What's a nurse to do when children arrive in the emergency department (ED) and there aren't any pediatric specialty nurses to care for them? From the ABCs to PAT, a number of mnemonic devices can help you provide quick, efficient care.
Fast initial assessment
Keeping the potential for rapid deterioration in mind when you triage a child, you want your assessment to be both thorough and fast. An excellent resource to help with initial triage is the Pediatric Assessment Triangle (PAT). Originally an element of the Pediatric Education for Prehospital Professionals program, the PAT is now generally accepted as the best way to perform an initial evaluation of a sick or injured child. You can use this model without touching the patient. Here are its three elements:
* Appearance: Refers to the child's overall "look," which reflects adequacy of brain perfusion. Two mnemonics you can use to assess appearance are AVPU or TICLS ("tickles").The simpler of the two, AVPU stands for alert, rousable to voice, rousable to pain, or unresponsive. Use TICLS to assess tone, interactiveness, consolability, look (gaze), and speech/cry.A child with intact appearance will be alert, interactive, easy to console, and able to recognize caregivers.
* Work of breathing: Experts recognize this as a better indication of oxygenation and ventilation than respiratory rate or breath sounds. Labored respirations with accessory muscle use indicate impending respiratory failure.
* Perfusion to the skin: Reflects the adequacy of circulating blood volume. Blood volume is probably adequate in children with light complexions whose extremities are pink. In children with deeper complexions, assess skin color on the palms, soles of the feet, and nail beds.
Children who exhibit a fully intact PAT are in reasonably stable condition at the time of assessment. Problems with one PAT component indicate that the child is compromised and requires more urgent care. If the patient has alterations in two or three of the components, intervene immediately to prevent further compromise and death.
Reciting the ABCs
As with adults, your first priority in any pediatric emergency is the ABCs. Here's how to proceed.
Airway: This is always your first priority, because any other supports or drugs are useless if the airway isn't patent.
If the child can't protect her airway, open it immediately using basic life-support measures, such as a head-tilt/chin-lift maneuver. If you suspect trauma, stabilize the head and neck in a neutral position and use a jaw thrust.
Breathing: First, determine whether the child is breathing. If not, call for help and initiate basic life support as indicated. If the child is breathing, assess the adequacy of respirations by asking:
* Is the respiratory rate fast, slow, or normal? Charts listing the normal respiratory rate for different ages can help, but here's a quick-and-dirty method to use in a pinch: If you feel out of breath watching a child breathe, the rate is abnormally fast. And if you feel the need to help a child breathe, the rate is probably too slow.
* What's the depth of respirations? Deep respirations can suggest a metabolic problem. Shallow respirations more commonly accompany neurologic problems or shock.
* How would you describe the patient's respiratory effort? Easy respiratory effort points away from a pulmonary reason for the child's distress. Increased effort with accessory muscle use or retractions indicates a primary pulmonary problem.
* Can you auscultate any abnormal breath sounds? Wheezes generally arise from narrowing of small airways and bronchospasm. Fluid in the alveoli causes crackles. Narrowing or, more commonly in children, obstruction of larger airways causes stridor.
Assuming the airway is patent, the first step in respiratory support is to administer supplemental oxygen-the higher the concentration, the better. High-flow oxygen via nonrebreather mask is ideal if the child can tolerate it. Blow-by oxygen is better than nothing if the patient refuses to wear a mask.
Most children won't tolerate nasal cannula prongs in their nostrils. If a child accepts a nasal cannula, he's probably too sick to care and needs more than low-flow oxygen. Although blow-by oxygen is a poor second choice to a face mask, it can give the child a higher oxygen concentration than a nasal cannula if the oxygen source is held close enough to his face.
Inadequate respiratory rate or depth indicates the need for support with a bag-valve-mask device and supplemental oxygen. Endotracheal intubation remains the gold standard for pediatric airway management, but adequate oxygenation and ventilation can be maintained for long periods by people skilled in basic airway management.
Circulation: When assessing cardiovascular status, focus on presence, location, and rate and strength of pulses; skin color and temperature; and capillary refill time. In children, blood pressure may not be a reliable indicator. Although low blood pressure is almost always a dire sign, normal or high blood pressure isn't necessarily reassuring. Vasoconstriction in response to fluid loss may keep a child's blood pressure up even if she's in severe shock.
First, assess central pulses for rate and strength. Check brachial or femoral pulses in infants under age 1, and check the carotid in older children. Then, assess peripheral pulses. Remember, in a child the first compensatory mechanisms for lost blood volume are increased heart rate and peripheral vasoconstriction. As blood vessels in the limbs become more constricted, pulses will become weaker until they disappear altogether. Because of decreased blood flow, arms and legs begin to feel cooler and look pale or mottled. However, in young infants, peripheral cyanosis and mottling can be normal findings, so check other assessment parameters to determine circulatory status.
Check capillary refill time by pressing gently on the patient deep enough to blanch the skin. The time it takes for the blanched area to fill back is the capillary refill time. Using body parts proximal to the elbows and knees will minimize false delays caused by cold temperatures.
A capillary refill time of 2 seconds is considered normal. A capillary refill time of more than 3 seconds indicates impaired circulation. A capillary refill time of less than 2 seconds may be a sign of some type of distributive shock (septic or neurogenic). To get the full picture, look at all parameters, including patient history.
Facing special challenges
Take advantage of any educational opportunities to improve your expertise with pediatric patients. We owe them the best care we can give.
David S. Salati is a staff paramedic at Virtua Health in Mt. Laurel, N.J.
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