Pediatric assessment triangle

The Pediatric Assessment Triangle is a tool used in emergency medicine to form a general impression of a pediatric patient. In emergency medicine, a general impression is formed the first time the medical professional views the patient, usually within seconds. The Pediatric Assessment Triangle is used as a method of quickly determining the acuity of the child, and can determine whether the child is in respiratory distress, respiratory failure, or shock.
The Pediatric Assessment Triangle is taught, among other contexts, in Advanced Pediatric Life Support courses.
Components of the Triangle.
The Pediatric Assessment Triangle consists of three areas of assessment: Appearance; Work of Breathing; and Circulation to Skin.
Appearance.
The "Appearance" portion of the Pediatric Assessment Triangle measures a variety of things, designed to determine whether the child is experiencing mental status changes (as these can be difficult to identify in an infant or young child). Components of the "Appearance" item also help to determine whether the child's airway is clear.
The acronym "TICLS" (pronounced "tickles") is sometimes used by emergency medical providers to recall the components of the "Appearance" item:
Work of Breathing.
"Work of Breathing" measures respiratory effort and visible signs of respiratory distress.
A normal score on the "Work of Breathing" item requires that the child's breathing be noiseless, effortless, and painless. The child should not appear to be trying harder than usual to breathe.
An abnormal score on this item indicates that the child is exhibiting an abnormal respiratory effort. The respiratory effort may be increased (indicating that the child is trying harder than normal to breathe), decreased, or absent.
Signs of increased work of breathing include:
A child exhibiting decreased work of breathing may be bradypneic (breathing too slowly) or too weak to engage the muscles required for inhalation.
Circulation to Skin.
"Circulation to Skin" is measured by skin color and obvious bleeding. Circulation, as measured by skin color and capillary refill, is an excellent indicator of perfusion in children.
A child with normal circulation will have his or her usual skin color. There will be no obvious bleeding.
Abnormal circulation to the skin may be indicated by:
"Scoring" the Triangle.
The Pediatric Assessment Triangle assigns no numerical scores, its goal being to help medical providers formulate a quick assessment of a pediatric patient's acuity. However, based on the results of the assessment, some initial conclusions can be drawn. These initial conclusions can help to guide medical decisions, such as whether to call for additional medical resources, but further assessment is always done, and repeated, following the quick usage of the Pediatric Assessment Triangle.
Respiratory distress.
A child who is exhibiting increased work of breathing, but has normal appearance and circulation to skin, can be initially assumed to be in respiratory distress. While the child is having trouble breathing, he or she is getting enough oxygen to perfuse the body well (hence normal circulation) and to oxygenate the brain (preventing mental status changes).
Respiratory failure.
Respiratory failure can be presumed when a child is exhibiting increased work of breathing, along with either abnormal appearance or abnormal circulation. The abnormal appearance (mental status) or circulation indicate that the child is not breathing well enough to perfuse the body, or to oxygenate the brain.
Shock.
A child with abnormal appearance and circulation to skin is likely to be in shock. Problems in both of these areas indicate that the child's body is not perfusing the brain or other tissues. (Work of breathing is unlikely to be increased, though the child is likely to be breathing quickly.)
In extremis.
A child with abnormal appearance, work of breathing, and circulation to the skin is generally in extremis - for example, due to imminent respiratory collapse.