The Sick Child Assessment

Expansion

The paediatric assessment triangle, formed from the doorway in seconds:

1. Appearance: tone, interactiveness, consolability, gaze, speech or cry
2. Work of breathing: rate, recession, nasal flaring, grunting, stridor, wheeze, head bobbing
3. Circulation to skin: pallor, mottling, cyanosis

Any abnormal side indicates a potentially unstable child.

Amber and red features, following the traffic light approach

• Colour: pale, mottled, ashen or blue
• Activity: no response to social cues, does not wake, weak, high-pitched or continuous cry
• Respiratory: grunting, tachypnoea over 60, moderate or severe recession
• Circulation and hydration: reduced skin turgor, capillary refill over 3 seconds, reduced urine output
• Other: age under 3 months with fever 38 degrees or above, non-blanching rash, bulging fontanelle, neck stiffness, status epilepticus, focal neurology, bile-stained vomiting

Signs of exhaustion in a child who has been working hard to breathe are more worrying than the earlier distress: a falling respiratory rate, quiet chest, drowsiness and a rising carbon dioxide indicate imminent arrest, not improvement.

Parental concern that this illness is different is an independent predictor of serious illness and should never be dismissed.