The Initial Assessment: Diagnoses & Treatment

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 ILCOR’s recommended initial diagnosis method:

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 Breathing
Can the airway be kept open manually?	Jaw Lift/Chin Thrust Nasopharyngeal or oropharyngeal airway
Is 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
Is 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 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 change 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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