Pediatric Assessment Triangle: The From-the-Door Look
The three sides of the pediatric assessment triangle (appearance, work of breathing and circulation to skin), what to look for in each, how to read the combinations, and how it leads into the hands-on assessment.
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The pediatric assessment triangle is a way to decide how sick a child is, and what kind of sick, in the first moments of a call and before you touch them. It looks at three things: the child's appearance, their work of breathing, and the circulation to their skin. It needs no equipment, and it works on a child who is too young, too frightened or too sick to tell you anything.
Why look before you touch
A child who is examined by a stranger will often cry, and a crying child breathes fast, flushes and is hard to assess. The look from across the room happens while the child is still behaving the way the illness is making them behave. Let a caregiver hold the child, keep your distance for a moment, and watch. You are forming a general impression, and you can do it in the time it takes to walk across the room.
Side one: appearance
Appearance tells you most about whether the brain is getting enough oxygen and blood. It is usually the most important of the three. The common memory aid is TICLS, pronounced "tickles".
| Letter | What you are looking at | Worrying finding |
|---|---|---|
| T: Tone | Is the child moving, sitting up or resisting, or limp? | Floppy, limp, not moving |
| I: Interactiveness | Does the child notice you, reach for things, play? | Uninterested in the surroundings or the caregiver |
| C: Consolability | Can the caregiver settle the child? | Crying or agitation nothing will settle |
| L: Look or gaze | Does the child focus on faces and follow them? | A vacant, glassy or unfocused stare |
| S: Speech or cry | Is the voice or cry strong and appropriate for the age? | Weak, muffled, hoarse or absent |
Side two: work of breathing
Work of breathing shows how hard the child is working to move air, and it is often the earliest sign of a breathing problem. Look and listen without a stethoscope.
- Abnormal airway sounds you can hear from where you stand: stridor, grunting, wheezing, snoring or a muffled voice.
- Abnormal positioning: sitting forward braced on the arms, sniffing with the chin pushed forward, or refusing to lie down.
- Retractions: the skin pulling in between the ribs, below the ribs or above the collarbones with each breath.
- Nasal flaring.
- Head bobbing in an infant, as the neck muscles help with each breath.
Side three: circulation to skin
When a child's circulation is failing, the body pulls blood away from the skin to protect the heart and brain. The skin is where you see it first.
- Pallor: pale skin or lips.
- Mottling: a patchy, lacy pattern of color.
- Cyanosis: a blue or gray color, which is a late finding.
Reading the combinations
Each side is either normal or abnormal. The combination of abnormal sides gives a general impression of the kind of problem the child has, which tells you what to look at first in the hands-on assessment.
| Appearance | Work of breathing | Circulation to skin | General impression |
|---|---|---|---|
| Normal | Normal | Normal | Stable |
| Normal | Abnormal | Normal | Respiratory distress |
| Abnormal | Abnormal | Normal | Respiratory failure |
| Normal | Normal | Abnormal | Compensated shock |
| Abnormal | Normal | Abnormal | Decompensated shock |
| Abnormal | Normal | Normal | Primary brain or metabolic problem, or a systemic problem such as sepsis or poisoning |
| Abnormal | Abnormal | Abnormal | Cardiopulmonary failure |
An abnormal appearance moves any of these impressions toward the more urgent end. A child working hard to breathe who still looks alert and interested is compensating; the same child who has gone quiet and floppy is tiring, and that child needs help with breathing now.
After the triangle
The triangle is a general impression, not a diagnosis, and it does not replace the hands-on primary assessment. It tells you how fast to move and what to look at first. Then do the full assessment of airway, breathing, circulation, disability and exposure, take vital signs and judge them against the norms for the child's age, and estimate or establish a weight before anything that depends on one.
Repeat the triangle as you go. It is quick enough to use as a reassessment after every intervention and every few minutes on the way to the hospital, and a change in any side is worth noticing and reporting.
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Common mistakes
- Touching first. Putting on a cuff or a probe before looking turns the child's real presentation into a frightened one.
- Being reassured by a normal blood pressure. In children it is the last thing to change.
- Reading a quiet child as a calm one. A sick child who has stopped crying and stopped resisting may be getting worse.
- Treating the triangle as the whole assessment. It is the first minute, not the call.
- Forgetting to repeat it. A general impression formed at the door is a starting point, and the child will change.
The short version
- Three sides: appearance, work of breathing, circulation to skin.
- Appearance is TICLS: tone, interactiveness, consolability, look or gaze, speech or cry.
- Look from a distance before you touch, with the child on a caregiver's lap if possible.
- The pattern of abnormal sides gives a general impression of what kind of sick the child is.
- Children compensate well and then decompensate fast. Normal blood pressure does not mean no shock.
- Follow it with the hands-on primary assessment, and repeat it as you go.