The Pediatric Assessment Triangle
The Pediatric Assessment Triangle (PAT) is a rapid assessment tool that allows you to evaluate a pediatric patient's severity within seconds, before touching the child. It uses three components that can be assessed from across the room: Appearance, Work of Breathing, and Circulation to the Skin. The NREMT frequently tests your ability to use the PAT to determine acuity and guide management.
Appearance (TICLS)
Appearance is the most important component because it reflects the adequacy of ventilation, oxygenation, brain perfusion, and overall homeostasis.
- T - Tone: Is the child moving spontaneously? Does the child have normal muscle tone or appear limp?
- I - Interactiveness: Does the child reach for objects, look around, and interact with caregivers?
- C - Consolability: Can the parent or caregiver console the child?
- L - Look/Gaze: Does the child make eye contact? Is the gaze fixed or glassy?
- S - Speech/Cry: Is the cry strong? Is speech age-appropriate?
An abnormal appearance is the single best indicator that the child is seriously ill, regardless of the other two components.
Work of Breathing
Assess the child's respiratory effort visually and audibly:
- Abnormal positioning: Sniffing position, tripod position, refusal to lie down
- Retractions: Supraclavicular, intercostal, substernal, or subcostal retractions indicate increased effort
- Nasal flaring: Common in infants with respiratory distress
- Audible sounds: Stridor (upper airway obstruction), wheezing (lower airway obstruction), grunting (attempting to maintain positive end-expiratory pressure)
- Head bobbing: In infants, rhythmic head movement with breathing indicates severe respiratory distress
Circulation to the Skin
Assess perfusion by observing skin color:
- Pallor: Pale skin suggests poor perfusion from vasoconstriction (compensated shock)
- Mottling: Patchy, irregular skin color indicates poor peripheral perfusion
- Cyanosis: Blue discoloration, especially central (lips, tongue, mucous membranes), indicates significant hypoxemia
Interpreting the PAT
All three normal: Stable patient. Proceed with focused history and exam.
Abnormal appearance only: Consider metabolic cause, poisoning, head injury, or postictal state
Abnormal work of breathing only: Respiratory distress. The child is compensating. Provide appropriate respiratory support.
Abnormal appearance + work of breathing: Respiratory failure. This child is decompensating. Immediate intervention required.
Abnormal appearance + circulation: Decompensated shock. Immediate fluid resuscitation and transport.
All three abnormal: Cardiopulmonary failure. Immediate resuscitation required.
Age-Specific Vital Signs
Pediatric vital signs vary significantly by age. You must know normal ranges to identify abnormalities:
- Newborn: HR 120-160, RR 30-60, BP 60-80 systolic
- Infant (1-12 months): HR 100-160, RR 25-50, BP 70-100 systolic
- Toddler (1-3 years): HR 90-150, RR 20-30, BP 80-100 systolic
- School age (6-12 years): HR 70-120, RR 15-20, BP 80-120 systolic
- Adolescent: Approaches adult values