Pediatric Critical Care DivisionChild Health Department, Faculty of Medicine University of Indonesia

Emergency sign

Priority sign

Non Urgent

Triage

Emergency sign

CNSRespiratoryCardiovascularGastrointestinalEndocrineEtc

PATABCDE

The PAT

Appe

aran

ceW

ork of Breathing

Circulation to Skin

Appearance (“Tickles” =TICLS)

Tonus

Interactiveness

Consolability

Look/Gaze

Speech/CryAp

pear

ance

Work of Breathings

Work of B

reathings

Abnormal airway soundsAbnormal positioningRetractionsNasal flaring

Pallor

Mottling

Cyanosis

Circulation to Skin

Circulation to Skin

Respiratory distress

N

N

N

Cardiopulmonary failure

/

Shock

N

N

Primary CNS dysfunction/

metabolic abnormality

N

NN

N

N

The ABCDEs

AirwayBreathingCirculationDisabilityExposure

Airway Assessment

Clear Maintainable Unmaintainable

without intubation

Obstructed

Breathing Assessment

Rate Effort /

mechanics Air entry Skin color

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

Circulation Assessment

Heart rate Systematic perfusion

Peripheral pulses Skin perfusion Appearance (Urine output)

Blood pressure

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

Skin Perfusion

Extremity temperature Capillary refill Color

Pink Mottled Pale Blue

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)

Disability (neurologic status)

Cerebral cortex Brain Stem Motor activity

Level of Consciousness

A = Awake V = Responsive to

voice P = Responsive to pain U = Unresponsive

Brain Stem

Posture Central respiration Pupil response Cranial nerve

Motor Activity

Symmetrical movements

Seizures Posturing Flaccidity

Exposure

Skin rashes Bruises Excoriation etc.

Stable

Respiratory dysfunction Potential respiratory failure Probable respiratory failure

Shock

Compensated Decompensated

Cardiopulmonary failure

Classification of Physiologic status

Case Scenario 1

15-month-old childHistory Diarrhea, vomitting for 3 days Refused bottle this morning Sleepy, lethargic today

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

What would be your approach to this patient?

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

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?

UKKPGD IDAI 29

What fluid would you give?

How much and how fast?

Treatment of Shock

Initial rapid fluid administration of 20 mL/Kg

of: Crystalloid Colloid Blood