The pediatric general assessment triangle

Caring for and assessing critically ill pediatric patients brings added stress and anxiety to all emergency providers. This year, we have the added burden of the combination of the COVID-19 pandemic and associated multi-system inflammatory disease of children (MIS-C) on top of the oncoming winter season that includes croup, respiratory syncytial virus (RSV), influenza and other various viral respiratory pathogens.

Recognizing the sick child requires diligence and a structured approach to avoid missing the proverbial needle in the haystack. This framework begins with the pediatric assessment triangle, which is the foundation for any thorough pediatric patient exam:

1. Appearance
2. Breathing
3. Circulation

Before delving into the assessment triangle, it’s time to introduce the single law of the pediatric examination.

The single pediatric exam law: You can’t properly assess a baby/toddler or child who is fully clothed. Undress the child every single time.

Assessing the pediatric patient’s appearance

The examination of the pediatric patient begins before even touching the patient. How is the patient behaving when held in the parent’s arms? Is this child eating, laughing, walking, playing or crying? These are all questions that are sometimes subconsciously asked and answered but do not minimize the importance of general appearance. In children, appearance encompasses several specific components:

1. Tone. A child’s muscle tone can be assessed in various methods depending upon patient age. If a child can walk, for the most part, muscle tone is normal. However, for babies, an examination of tone can be a bit more complicated. There are reflexes like the Moro and startle responses that can be assessed by dropping the child’s head or clapping, respectively. Stimulation of these reflexes should elicit an extension-flexion response in the extremities through 6 months of age, then they both usually disappear. Even if specific reflexes are too confusing, the examiner can hold the baby under the abdomen face down, and the child should extend against gravity. Always beware of the upside-down U appearance, which should be concerning for a floppy infant.
2. Activity. Assessing activity in toddlers and above is relatively simple. Are they playing, walking or even watching smart phones/screens? However, in infants, judging normal activity level entails knowing what babies should be capable of doing at certain ages. There is no need to memorize every single pediatric milestone as an emergency provider, but it is a good idea to be familiar with a few of the major ones. Babies should roll over and sit up at three months of age, crawl at nine months, and walk at about one year.
3. Gaze. Now, the exam gets more up close and personal. Unlike in adults, formal extraocular movement examination in infants is impossible. However, it is still vital to assess their gaze. Are their eyes focusing and in tandem, or is there gaze restriction or deviation? An infant should track with their eyes by three months of age. Any gaze disturbance should raise concern for neurologic deficit, such as mass or seizure.
4. Cry. Babies should not like being undressed and examined by strangers – not a shocking revelation. Do not, though, underestimate the importance of eliciting and then noticing an appropriate cry as a vital part of the pediatric exam. Alarm bells should ring for potential critical illness if the child does not cry during the examination. Also, note that high-pitched cries can be associated with specific chromosomal abnormalities.
5. Consolable. After the commotion, poking and prodding, the infant should calm when given back to the parents or caregivers. A comfortable and well-appearing infant in their parent’s arms is the final piece of the appearance puzzle.

Pediatric respiratory distress

After assessing appearance and the physical examination proceeds, the pediatric assessment triangle’s second side should be obvious. Of course, with the child undressed, a quick visual glance yields valuable information regarding the child’s work of breathing. Remember, 90% of breathing work is visible just with the patient undressed and without auscultation. Look for:

1. Flaring. Starting from the head and working caudally, look initially for nasal flaring. When present, this reflects the child attempting to increase airflow and is often a sign of pediatric respiratory distress.
2. Grunting. Then listen to any upper airway sounds, with particular concern paid to any grunting sounds. Grunting occurs due to the child exhaling against a closed glottis, which is equivalent to natural auto-PEEP. If a baby decides they need to administer PEEP, be concerned for significant respiratory pathology.
3. Retractions. Next, look at the neck and chest for retractions. Intercostal retractions are probably most familiar, but these can occur in sternal and clavicular areas as well. Most commonly, retractions are an effort to increase airflow in response to obstructive pathology such as asthma. Regardless of the diagnosis, any retractions should be considered abnormal and considered a red flag for respiratory distress.
4. Auscultation. Lastly, get out the stethoscope and take a listen. Wheezes suggest obstructive pathology. Stridor occurs in conditions like croup with upper airway narrowing. Importantly, don’t ignore the absence of sound. Lack of breath sounds could signal a pneumothorax or an asthmatic with near-complete obstruction. A wheezing asthmatic is much better off than one who is quiet.

Pediatric circulation warning signs

The final side of the pediatric general assessment triangle is to evaluate the child’s circulation. A broad look for pallor is the initial step. How is the child’s overall color? Remember to consider lighting and the child’s ethnicity when assessing pallor.

Does anyone actually time capillary refill? In reality, the answer is very few, but seeing “normal” hundreds of times allows abnormal to become quite apparent. Developing this exam acumen is impossible without examining capillary refill in every patient, young and old. If the child appears pale with abnormal capillary refill, then a look for mottling and cyanosis should be reflexive. Mottling is a splotchy discoloration of the extremities that reflects impaired perfusion, and cyanosis is a blueish discoloration concerning for hypoxia. Yes, there are benign causes of both mottling and cyanosis, but these should be considered warning signs until completion of a full diagnostic work-up.

Putting it all together

Once the general assessment is complete, the information gleaned should begin the generation of the differential diagnosis. Increased work of breathing alone only suggests respiratory distress, and when combined with abnormal appearance, this should be considered frank respiratory failure. Poor circulation is concerning for early shock and, in conjunction with abnormal appearance, suggests severe shock. Isolated abnormal appearance can occur in isolated CNS pathology and metabolic abnormalities. Finally, the most ominous of all is an entirely abnormal triangle, which should be considered a pre-arrest situation.

Adequate evaluation of any single side of the assessment triangle is impossible if the child is wrapped and swaddled. Don’t be afraid to undress the child and make them cry. Both are vital to a proper examination. An unfortunate, but necessary, benefit of undressing children is the ability to consider and assess for non-accidental trauma. None of the exam findings and techniques discussed are technically challenging, but you can’t see what you don’t look for. Be diligent and proactive in examining every pediatric patient thoroughly and systematically.

Thankfully, kids are generally healthy, and a large majority of exam findings will be normal. Gather normal after normal so that abnormal is glaringly apparent. Use these assessment skills to provide an initial framework; this will help to minimize anxiety and focus treatment efforts.