PEDIATRIC EVALUATION TRIANGLE

Initial evaluation
of the pediatric urgent patient

Francesc Ferrés Serrat Cap

de Secció URGP HUSE 20
de Maig 2019
•••
•••

•• •
s on Espase s
university hospital
 Teaching objectives

1. Learn the 3 components of the Pediatric Assessment

Triangle (PET)
2. Integrate the PET results into a first General Impression
3. Know the 2 components of the Initial Evaluation of the
urgent pediatric patient
4. To understand the therapeutic priorities depending on
the PET
• An 11-year-old girl presented with abdominal pain that
had been going on for 12 hours.
• 1 vomit. No diarrheal stools.
• Continuous pain that begins periumbilically and is
currently located in FID.
• Painful wandering.
• Normal sensory. Normal color. No respiratory distress.
 Clinical case
1
Constants :
Weight 32 kg, Tª 37.9 ° C Ax
BP 106/65, HR 89 bpm, Sat 907%
A. No evidence of obstruction
B. Regular breathing without difficulty. AR:
normal.
C. Normal
D. Normal sensory.
E. No bruises. Intense pain on palpation in FID
with guarding. Positive Blumberg.
 Clinical case 1:
MANAGEMENT PRIORITY

1) abdominal ultrasound

2) abdominal x-ray

3) Surgery assessment

4) Oxygen, blood glucose, monitoring and venous

route
5) None of the above
 Clinical case 1:
MANAGEMENT PRIORITY

1) abdominal ultrasound

2) abdominal x-ray

3) Surgery assessment

4) Oxygen, blood glucose, monitoring and venous

route
5) None of the above
 Teaching objectives:
OBJECTIVE 1

1. Learn the 3 components of the Pediatric Assessment

Triangle (PET)
2. Integrate the PET results into a first General Impression
3. Know the 2 components of the Initial Evaluation of the urgent
pediatric patient
4. Learn the therapeutic priorities depending on the PET and the
ABCDE
CIRCULATION
 TEP objectives

1. I identify the most probable functional alteration:

Establish a Pathophysiological Diagnosis
2. Perform a physiology “restorative” treatment
3. Initially assess what the patient needs now ? NO,
what does the patient have?
4. Set priorities
 TEP:
Appearance

• Aspect KAC
• Tone {
• Activity
• Connection / Consolable
• Look
• Crying/words
• Drowsiness/Irritability

It reflects the state of oxygenation, ventilation,

cerebral perfusion and CNS function
 TEP:
Breathing
Retractions
Nasal flaring
Abnormal breath
sounds
Breathing position
Shallow breathing, bradypnea

Reflects the state of

oxygenation and ventilation
 TEP:
Circulation
The appearance of the skin is
assessed: • Paleness

• Mottled skin
• Cyanosi
s

It reflects whether
cardiac output and perfusion
of vital organs are adequate
 Teaching objectives:
GOAL 2

1. Learn the 3 components of the Pediatric Assessment Triangle

(PET)

2. Integrate the PET results into a first General

Impression
3. Know the 2 components of the Initial Evaluation of the urgent
pediatric patient
4. Learn the therapeutic priorities depending on the PET and the
ABCDE
 7 pathophysiological
diagnoses
Pathophysiological
Appearance Breathing Circulation
Diagnosis
N N N Stable
TO N N CNS dysfunction
N TO N Respiratory difficulty
TO TO N respiratory failure
N N TO Compensated shock
TO N TO Decompensated shock
TO TO TO cardiopulmonary failure
 Clinical case
2

□ 11-year-old girl who consults for abdominal

pain of 12 hours' duration
□ 1 vomit. No diarrheal stools
□ Continuous pain that begins periumbilically
and is currently located in FID
□ painful wandering
□ Normal sensory. Normal color. No
respiratory distress.
TEP? 3

AA A
APPEARANCE A A normal
normal h RESPIRATORY
TO normal WORK

CIRCULATION TO -
 Pathophysiological
diagnoses?
Appearance Breathing Circulation Physiopathological Dg

N N N Stable

TO N N CNS dysfunction

N TO N Respiratory difficulty

TO TO N respiratory failure

N N TO Compensated shock

TO N TO Decompensated shock

TO TO TO cardiopulmonary failure
 Clinical case
2

Weight 32 kg, Tª 37.9 ° C Ax

BP 106/65, HR 89 bpm, Sat 907%
A. No evidence of obstruction
B. Regular breathing without difficulty
C. Normal
D. Normal sensory.
E. No bruises. Intense pain on palpation in FID
with guarding. Positive Blumberg.
 Clinical case 1:
MANAGEMENT PRIORITY

1) abdominal ultrasound

2) abdominal x-ray

3) Surgery assessment

4) Oxygen, blood glucose, monitoring and venous

route
5) None of the above
 Clinical case 1:
MANAGEMENT PRIORITY

1) abdominal ultrasound

2) abdominal x-ray

3) Surgery assessment

4) Oxygen, blood glucose, monitoring and venous

route
5) None of the above
 Clinical case 1:
MANAGEMENT PRIORITY

1) abdominal ultrasound

2) abdominal x-ray

3) Surgery assessment

4) Oxygen, blood glucose, monitoring and venous

route
5) Vascular access with analysis and pain treatment
(IV metamizole)
What does this child need FIRST?

CALM THE PAIN

□ 9-month-old infant who suddenly began unusual
intense crying about 3 hours ago.
□ Then he had 3 vomitings and drowsiness
□ No diarrhea, no fever
□ Upon arrival at the emergency room, he noted
drowsiness, pale skin, and no respiratory distress.
 Clinical case
2
7,500 gr, 36.9ºC Rect, TA 95/65, HR 125 lpm, Sat O2 96%

A. No evidence of respiratory obstruction

B. AR: Normal, without respiratory distress
C. Pale. Nondescript AC, fast full pulse, 2 sec capillary
refill
D. Sleepy. Reacts to stimuli. Non-neurological focality
E. Exam without clothes. No rash or lesions. Soft
abdomen doubtfully painful on palpation in HD
 Clinical case:
MANAGEMENT PRIORITIES

1) Urgent abdominal ultrasound

2) Urgent cranial CT
3) Oxygen, blood glucose, monitoring and venous
route
4) Blood analysis and monitoring
5) None of the above
 Clinical case:
MANAGEMENT PRIORITIES

1) Urgent abdominal ultrasound

2) Urgent cranial CT
3) Oxygen, blood glucose, monitoring and venous
route
4) Blood analysis and monitoring
5) None of the above
TEP?

CIRCULATION
 Pathophysiological
diagnosis?
Appearance Breathing Circulation Physiopathological Dg

N N N Stable

TO N N CNS dysfunction

N TO N Respiratory difficulty

TO TO N respiratory failure

N N TO Compensated shock

TO N TO Decompensated shock

TO TO TO cardiopulmonary failure
What's wrong with this child?

DECOMPENSATED SHOCK
 Clinical case:
MANAGEMENT PRIORITIES

1. Assess Oxygen
2. Capillary blood glucose: 145 mg/dl
3. Continuous monitoring
4. Venous and analytical route
5. SSFF Load
It was requested:
> Blood analysis: unremarkable
> Cranial CT: normal
> Abdominal ultrasound: Intussusception
 Clinical case:
MANAGEMENT PRIORITIES

FI OF THE 1ST
PART
 Teaching objectives:
GOAL 3

1. Learn the 3 components of the Pediatric Assessment Triangle

(PET)
2. Integrate the PET results into a first General Impression

3. Know the 2 components of the Initial

Evaluation of the urgent pediatric patient
4. Learn the therapeutic priorities depending on the PET and the
ABCDE
 TEP + Constants + ABCDE?:
PRIORITIES

□ Position?
□ Airway?
□ Oxygen?
□ Venous route?
□ Capillary blood glucose?
□ Glucose?
□ IV fluid loading?
□ Analgesia?
 Initial evaluation

□ It consists of 2 parts :
> Physiopathological Dg after performing the PET
> Primary evaluation : Constants + ABCDE
> Objectives:
> Quickly identify functional alterations
> Determine the severity of the process
> Determine the urgency of the intervention
> Guide initial restorative treatment
 Systematic approach to the
PUP

1. Pediatric Evaluation Triangle ( PET )

Pathophysiological Diagnosis «u WITHOUT
HANDS
1st Priorities
2. Primary evaluation:
Constants
Physical examination following ABCDE WITH
INITIAL EVALUATION : Priorities and initial restorative treatment
HANDS
3. Secondary evaluation:
COMPLETE Physical Examination
Directed anamnesis following SAMPLE
1st Dg Orientation : Plan EECC and initiate specific treatment
 Systematic approach to the
4. Tertiary evaluation: Additional investigations
PUP : Complete specific treatment
Diagnosis
5. Continuous monitoring and reassessment
 Directed anamnesis:
SAMPLE
S: Current illness
A: Allergies
M: Medication you take
Q: Background of interest
L: Last intake
E: Environmental circumstances that could have
triggered the disease

Complete Physical Examination

 Clinical case
3
□ 4-year-old boy, who for about 30 minutes his parents
have found him sleepy on the floor of the garage of
the house
□ They say that it was fine previously and that in the
garage they keep paints, garden fertilizers, oils and
other products for their car.
□ No one has witnessed what happened
□ In the emergency room he remains sleepy although
he cries easily when stimulated.
□ There is no increased work of breathing and skin color
is normal
 Clinical case
3
A: Normal
B: Normal, no difficulty
C: Normal, pulse full, 1 sec capillary refill
D: Sleepy. Normal pupils.
E: No external injuries.

TªAx: 36.1ºC SatO2: 98% HR: 80 lpmx'. TA 84/45

 Clinical case 3:
PRIORITIES

1) Complete the anamnesis

2) Complete the physical examination
3) Monitor, oxygen, blood glucose, EV route
4) Administer Naloxone and Flumazenil IV
5) All of the above is correct
 Clinical case 3:
PRIORITIES

1) Complete the anamnesis

2) Complete the physical examination
3) Monitor oxygen, blood glucose, viaEV
4) Administer Naloxone and FlumazenilIV
5) All of the above is correct
 TEP?

AC
E

CIRCULATION
 Pathophysiological
diagnoses
Appearance Breathing Circulation Physiopathological Dg

N N N Stable

TO N N CNS dysfunction

N TO N Respiratory difficulty

TO TO N respiratory failure

N N TO Compensated shock

TO N TO Decompensated shock

TO TO TO cardiopulmonary failure
 Clinical case 3:
PRIORITIES

1. Assess Oxygen
2. Capillary blood glucose: 79 mg/dl
3. Continuous monitoring
4. venous route
5. Gastric lavage was performed: blue liquid
It was requested:
> Gasometry: pH 7.19, Anion gap 30 mEq/L
> Analytical with osmolarity: Osmolar gap 23
mOsm/Kg
> Methanol and ethylene glycol levels: methanol 22
mg/dl
 Teaching objectives:
GOAL 4

1. Learn the 3 components of the Pediatric Assessment Triangle

(PET)

2. Integrate the PET results into a first General Impression

3. Know the 2 components of the Initial Evaluation of the urgent

pediatric patient

4. To understand the therapeutic priorities depending

on the PET
CIRCULATION
 7 pathophysiological
diagnoses
Pathophysiological
Appearance Breathing Circulation
Diagnosis
N N N Stable
TO N N CNS dysfunction
N TO N Respiratory difficulty
TO TO N respiratory failure
N N TO Compensated shock
TO N TO Decompensated shock
TO TO TO cardiopulmonary failure
 TEP?:
PRIORITIES

□ Position?
□ Airway?
□ Oxygen?
□ Capillary blood
glucose?
□ Venous route?
□ IV fluid loading?
□ Analgesia?
 Priorities according to Dg Fp »

(1)
Apar Resp Circ Physiopathological Dg

■ Stable:
N N N Stable

TO N N CNS dysfunction
N TO N Respiratory difficulty
TO TO N respiratory failure

1. Soothe the pain

N N TO Shc compensated
TO N TO decompensated shc
TO TO TO cardiopulmonary failure

□ Specific treatment
 Priorities according to Dg Fp
»

(2) Physiopathological Dg
Apar Resp Circ
Stable
N N N
TO N N CNS dysfunction
N TO N Respiratory difficulty

■ CNS dysfunction: TO
N
TO
N
N
TO
respiratory failure
Shc compensated

1. Assess Oxygen TO
TO
N
TO
TO
TO
decompensated shc
cardiopulmonary failure

2. Monitoring
3. capillary blood glucose
4. vascular access
5. Soothe the pain
□ Specific treatment
 Priorities according to Dg
Fp (3 ) Apar Resp Circ
Dg
Physiopathological

N N N Stable

■ Respiratory Difficulty: TO
N
N
TO
N
N
CNS dysfunction
Respiratory difficulty

1. Position TO
N
TO
N
N
TO
respiratory failure
Shc compensated
2. Assess Oxygen TO N TO decompensated shc
TO cardiopulmonary failure
3. Aspiration of secretions if pro
TO
To UUV
•

4. Monitoring
5. Soothe the pain
□ Specific treatment
 Priorities according to Dg
Fp (4 ) Apar Resp Circ
Dg
Physiopathological

■ Respiratory Failure:
N N N Stable

TO N N CNS dysfunction
N TO N Respiratory difficulty
1. Place head and open airway TO TO N respiratory failure

2. Oxygen N
TO
N
N
TO
TO
Shc compensated
decompensated shc

3. Monitoring TO TO TO cardiopulmonary failure

4. Capillary blood glucose

5. Assess CPR
6. Remove possible foreign body
7. vascular access
 Priorities according to Dg
Fp (5 )

■ Compensated Shock /
Apar Resp Circ Physiopathological
Dg
N N N Stable

Decompensated:
TO N N CNS dysfunction
N TO N Respiratory difficulty

1. Assess Oxygen
TO TO N respiratory failure
N N TO Shc compensated

2. Monitoring TO
TO
N
TO
TO
TO
decompensated shc
cardiopulmonary failure
3. capillary blood glucose
4. vascular access
5. IV fluid loading
□ Soothe the pain
□ Specific treatment
 Priorities according to Dg Fp
»

(6) Physiopathological Dg
Apar Resp Circ
Stable
N N N
TO N N CNS dysfunction
N TO N Respiratory difficulty

■ Cardiopulmonary Failure: TO
N
TO
N
N
TO
respiratory failure
Shc compensated

1. Oxygen TO
TO
N
TO
TO
TO
decompensated shc
cardiopulmonary failure

2. Monitoring
3. capillary blood glucose
□ Consider starting CPR
□ vascular access
□ Soothe the pain
 To remember …

1. The evaluation of a child begins with :

1) The Pediatric Assessment Triangle ( Overview )
2) Taking constants + Initial physical examination ABCDE
2. After which :
• We will have a first INITIAL EVALUATION
• We will establish the diagnostic-therapeutic PRIORITIES
3. After which:
• WE WILL COMPLETE the Physical Examination + History (SAMPLE)
• We will form a 1st Diagnostic Orientation
• We will establish the diagnostic-therapeutic STRATEGY
 Moltes
Thank you!!!