2OBJECTIVESKnow the three components of the Paediatric Assessment TriangleDescribe abnormal appearance and its significance in the evaluation of paediatric injury and illnessList three key features of increased work of breathingList three skin signs of abnormal perfusion
3THE PATThe PAT is rapid, simple, reproducible and useful for children of all ages with all levels of illness and injury severity. The paradigm is generic and fits medical, traumatic and neonatal patients.For the critically ill or injured child, inadequate oxygenation, ventilation or perfusion from any cause will eventually progress to the generic picture of cardiopulmonary failure.
4THE PATAppearanceEffort Of breathingCirculation to skin
5FEATURES OF PATIt does not require a stethoscope, blood pressure cuff, cardiac monitor, pulse oximeter, or any other equipment or test.It entails simply observing a properly exposed child.Early recognition of problemsPrioritization of problems,Basis for an organized resuscitation, general support and specific treatment.
6Characteristics of Appearance The child's general appearance is the single most important parameter when assessing severity of illness or injury.Appearance reflects the adequacy of ventilation, oxygenation, brain perfusion, body homeostasis and CNS function.It is more accurate than any other clinical characteristic of the patient in predicting overall distress, need for treatment and response to treatment.
7Components of Appearance “tickles” (TICLS):Tone,InteractabilityConsolabilty,Look/Gaze,Speech/Cry.AVPU (Alert, responsive to Verbal, Painful stimuli, or Unresponsive)Most children with mild to moderate illness or injury, even when they are progressing to more severe degrees of distress, are “alert” and have a “normal” neurologic exam, although they have an abnormal appearance.
8The “tickles” (TICLS) mnemonic TONEIs she moving around or resisting examination vigorously and spontaneously?Is there good muscle tone?INTERACTABILITYHow alert is she?How readily does a person, object, or sound distract her or draw her attention?Will she reach out, grasp and play with a toy or new object, like a penlight or tongue blade?
9“tickles” (TICLS) continued.. CONSOLABILITYCan she be consoled or comforted by the caregiver or by the clinician?LOOK/GAZECan she fix her gaze on the clinician’s or caregiver’s face or is there a“nobody home,” glassy-eyed stare?SPEECH/CRYIs her speech/cry strong and spontaneous?Or weak, muffled, or hoarse?
10Caution in assessing Appearance Poisoning e.g. acetaminophen may appear stable only to crash later and rapidlyBlunt trauma may be able to maintain adequate core perfusion despite internal bleeding by increasing cardiac output and systemic vascular resistance. When these compensatory mechanisms fail, she may acutely “crash”, with rapid progression to clinical shock.
11Caution in assessing Appearance The appearance of an infant with early shock or decreased brain perfusion may include irritability and failure to console. When the noxious stimulus is removed, lethargy returns quickly. As symptoms progress, lethargy becomes the dominant observation. The “glassy-eyed” or “nobody home” stare is a sign of altered consciousness in infants.A high-pitched screeching or cephalic cry may indicate poor brain perfusion, brain injury or a central nervous system infection in infants.
12REMEMBERWhile appearance reflects the presence of real illness or injury, it does not necessarily indicate the source of the distress.
13Work of breathing aka Respiratory Distress This a more accurate immediate indicator of oxygenation and ventilation than conventional adult measures, such as counting RR or chest auscultation.It reflects the child’s physiologic compensatory response to cardiopulmonary stress.It entails careful listening for abnormal airway sounds and observing for specific visual information about breathing effort.
14Characteristics of Work of Breathing/Respiratory Distress Abnormal airway soundsAltered speechStridorWheezingGruntingAbnormal positioningHead bobbingTripoding
15Characteristics of Work of Breathing/Respiratory Distress RetractionsSupraclavicularIntercostalSubsternalFlaring of nose
16Appearance and work of breathing A child with normal appearance and increased work of breathing is in respiratory distress.Abnormal appearance and increased work of breathing means early respiratory failure.Abnormal appearance and abnormally decreased work of breathing is late respiratory failure.
17Characteristics of circulation to skin When cardiac output is inadequate, the body shuts down circulation to non-essential anatomic areas such as the skin in order to preserve blood supply to vital end organs (e.g. brain, heart and kidney).Pallor, mottling and cyanosis are key visual indicators of reduced circulation to skin.
18Characteristics of Circulation to Skin PallorWhite skin coloration from lack of peripheral blood flow.Early compensation to shock.MottlingPatchy skin discoloration, with patches of cyanosis, due to vascular instability or coldLoss of compensatory mechanism to shockCyanosisBluish discoloration of skin and mucus membranes.Shock or respiratory failure
19SummaryThe PAT only takes seconds, identifies need for life- saving interventions, and blends rapidly into the primary survey.It does not require any tools or specialist equipment.It can be taught to the lay public and caregivers.The three components of PAT can be assessed in any order. Any sequence of the ABCs (appearance, breathing, circulation) works, regardless of which is first or second or third, and the ABC order is purely for easy recall in an emergency.Do ensure that you are trained in basic emergency servicesDo identify and quickly refer any life-threatening conditions.
20Acknowledgements Bibliography: 1. Dieckmann RA, Gausche M, Brownstein D: Textbook of Paediatric Education for Prehospital Professionals, Jones and Bartlett, 20052. Zitelli B, Davis H: Atlas of Paediatric Physical Diagnosis, 4th Edition. Philadelphia, Mosby, 20023. Anne M, Agur A, Dalley A: Grant’s Atlas of Anatomy, 11 th Edition, Lippincott Williams & Wilkins, 20044. Hazinski M, Zaritsky A, Nadkarni V, et al: PALS Provider Manual, American Heart Association, 20025. American Academy of Paediatrics and the American College of Emergency Physicians. Textbook for APLS: The Paediatric Emergency Medicine Resource. 4th ed. Sudbury, MA. Jones and Bartlett Publishers