When a child is seriously ill or injured, the doctor follows the algorithms of the pediatric advanced life support (PALS) course to rapidly evaluate and treat the patient.
The first step is a rapid general assessment (the pediatric assessment triangle – – discussed in yesterday’s post). If any life threatening conditions are found in that assessment they are immediately treated.
If no life-threatening conditions are detected on the general assessment, then the doctor moves to the second step in the PALS algorithm, the primary assessment which is a systematic physical examination.
The mnemonic for the exam is: Airway, breathing, circulation, disability, and exposure (ABCDE). The doctor proceeds in that order. If any life threatening condition is found in any step in the examination it is addressed first before proceeding to the next step.
The doctor assesses the airway to see if it’s open. He does this by looking for movement of the chest or abdomen, by listening for the breath sounds, and feeling for air movement at the nose and mouth (by placing his hand or face near the mouth or nose).
If there’s no air movement, the doctor immediately takes steps to open the airway as this is the most critical part of emergency care.
This assessment involves determining the respiratory rate, determining respiratory effort, noting the depth of respiration (tidal volume). In addition, the doctor listens to the lungs with a stethoscope, and attaches a pulse oximeter to the child’s finger (the oximeter measures the oxygen saturation [roughly, the amount of oxygen in the child’s blood]).
If any abnormalities are noted on any of these assessments, the doctor will support the breathing by giving oxygen, giving inhaled breathing medicines, and/or helping the patient breathe with bag-mask ventilation. Once breathing problems have been addressed, the doctor proceeds to the next step.
The doctor assesses two things in this step. First is the heart pumping blood adequately and second are the organs of the body getting enough blood.
Heart function (cardiovascular function) is evaluated by checking the heart rate, the heart rhythm (regular or irregular), and the blood pressure. The doctor will check the pulses in the arms and legs and in the neck if the child is old enough to see if they are weak or strong. The doctor will check the capillary refill time. He does this by placing his thumb on the child’s forehead, sternum, or kneecap and gently pressing on the skin. He then lifts his thumb and sees how long it takes the skin color where his thumb was to return to normal.
Organ function is checked by noting if the brain, skin, and kidneys are getting enough blood flow. The mental status (the patient’s level of alertness) tells us if the brain is getting enough blood flow. The skin color and temperature tells us if the skin is enough blood flow. And kidney blood flow is assessed by recording how much urine the kidney is making.
If these examinations reveal that the circulation is inadequate, the doctor immediately takes steps to improve the amount of blood flowing through the body. Treatment might include intravenous fluids or intravenous medicines or other treatments.
After the doctor has treated any circulation problems found, he then proceeds to the next step.
This refers to a check of the nervous system. The doctor determines the child’s level of consciousness. Is the child alert? Or does the child respond only when his name is called or when you yell? Or does the child respond only to painful stimulus such as when you press on his nail bed? Or is the child completely unresponsive (unconscious).
The next check of the nervous system is to shine a light in the pupils and see how they respond.
If the disability exam is abnormal, the doctor treats the cause if he has determined it. He will once again make sure that breathing and circulation are being adequately treated. A bedside blood sugar check may be performed at this step.
Then we go to the last step of the primary assessment.
The doctor needs to undress the child to look for evidence of bruises, bleeding, and abdominal distention. This needs to be done quickly and the child recovered so he doesn’t get cold.
In summary, the signs of a life-threatening problems evaluated in the primary survey are:
A-Airway obstruction: Get and keep the airway open.
B-Breathing: If the child is having trouble breathing, give treatment (oxygen, inhaled medicine, bag-mask ventilation).
C-Circulation: If the pulses are not palpable, or the blood pressure is low, or there is poor organ perfusion, treat (with IV fluids, or IV medicines, or other treatments).
D-Disability: If the child is unconscious or confused or drowsy, determine cause (respiratory, cardiac, or other) and treat.
E-Exposure: Look at the child to make sure that there are no bruises or bleeding or cool skin and treat if found.
Tomorrow, I’ll go over the next steps in pediatric emergency evaluation: the secondary assessment and the tertiary assessment.