Emergency Management: Introduction

IMMEDIATE MANAGEMENT

Managing uncertainty in paediatrics is a challenge for any clinician. Being able to discern between low complexity cases, with more or less complex features, and the cases that require supervision by a specialist (or which represent a threat) is a very frequent problem in primary care.

The Paediatric Assessment Triangle (PAT) attempts to systematise the concept of “great diagnostician” attributed to the clinical expert. This is a useful, quick, and simple assessment method that identifies the type and severity of the problem and prioritises the initial treatment (Figure 1. The Paediatric Assessment Triangle PAT) ( Figure 1. The Paediatric Assessment Triangle PAT Translation)

The PAT formally categorises the general impression of the patient’s condition in line with the fact that emergency management requires a shift in approach in order to focus on what the patient needs rather than on what the patient has.

The TAP is based on audio-visual examination, without using hands or any other element. The assessment of the appearance, the analysis of the work of breathing, and the appearance of the skin as indicators of circulatory status make up the three sides of the triangle.

The approach of these bulletins is focused on patients with a stable clinical situation in which primary and secondary assessments will allow us to follow an effective and purpose-oriented therapeutic approach in the majority of cases (Horeczko, Enriquez, McGrath, Gausche-Hill, & Lewis, 2013)

DEVELOPMENT

Appearance assesses tone (if the child moves spontaneously, resists examination, is seated or standing, etc.), interactiveness (if the child is alert and connects), consolability, look/gaze (if the child makes contact, if there is visual tracking), and speech/crying (loud crying, inappropriate words, etc.).

The analysis of the work of breathing consists of observing the position adopted by the child (on a tripod, not tolerating decubitus, etc.), any pulling, nasal flaring, or head nodding, as well as any abnormal respiratory noises (whimpering, hissing, nasal voice) that can be heard without the need for auscultation with a stethoscope.

Circulatory status is assessed based on the appearance of the skin: Is there pallor? Is it cyanotic? Does it present with cutis marmorata (a marble-like complexion)?

These factors provide a benchmark for cardiac output and organ perfusion (Carles Luaces Cubells, Montse Delgado Maireles, Yolanda Fernández Santervás, 2015) (Cázares-Ramírez & Acosta-Bastidas, 2014)

CLINICAL ORIENTATION: SUMMARY

(Table 2. Orientation according to the PAT)

PRIMARY AND SECONDARY ASSESSMENTS

Primary paediatric assessment uses the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach for assessment and management.

Primary paediatric assessment is a practical assessment of respiratory, cardiac, and neurological function, including assessment of vital signs and determination of oxygen saturation (Cázares-Ramírez & Acosta-Bastidas, 2014)

This part of the primary evaluation includes the following (Table 3. Management summary):

In this method, thorough examination (use of hands) is added to observation.

S: signs and symptoms.

A: allergies.

M: medications.

P: pertinent past medical history.

L: last oral intake.

E: events leading to present illness/injury. This must include the mechanism of the injury, the time it occurred, and what happened until the child became cared for.

This gives way to a complete examination and assessment of the patient’s situation and whether there is a need for transfer to or management at another level of care.