Circulation to the skin

This helps determine the adequacy of perfusion to vital organs, using three characteristics:

• pallor, which reflects inadequate blood flow
  
• mottling, which is due to vasoconstriction
  
• cyanosis, which is blue coloration of the skin and mucous membranes [6].

If there is an abnormality in one or more aspects of the triangle, this can help the provider decide how severely ill or injured the child is and the most likely physiological abnormality. For example, abnormal appearance and breathing point to a respiratory problem, whereas abnormal appearance and circulation point to a circulatory disorder. Abnormalities in all three areas point to a critically ill child who requires rapid scene interventions.

The next step in patient assessment is the ABCDEs.

• A – Airway: Assessment of the patient’s airway should include: Is it patent? Is the child maintaining his or her own airway or is assistance needed in the form of airway positioning: jaw thrust, chin-lift, oral airway, nasal airway, bag-mask, or endotracheal (ET) tube?
  
• B – Breathing: Respiratory rate varies with age and can be very difficult to obtain in a crying child. Children in respiratory distress will usually breathe fast but as they tire, the rate will decrease, which is an ominous sign. When one listens to the chest, are there any adventitious sounds (grunting, stridor, wheezing, rales, rhonchi) or no sounds (no air movement)? Depending on available equipment, the use of a pulse oximeter can help determine oxygen saturation and the need for supplemental oxygen and/or assisted ventilation.
  
• C – Circulation: Determining heart rate and strength of peripheral pulses (radial) can be accomplished together. Heart rate varies with age and can also increase with fever and anxiety, but a heart rate below the normal range is worrisome and can imply hypoxia or pending arrest. If peripheral pulses are weak, central pulses should be checked as a means of assessing circulation. Capillary refill, which should be less than 2 seconds, can be assessed with the evaluation of the temperature and color of the extremity. Cold, blue, pale, or mottled extremities indicate poor circulation and shock. Although obtaining a blood pressure is part of the vital signs, in children it is often inaccurate because of the wrong size cuff or a fighting child. A normal blood pressure in the face of some of the above abnormalities should not make a prehospital care provider comfortable. In fact, hypotension in a child is a late finding of shock.
  
• D – Disability: This is a brief assessment of level of consciousness (mental status). The key is a quick assessment done initially as general appearance, so this is a recheck. It is not necessary to memorize a pediatric Glasgow Coma Scale, as a rapid assessment uses the mnemonic AVPU: Awake, responsive to Voice, responsive to Pain, and Unresponsive.
  
• E – Exposure: Although parts of the ABCDEs require that parts of the body be exposed for a complete assessment, it is necessary to ensure that all of the child’s body has been examined to fully evaluate any abnormalities. At the same time, it is also important to prevent heat loss and hypothermia.