The Paediatric Assessment Triangle
This post accompanies the talk I was asked to give to a fantastic group of Ambulance Victoria paramedics. I was given the title “Everything you NEED to know about paediatrics“, but since I don’t know everything yet, I decided to drill down and focus on doing one thing well.
One of the biggest challenges is identifying the difference between sick and not sick. In the prehospital environment, you don’t have the luxury of time and observation. All you can go on is what is in front of you. So, how can you distil years of training and exposure? Perhaps what we call gut feeling is really a synthesis of the paediatric assessment triangle—a decision based on one snapshot in time.
The basics
The American Academy of Pediatrics introduced the Pediatric Assessment Triangle – PAT – (Editors note: I’m going to call it the PAediatric Assessment Triangle throughout this post as I just cannot bring myself to spell it that way. Sorry, Tim) in 2000 in the Pediatric Education for Pre-hospital Providers course. It was an effort to make it easier for pre-hospital providers to triage children into sick or not-sick, and perhaps to help them determine the cause of illness.
Appearance
So, what does that child actually look like? What do we notice at first glance that might concern us? Consider this mnemonic.
Tone
Are they unusually floppy, like a rag doll, and unable to hold themselves upright? By six months, nearly all children should be able to sit up and support their own heads.
Interactiveness
To a newborn child, the world is an amazing place, full of strange sights, sounds, and smells. Babies learn to smile by about two months of age, and by a year or so, they are following objects around the room with their gaze. If they don’t seem interested in what is happening in the world around them, it is time to be a little more concerned.
Consolabilty
Children cry all the time. They cry because you want to brush their hair, because you don’t want to brush it, and because you have looked at them. But they are also consolable. If they can’t be consoled, despite their mother’s best efforts, then something is amiss.
Look/gaze
Staring off into the distance may be normal for a teenager, but it’s probably not normal for a three-year-old (unless they are very hungry).
Speech/cry
Crying is generally good, especially if it is someone else’s child and not your own, as long as they are consolable (see above). But that high-pitched squealing cry means something different entirely.
All of these things help make up our clinical gestalt. We are often not even aware of them. Assessing their breathing may take a little more attention.
Breathing
Assessing their work of breathing doesn’t require an eidetic memory of age-based norms but, again, is a snapshot taken in seconds. Problems can occur anywhere in the respiratory tree, from snotty nostrils to tightened tracheas and blocked bronchioles. Assessing this means looking AND listening.
Here are some of the things we are looking for…
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nasal flaring
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tracheal tug
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intercostal/subcostal recession
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abdominal breathing
But we can take in as much information through our ears as we can through our eyes.
As air passes through the nostrils to pulmonary alveoli, it can be subject to smooth, laminar flow or the chaotic eddies of turbulent flow. Any point of narrowing in an already small airway can make a sound. I liken it to my 2-year-old trying to breathe through a recorder. If I want silence, I need to remove the narrow mouthpiece, the part that starts the noise.
As it passes inward through a narrowed larynx (for whatever reason), we may hear stridor; as it reaches the narrowed bronchial tree of an asthmatic (for example), we may hear a wheeze. If the air hunger is great enough, we don’t need a stethoscope to hear these noises. You can hear them from the end of the bed. These noises, coupled with the grunt of a child trying to generate enough PEEP to keep their alveoli from collapsing, are the sounds of respiratory distress. In the pre-verbal child, there seem to be several overlaps with veterinary science.
Circulation
An embarrassment of the circulatory system is much harder to spot.
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pallor
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mottling
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cyanosis
Often, you need to undress the child to make these changes more obvious. You might want to rely on the capillary refill time, too, but this is not part of the assessment triangle. It is a strictly no-touch technique.
Once we have a basic snapshot of appearance, breathing, and circulation, we can combine these elements to help determine how unwell the child is and what could be wrong.
So, does it actually work?
Even after 20 years in practice, I cannot remember the age-based norms for vital signs (and there is some evidence that the ones we have may not be accurate anyway). I like to think of patients as either sick or not sick in the first instance. If I feel they are sick, then the next question is nearly always, why? Does the Paediatric Assessment Triangle framework work in real life?
One group at UCLA examined how accurately triage nurses used the tool. In their prospective observational cohort, they provided a multimedia training package. Then, they asked nurses to complete a PAT card for every child who met the inclusion criteria. The investigators then conducted a structured chart review to assess the PAT’s quality. 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 with EMS providers found similar results. Paramedics were very good at detecting stability and instability using the tool. Both groups have some medical knowledge, and it would be hard to determine how that might bias their assessment. Could non-medics be trained to use the tool? Could a computer?
Limitations
Most of the data applies only to children under 14 years of age and those with what could be called a normal baseline. It is much less useful in children with developmental delays, those with congenital abnormalities or those reliant on technology to keep them alive.
For an aural version of some of the things covered in this talk, you could not do better than listening to Tim Horeczko.
Selected references
Dieckmann RA, Brownstein D, Gausche-Hill M (eds) (2000) Pediatric Education for Prehospital Professionals: PEPP Textbook. Jones & Bartlett Publishers, Sudbury, MA
Dieckmann, R.A., Brownstein, D. and Gausche-Hill, M., 2010. The pediatric assessment triangle: a novel approach for the rapid evaluation of children. Pediatric emergency care, 26(4), pp.312-315.
Gausche-Hill, M., Eckstein, M., Horeczko, T., McGrath, N., Kurobe, A., Ullum, L., Kaji, A.H. and Lewis, R.J., 2014. Paramedics accurately apply the pediatric assessment triangle to drive management. Prehospital Emergency Care, 18(4), pp.520-530.
Horeczko T, Gausche-Hill M. The paediatric assessment triangle: a powerful tool for the prehospital provider. Journal of Paramedic Practice. 2011 Jan 13;3(1):20-5.
Horeczko T, Enriquez B, McGrath NE, Gausche-Hill M, Lewis RJ. The Pediatric Assessment Triangle: accuracy of its application by nurses in the triage of children. Journal of Emergency Nursing. 2013 Mar 1;39(2):182-9.
