Lou Romig MD, FAAP, FACEP

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• Lou Romig MD, FAAP, FACEP
• Pediatric Emergency Medicine
• Miami Childrens Hospital
• Medical Advisor, FL DOH EMS for Children Program

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Objectives

• Recognize how much information children can give
  you without saying a word
• Learn the Pediatric Assessment Triangle and its
  applications

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Goals for the Acute Early Assessment Phase

• Filter and focus
• Access knowledge and experience
• Control the emotional environment

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Problems with the Assessment of Children

• Physical and cognitive immaturity
• Normal vs. abnormal
• Dependence on information from caregivers
• Dealing with caregivers

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Problems with the Assessment of Children

• They cant talk to me!

Children speak with their bodies. We must listen
with our eyes.
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The Pediatric Assessment Triangle (PAT)
From the AAPs Pediatric Education for
Prehospital Professionals (PEPP) course.
www.PEPPsite.com
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The PAT

• Quick physiological gestalt
• Often best done from a distance
• Takes seconds
• Can be repeated as needed
• Answers two questions

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The PAT
General Appearance Work of Breathing Circulation
to the Skin
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The Pediatric Assessment Triangle (PAT)
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General Appearance

• T Tone
• I Interactiveness
• C Consolability
• L Look/gaze
• S Speech/cry

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General Appearance

• Assesses higher brain function by looking mostly
  at interaction with the environment
• Higher brain function depends on good
  oxygenation, ventilation and perfusion to the
  brain
• Dont be fooled by chronic features or dramatic
  physical findings that dont affect vital
  functions

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Good general appearanceNormal to
well-compensated physiologyNot sickNot
quick
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Poor general appearanceInadequate physiologic
compensationSick!Quick!
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Sick or not sick?
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Sick or not sick?
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Sick or not sick?
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Sick or not sick?
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Sick or not sick?
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The Pediatric Assessment Triangle (PAT)
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Work of Breathing

• More important than respiratory rate
• Reflects unique anatomy

• Increased WOB is good
• Decreased WOB is bad

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The Pediatric Assessment Triangle (PAT)
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Circulation to the Skin

• Decreased circulation to the skin is an early
  sign of compensation for a circulatory problem in
  kids (not always true in adults)
• Capillary refill is a good measure in kids,
  especially when done in a serial fashion in a
  normothermic environment

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You dont need a blood pressure
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Remember these eyes
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Putting the PAT together
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Respiratory
A B C PhysiologicCategory Sick?
Good Respiratory Distress
Poor Respiratory Failure
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Circulatory
A B C Physiologic Category Sick?
Good Nonspecific Peripheral Vasoconstriction
Poor Shock
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Central Nervous System
A B C Physiologic Category Sick?
Poor Good Good CNS Dysfunction
Seizure/Post-ictal Head injury Intoxication/Drug
effect Metabolic Meningitis/Encephalitis Chronic
disability
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The Last Chance
A B C Physiologic Category Sick?
Cardiopulmonary Failure
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Hear here!
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Child with a cold and a raised red rash
Sick?
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• Alert
• Interacts with toy
• Good spontaneous movement
• Good coordination and strength

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Another blotchy kid
Sick?
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Not sick
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Mottling
Sick?
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Cutis Marmorata
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Child with fever and petechiae
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Small red dots Do not blanch Not palpable
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More fever and petechiae
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Purpura fulminansMeningococcemia
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Purpura fulminansMeningococcemia
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Vomiting and diarrhea x 3 days
Dry, sunken eyes
Dry oral membranes
But is he sick?
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Vomiting and diarrhea x 3 days
Watching passively Since when does a kid this age
stay still?
Is he sick?
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Compare
Which would you treat first?
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Before and After
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Distress or failure?
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Distress or failure?
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Kussmaul breathing
Respiratory distress
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A known asthmatic
Respiratory distress
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Two hours later
Respiratory failure
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The Pediatric Assessment Triangle (PAT)
From the AAPs Pediatric Education for
Prehospital Professionals (PEPP) course.
www.PEPPsite.com
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Can you hear them now?
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• www.jumpstarttriage.com