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Initial Assessment: Diagnose & Treat

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If you have reached the Diagnose and Treat phase of care, the patient 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 AHA recommends following ABCDE when making your initial assessment.

initial assessment flow chart

 

Airway


Assess the airway and make a determination between one of three possibilities.

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 B
Can the airway be kept open manually?
  • Jaw Lift/ Chin Thrust
  • Nasopharygeal or oropharygeal airway
In an advanced airway required?
  • Endotracheal intubation
  • Cricothyrotomy, if necessary
Breathing

If the patient is not breathing effectively, it is a life-threatening event and should be treated as respiratory arrest (detailed in a later section). However, abnormal yet marginally effective breathing can be assessed and managed.

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

Circulation


Assessment of circulation in children 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 young patients. 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 2 seconds to respond. Abnormally cool skin can also suggests poor circulation.

The normal heart rate and blood pressure in children are quite different than adults and change with age. Likewise, heart rates are slower when children 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 below.

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

 

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

Neurologic assessments include the AVPU Pediatric Response Scale Fig. 1, and the Glasgow Coma Scale (GCS). A specially-modified GCS is used for infants and children and takes developmental differences into account. See Fig. 2 on the next page.

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
Fig. 1 AVPU Response Scale

Glasgow Coma Scale–Infants & Children

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

Figure 2: Modified Glasgow Coma Scale for Infants and Children

 

Exposure


Exposure is classically most important when you are responding to a patient 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 or 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 patient’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 lose core body temperature faster than adults do. So while it is important to evaluate the entire patient, be sure to cover and warm the patient after the diagnostic survey.

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