The Pediatric Assessment Triangle

One of the most difficult types of calls that we can respond to as emergency services providers is a call involving a critically injured or ill child.  In this Medical Monday we will discuss the Pediatric Assessment Triangle.  This tool is used by EMS professionals as a step by step guide that will assist with forming a general impression of what exactly is wrong with the child.  In my experience, I have found that the Pediatric Assessment Triangle helps to keep me focused during a high stress event (responding to help a very sick kiddo whether trauma or medically induced) as well as helping to guide me to a fast differential diagnosis so that I can begin accurately treating what is going on.  

As the name implies, the Pediatric Assessment Triangle consists of three components.  They are: Appearance, Work of Breathing, and Circulation to the Skin.  Allow me to break these components down individually.  

Appearance – I have always preached that 90% of emergency medicine at the street level is common sense.  My personal belief when it comes to the appearance of anyone whether a child, or an adult is that if they truly look “bad” then they ARE “bad” until proven otherwise.  To simplify this, if they look really sick, move urgently.  If they don’t look that sick, you have a little time to do a more detailed assessment.  Now for the technical answer.  For the appearance section of the triangle, we use the mnemonic TICLS.  

  • T – Tone (Muscle Tone) Is the child limp?  Are they rigid?  Are they moving normally for their age?
  • I – Irritability Is the child crying?  Is their airway blocked to the point that they can’t cry?  Are they unresponsive?  I have always believed as a paramedic responding to a call involving a baby or a child that it is a wonderful thing to hear them crying loudly.  This means that their airway is open, and they are alert to the fact that they are in pain.  
  • C – Consolability Is the child able to be comforted by their parents / guardians?  Does the child withdraw or act fearful of their parents / guardians?  Are you able to calm the child down with a distraction such as a toy?  
  • L – Look or gaze Does the child have a fixed and vacant stare?  Is the child looking around normally? If the child has a vacant stare, ask about seizure activity or any possibility of a head injury.  
  • S – Speech Is the child able to express themselves at an age appropriate level?  If it is an infant, are they crying, and if they are, is it a normal type of cry?

Work of Breathing – This portion of the triangle measures how hard the child or infant is working to breathe.  Are they breathing normally?  Are they using accessory muscles to breathe?  Do you see retractions (the skin between the ribs being sucked in)?  Do you see nasal flaring?  Do you hear any abnormal noises such as snoring, wheezing, or a high-pitched bark?  In infants specifically, grunting noises are a sign of respiratory distress. Most generally, when pediatric patients are experiencing a serious medical issue, the issue is respiratory in nature.  If you can begin to fix the respiratory issue, the patient in most cases will begin to improve.  

Circulation to the Skin – This segment of the triangle covers obvious blood loss.  Mottling (a marbled appearance), cyanosis (bluish coloring around the face, or tips of fingers and toes), and pallor (paleness of skin) all point to a decrease in circulatory function and or a lack of oxygenation.  An important note:  CAT Tourniquets WILL work in any age of patient.  It used to be taught that this was not the case, but a study was conducted and showed that to be inaccurate.  With that being said, pediatric patients have lower blood pressures, so direct pressure is more effective when it comes to stopping blood flow.   

Here are a few tips that have worked well for me over the years of responding to emergencies involving children:

On the way to the scene make sure that you are taking deep breaths and focus on being / remaining calm.  This may sound cliché, however oftentimes these calls can quickly become overwhelming and people are looking to you to make solid and urgent decisions.  Once you have arrived on the scene, our inclination is to immediately rush to the patient.  I make it an absolute point to stop at the doorway for approximately 10 seconds and survey the big picture of the scene before I enter.  Once you are beside the child, it can be very easy to be overcome with tunnel vision and miss something such as an empty pill bottle nearby, or other clues that can guide you to what is going on.   

If the parent / guardian / caregiver is available, not panicking, and remaining somewhat calm, allow the child or baby to be held by them while you perform your assessment.  Generally, the child will remain calmer, the parents will be calmer, and you can get a more accurate assessment.  When it comes to calls involving pediatrics, it is very important to remember that the parents are a patient also.  Communicate calmly, and clearly.  Avoid phrases such as “everything will be fine.”  A great replacement phrase is to assure them that you are doing everything possible for their child.  Generally speaking, the parents or caregiver of the child will be a great resource for gathering the health history of the child.  Important questions include but are not limited to:  What kind of medical problems does the child have?  Have they had any recent complications?  Is the child taking any medications?  Does the child have any allergies?  Have they been peeing / pooping normally?  How many wet diapers has the infant had today?  When was the last time they ate or drank anything?  What led up to this medical event today?

When assessing a responsive child, make sure to lower yourself to their level, and then begin at the feet and work your way up.  This will allow the child to be more comfortable.  I highly recommend carrying a couple of small stuffed animals in your patrol car to give to pediatric patients.  They can be used as a distraction, but they can be used as a great assessment tool.  If the child is age appropriate, you can ask the child to point on the stuffed animal where they are hurting.  Another strategy is to see if you can track down their favorite toy or blanket.  

When other responders arrive, whether it be firefighters, medics, or other officers, refer to them as your friends.  Use calm and reassuring voice levels.  It is very helpful once a rapport has been established to try your best to remain with the child for as long as possible before they are transported.  

When it comes to cardiac arrest in pediatrics remember these three things:

  • The SINGLE RESUCER chest compression to ventilation ratio remains the same for adult, child, and infant.  That rate is 30 compressions to 2 breaths.  
  • For SINGLE rescuer use the two-finger method for infants.  Many responders have stated that the thumb encircling the hand method seems more effective, and more comfortable.  The problem is that it takes too much time to get back into position after delivering the ventilations.  Once TWO rescuers are on scene, the thumb encircling the hand method is preferred.  Once TWO rescuers are on scene, the compression to ventilation ratio for CHILD AND INFANT changes to 15 compressions to 2 breaths.    
  • When opening the airway, it is very important to remember that extending the head too far can cause hyperflexion which can also block the airway.  Primarily in infants, the best way to get their head into a neutral in line position is to place a towel or sheet, or whatever you have available that you can manipulate between their shoulder blades.  This will naturally raise the torso allowing their head to get into the optimal position for their airway to be open.  

I have no doubt that there are several of you out there who have your own tips and tricks that have worked well for you when it comes to responding to calls involving children.  I would love for you to share them in the comments.  As always, if you have any questions, please let me know in the comments section as well.  

The Correct Way To Perform Wound Packing

A couple of weeks ago I had the privilege attending a meeting with a few representatives from the company QuikClot.  QuikClot is one of a few different manufactures that produces impregnated gauze that is used for wound packing.  In this Medical Monday we will discuss the correct way to perform wound packing as well as the areas in which wound packing can be performed.  

One thing that sets QuikClot apart from other manufactures is that QuikClot is impregnated with kaolin as the agent that assists with faster clotting of blood.  The Committee of Tactical Combat Casualty Care also recognizes QuikClot as a superior product.  An long conversation ensued discussing the two methods approved by QuikClot when using their product.  One theory is that if you have used an entire roll of QuikClot inside of a wound, and the wound is still bleeding, you pull all of it out and place a fresh pack of QuikClot into the wound.  

The rationale behind that theory is that the fresh kaolin will make contact with the blood and provide a better clot to slow down and stop the bleeding.  In my entire career I have always been taught that you should never remove gauze from the wound once the wound is packed with gauze.  

If the bleeding continues, add fresh gauze on top of the existing gauze and hold pressure.  I brought this point up to the QuikClot representatives who after a long discussion agreed that EITHER method would be acceptable.  The tactical physician in the room advised that he personally would just add gauze, he would not remove what was already in place.  This is what I recommend as well.  My thought process says that if you remove the gauze that has already become soaked, you are removing any clot, or beginning of a clot that has already formed, and you are starting back at square one.  

This brings me to my next point.  When you encounter a wound with a large amount of bleeding in a place that is not amendable to tourniquet use, it is imperative to try to pinpoint exactly where the bleeding is coming from.  To do this, if blood has pooled within the wound, use your hand and “scoop” the blood out to assist you with finding the source.  Once you find the source, begin packing the wound using your finger to hold pressure directly on the source of the bleeding.  Ensure that you fill ALL of the voids of the wound cavity.  Especially in the case of a gunshot wound, the energy that enters into the body with the bullet will cause tissue to expand and tear.  It is important to pack all areas of the wound that were affected.  

Let me clarify a few things.  Wound packing is most generally performed in the junctions of the body.  Your arm pits, groin, and the base of your neck are a few examples.  Do NOT put QuikClot or any other type of gauze into major head trauma, the chest, or the abdomen.  

QuikClot offers several different sizes of gauze for different applications.  The packaging will look different, but the product itself is the same.  No longer is quikclot the granules that used to cause burns.  I have used the current quikclot product and it is absolutely incredible how well it works.  A friend of mine took a sim round to the nose during SWAT school last year and his nose would not stop bleeding.  I used a small piece of the QuikClot gauze to place into his nose, and the bleeding stopped immediately.  If you have any questions or comments, please let me know.  

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