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Pediatric Critical Care DivisionChild Health Department, Faculty of Medicine University of Indonesia
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Emergency sign
Priority sign
Non Urgent
Triage
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Emergency sign
CNSRespiratoryCardiovascularGastrointestinalEndocrineEtc
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PATABCDE
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The PAT
Appe
aran
ceW
ork of Breathing
Circulation to Skin
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Appearance (“Tickles” =TICLS)
Tonus
Interactiveness
Consolability
Look/Gaze
Speech/CryAp
pear
ance
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Work of Breathings
Work of B
reathings
Abnormal airway soundsAbnormal positioningRetractionsNasal flaring
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Pallor
Mottling
Cyanosis
Circulation to Skin
Circulation to Skin
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Respiratory distress
N
N
N
Cardiopulmonary failure
/
Shock
N
N
Primary CNS dysfunction/
metabolic abnormality
N
NN
N
N
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The ABCDEs
AirwayBreathingCirculationDisabilityExposure
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Airway Assessment
Clear Maintainable Unmaintainable
without intubation
Obstructed
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Breathing Assessment
Rate Effort /
mechanics Air entry Skin color
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Respiratory Rate by Age
Age
(years)
Respiratory rate
(breaths per minute)
<1
2-5
5-12
>12
30-40
20-30
15-20
12-16
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Circulation Assessment
Heart rate Systematic perfusion
Peripheral pulses Skin perfusion Appearance (Urine output)
Blood pressure
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Heart Rate by Age
Age Range
Newborn – 3 mos 85 – 200 bpm
3 mos – 2 yrs 100 – 190 bpm
2 – 10 yrs 60 – 140 bpm
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Skin Perfusion
Extremity temperature Capillary refill Color
Pink Mottled Pale Blue
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Minimal Systolic Blood Pressure by Age
Age Fifth percentile mmHg
Systolic BP
0 – 1 Mo 60
> 1 mo – 1 yr 70
> 1 yr 70 + (2 x age in years)
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Disability (neurologic status)
Cerebral cortex Brain Stem Motor activity
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Level of Consciousness
A = Awake V = Responsive to
voice P = Responsive to pain U = Unresponsive
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Brain Stem
Posture Central respiration Pupil response Cranial nerve
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Motor Activity
Symmetrical movements
Seizures Posturing Flaccidity
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Exposure
Skin rashes Bruises Excoriation etc.
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Stable
Respiratory dysfunction Potential respiratory failure Probable respiratory failure
Shock
Compensated Decompensated
Cardiopulmonary failure
Classification of Physiologic status
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Case Scenario 1
15-month-old childHistory Diarrhea, vomitting for 3 days Refused bottle this morning Sleepy, lethargic today
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Physical Examination PAT:
A : Very lethargic child in mother’s lap WB: Normal CS : mottled ABC
A : clearB : RR 45/min, breath sounds clear bilaterallyC : HR 178 regular, BP 90 mmHG systolic, CRT : > 4 sec, Temp 38oC Weak peripheral pulses Cool, mottled extremities,dry mucous
membranes
CNS: V
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What would be your approach to this patient?
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UKKPGD IDAI 27
Initial Approach to the Patient in Shock
Evaluate the ABCs Deliver high concentration of
oxygen Monitor oxygenation and heart
rate Achieve vascular access
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UKKPGD IDAI 28
Case Scenario 1: progression
The patient receives oxygen and is placed on a monitor; attempts at peripheral vascular access fail
What would you do now?
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UKKPGD IDAI 29
What fluid would you give?
How much and how fast?
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Treatment of Shock
Initial rapid fluid administration of 20 mL/Kg
of: Crystalloid Colloid Blood
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