The clinician should use the Airway-Breathing-Circulation-Disability-Exposure approach (ABCDE) to evaluate the respiratory, cardiac, and neurologic functioning of the pediatric patient. Vital signs (including oxygen saturation) are assessed during the primary assessment phase. Should any life-threatening problems be identified during the primary assessment, they should be treated immediately before proceeding with the assessment.

Normal Pediatric Vital Signs⁵

The clinician performing the primary assessment should know the normal vital signs for pediatric patients:

Normal Pediatric Vital Signs

Airway

The goal of assessing the pediatric patient’s airway is to decide whether it is clear, maintainable, or not maintainable:

• A clear airway is open and maintainable without intervention.
• A maintainable airway is obstructed (e.g., by the patient’s tongue), but the team can maintain it using simple measures such as the head tilt-chin lift maneuver.
• An airway that is not maintainable requires the team to apply advanced interventions such as intubation.

The clinician should look, listen, and feel for movement of the chest (or abdomen, as is common in children), the sound of air movement or breath sounds, and the feel of air moving through the child’s nose and mouth. Scanning the patient’s chest should take no longer than 10 seconds.

If the patient is breathing, simple monitoring is all that is required until assistance arrives. If the patient is not breathing or is only gasping, the team should administer emergency interventions. The pulse should be checked at the same time as breathing. Both assessments done together should take the clinician < 10 seconds.

Signs of an obstructed airway include increased work of breathing with retractions, abnormal sounds on inspiration such as stridor or snoring (upper airway involvement), or signs of complete obstruction in which the patient is making an ineffective respiratory effort. 

Simple Maneuvers

The provider must open the airway with either simple maneuvers or with the use of advanced airway techniques. Repositioning the patient to make them as comfortable as possible is one example of a simple maneuver to open the airway and maintain its patency, e.g., elevating the head of the bed if the child is responsive or conscious.

The tripod position is the most comfortable to breathe.

Raised Bed Position for Effective Respirations

If the child is unconscious, the provider may open the airway with the head tilt-chin lift or the jaw-thrust maneuver. The patient can also be turned to the side if there are no suspected spinal injuries.

When using the head tilt-chin lift maneuver to keep the airway patent, it is important to ensure the neck is not overextended in infants, as this may cause an obstruction. In the unconscious patient, when trauma is not suspected, the head tilt-chin lift maneuver is the preferred method to open the airway. 

When a spinal injury is suspected in the unconscious patient, the jaw-thrust maneuver is used to allow airway patency without manipulating the neck. However, if the jaw-thrust maneuver fails to open the airway, the head tilt-chin lift maneuver or a jaw-thrust with neck extension may be required because opening the airway is imperative when performing CPR.

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Related Video –  Understanding the Steps of the Primary Assessment

Images demonstrating properProper Hhead Ttilt-Cchin Llift Ppositioning.

Proper Head Tilt-Chin Lift Positioning Illustration

Suctioning blood and secretions is another simple maneuver to clear the airway of obstruction. The nasopharynx and oropharynx are the primary areas of focus when clearing secretions or blood from the upper airway. 

Back slaps and chest thrusts are simple maneuvers to remove a foreign-body airway obstruction in responsive infants < 1 year of age. The procedure consists of cycles of five back slaps and five chest thrusts. Abdominal thrusts are used for responsive pediatric patients 1 year of age and above with foreign-body obstruction of the upper airways. 

When performing these maneuvers, if the patient becomes unresponsive at any point, the rescuer should activate the emergency response system and start CPR.

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Related Video – How to Treat Conscious Choking Children

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Related Video – How to Treat Conscious Choking Infants

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Related Video – CPR Techniques – Treating an Unconscious Choking Child

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Related Video – CPR Techniques – Treating an Unconscious Choking Infant

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Back Slap and Chest Thrust Maneuvers for Responsive Infants Under One-Year Old

Other simple maneuvers include airway adjuncts such as oropharyngeal airway (OPA) placement to prevent the tongue from obstructing the airway. The team should use this device for patients without an active gag reflex. A nasopharyngeal airway (NPA) would be preferred if the patient has an intact cough or gag reflex and there is no mid-face trauma. 

When airway adjuncts are in place, the provider must still maintain patency by performing maneuvers such as the head tilt-chin lift maneuver and patient positioning. The airway must continually be reassessed for patency.

Nasopharyngeal Airway Insertion

Oral Airways

Advanced Maneuvers

Advanced interventions for maintaining airway patency include the use of an endotracheal tube (ET tube) a laryngeal mask airway (LMA) continuous positive airway pressure (CPAP) emergency cricothyrotomy or foreign-body removal via direct laryngoscopy.

Infant ET Tube Intubation on a Mannequin

Breathing

Once the airway is patent, the provider assesses for breathing. The patient’s respiratory rate and breathing pattern should be evaluated, noting increased respiratory effort, the degree of chest expansion, and air movement. The clinician auscultates for breath sounds and measures the patient’s oxygen saturation via pulse oximetry 

The seriously ill child may present with a respiratory rate of < 10 or > 60 breaths per minute. The provider must also be aware that the patient may have an increased metabolic demand due to excitement, pain, exercise, or fever, causing an elevated respiratory rate. Underlying conditions such as diabetic ketoacidosis (DKA) can also cause an increase in respiratory rate without signs of respiratory distress. During DKA, the respiratory rate increases in an attempt to blow off carbon dioxide to correct the metabolic acidosis. 

If possible, it is best to assess the pediatric patient’s respiratory rate before performing a physical assessment. Fear and anxiety may falsely elevate the baseline respiratory rate. To determine the respiratory rate, the provider counts the number of times the chest rises in 30 seconds and multiplies it by 2. 

A sleeping infant may have periodic breathing with regular pauses lasting up to 15 seconds, and an estimate may be inaccurate. Counting for a full minute may be needed for an accurate rate assessment.

The patient’s respiratory rate should be frequently reassessed to detect critical changes that may indicate the patient is deteriorating. If there are concerns, continuous respiratory monitoring should be utilized if available. 

When the respiratory rate returns to more normal values, it indicates the child may be improving with interventions, especially if it is associated with neurologic improvement and reduced work of breathing. 

On the other hand, a child may actually be deteriorating if the initially elevated rate is lower but is observed along with increased work of breathing, decreasing level of consciousness, or ineffective respiratory effort.

Abnormal Respirations

Pediatric patients with abnormal respirations have irregular respiratory patterns, a respiratory rate that is too fast or too slow, or apnea An irregular respiratory pattern may indicate a neurologic pathology, either from trauma, anoxia, or other metabolic problems. Patients may present with unusually deep breaths or a rapid respiratory rate followed by a period of apnea or shallow breathing. These irregular patterns indicate a severe condition that requires immediate intervention.

Patients, especially infants with respiratory distress, may present with tachypnea which indicates that the respiratory problem is relatively new or early. Alternatively, tachypnea may denote that the patient is stressed by physiologic disturbances such as fever, pain, sepsis metabolic abnormalities, or dehydration. 

An increased respiratory effort may be a sign of increased airway resistance to airflow. It represents the pediatric patient’s attempt to improve ventilation or oxygenation, which can be due to pneumonia pulmonary edema, asthma, or bronchiolitis conditions that make it difficult for the lungs to expand and inflate. Patients may present with nasal flaring, retractions, grunting, head bobbing, the use of accessory muscles, or seesaw respirations 

Bradypnea, on the other hand, may indicate that the patient’s breathing muscles have fatigued from prolonged tachypnea or increased respiratory effort. A neurologic insult can also present with a slow respiratory rate. Other causes of bradypnea include hypoxia shock, hypothermia narcotics, and familial muscular dystrophy syndromes. Bradypnea or irregular respiratory patterns may denote impending respiratory arrest, and the provider must proceed with extreme caution. 

apnea is a cessation of breathing for 20 seconds or more. The cause of apnea can be neurologic if the respiratory centers of the brain or the spinal cord fail to function normally. Apnea of neurologic etiology is also known as central apnea. Obstructive apnea occurs when there is a physical obstruction of the airways. Apnea of any etiology will result in hypoxemia and hypercapnia

Agonal gasps are a form of abnormal breathing that present late when a very ill child or infant deteriorates. The provider must be able to identify agonal gasps, which are ineffective respirations that lead to cardiorespiratory arrest. These patients will require CPR.

The provider must also observe chest wall expansion. This requires the removal of the clothing to visually inspect the chest. The rescuer must identify if the chest expansion is symmetrical or asymmetrical, especially in cases of trauma. Atelectasis pneumothorax hemothorax mucus plugging, pleural effusion or foreign-body aspiration can result in decreased or asymmetrical chest wall expansion. In infants, it is common for the abdomen to move more than the chest on inspiration.

Breath Sounds

The provider evaluates air movement via auscultation of the chest. The rescuer must note the intensity of breath sounds and their location. Anterior breath sounds are evaluated in the mid-chest area to the left and right of the sternal body. The lateral breath sounds are located just under the armpits, and the posterior breath sounds are on either side of the back. Due to the small size of an infant’s chest, the breath sounds easily resonate from one location to the next. To evaluate distal breath sounds, one can auscultate under the axillae, as these areas are farthest from the large conducting airways and are less likely to represent breath sounds transmitted from the upper airway.

A clinician auscultates child’s breath sounds.

Decreased or muffled breath sounds may indicate poor air movement in that location. If a child has increased respiratory effort but diminished air sounds distally, the provider should assume an airway obstruction. 

Stridor is a coarse, high-pitched sound heard during inspiration. It is a sign of upper airway obstruction

Snoring is due to soft tissue enlargement or swelling that causes the obstruction and can cause an altered level of consciousness.

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Stridor Voice clip

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Grunting is a low-pitched sound heard during expiration. It can be due to a partially closed glottis pain, fever, or an effort by the infant to keep alveolar sacs open to maintain oxygenation and ventilation. Grunting can be due to lung tissue disease such as pneumonia or acute respiratory distress syndrome (ARDS) that has caused the small airways to collapse.

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Grunting Voice file

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Gurgling sounds indicate secretions, blood, or vomitus obstructing the upper airway. 

Wheezing is a high-pitched whistling sound heard during exhalation and occasionally during inspiration. It indicates lower airway obstruction such as occurs with asthma.

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Wheezing voice file

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Crackles (also known as rales) are sharp crackling inspiratory sounds. They indicate an accumulation of fluid in the alveoli. Dry crackles can also be due to atelectasis. 

A change in cry, cough, or phonation can indicate severe respiratory distress or shortness of breath. An infant’s cry may become softer and shorter, while an older child may talk in single words or short phrases rather than sentences. A barking cough (sounding almost like a seal) or a marked change in the voice or cry may indicate an upper airway obstruction caused by a foreign body or infection.

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Crackles voice clip

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Oxygen Saturation

The child’s oxygen saturation (SpO₂) can be measured using a pulse oximeter, which uses a sensor attached to the patient’s finger, ear, or toe and displays the percentage of oxygen-bound hemoglobin. Pulse oximetry may detect low oxygen concentrations early before cyanosis occurs.

An SpO₂ of 94% and above on room air is considered normal. An SpO₂ reading < 94% indicates hypoxemia and the need for supplementary oxygen. Likewise, the clinician must consider further respiratory interventions if the oxygen saturation remains < 90% after the child is administered supplementary oxygen.

Children in respiratory distress must be monitored continuously with a pulse oximeter to monitor the effectiveness of treatment. The team should monitor the patient with pulse oximetry after cardiac arrest and during patient transport.

Clinicians must always assess the patient clinically and avoid relying solely on pulse oximeter readings. A child may increase their respiratory effort or respiratory rate to compensate for a pulmonary pathology while the pulse oximeter readings remain unchanged. 

Oxyhemoglobin saturation does NOT indicate the amount of oxygen that is being delivered to the tissues. Oxygen delivery is dependent on cardiac output and perfusion. SpO₂ monitoring also does not provide any information regarding the effectiveness of ventilation, i.e., the elimination of carbon dioxide. End-tidal CO₂ monitoring is a noninvasive way to assess ventilation.

Pulse Oximeter on Infant’s Hand

Pulse Oximeter on Infant’s Foot

Pulse oximetry is prone to artifact from motion and may measure inaccurately if the child is cold or poorly perfused. Readings will not be accurate in cases of severe shock, where blood is shunted away from the extremities to support the core organs. In addition, hypothermia and fingernail polish can inhibit accurate pulse oximetry readings.

Pulse oximetry measures both the SpO₂ and the heart rate. If the heart rate measured by the pulse oximeter does not match the palpated heart rate or the rate shown on a cardiac monitor, the pulse oximeter reading is likely not accurate. A dampened or erratic pulse oximetry waveform also lends doubt to the accuracy of the SpO₂ value.

Patients with severe anemia may have a misleadingly high SpO₂. Despite a normal oxygen saturation of the hemoglobin that is present, the actual amount of hemoglobin in the blood is low, and thus the patient’s oxygen content in the blood and oxygen delivery to the tissues may be inadequate. 

Carbon monoxide binds to hemoglobin with a stronger affinity than oxygen does. If a child has carbon monoxide poisoning, they may have a normal SpO₂ measurement, but in actuality, the hemoglobin is saturated with carbon monoxide rather than oxygen. Methemoglobin abnormalities can also cause erroneous SpO₂ values.

When SpO₂ values are suspect, the clinician should request a laboratory analysis of arterial blood gases instead.

Circulation

Heart Rate and Rhythm

To assess the circulation of the critically ill child, the provider must evaluate the heart rate, rhythm, pulses (central and peripheral), capillary refill time skin color, temperature, blood pressure, and urine output.

Arrhythmias may signify conduction issues in the myocardium or injury to heart tissue. Shock and hypoxia can also cause arrhythmias. The PALS provider assesses the arrhythmia based on the observed heart rate, ECG rhythm morphology, and its effect on tissue perfusion. 

Bradycardia is an arrhythmia where the heart rate is at or below the lower limit of the normal age-based heart rate. Heart rates persistently < 60 bpm in a seriously ill child indicate that cardiac arrest is imminent. 

Some athletic children may have resting heart rates < 60 bpm. Pediatric patients may also experience a reduced heart rate while sleeping.

Hypoxia is a common cause of pathologic bradycardia in children due to the lack of cardiac perfusion. Signs of poor perfusion include altered mental status, weak peripheral pulses, or cool mottled skin. These patients must be supported immediately with positive pressure ventilation and supplementary oxygen. A child with bradycardia and no signs of poor perfusion must be assessed for exposure to narcotics or the presence of a heart block.

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Related Video – ECG Rhythm Review – Sinus Bradycardia

Common descriptions of skin color changes in the critically ill child:

• Pallor – the lack of normal color (paleness) in the skin and mucous membranes
• Central pallor – paleness in the lips and mucous membranes
• Mottling – an irregular or patchy discoloration of the skin; an uneven combination of pink, bluish-gray, or pale skin tones  
• Cyanosis – a bluish discoloration of the skin
• Acrocyanosis – a normal variant in the newborn; cyanosis occurs in the hands and feet and sometimes around the mouth
• Peripheral cyanosis – a bluish discoloration of the hands and feet 
• Central cyanosis – a bluish discoloration of the lips and mucous membranes

Cyanosis occurs in patients when 5 g/dL of hemoglobin becomes desaturated with oxygen. This corresponds to an SpO₂ of 70%. Cyanosis is more likely to be seen in the mucous membranes and nail beds rather than the skin. It can be visible in the soles and palms, tip of the nose, and earlobes. 

If central cyanosis develops, the need for emergency interventions such as oxygen supplementation and ventilation support increases.

Some patients with cyanotic heart diseases or polycythemia may become cyanotic despite relatively mild hypoxemia. On the other hand, in some disease states, such as anemia, where there is a low hemoglobin concentration (about 8 g/dL), cyanosis will not be apparent until the actual oxygen saturation reaches less than 40%.

Infant Cyanosis

Pediatric patients may be pale due to a lack of exposure to sunlight. Pallor may be a family trait and more common in specific populations. For example, people of Scandinavian and Western European descent may be naturally pale due to their countries’ distance from the equator. The rescuer should evaluate pallor in conjunction with other signs and symptoms.

Note the skin tone of the infant on the right, displaying pallor when compared to the infant on the left.Pallor Skin Tone (Right) and Normal Skin Tone (Left)

Blood Pressure

When measuring the blood pressure of the pediatric patient, the blood pressure cuff must fit the child properly. The cuff should cover 40% of the arm circumference and 50–75% of the length of the upper arm. Poorly fitted blood pressure cuffs result in inaccurate blood pressure readings. If the blood pressure cuff is too large, it produces a falsely low reading. If the cuff is too small, it produces a falsely elevated reading.

Vasoconstriction and tachycardia are compensating measures that maintain blood pressure when there is shock,

dehydration, and trauma. Hypotension (low blood pressure) occurs when these compensatory mechanisms fail.⁶

Hypotension from hemorrhaging occurs when there is an acute loss of 20–25% of blood volume. Shock can cause intravascular volume losses through vasodilation or severe vasoconstriction with poor cardiac output. These can all herald impending arrest.

Urine Output

Urine output is an additional indicator of circulatory function. For a person to produce normal urine output, blood volume, and kidney perfusion must be adequate. 

• Urine output for infants and young children: 1.5–2.0 mL/kg per hour
• Urine output for an older child: 1.0 mL/kg per hour 

All fluid intake and output should be closely monitored and documented. Accurate measurement of urinary output requires the insertion of an indwelling urinary catheter. An increase in urine output in a severely ill child is an indication that they are responding favorably to resuscitative efforts.

Disability

Assessing for disability is essential to determine the neurologic function of the critically ill child. The provider can use several tools to rapidly evaluate the neurologic function of a pediatric patient for responsiveness and level of consciousness. Evaluating disability is usually performed at the end of the primary assessment and repeated frequently, especially if the team is monitoring the effectiveness of an intervention. 

The patient’s level of consciousness and TICLS assessment (muscle tone, interactiveness, consolability, look, and speech or cry) provide evidence of cardiovascular function and adequate brain perfusion. The healthcare provider has a wide variety of other evaluation tools to assess neurologic function, including the AVPU Pediatric Response Scale (alert, responsive to voice, responsive to pain, or unresponsive), the Glasgow Coma Scale (GCS) pupil response to light, and the blood glucose test.

When a child’s cerebral function is affected by a gradual decrease in brain perfusion, the patient may show a decreasing level of consciousness or confusion, irritability, lethargy, and agitation alternating with lethargy. If cerebral hypoxia is sudden, the patient will immediately exhibit a decreased level of consciousness, loss of muscular tone, generalized seizures, and pupil dilation.

AVPU Pediatric Response Scale

The AVPU Pediatric Response Scale is a rapid cerebral cortex function evaluation tool:

• Alert – the child is awake, active, and appropriately responsive to external stimuli and caregivers
• Voice – the child only responds to voice when called by name or spoken to loudly
• Painful – the child only responds to painful stimuli, such as a sternal rub or pinching the trapezius muscle
• Unresponsive – the child does not respond to any stimulus

When a seriously ill child exhibits deteriorating responsiveness, the clinician should immediately assess oxygenation, ventilation, perfusion, and blood glucose to guide the next immediate interventions.

Glasgow Coma Scale⁷

The Glasgow Coma Scale (GCS) is a popular method for evaluating the patient’s neurologic status. It assesses eye-opening, verbal function, and motor function. The clinician scores each of the three functions individually then adds them together. The highest score possible is 15, indicating that the patient opens their eyes spontaneously, obeys commands, and is oriented to person, place, and time. The lowest score is 3, indicating that a patient is entirely unresponsive. 

After the team resuscitates the patient, they can use the GCS to evaluate the severity of head injuries:

• Mild head injury: GCS scores 13–15
• Moderate head injury: GCS scores 9–12
• Severe head injury: GCS scores 3–8

The Glasgow Coma Scale

The Glasgow Coma Scale

A modified Pediatric Glasgow Coma Scale should be used for children who cannot yet talk or who may not be old enough to follow commands. Scoring for eye-opening is unchanged from the adult GCS. The pediatric GCS uses different criteria for assessing motor and verbal responses in the verbal and nonverbal child.

The choice of evaluation tool depends on the situation. The AVPU pediatric scale is more appropriate in the out-of-hospital setting. The GCS scale performs better in the emergency department or the in-hospital environment.⁸

The AVPU scale’s approximation with the GCS score is shown in the table below.⁹

Pediatric AVPU Correlation With the GCS Score

Pediatric AVPU Correlation With the GCS Score

Pupil Response to Light

The size and reaction of both pupils help the provider assess the seriously ill child with poor neurologic function. Pupillary response evaluates brainstem function, particularly that of cranial nerve III in the brainstem. 

Pupil assessment should include:

• The size of the pupils in mm.
• Whether the pupils are equal or unequal.
• The presence or absence of constriction to light stimulus.

The pupil should constrict when exposed to light. If they do not constrict appropriately, the clinician should suspect a lesion in the brainstem. 

The pupils should be approximately equal in size. If they are not, this may be a sign of increased intracranial pressure, and the oculomotor nerves supplying the pupillary muscles may be affected.

Abnormal Pupillary Reactions and Possible Causes

Abnormal Pupillary Reactions and Possible Causes

A provider uses a light to assess pupillary response.

Blood Glucose

Hypoglycemia is a low blood glucose concentration. If not corrected promptly, it can cause brain injury. All seriously ill pediatric patients must have their blood glucose monitored with a point-of-care glucose test. Treatment includes oral glucose or IV dextrose.

Hypoglycemia is present when the blood glucose level is:

• < 45 mg/dL in the newborn
• < 60 mg/dL in the child

Infant Blood Glucose Level Assessment

Exposure

Exposure pertains to performing a focused visual physical examination of the seriously ill child. If appropriate, the provider should remove the patient’s clothing one area at a time. The child’s head, torso, and extremities (front and back) should be assessed for any injuries, bleeding, burns, unusual markings, or other signs suspicious of abuse. 

If a spinal injury is suspected, the provider must support and protect the cervical spine with any movement of the patient. 

The patient should be kept warm by using warm blankets or a heat lamp after the initial assessment. The core temperature should be monitored along with the vital signs to identify hypothermia caused by inadvertent exposure to cold or a fever in the setting of sepsis or infection. 

The clinician should assess the skin by direct visualization and note the presence of skin lesions such as petechiae or purpura. Petechiae are tiny red spots that suggest spontaneous bleeding secondary to a low platelet count. Purpura are larger reddish discolorations that also signify a coagulation pathology. Rashes, purpura, and petechiae can be related to infections, such as meningitis or shock. Hives may be an indicator of anaphylactic shock 

The extremities should be assessed for bone deformities and bruising. Tenderness may suggest underlying injury from a traumatic event. The patient’s affected extremity should be immobilized to prevent further damage to a suspected fracture.

Although most clinicians hate to think about abuse, the astute clinician should always be on the lookout for signs of abuse. Multiple bruises in various stages of healing, a history of previous fractures, a clinical history that does not correlate with the injuries or keeps changing, a delay in seeking treatment, or the reluctance of a child to speak are worrisome for abuse and warrant further investigation and intervention.

Hand Imprint on Child’s Face

Child’s Severely Beaten Back