the aetiology > information required for assessment and
management is the same for all children
• simple clinical tools are sufficient to recognize sick or potentially sick
children
• kid can deteriorate quickly ... so act in time
• Golden hour will be with you , be prepared
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Take home message

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THANK YOU