pediatric assessment

hi colleagues, if any of you like me get intimidated by getting involved in the perioperative management  of a child then I advice you to attend the PALS course as I did this week.
it gives you a new prospective in preoperative evaluation of pediatric patients or more sprcifically a sick child in PICU or presenting for emergency surgery.
here I like to share you some of the valuble points on
systematic approach to pediatric assessment
general assessment
the general assessment is a visual and auditory assessment of the child general appearance during the first few seconds of encounter. the pediatric assessment triangle(PAT) is a reminder to evaluate the appearance, work of breathing, and circulation.
if you recognize a life threatening condition at any time, immediately begin life-saving interventions and activate the emergency response system(ERS).
life threatening conditions are:
Airway                               complete or severe airway obstruction
Breathing                            apnea, significant work of breathing, bradypnea
Circulation                          no pilse, poor perfusion, hypottension, bradycardia
Disability                            unresposiveness, depressed consioueness
Exposure                           significant hypothermia, bleeding, petechiae(septic shoch),
                                         abdominal distention(acute abdome
interventions
if you recognize a life threatening condition, begin life-saving interventions. examles of these interventions are:

• support ABC
• provide supplemental O2 100%
• provide assessted ventilation(bag mask- ET intubation)
• start cardiac and respiratory monitoring
• estabilish IV/IO acess
• give a bolus of isotonic crystalloid
• obtain laboratory studies
• administer drugs
• provide electrical therapy 

 if the general assessment dose nor reveal a life threatening condition requiring immediate intervention, proceed with the primary assessment.

primary assessment
the primary assessment is a rapid hands on ABCDE evaluation of cardiopulmonary and neurologic function.
this assessment includes vitalsigns and oygen saturation by pulse oxymetry.
Airway: assess patent or not, maintainable or not.
Breathing: 

1.  respiratory rate
2. respiratory effort
3. tidal volume
4. airway and lung sounds
5. oxygen saturation

Circulation: evaluation is 2 parts
1- cardiovascular function

• skin colour and temperature
• heart rate and rhyth
• peripheral and central ulse
• blood pressure

2-end organ function:

• brain perfusion(mental status)
• skin perfusion
• renal perfusion

Disability: assess the child level of consiousness by

• AVPU pediatric response scale
• GCS
• pupilary responses

Exposure: expose the child to assess

• signs of truama
• rashes
• core temperature

after you finish primary assessment you should be able to categorize the clinical condition of the child into respiratory or circulatory
respiratory problems can be furthue categorized by severity into respiratory distress or respiratory failure.
circulatory problems can be furthur categorized by severity into comensated shock or hypotensive shock.
the clinical condition can be also a combination of respiratory and circulatory problems.

now you can proceed to the secondry assessment for more specific diagnosis.
secondry assessment
the secondry assessment consists of a focused medical history using the SAMPLE mnemonic, a thorough physical examination and a review of vital signs.
SAMPLE stands for:

• Signs and Symptoms
• Allergies
• Medications
• Past medical history
• Last meal
• Events leading to presentation

physical examination should go systematicaly from head to toe.
now you finished the secondry assessment, you should be able to provide more specific diagnosis by type.
respiratory problem can be caused by

• upper airway obstruction
• lower airway obstruction
• lung tissue diseases
• disordered control of breathing

circulatory problem can be caused by

• hypotensive shock
• obstructive shock
• distributive shock
• cardiogenic shock

after you reach a specific diagnosis, you should decide appropiate management for the clinical condition.
tertiary assessment
the tertiary assessment includes laboratory, radiological and other advanced tests to help esabilsh the child physiologic ondition and diagnosis.
pay attention that the term tertiary dosenot mean these tests are performed third. the timing of these tests is dictated by the clinical situation.
for example if during your secondary you recognize a hypotensive shock due to hemorrhage you should request now blood typing and cross match, and so on.