So this is a pediatric assessment triangle.
It's a rapid assessment technique.
And it's an objective tool
that clinicians can use
to aid in their respiratory assessment.
There are 3 components and using this tool,
the clinician should be able
to just scan the room,
look at the child, and in
about 30 seconds or less
decide how sick this child is
regarding their respiratory status.
You can use this tool throughout
your management of a patient
to see if they're improving
or actually deteriorating.
The acronym TICLS, pronounced "tickles,"
is sometimes used by emergency
to remember the components
of the appearance item.
Regarding the child's appearance,
the clinician's going to look at the
patient for, first, their tone.
Look at their muscle tone.
Is this a limp child?
Is this child rigid?
Are they laying on the exam table?
Are they running around the
room eating goldfish crackers?
What's sort of the activity and
the appearance of this child?
Is it a sick child or a non-sick child?
Normally, infants are going
to have good muscle tone.
They're going to stay in a flexed position,
and they should want to resist your
attempts to straighten their limbs.
It's concerning when a baby
is not able to resist.
There are variations on the
theme for the letter I.
It's either interactiveness
or level of irritability.
So, normally, a child is able to
interact with caregivers and staff
based on age-appropriate milestones.
It would be abnormal if the
child is not interactive
or engaged with their caregivers
or their surrounding activities.
The C stands for consolability.
Normally, a child can be comforted
by its usual caregivers
and the child is acting like themselves
in regard to environmental stimuli.
An abnormal presentation would
be the child cannot be consoled
or comforted by their usual caregivers,
and the parents will tell you this.
They will say, you know, "Normally,
my child is in a great mood.
Normally, I pick them up and I do
this or that and they stop crying,
and they just won't stop crying,"
and that's a concerning sign.
The child doesn't respond normally
to their environmental stimuli
and their preferred toys and they're
just not acting like themselves.
The L stands for the look or the gaze.
So, normally, depending on the child's age,
they should be able to make
really good eye contact
and maintain that eye contact.
Abnormally, the patient's
going to have a vacant stare.
They're not going to maintain eye contact,
and it kind of looks like
these kids have checked out.
They might not recognize their normal
caregivers, and they may just look out of it.
And the final component of the
appearance section is the speech or cry.
Normally, a child will use
age-appropriate verbal communication.
And when speech and crying are normal,
this also lets the provider know that the
child has a patent and clear airway.
Abnormally, the child will be unable to
use their age-appropriate communications,
or their speech or cry
is absent or abnormal,
and this raises a huge concern for an
occluded airway or an altered mental status.
The next component of the
pediatric assessment triangle
is the work of breathing.
The first part of that involves
looking for nasal flaring.
Nasal flaring is a compensatory system
that increases the upper airway diameter
to decrease the resistance
of airflow through the nose.
This is where the patient increases the
air that can move through their nostrils.
Next, you can assess the work of
breathing by looking for retractions,
and this is under the patient
gown and under the shirt.
You're looking right at their skin.
Retractions are a sign that someone
is working really hard to breathe.
Normally, when you take in a breath,
the diaphragm and the muscles
around your ribs create a vacuum
that will pull that air into your lungs.
But if a person is having trouble breathing,
they will involve these
extra accessory muscles
and the muscles between their
ribs to kick in and try to help.
Next, you'll assess the patient's work of
breathing by looking at their posturing.
Just look at your patient.
Are they propped up in an
abnormal position to breathe?
Are they in a tripod position
trying to open their chest?
What is the patient's position of comfort?
Do they have difficulty breathing
if they lay flat on their back?
If so, you can always raise
the head of their bed.
Next, you're going to listen
to the breath sounds.
Look for abnormal sounds.
Is there any wheezing?
Do you hear crackles, rales,
stridor, or any cough?
Circulation's next and that's measured
by skin color and capillary refill.
Those are great indicators
of perfusion in children.
So capillary refill is defined
as the time taken for the color
to return to an external capillary
bed after pressure's applied.
So, basically, you press on the
distal extremity, you let go,
and you count and see how long it
takes for that blood to reperfuse.
You'll next look for pallor.
Pallor is associated with
early stages of hypoxia,
and occurs as a result of the
This means your patient looks pale.
The skin can become mottled, which is
another sign of compromised perfusion.
It indicates abnormal capillary tone, and
this skin will have a speckled, lacy look.
Perhaps your patient has
blue cyanotic coloring
because of low oxygen levels in the blood.
The peripheral blood vessels
are going to vasoconstrict
and this is going to
decrease the hemoglobin
causing a bluish hue to the skin
and the mucous membranes.
It's most easily seen around the
mouth and in the oral mucosa.
And this is perioral cyanosis.
These indicators of poor perfusion
might be your only clues
to intervene with your patient.
These can be the early signs that
your patient is experiencing shock.
The clinician should review
the health history completely
to evaluate for any underlying cardiac or
pulmonary disease, immune deficiencies,
neuromuscular disorders, or any
other high risk conditions.
The clinician should also ask
maybe the child had access
to a foreign body aspiration or
ingestion of toxic substances.
These also need to be excluded.
The physical exam starts next,
and this begins with an overall
assessment of the child's well-being
and identification of obvious
signs of hypoxia and dehydration.
You're going to check a younger child,
especially, for a toxic appearance.
And this is basically if a lay person
looked at this child, would they say,
"Wow, that child looks really sick,"
or does this child appear okay pretty well?
Next, look for tachypnea, which
is an increased respiratory rate.
Check the vital signs to
look for their temperature.
Observe for retractions.
Listen for grunting, and look at the chest
wall for the use of accessory muscles.
The upper respiratory tract should also
be examined for evidence of otitis media,
which is ear infections,
rhinorrhea, which is a runny nose,
nasal obstruction, and swelling
or redness in the throat.
The most common causes
of pneumonia are also
common causes of infection in
the upper respiratory tract,
so this can help the clinician
solidify a diagnosis.
Next, on exam you'll look at physical signs,
such as heart murmurs or nail clubbing,
which can suggest an underlying
cardiac or pulmonary disease.
Next, you do the full assessment.
You do a full respiratory exam,
including inspection, palpation,
percussion, and auscultation.
Now, older children and adults
are more likely to have findings
that are abnormal on their
respiratory exam such as rales,
dullness to percussion,
bronchial breath sounds,
changes in their tactile fremitus,
and maybe a pleural rub.
Careful auscultation with an appropriate
sized stethoscope can reveal a lot of clues
and localize rales and
wheezing in younger children.
So, remember, your stethoscope
is going to have 2 sides.
An adult-sized diaphragm and bell and
a pediatric-sized diaphragm and bell.
This is when it's important to use
the appropriate sized stethoscope.
So, children with dehydration may not
have any abnormal auscultatory findings.
And this is really important
when these kids present, they're
really sick with their pneumonia.
They haven't been drinking well.
They're not tolerating PO.
They're not thirsty, and they
can easily become dehydrated.
And so, when the clinician listens
to the lungs, they may sound okay.
It's only when you hydrate these children
and actually fluff up their pneumonia,
that you can actually hear a difference.
So be sure that you're listening
to a child who is hydrated
and if they're not hydrated,
get them hydrated before
you make the decision on
whether or not they have pneumonia.