Initial Assessment: Diagnose & Treat

If you have reached the initial diagnosis and treatment phase of care, the child or infant is not in immediate danger of death. While this means that you likely have a brief period to find the cause of the problem and intervene with appropriate treatment, it does not mean that a life-threatening event is impossible. Always be vigilant for any indication to initiate high-quality CPR and look for life-threatening events such as respiratory distress, a change in consciousness, or cyanosis. The ILCOR recommends following the ABCDE method when making an initial assessment (Figure 7).

AIRWAY

Assess the airway and make a determination between one of three possibilities (Table 3). Once an airway has been established and maintained, move on to breathing.

IS THE AIRWAY OPEN?	This means open and unobstructed If yes, proceed to Breathing
CAN THE AIRWAY BE KEPT OPEN MANUALLY?	Jaw Lift/Chin Thrust Nasopharyngeal or oropharyngeal airway
IS AN ADVANCED AIRWAY REQUIRED?	Endotracheal intubation Cricothyrotomy, if necessary

Table 3

BREATHING

If the child or infant is not breathing effectively, it is a life-threatening event and should be treated as respiratory arrest. However, abnormal yet marginally effective breathing can be assessed and managed (Table 4).

IS BREATHING TOO FAST OR TOO SLOW?	Tachypnea has an extensive differential diagnosis Bradypnea can be a sign of impending respiratory arrest
IS THERE INCREASED RESPIRATORY EFFORT?	Signs of increased respiratory effort include nasal flaring, rapid breathing, chest retractions, abdominal breathing,stridor, grunting, wheezing, and crackles
IS AN ADVANCED AIRWAY REQUIRED?	Endotracheal intubation Cricothyrotomy, if necessary

Table 4

CIRCULATION

Assessment of circulation in pediatrics involves more than checking the pulse and blood pressure. The color and temperature of the skin and mucous membranes can help to assess effective circulation. Pale or blue skin indicates poor tissue perfusion. Capillary refill time is also a useful assessment in pediatrics. Adequately, perfused skin will rapidly refill with blood after it is squeezed (e.g. by bending the tip of the finger at the nail bed). Inadequately perfused tissues will take longer than two seconds to respond. Abnormally, cool skin can also suggest poor circulation. The normal heart rate and blood pressure in pediatrics are quite different than in adults and change with age. Likewise, heart rates are slower when children and infants are asleep. Most centers will have acceptable ranges that they use for normal and abnormal heart rates for a given age. While you should follow your local guidelines, approximate ranges are listed in (Table 5).

AGE	NORMAL HEART RATE (AWAKE)	NORMAL HEART RATE (ASLEEP)	NORMAL BLOOD PRESSURE (SYSTOLIC)	NORMAL BLOOD PRESSURE (DIASTOLIC)	HYPOTENSION BLOOD PRESSURE (SYSTOLIC)
Neonate	85-190	80-160	60-75	30-45	<60
One Month	85-190	80-160	70-95	35-55	<70
Two Months	85-190	80-160	75-95	40-60	<70
Three Months	100-190	75-160	80-100	45-65	<70
Six Months	100-190	75-160	85-105	45-70	<70
One Year	100-190	75-160	85-105	40-60	<72
Two Years	100-140	60-90	85-105	40-65	<74
Child (2 to 10 years)	60-140	60-90	95-115	55-75	<70 + (age x 2)
Adolescent (over 10 years)	60-100	60-90	110-130	65-85	<90

Table 5

DISABILITY

In PALS, disability refers to performing a rapid neurological assessment. A great deal of information can be gained from determining the level of consciousness on a four-level scale.

AWAKE	May be sleepy, but still interactive
RESPONDS TO VOICE	Can only be aroused by talking or yelling
RESPONDS TO PAIN	Can only be aroused by inducing pain
UNRESPONSIVE	Cannot get the patient to respond

Table 6

Pupillary response to light is also a fast and useful way to assess neurological function.

Neurologic assessments include the AVPU (alert, voice, pain, unresponsive) response scale and the Glasgow Coma Scale (GCS). A specially-modified GCS is used for children and infants and takes developmental differences into account (Tables 6 and 7).

Glasgow Coma Scale for Children and Infants

AREA ASSESSED	INFANTS	CHILDREN	SCORE
Eye-opening	Open spontaneously	Open spontaneously	4
	Open in response to verbal stimuli	Open in response to verbal stimuli	3
	Open in response to pain only	Open in response to pain only	2
	No response	No response	1
Verbal Response	Coos and babbles	Oriented, appropriate	5
	Irritable cries	Confused	4
	Cries in response to pain	Inappropriate words	3
	Moans in response to pain	Incomprehensible words or nonspecific sounds	2
	No response	No response	1
Motor response	Moves spontaneously and purposefully	Obeys commands	6
	Withdraws to touch	Localizes painful stimulus	5
	Withdraws in response to pain	Withdraws in response to pain	4
	Responds to pain with decorticate posturing (abnormal flexion)	Responds to pain with flexion	3
	Responds to pain with decerebrate posturing (abnormal extension)	Responds to pain with extension	2
	No response	No response	1

Table 7

EXPOSURE

Exposure is classically most important when you are responding to a child or infant who may have experienced trauma; however, it has a place in all PALS evaluations. Exposure reminds the provider to look for signs of trauma, burns, fractures, and any other obvious sign that might provide a clue as to the cause of the current problem. Skin temperature and color can provide information about the child or infant’s cardiovascular system, tissue perfusion, and mechanism of injury. If time allows, the PALS provider can look for more subtle signs such as petechiae or bruising. Exposure also reminds the provider that children and infants lose core body temperature faster than adults do. Therefore, while it is important to evaluate the entire body, be sure to cover and warm the individual after the diagnostic survey.

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