The Initial Assessment: Diagnoses & Treatment

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Reaching the Initial Diagnosis and Treatment phase of care means that the child or infant that you are rescuing is not presently experiencing the threats of immediate death. This means that you have time to carefully assess the situation and come up with a solution—but also know that at any given point, the situation could become life-threatening in an instant. Stay vigilant for any changes and immediately perform high-quality CPR while watching out for life-threatening events such as respiratory distress, alternating consciousness, or cyanosis.

The ABCDE method (Figure 7) is the AHA’s recommended initial diagnosis method:

PALS Initial Assessment - ABCDE

Figure 7

Airway

Evaluate the airway and make a choice between one of three possibilities (Table 3). Once a case has been established, proceed 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 having trouble breathing, it is considered to be a life-threatening respiratory arrest. Note that if abnormal breathing can be considered as relatively effective, it can still be diagnosed 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

Assessing proper circulation in pediatrics involves more than just checking the pulse or blood pressure. In addition, paying attention to skin color and body temperature and an added attention to the mucous membranes can help any rescuer arrive at a more effective assessment.

Poor tissue perfusion can be recognized from pale or blue skin. Capillary refill time is also a useful assessment in pediatrics. Perfused skin will rapidly refill with blood after being squeezed (e.g., bending the tip of the finger at the nail bed). It is easy to identify perfused tissues when they take longer than two seconds to respond. Moreover, poor circulation can also be determined by cool skin.

Heart rate and blood pressure changes with age; the averages are different in adults and children. Similarly, sleeping produces generally slower heart rates in children and infants. Centers usually provide reasonable heart ranges that they use in addressing normal and abnormal heart rates according to specific ages. Though local guides are usually sufficient, we have provided approximate ranges as 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

A quick neurological diagnosis is referred to as disability in the PALS vocabulary. Based on a four-level scale used in determining the patient’s consciousness and responsiveness, useful information can be extracted from this process.

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 an effective way of assessing neurological function.

The AVPU (alert, voice, pain, unresponsive) response scale and the Glasgow Coma Scale (GCS) are some procedures for neurological assessment. A GCS modified especially for children and infants will take 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 can be used in all PALS evaluations, though it is a mandatory element when responding to a child or infant who is likely to have experienced trauma, as it pays attention to signs of trauma such as fractures, burns, and other physical signs that may be indicative of the problem at hand. Tissue perfusion and the state of the child or infant’s cardiovascular system may also be identified by observing the child’s skin temperature and color. In the event that the rescuer has enough response time, additional signs such as petechiae or bruising may be inspected. Exposure reminds the rescuer that the core body temperatures of children and infants drop faster than adults, which is why it is of utmost urgency to keep the patient warm and covered after the diagnosis, as the body is being evaluated.

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