Initial Assessment: Diagnose & Treat

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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 AHA recommends following ABCDE method when making initial assessment (Figure 7).

PALS Initial Assessment ABCDE

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 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

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
In 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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