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The Pediatric Assessment Triangle: Still A Valuable Tool In 2018


Guide to the Pediatric Assessment Triangle

First responders perform the Pediatric Assessment Triangle to gain a quick impression of how critical a child’s illness is. It’s a pediatric assessment tool that works well with children because it is non-invasive and doesn’t require EMTs and paramedics to have any physical contact with the child. This is very important with pediatric patients who benefit from non-threatening assessments. 

 

Benefits of Pediatric Assessment Triangle 

 

Rapid assessment done in 30-60 seconds

No tools needed

Non-threatening to children

Non-invasive

Simple to do

 

When to use the Pediatric Assessment Triangle

The Pediatric Assessment Triangle should be used to evaluate the patient’s status before you have any physical contact with the child. It can help EMTs and paramedics get a quick initial impression of how sick the patient is during a pediatric emergency.

 

EMTs should begin the assessment at the moment they walk in the front door or arrive on scene. In fact, the Pediatric Assessment Triangle is very similar to the adult “view from the door” or “across the room” patient assessment.

 

When responding to a pediatric emergency, immediately upon entering the patient’s home, the EMT should look towards the child and begin to take in relevant information.

 

EMTs and paramedics can perform the Pediatric Assessment Triangle in 30 – 60 seconds using only auditory and visual signals from the child. 

 

Pediatric Assessment Triangle

 

 

What the Pediatric Assessment Triangle Does

First responders use the Pediatric Assessment Triangle to quickly form a general impression of a child and determine if the child is sick or not sick. In the past this was considered a “gut feeling” that EMTs and paramedics would get about how critical the patients was.

 

However, in 2000 the American Academy of Pediatrics introduced the Pediatric Assessment Triangle as a new assessment tool for use with pediatric emergency patients. The tool provided a consistent and professional way for EMTs and paramedics to articulate their “gut feelings” about how critical a child is. 

 

The Pediatric Assessment Triangle doesn’t assign numbers or a rating system, it stays true to the original system of rapidly forming a gut impression of the patient. 

 

Once first responders have used the Pediatric Assessment Triangle to determined how critical the patient is, they will use the results to help guide medical decisions. It can help influence decisions like calling in additional resources or speeding up patient transport.

 

EMTs and paramedics will always do additional hands on assessments after using the Pediatric Assessment Tool to form an impression of whether the patient is stable, in shock, respiratory failure, or respiratory distress.

 

The pediatric triangle is a great pediatric assessment tool, but it is just the first step in patient care.

 

Is the Pediatric Assessment Triangle Still Valid

This is a good question, everything in the medical field should be questioned and updated regularly. The field of Emergency Medical Services (EMS) is no different. In fact, EMS has been making big changes lately with decisions about intubation and whether to continue treating and transporting legally deceased patients.

 

The last thing you want to do is read an article from 2009 or learn something only to find out that it’s not even relevant to EMTs in the field today. I’ve had this happen to me repeatedly and it’s part of the reason I started this website. 

 

I was able to find two recent studies about the Pediatric Assessment Triangle and both of them concluded that it is still a valid tool. I’m including links to both studies because I don’t want to get into specific details here about each study.

 

Overall, they show that research is being done about the pediatric triangle and the research indicates it’s a useful tool. This is good news for EMTs and paramedics because we perform a similar assessment with adults and it’s reassuring to know our techniques are not outdated or harmful to patients.

 

The first study can be found at https://www.osieec.eus… and it concluded:

“The PAT has demonstrated to be useful to assess sick children in the prehospital setting and to make transport decisions.”

 

The second study had nurses using the Patient Assessment Triangle (PAT) to assess patients in triage at a pediatric emergency department. The study abstract and conclusions can be found at https://journals.lww.com… This study found: 

“Abnormal findings in the PAT applied by trained nurses at triage identify patients with a higher risk of hospitalization. The PAT seems to be a valid tool for identifying the most severe patients as a first step in the triage process.”

 

Obviously this is just a summary so check out the studies yourself if you want more information about each one.

 

Pediatric Assessment Triangle

The Pediatric Assessment Triangle uses 3 variables to determine if the child is sick or not sick by using a rapid assessment. Each variable makes up one side of the triangle.

 

The 3 sides of the triangle are:

 

Appearance

Work of Breathing

Circulation

 

Remember you will complete the entire Pediatric Assessment Triangle in about 30 – 60 seconds. This explanation may seem long but the actual assessment is fast and organic. 

 

Appearance

Appearance is extremely important when assessing pediatric patients. It reflects the patients overall ventilation, oxygenation and perfusion status. First responders can use the TICLS mnemonic to quickly assess patient appearance during a pediatric emergency.

 

Tired looking boy on a couch

 

EMTs and paramedics need to have basic knowledge about normal childhood development in order to perform the appearance portion efficiently. After all if you don’t know what a healthy child of each age group should look and act like, it will be harder to recognize abnormalities.

 

TICLS Mnemonic 

T – Tone 

I  Interactiveness 

C – Consolability 

L – Look or Gaze 

S  Speech & Cry

 

Tone in the pediatric triangle will be your assessment of the child’s muscle tone. Does the child seem listless or is the child active. Pay attention to the child’s neck for muscle tone clues during your pediatric assessment. Is the child leaning their head against an object or supporting the weight of their own head?

 

Healthy infants should be able to hold their heads up steady and unsupported by 4 – 6 months of age.

 

Interactiveness can be assessed by observing how the child relates to family or anyone else present. This part of the pediatric triangle will look for signs that the child is able to engage in their environment. Does the child grab onto a parents leg or turn towards first responders when they walk into the room?

 

Does your pediatric assessment uncover a patient who keeps closing their eyes and doesn’t look up? Or does the child show interest in the people around the room?

 

Shy female pediatric with stuffed toy

 

Consolability is a little trickier because it can be affected by the child’s normal temperament. However, this portion of the pediatric triangle will assess whether the child can be consoled. Is the child comforted by parents or caregivers. Are they inconsolable? Does the child know what’s going on around them. All of these factors contribute to your overall impression of the child.

 

Look and gaze is usually an easy part of the Pediatric Assessment Triangle. EMTs and paramedics can look for signs that the child is interested in the environment and is “present.” Does the child look at your face, look at the objects you’re carrying, or stare out into space with a vacant gaze?

 

Even infants should actively move their gaze to look at interesting visual cues.

 

The speech and cry portion of the pediatric triangle can be assessed by determining if the patient has spontaneous speech and a strong cry. Does the child remain silent, speak quietly, only speak if prompted, or is the child too withdrawn to speak.

 

You want to decide if the child is using appropriate language for their age, or is respiratory compromise inhibiting their ability and desire to communicate. 

 

Work of Breathing

This part of the Pediatric Assessment Triangle looks at the child’s respiratory status. First responders will look for signs that the child is struggling to breathe and that each breath is taking effort.

 

EMTs and paramedics will look for nasal flaring, retraction breathing, body positions, and abnormal breath sounds. Also pay attention to how rapidly your patient is breathing.

 

Nasal flaring on inspiration and retraction breathing are signs of labored breathing in a child. There are different types of retractions like supraclavicular, subcostal, substernal and intercostal retractions that can all be present in children.

 

They all indicate difficulty breathing, but some locations, like intercostal retractions, will be easier to visualize if the child isn’t wearing a shirt.

Figure in Tri-pod position due to trouble breathing
Tri-pod Postion

 

Body position is another pediatric assessment that will be obvious when you enter the room. Older children with difficult or labored breathing may be in a tri-pod position, while younger children and infants tend to stiffen the body with the head up and in alignment with the body.  

 

Along with nasal flaring and positioning, you should also assess for abnormal breath sounds during the pediatric triangle. Wheezing, grunting, hoarseness and stridor are all signs the child is having airway issues.

 

Circulation

The last side of the Pediatric Assessment Triangle is circulation. The first responder can see skin color immediately and use it to assess circulation during a pediatric emergency. EMTs and paramedics will look for cyanotic, pale, ashen, or mottled skin. 

 

Children may show cyanosis around the mouth and nose. EMTs and paramedics are looking for indications that the child is experiencing the onset of shock. This is important because pediatric patients can plateau while maintaining compensatory shock mechanisms for an extended period of time.

 

However, when children can no longer compensate they tend to crash much faster than adult patients. For this reason you want to recognize early signs of shock and plan the urgency of your interventions.

 

The Pediatric Assessment Triangle is a useful tool for quickly assessing children in the prehospital setting. It can help EMTs and paramedics by providing useful information about the patient’s condition which can help the first responder plan for the urgency of transport. EMTs and paramedics can rapidly perform the Pediatric Assessment Triangle using only visual and auditory signals without having any physical contact with the patient. This makes it a great way to begin the pediatric assessment without intimidating the patient.

 

Interested in patient assessment? Check out:

How to Perform a Primary Survey 

Taking a SAMPLE History and OPQRST Pain Assessment

 

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