The Paediatric Assessment Triangle

This post accompanies the talk I was asked to give to a fantastic group of Ambulance Victoria paramedics. I was given the title “Everything you NEED to know about paediatrics“, but given that I don’t know everything I need to know yet I thought I would drill down and focus on doing one thing well.

One of the biggest challenges is identifying the difference between sick and not sick.  In the prehospital environment, you don’t have the luxury of time and observation. All you can go on is what is in front of you. So how can you distil years of training and exposure? Perhaps what we call gut feeling is really a synthesis of the paediatric assessment triangle – a decision based on one snapshot in time.

The basics

The American Academy of Pediatrics introduced the Pediatric Assessment Triangle – PAT – (Editors note: I’m going to call it the PAediatric Assessment Triangle throughout this post as I just cannot bring myself to spell it that way. Sorry, Tim) in 2000 in the Pediatric Education for Pre-hospital Providers course. It was an effort to make it easier for pre-hospital providers to triage children into sick or not-sick, and perhaps to help them determine the cause of illness too.

Appearance

So what does that child actually look like? What do we take in at first glance that might make us concerned? Consider this mnemonic.

Tone

Are they unusually floppy, like a ragdoll, unable to hold themselves upright? By six months of age, nearly all children should be able to sit up and support their own heads.

Interactiveness

To a newborn child, the world is an amazing place, full of strange sights and sounds and smells. Babies have learnt to smile by about two months of age, and by a year or so, they are following objects around the room with their gaze. If they do not appear to be interested in what is going on in the world around them, then it is time to be a little more concerned.

Consolabilty

Children cry – all of the time. They cry because you want to brush their hair, they cry because you don’t want to brush their hair, and they cry because you have looked at them. But they are also consolable. If they can’t be consoled, despite the best efforts of their mother, then something is amiss.

Look/gaze

Whilst staring off into the distance may be normal for a teenager, it is probably not normal for a three-year-old (unless they are very hungry).

Speech/cry

Crying, generally, is good, especially if it is someone else’s child and not your own, as long as they are consolable (see above). But that high-pitched squealing cry means something different entirely.

All of these things help make up our clinical gestalt. They are something that we are often not even aware that we are aware of. Taking a look at their breathing may require a little more attention.

Breathing

Assessing their work of breathing does not require an eidetic memory of age-based norms but, once again, is a snapshot taken in seconds. Problems can occur at any point of the respiratory tree, from snotty nostrils to tightened tracheas and blocked bronchioles. Assessing this is a matter of looking AND listening.

Here are some of the things we are looking for…

what position they are sitting in
nasal flaring
tracheal tug
intercostal/subcostal recession
abdominal breathing

But we can take in just as much information through our ears as we can through our eyes.

As air passes through the nostrils on its way to pulmonary alveoli, it can be subject to smooth, laminar flow or the chaotic eddies of turbulent flow. Any point of narrowing in an already small airway can make a sound. I liken it to my 2 year old trying to breathe through a recorder. If I want silence, I need to remove the narrow mouthpiece, the part that starts the noise.

As it passes inwards through a narrowed larynx (for whatever reason), we may hear stridor, and as it gets to the narrowed bronchial tree of an asthmatic (for example), we may hear a wheeze. If the air hunger is great enough, we don’t need a stethoscope to hear these noises, you can hear them from the end of the bed. These noises, coupled with the grunt of a child trying to generate enough PEEP to keep their alveoli from collapsing, are the sounds of respiratory distress. In the pre-verbal child, then, there seem to be a number of overlaps with veterinary science.

Circulation

An embarrassment of the circulatory system is much harder to spot.

pallor
mottling
cyanosis

Often the child needs to be undressed to make these changes a little more obvious. You might want to rely on the capillary refill time, too but this is not part of the assessment triangle. It is a strictly no-touch technique.

Once we have a basic snapshot of appearance, breathing and circulation, we can combine the elements to help determine both how unwell the child is and what could be wrong with them.

So does it actually work?

Even after 20 years in practice, I cannot remember the age-based norms for vital signs (and there is some evidence that the ones we have may not be accurate anyway). I like to think of patients as either sick or not sick in the first instance. If I feel they are sick, then the next question is nearly always, why? Does the Paediatric Assessment Triangle framework actually work in real life?

One group from UCLA examined how accurate triage nurses were at using the tool. In their prospective observational cohort, they provided a multimedia training package and then asked nurses to fill in a PAT card for every child that came through the door that met inclusion criteria. The investigators then performed a structured chart review to assess just how good the PAT was. They found that it did a great job of identifying stable patients (LR 0.12) but an even better job of determining their pathophysiology.

A similar study was done with EMS providers and had similar results. Paramedics were very good at detecting stability and instability using the tool. Both groups have a degree of medical knowledge, and it would be hard to determine how that might bias their assessment. Could non-medics be trained to use the tool? Could a computer?

Limitations

Most of the data only applies to children under 14 years of age and those with what could be termed a normal baseline. It is much less useful in children with developmental delays, those with congenital abnormalities or those reliant on technology to keep them alive.

For an aural version of some of the things covered in this talk, you could not do better than listening to Tim Horeczko.

Selected references

Dieckmann RA, Brownstein D, Gausche-Hill M (eds) (2000) Pediatric Education for Prehospital Professionals: PEPP Textbook. Jones & Bartlett Publishers, Sudbury, MA

Dieckmann, R.A., Brownstein, D. and Gausche-Hill, M., 2010. The pediatric assessment triangle: a novel approach for the rapid evaluation of children. Pediatric emergency care, 26(4), pp.312-315.

Gausche-Hill, M., Eckstein, M., Horeczko, T., McGrath, N., Kurobe, A., Ullum, L., Kaji, A.H. and Lewis, R.J., 2014. Paramedics accurately apply the pediatric assessment triangle to drive management. Prehospital Emergency Care, 18(4), pp.520-530.

Horeczko T, Gausche-Hill M. The paediatric assessment triangle: a powerful tool for the prehospital provider. Journal of Paramedic Practice. 2011 Jan 13;3(1):20-5.

Horeczko T, Enriquez B, McGrath NE, Gausche-Hill M, Lewis RJ. The Pediatric Assessment Triangle: accuracy of its application by nurses in the triage of children. Journal of Emergency Nursing. 2013 Mar 1;39(2):182-9.