1.4 Primary & Secondary Pediatric Emergency Assessment

1.4 Primary & Secondary Pediatric Emergency Assessment

Overview of Emergency Assessment Frameworks

Once the Pediatric Assessment Triangle (PAT) establishes the initial general impression, the emergency nurse immediately executes a systematic, hands-on clinical evaluation. Pediatric emergency assessment is divided into two sequential phases:

1. Primary Assessment (ABCDE Framework): A rapid, hands-on physical evaluation designed to identify and treat immediate life-threatening abnormalities in vital organ functions.
2. Secondary Assessment (FGHI Framework): A comprehensive head-to-toe physical examination, full vital sign collection, diagnostic testing, and detailed history gathering (SAMPLE / CIAMPESS).

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|                   PRIMARY ASSESSMENT (ABCDE)                            |
|  A - Airway      Patency, positioning, suctioning, adjuncts             |
|  B - Breathing   Rate, effort, breath sounds, SpO2, EtCO2               |
|  C - Circulation Pulses, cap refill, BP, heart rate, skin perfusion     |
|  D - Disability  AVPU, pGCS, pupils, bedside blood glucose              |
|  E - Exposure    Full exposure, injury inspection, thermoregulation     |
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                                     |
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|                  SECONDARY ASSESSMENT (FGHI)                            |
|  F - Full Vitals / Family Presence                                      |
|  G - Give Comfort Measures (Non-pharm & Pharmacologic)                  |
|  H - History (SAMPLE/CIAMPESS) & Head-to-Toe Exam                       |
|  I - Inspect Posterior Surfaces (Log-roll with spinal stability)        |
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Systematic Primary Assessment (ABCDE)

A — Airway (Patency & Positioning)

Assess whether the airway is clear, maintainable with simple maneuvers, or unmaintainable requiring advanced interventions.

• Anatomical Positioning Nuance: Infants have a large, prominent occiput. When placed supine on a flat surface, the heavy head flexes the neck forward, causing anatomical airway occlusion. Nurses must place a small towel roll under the shoulders to achieve a neutral "sniffing position".
• Manual Airway Maneuvers: Use the Head-Tilt/Chin-Lift for medical cases. Use the Jaw-Thrust maneuver without head tilt if cervical spine trauma is suspected.
• Airway Adjuncts:
  • Oropharyngeal Airway (OPA): Used ONLY in unconscious patients with absent gag reflex. Measure from corner of mouth to angle of mandible. In children, insert directly over the tongue using a tongue depressor; do NOT rotate 180 degrees as in adults to avoid lacerating the soft palate.
  • Nasopharyngeal Airway (NPA): Used in conscious/semi-conscious patients with intact gag reflex. Measure from tip of nose to tragus of ear. Contraindicated in basilar skull fracture or severe facial trauma.

B — Breathing (Ventilatory Status & Oxygenation)

Evaluate respiratory rate, respiratory effort, chest expansion, breath sounds, and gas exchange monitors.

• Auscultation: Listen in mid-axillary lines and anterior/posterior chest fields. Transmitted upper airway sounds easily mimic lower airway adventitious sounds in small chest cavities.
• Capnography ($EtCO_2$): Continuous end-tidal $CO_2$ monitoring is the gold standard for verifying endotracheal tube placement and monitoring hypoventilation ($EtCO_2 > 45$ mmHg) or hyperventilation.
• Oxygenation Modalities:
  • Nasal Cannula: 0.5 to 4 L/min ($FiO_2$ 24%–38%).
  • Non-Rebreather Mask (NRB): 10 to 15 L/min ($FiO_2$ 80%–95%). Reservoir bag must be fully inflated prior to placement.
  • High-Flow Nasal Cannula (HFNC): Provides heated, humidified gas up to 2 L/kg/min, delivering low-level positive airway pressure.
  • Bag-Valve-Mask (BVM) Ventilation: Indicated for hypoventilation, severe respiratory depression, or apnea. Deliver 1 breath every 2 to 3 seconds (20–30 breaths/min for infants/children). Ensure visible chest rise.

C — Circulation (Perfusion & Hemodynamic Stability)

Assess central versus peripheral pulses, capillary refill time, skin temperature, blood pressure, and cardiac rhythm.

• Pulse Assessment: Compare central pulses (brachial/femoral in infants; carotid/femoral in children) with peripheral pulses (radial/dorsalis pedis). Loss of peripheral pulses with weak central pulses indicates severe shock.
• Capillary Refill Time (CRT): Depress sternum or forehead for 5 seconds. Normal CRT is $< 2$ seconds. Delayed CRT ($> 3$ seconds) indicates poor peripheral perfusion.
• Blood Pressure Standards: Hypotension is a LATE sign of pediatric shock. Compensated shock preserves normal blood pressure through profound vasoconstriction and tachycardia.

Formula for Minimum Acceptable Systolic BP (5th Percentile):

• Term Neonates (0–28 days): $> 60$ mmHg
• Infants (1–12 months): $> 70$ mmHg
• Children 1 to 10 years: $70 + (2 \times \text{age in years})$ mmHg
• Children $> 10$ years: $> 90$ mmHg

• Vascular Access Protocol: Attempt peripheral IV placement twice. If peripheral access fails or is impossible in a critically ill patient, immediately establish Intraosseous (IO) access (proximal tibia or distal femur) within 90 seconds.

D — Disability (Neurological Status)

• AVPU Scale: Alert (A), Responds to Voice (V), Responds to Pain (P), Unresponsive (U).
• Pediatric Glasgow Coma Scale (pGCS): Scored from 3 to 15, modified for non-verbal infants (evaluates best eye, verbal, and motor responses).
• Pupillary Reflexes: Size, equality, and light reactivity.
• Bedside Blood Glucose: Must be checked immediately in any child with altered mental status. Hypoglycemia thresholds:
  • Neonates: $< 45$ mg/dL (treat with 2 mL/kg $D_{10}W$)
  • Infants & Children: $< 60$ mg/dL (treat with 2 mL/kg $D_{10}W$ or 1 mL/kg $D_{25}W$)

E — Exposure & Environmental Control

Fully undress the child to inspect for hidden trauma, rashes, petechiae, or signs of abuse. Prevent Hypothermia: Infants have high body surface area-to-mass ratios. Utilize radiant warmers, warm blankets, and warmed IV fluids immediately after exposure.

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Secondary Assessment Framework (FGHI)

F — Full Vitals & Family Presence

Collect a complete set of baseline vital signs (HR, RR, BP, $SpO_2$, temp). Support family-centered care by maintaining primary caregivers at the bedside during resuscitation.

G — Give Comfort Measures

Implement non-pharmacologic comfort (sucrose pacifiers for infants, swaddling, distraction) and prompt pharmacologic analgesia.

H — History & Head-to-Toe Physical Exam

Obtain a detailed clinical history using standardized mnemonics:

Perform a systemic head-to-toe examination inspecting fontanelles, ears, throat, chest, abdomen (palpate for tenderness/masses), extremities, and skin integrity.

I — Inspect Posterior Surfaces

Log-roll the patient while maintaining manual in-line cervical spine stabilization to inspect the back, spine, buttocks, and posterior skin surfaces for bruising, bony deformity, or tenderness.