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Pediatric Emergencies

This Course Has Expired

Authors:    Caitlinrae T. Montpetit (RN, BN) , Tosca R. Moore (RN, BSN)


Americans make approximately 115 million visits to the emergency department annually. Out of those visits, approximately one quarter or almost 24 million visits are with children (Merrill et al 2005). The pediatric age is 0-18 years, which includes infancy, toddler, pre-school and schoolage children. Rates of pediatric emergency department visits are widely varied with the highest average age being the very young (ages 0-4 years). Boys tend to be seen more frequently than girls, especially the school age, with the mean age being seven years old. The largest portion of emergency room visits are the type where the patient is treated and released, however over a half million pediatric visits result in hospital admissions, especially amongst the youngest children (Merrill et al 2005).

Emergency Department Visits

The most common reasons for visits to the emergency department by children are respiratory infections, fever, cough, vomiting, ear infection/ache, skin rash, abdominal pain, sore throat, urinary infections and injuries, including sprains, bruises, fractures, open wounds and lacerations (CDC 2006). Injuries are the main culprit for emergency room visits by older children (6 years or older), whereas in children 0-4 years old, the main culprit is the respiratory system ailments, such as acute bronchitis and upper respiratory infections. (Merrill et al 2005).

The four most common reasons pediatric patients are admitted to the hospital are related to the respiratory system pneumonia, asthma, acute bronchitis and upper respiratory infections (HCUP 2008).

Injuries, including sprains, bruises, fractures, open wounds and lacerations are often accidents but can be related to abuse. If the caregivers or parents account of events does not adequately explain the injury with regard to its nature, distribution or severity then the disparity may be a case of abuse. Health care providers of all types must be alert to the indicators of abuse and must be willing to report their suspicions to the appropriate child protective agencies.


The process of triage for the emergently/urgently ill or injured pediatric patient entails a similar process as that of an adult with special attention required based on the developmental and physiologic differences of the child (Dieckmann 2005). The assessment of the pediatric patient is rapid, simple and duplicable for each and every pediatric patient, despite their injury or illness. A rapid assessment is vital to determine the urgent or emergent treatment modalities necessary.

The pediatric assessment triangle (PAT) is a quick, precise, easily adaptable model for the triage assessment of the pediatric patient (Fuzak & Mahar2009). The triangle consists of appearance, breathing, and circulation (ABC approach). This ABC approach allows the triage nurse to use visual clues to swiftly assess the urgency of treatment related to the child's illness or injury. Because of this fast assessment can be done from across the room. It does require an experienced pediatric triage nurse with good judgment and insight in pediatric cardiopulmonary assessment skills to complete the triage process (Dieckmann 2005). The triage nurse must remember that an immediate hands-on approach may cause fear, agitation and/or crying, which as a result, impedes the assessment process. Awareness of developmental age and psychological aspects must be considered for each age group (APLS, 2012). The pediatric assessment triangle has become the cornerstone for pediatric assessment related to emergency medical services.

This rapid approach assessment is a tool for medical professionals to quickly assess a child on sight to determine if the child needs immediate intervention. See the table below for the PAT general impression and first view use.


The appearance of a child is a significant and precise measurement directly related to the degree of distress, illness or injury in a pediatric emergency (APLS, 2012). Most children with mild or moderate distress (and even those moving toward severe distress) are alert and will probably have a normal neurological exam. If the child does not appear to have a normal neurological exam, it is most likely due to such conditions as childhood epilepsy, brain injury in infants and children, neuromuscular diseases, neurogenic and neurodevelopmental disorders (Wong & Kee, 2010). The emergency is then based on what the parent or the caregiver state is abnormal for the child. Another aspect is injuries based on traumatic accidents involving motor vehicles, near drowning, bicycle accidents and falls. In fact, one of the highest causes of death specifically targeting toddler deaths is drowning. Approximately 50% of all pediatric trauma victims will have a head injury with 90% of pediatric deaths from trauma directly related to head injury and/or trauma (Bemis, 2007).

Evaluation of the child's airway and appearance is based on an open and clear airway with normal muscle tone and body position. The pediatric patient should have a normal cry or speech pattern, rate and pitch for their stated age (Bemis, 2007). If the presence of an abnormal cry, absent cry or absent speech is present, the pediatric illness or injury must be considered emergent (Behrman et al, 2004).

Likewise, the pediatric patient should be able to move all of their extremities normally and without problems, responding normally to their parent or caregiver and to the environment around them (i.e. plays with a rattle, toy, stethoscope, name badge and/or lights) (Fleisher et al, 2006). 

If the muscle tone is floppy, rigid or nonexistent, in conjunction with decreased response to parents or caregiver (i.e. the parent or caregiver is unable to console the child or wake the child up by their voice or touch) and the child has a decreased response to the environment, this first impression of the patient absolutely should be considered emergent (Roy, 2008).

A simple mnemonic for the appearance assessment is TICLS (tickles) (Behrman et al, 2004):

  • Tone
  • Interactability
  • Consolability
  • Look (or Gaze)
  • Speech (or Cry)


Breathing is the next part of the triangle. The effort of breathing is a great indicator of oxygenation and ventilation. If the patients breathing pattern appears normal and is without distress, tachypnea, retractions, increased muscle effort, nasal flaring, head bobbing, tripoding, noisy breath sounds (i.e. stridor, wheeze or grunting) and/or absent breath sounds, the patient may be considered a non-urgent patient (Agur & Dalley, 2005). Retractions are usually easily seen in the pediatric patient because of the thin chest wall tissue. Therefore, even if the patient is obese, their ribs are still in the process of maturing and are malleable. Because of this malleable state, the retractions may be more readily seen than in an adult.

Professional Hint: The telltale signs of pediatric respiratory distress are nasal flaring (i.e. light outward/inward flaring of the nostrils when breathing in or out); constant nasal flaring (i.e. the nares are in an outward flared position continuously) and/or retractions of the chest wall (Dieckmann et al, 2005).

They indicate significant effort on the part of the child to breathe easier and move more air. Increased work of breathing will be evident from the doorway or across the room. In the presence of any abnormal findings, the pediatric patient must be considered emergent (Dieckmann et al, 2005).


Circulation is an astute direct observation of color such as mottling, cyanosis, pallor or paleness and bleeding that is significant or overtly obvious. If the skin of the pediatric patient appears white, pale or pasty, it is an indicator for lack of peripheral blood flow and pallor or paleness can be one of the first signs of shock in the pediatric patient (Agur & Dalley, 2005).

The nurse must not accidently confuse vascular instability with being cold as babies can often appear marbled when they are cold, while on the other hand, a bluish discoloration of the skin and mucus membranes is cyanosis. So should the skin have areas of bluish or purple discoloration, these may be patches of cyanosis. Cyanosis and mottling are latent signs of shock and can indicate lack of compensation of vital organs, or be a sign of respiratory failure (Fleisher et al, 2006). Circulation is a direct gauge for core perfusion to vital organs and cardiac output and an alteration in circulation may suggest the patient is in respiratory failure or compensating for shock (Bemis, 2007).

Professional Hint: The decision point for any pediatric emergency is any abnormal finding. Only one leg of the pediatric assessment triangle needs an abnormal assessment finding to consider the patient in need of immediate and/or emergent intervention.

Pediatric vital signs vary significantly based on age. A general guide is the following (Family Practice Note Book, 2012, pg. 1):

  1. Term Newborn (3 kg)
    1. Blood Pressure:
      1. Age 12 hours: 50-70 / 25-45
      2. Age 96 hours: 60-90 / 20-60
      3. Age 7 days: 74 +/- 22 mmHg (Systolic BP)
      4. Age 42 days: 96 +/- 20 mmHg (Systolic BP)
    2. Pulse: 80-200
    3. Respiratory Rate: 40-60
  2. Infant (6 months old)
    1. Blood Pressure: 87-105 / 53-66
    2. Pulse: 80-180
  3. Toddler (2 years old)
    1. Blood Pressure: 95-105/53-66
    2. Pulse: 80-180
    3. Respiratory Rate = 24
  4. School age (7 years old)
    1. Blood Pressure: 97-112 / 57-71
    2. Pulse: 60-160
  5. Adolescent (15 years old)
    1. Blood Pressure: 112-128 / 66-80
    2. Pulse: 60-160
    3. Respiratory Rate = 12

Danger Signs (Hazinski et al, 2002)

  • Choking/drooling not related to teething
  • RR < 8 or >60
  • HR <60 or >200
  • Altered age appropriate mental status
  • Abnormal Temperature >40C or 104F or <35C or 95F (Although a Temperature of 100.4F or greater is considered a Fever)
  • Severe Pain especially if disproportionate to exam
  • Oxygen Saturation < 92%
  • Parent or caregiver account of events do not accurately reflect Illness or injury

Assessment Skills

After completing a rapid assessment from across the room and noting the pediatric patients general appearance, the hands on assessment can begin. Infants and young children should be undressed or at least have their chest exposed for visual assessment including the ABCDE (Airway, Breathing, Circulation, Disability and Exposure) assessment (AHRQ, 2011). The ABCDE assessment will be addressed in detail below:


Airway patency is the first priority. If at any time during the triage or assessment the airway is compromised then immediate treatment is initiated. The sniffing position or head tilt-chin lift or jaw thrust is utilized. In infants, the sniffing position is recommended and for toddlers or school age children, the head tilt-chin lift is suggested (Newberry & Criddle, 2005). If cervical trauma is suspected, do not perform a head tilt, use jaw thrust only. Something as simple as suctioning can result in significant improvement of airway obstruction. However, absent or decreased breath sounds are an indicator of complete airway obstruction and require immediate emergent intervention. (Dieckmann, 2005)


Breathing, along with respiratory rate and effort, is a critical part of the primary assessment. Auscultation should be done with a stethoscope at the midaxillary area anterior to the sternal notch. Respiratory syncytial virus is the most common virus in infants and is a marker for lower respiratory infections.

Types of auscultation:

  • Stridor is an indicator of foreign body obstruction, upper airway edema or croup. This is especially common in toddlers as they like to swallow small objects (Agur & Dalley, 2004).
  • Wheezing is common in children with asthma. It is an indicator for lower airway obstruction, edema, and severe allergic reaction (APLS, 2004).
  • Grunting is a signal of poor or inadequate oxygenation usually associated with near drowning, pneumonia or pulmonary contusion. Grunting implies alveoli disease and hypoxia. Grunting is an immediate emergency and should be treated aggressively with oxygen and possible ventilation (Hazinski et al 2002).
  • Crackles are wet sounds in the airway or lungs and suggest the presence of fluid, blood, or mucus in the airway, which may be alleviated or at least helped, by suctioning. Crackles are heard with pneumonia and injury to lung parenchyma (Bemis, 2007).

A Patients respiratory rate and pulse oximetry are useful tools in assessing whether or not the pediatric patient has to work harder at breathing. The nurse needs to remember that children compensate more effectively than adults. It is important to not underestimate the effort of breathing even if the oxygen saturation is greater than 94% (APLS, 2012). One could be easily fooled into believing the patient is in a more stable state than they truly are by ignoring the patients respiratory rate and oxygen saturation. In addition, also note, a rapid respiratory rate could be a sign of fever, fear, anxiety, or pain. Respiratory rate danger zones are >60 respirations/minute or <10 respirations/minute (Fleisher et al, 2006).


The circulation assessment is checking for strength and quality of peripheral pulses, looking at capillary refill (less than 2-2.5 seconds), skin temperature and listening to heart sounds. An abnormal temperature has the potential to mislead the circulation assessment so it is important to determine that the child is not fevered or cold from exposure (James, 2008).


Disability or assessment of the neurological status is the next part of the continual assessment beyond triage. This assessment is done by observation of appearance, pupil response to light, motor activity and response to environment, as well as level of consciousness. The AVPU mnemonic is a widely accepted neurological assessment tool (Fleisher et al, 2006).

  • A - Alert with appropriate response to environment (remember developmental age). Spontaneous eye opening to speech and pain is appropriate.
  • V - Verbal response is appropriate to simple commands or babbling and cooing. Crying, but consolable is appropriate. However, irritable crying that is inconsolable is abnormal.
  • P - Pain response is appropriate as noted by withdrawal or cries with painful stimuli without posturing and moaning in children is considered an abnormal response to pain.
  • U - Unresponsive is without any kind of response to stimulus, pain, sound, or commands. This places the pediatric patient in one of the highest states of immediate need and requires emergent intervention (AHRQ, 2011).


Information regarding what kind of exposure (hypothermia or hyperthermia) and how long that exposure was must be inclusive in order to have accurate physiologic findings (APLS, 2012). Any child who has been exposed to extreme outdoor temperature (i.e. cold water drowning, snow or left in hot car) will have an abnormal finding in their assessment. It is important to maintain a warm ambient environment to properly assess and evaluate the pediatric patient (AHRQ 2011). This avoids the ambient temperature of the triage exam room or the emergency room from contributing or altering your assessment of the patient (Dieckmann et al, 2005). It is imperative to avoid confusing the fine marbled appearance often seen in infants due to a cool room with that of mottling due to a lower core temperature due over exposure or vascular instability (Dieckmann, 2005). One can be corrected easily with wrapping the infant or child in a warm blanket (the fine marbled appearance) whereas the other (mottling) may require more intensive interventions (Hazinski et al, 2002). Monitor temperature and treat fever as necessary. The infant will lose body heat rapidly. While exposing them is necessary for a through exam, young children, especially infants less than one year of age, are prone to hypothermia. Although complete exposure should be undertaken in order to get a complete and accurate assessment, care should be taken to preserve the patients body temperature throughout the process (AAP/ACEP, 2004).

Initiating Emergency Decisions

In the event of an emergency, the use of the Broselow tape (now more commonly called the resuscitation tape) should be used, if at all possible, to determine the weight and appropriate dosages of life saving drugs and emergency equipment sizes. It is not always convenient to weigh and measure an infant, toddler or child when time is of the essence and more critical. In the event this is the case, the resuscitation tape (or Broselow tape) is a better tool in determining the appropriate weight and drug doses to be utilized due to its color coded system. This color coded system helps clinicians decide what doses of medications are to be used based on height and weight. If a Broselow tape or resuscitation tape is not available, then the following chart will provide guidance (PALS Manual).


  • Infant birth weight average is 3.5kg
  • Infants birth weight doubles by 6 months to 7.0 Kg.
  • Infants triple birth weight at one year 10-12 kg
  • In older children, use their age as a guide to determine their Kg. Take the patients age and multiply it by 2 then add that to the constant of 8 kg.

Example: A 9 year old child would have an average weight of 26 kg. Kg of 8 + (9x2) =26 kg. The 26 kg is used to figure drug dosages.

Example: A 3 year old child would have an average weight 14 kg. Kg of 8 + (3x2) =14 kg. The 14 kg is used to figure drug dosages.

The SAMPLE mnemonic is useful for obtaining information related to the pediatric assessment.

  • S - signs and symptoms
  • A - allergies
  • M - medications
  • P - past medical history
  • L - last food, last immunizations, last medication
  • E - events leading to illness or injury

The goal of the pediatric triage assessment is to quickly determine acuity level for patients.

  • Level 1 (red)patients according to the emergency severity index as established by the American College of Emergency Physicians and the Emergency Nursing Association are in an emergent immediately life threatening situation and will require many resources.
  • Level 2 (yellow)patients are considered high risk and cannot wait to be seen. These patients are in potentially life threatening situations and will require a lot of resources.
  • Level 3 (green)patients are urgent but not in any imminent danger and will require two or more resources.
  • Level 4 (white) patients are less urgent, can wait to be seen and will use only one resource.
  • Level 5 patients are non-urgent and will utilize no resources.

Some examples of resources are labs, ECGs, X-rays, IV hydration, IV medications, IM medications, specialty consultation, simple procedure, and complex wound care. (AHRQ)

Emergency Severity Index (ESI)

ESI is a standardized triage system that is supported by both ENA, and ACEP (American College for Emergency Physicians), and provides validity and consistency of a rating system amongst medical institutions across the United States (Briggs & Grossman, 2006).

ESI permits the RN to have a means for quick, effective and accurate sorting of patients, which begins as soon as the nurse sees the patient. This allows the nurse to identify patients who are in immediate need of lifesaving interventions or those who are less critical (Trimarchi, 2012). This further allows the emergency room physician to have a guideline for determination of thresholds for diversions or natural disaster events.

ESI Triage Algorithm (Rockwill, 2005)

ESI levels 3-5 are determined by the number of resources utilized. Resources include:

  • ECG,
  • IV access, labs,
  • x-rays, CT scan, or ultrasound,
  • IV fluid therapy, IV meds, IM meds, nebulizer meds,
  • specialty consultations (social work, GI, Cardiac, Psychiatry, Surgery,)
  • procedures (laceration repair, foley catheter insertions, Incision, Drainage,) Conscious Sedation,
  • Airway management.

Count the different type of resources, not the individual tests. (i.e. all labs count as one resource, all x-rays count as one resource) (Eitel et al, 2001). Prediction of number of resources utilized is initiated immediately, starting with the first encounter of the patient by the triage nurse (Trimarchi, 2012). The triage nurse will use information obtained from the subjective and objective aspects of the triage assessment, the patients medical history, medications, age and gender.

The very young (< 3 months) may increase the patients ESI category up a level simply based on their age and (AHRQ, 2011). Co-morbidities may increase the patients ESI category up a level (Gilboy et al).

Level 5: Requires no resources and may be a Nurse only visit.


  • upper respiratory Infection (treated on complaint only),
  • medication refill,
  • blood pressure check,
  • point of care testing (such as pregnancy testing, blood glucose check) oral (PO) meds,
  • simple wound care (dressings, recheck),
  • bladder scan.

Level 4: One resource

Level 3: Two or more resources

Level 2: Does NOT require immediate lifesaving intervention, but is CRITICAL for recovery of the patient and would place the patient on a high risk status.

Level 1: REQUIRES immediate LIFE SAVING intervention

  • CPR (chest compressions, ambu)
  • Emergency Airway Access needed (intubation, vent)
  • Artificial Ventilation required (absent or diminished breath sounds, ambu, ventilator, bipap)
  • Electrical therapy (defibrillation, cardio version, external pacer)
  • Hemodynamic instability (controlling active bleeding, blood transfusion, orthostatic vitals with a significant change of BP>10mmhg systolic or >100 in heart rate, hypoglycemia, aortic aneurism, Traumatic events, MVA, near drowning.
  • Cardiac Arrhythmia
  • Medications: Narcan, D-50, Dopamine, Adenosine, Atropine, Levophed, Cardizem, Amiodarone, Vasopressin, Nitroglycerin,

Determining between level 1 and 2:

  • Is it a high risk situation or a life threatening situation
  • Severe pain versus traumatic injury
  • Chest pain versus acute MI
  • New onset confusion, AMS versus lethargy, ETOH, hypoglycemia
  • Suicidal ideation, homicidal ideation versus anxiety, panic

The patients ESI level may change from the triage time to time of disposition (Briggs & Grossman, 2006). It may increase or decreased depending upon the outcome of the diagnosis and what is revealed during the exam as the nurse and doctor work together to determine the patients needs. The patient may different aspects to different healthcare team member as the patient recalls or is prompted to provide additional information.

Regardless of the ESI level, depending on a patient's specific medical condition, the emergency room physician will admit the patient to the hospital, discharge the patient home or transfer the patient to a more appropriate medical facility (Gilboy et al). Remember, demographics, living arrangements, ability to pay for medications, primary care physician (PCP), must also be considered for final disposition.

ANY high risk situation can rapidly develop into a life threatening situation which requires lifesaving intervention, thereby upgrading a level 2 to a level 1.

Case Studies

Please note: for sake of the case studies, the pediatric assessment triangle (PAT) format will be used. Key points are that the three sides of the PAT tool are: appearance, breathing and circulation.

  1. A mother brings her one year old daughter with a chief complaint of coughing, difficulty breathing, nasal congestion and fever of 99.2. The toddler has been ill for two days and has no remarkable past medical history. She is alert and smiling. Her vital signs with the exception of low grade fever are within normal limits.

    What does the PAT say about this patient?
    What is the general impression?
    What is the ESI level of this patient?

    Rationale: The appearance and circulation of this patient are normal. Fever and breathing are abnormal, but not critical. Her TICLS is also normal. The ESI level is 5. This patient will most likely require outpatient medications and discharge from the emergency department.
  2. A 6 year old boy is brought to the emergency room by ambulance after being struck by a motor vehicle. He is pale and somnolent, but is breathing with non-labored respirations. His vital signs are T 98.0, RR 26, HR 100, B/P 84/palpable.

    What are the management priorities?
    Are any of the PAT findings abnormal?
    What is the ESI level of this patient?

    Rationale: This patient will require lifesaving intervention with assessment of traumatic cervical or head injury. The nurse must not be confused by the non-labored respirations. Respirations are controlled by the brain stem and are not indicative of cerebral edema. The AVPU scale is markedly abnormal. The appearance and color of this patient are also abnormal and he may require intubation. The ESI level is 1.
  3. A mother brings in her 12 year son who she claims cut his thumb with a pocket knife.

    He has a 2 cm superficial laceration to his right thumb. The mother reports he is up to date on his immunizations. He is crying, but consolable. His vital signs are B/P 106/71, HR 77, RR 16, T 98.3F.

    What are the PAT findings?
    What is the first impression of this patient?
    What is the ESI level of this patient?

    Rationale: This patient will require suturing, but not an immunization as school age children are given Tdap at the age of 11 and per the mother, is up to date on his immunizations. Crying is a normal response to a superficial laceration. The ESI level is a 4.
  4. A 15 year old teen is brought in by ambulance after diving into the pool and hitting his head. He is awake, alert and moving all extremities. He is immobilized on a back board with a hard collar in place. His vital signs are stable.

    What is the first priority?
    What did the PAT findings indicate?
    What is the ESI level?

    Rationale: Cervical trauma is a high risk injury requiring through neurological assessment and continual reassessment. This patient will also need cervical spine films due to the mechanism of injury. This patient is alert and oriented, but that does not preclude the patient from a traumatic cervical spine injury. He will remain on the back board with the hard collar in place until the films are completed and he is cleared by a physician. He will require constant neurological assessment. The ESI level is a 2.
  5. A 16 year old female with a history of suicidal ideations is found unresponsive by her parents and brought to the emergency room. There are several empty bottles of liquor and an empty bottle of Xanax next to the bed. Her VS are T 98.1, RR 8, HR 119, B/P 70/p.

    What is abnormal in the PAT?
    What is the first priority?
    What is the ESI level?

    Rationale: This is a life threatening emergency. All legs of the PAT are abnormal.
    Airway patency is the first priority. ESI level is 1.
  6. A 14 year old female comes to the ED with her boyfriend claiming, I think I might be pregnant. My parents threw me out of the house when I told them I thought I was pregnant. Her vital signs are B/P 132/61, HR 81, RR 20, and T98.6F.

    What does the PAT indicate regarding this patient?
    What is the ESI level?
    What kind of consult will be needed?

    Rationale: Social work should be contacted immediately for this young patient. All legs of the PAT are normal; however, the young female will need a pregnancy test and lab work. Additionally, she will need a referral to an obstetrician. Her ESI is level 3.
  7. An 8 year old boy is brought to the ED by his parents after falling off his bike. He has a laceration to the forehead that will need suturing. He was not wearing a helmet. He is awake and alert and his VS are stable. The parents state he is up to date on his immunizations.

    What are the PAT findings?
    What resources will be needed?
    What is the ESI level?

    Rationale: He will need sutures and a CT scan of the head due to striking his head. He will also need a Td immunization. School age children are not immunized until age 11 for tetanus. His neurological status is intact, but will need to be monitored. His ESI is a level 3.
  8. A 12 year old boy is brought to ED by his mother. His mother states, I did not realize he was out of his ADHD medications and I do not want him to miss a day. The patient is cooperative and answers questions appropriately. His VS are: B/P 110/74, HR 76, RR 16, and T 97.9F.

    What are the general PAT findings?
    What is the ESI level?
    How many resources are needed?

    Rationale: This child will need a medication refill only. There are no resources. There are no abnormal PAT findings. He will be treated and released. ESI level 5.
  9. A 7 month old female is brought into the ED due to vomiting for over 24 hours. The mother states, She is not tolerating her formula. The infant is listless, pale and has a weak cry. There are no abnormal airway sounds, retractions or flaring. Her lungs are clear to auscultation. She is breathing 58 times a minute. Her heart rate is 180/min, and her B/P is 50/p. Her skin is cool and capillary refill is 4 seconds. Her brachial pulse is weak but regular.

    Which PAT findings are abnormal?
    What is the first priority?
    What is the ESI level?

    Rationale: The PAT indicates poor appearance with poor tone, and a weak cry. Her work of breathing is normal, even if she is slightly tachypnic. She is most likely trying to compensate for acidosis. Her circulation is poor and altered most likely secondary to poor cardiopulmonary function and hypotension. Her TICLS is also abnormal: poor tone, poor interactiveness, lack of eye contact and weak cry. This is a critically ill child and intravenous access must be established immediately with fluid resuscitation started. This is a high risk situation and the ESI is a level 2.
  10. A mother brings in her one year old son to the ED because he awoke fussy and she thinks he has meningitis. She tells you a neighbor has meningitis and frequently babysits her son. The infant is pink and becomes anxious when approached by hospital staff. There are no abnormal airway sounds and his lungs are clear to auscultation. Vital signs are unable to be obtained secondary to the infants reaction to strangers.

    What is the priority of care?
    Is the PAT helpful in evaluating this infant?
    What is the ESI level?

    Rationale: The PAT is a good way to evaluate this infant when VS are not obtainable. The general impression is that of good tone, vigorous cry, and easily consoled by his mother. The TICLS assessment is also indicates good tone, normal interactiveness, consolability and good cry. The ESI is a level 4, because only labs will be drawn using a papoose board. The PAT findings show a well-child.
  11. A 14 year old girl is brought to the ED by her mom for an asthma attack. She cant breathe! cries the mother. The teen in on a daily albuterol MDI. She was seen by her pediatrician yesterday and was started on oral steroids for her worsening asthma symptoms. The girl is sleepy and pale with significant audible diffuse wheezing. She is sitting in a tripod position with notable retractions and nasal flaring. Her VS are RR 45, HR 160, B/P 118/64, Saturation is 83%. Her mom tells you she was up all night using her inhaler every hour.

    What is the first action that needs to be taken?
    What does the PAT formula indicate regarding this patient?
    What is the ESI level?

    Rationale: This teen is in respiratory failure and needs oxygen. She is fatigued from work of breathing. She will need oxygen via a non-rebreathing mask and she should remain in an upright sitting position. She will require IV access, high dose steroids, and multiple nebulizer treatments. All legs of the PAT are abnormal. This girl is at risk of losing her airway and may need to be intubated. The ESI is level 1.
  12. A six year old girl is hit by a car in the crosswalk at school. A witness reports she was thrown 15 feet and experienced a loss of consciousness. She has an obvious large bruised swelling to her frontal area. She is brought in by ambulance to the ED on a back board and neck collar in place. She is motionless on the stretcher, but does respond with eye opening to very loud verbal stimulation. She is not answering questions from the doctor or her parents. Her lungs are clear to auscultation, her skin is pink and her respiratory rate is 22/min. Her other VS are: HR 95, B/P 100/p, T 98.3, Saturation 99%. She is warm to touch and her capillary refill is brisk.

    What is the general first impression?
    What are the PAT findings?
    What is the ESI level?

    Rationale: The girls abnormal appearance and lethargy are very concerning for a head injury. She could easily decompensate and need an artificial airway if her intracranial injury worsens. The PAT and AVPU scale are abnormal even in light of normal respiration and clear lungs. She will need airway support, IV access, CT scan. This is a life threatening scenario. The ESI is level 1.
  13. A four month old boy is brought in by his parents for severe difficulty breathing. He is a bounce back from an ED visit 3 days ago. His previous ED visit diagnosis was bronchitis and he was sent home with antibiotics. He is lethargic and lacks muscle tone. He is tachypnic with significant retractions and shallow respirations. He is pale and is exhibiting peripheral cyanosis. His VS are T97.0, RR 61, HR 161, B/P 102/p, Saturation 82%.

    What is the overall impression?
    What does the PAT tell you?
    What is the ESI level?

    Rationale: This infant is in respiratory failure and needs oxygen immediately. His appearance, work of breathing and circulation are abnormal. His TICLS is also abnormal. His airway is at risk. He may require intubation. His ESI is level 1.
  14. 14. A 16 month old girl is brought in for a 2 day history of diarrhea. She was recently placed on singular. The diarrhea is watery with some blood noted. Mom states she wont drink from her Sippy cup. She is listless and sleepy. She is not interactive with mom or ED staff. She is pale and cool to touch. Her legs are mottled. She does not cry when IV access is attempted. Her lungs are clear and no retractions are noted. Her VS are T97.1, HR 190, RR 24, B/P 78/p.

    What are the management priorities?
    What does the PAT formula indicate?
    What is the ESI level?

    Rationale: The first priority is vascular access and administration of IVF. This toddler is at risk for severe dehydration and shock. Her appearance and circulation are abnormal. Her work of breathing is within normal limits. Her heart rate and B/P are beginning to show compensatory efforts for hypovolemic shock. Her TICLS is also abnormal with lack of tone, interaction, and no cry. Her ESI is level 2.
  15. An eight month old boy is brought to the ED by his mother after falling out of the bed onto a carpeted floor. His vital signs are T 98.1, RR 34, HR 155, B/P 92/p, Saturation 98%. He is sleepy and lethargic and has a poor response to the environment. His lungs are clear to auscultation. He is pink and warm to touch, with a brisk capillary refill.

    What is the general impression?
    What are the PAT findings?
    What is the ESI level?

    Rationale: This eight month old infant has an altered mental status and the events do not make sense for this type of presentation. The appearance is abnormal. The work of breathing and circulation are normal. However, this is a high risk situation and vascular access must be obtained. Labs and CT of the head are also indicated.
    The ESI is a level 2.
  16. A seven year old boy is brought to the ED by his mother for a complaint of a fever of 100.5F this morning at home. His face is flushed. He has a nonproductive cough, runny nose and poor appetite. His vital signs are T101.9F, HR 110, RR 28, B/P 96/p. He is asleep in his mothers arms, but is easily aroused and able to answer simple questions. He denies any nausea or vomiting. His lungs are clear and his oxygen saturation is 96% on room air.

    What is the main concern?
    What are the PAT findings?
    What is the ESI level?

    Rationale: This is an acutely ill child, but not critical. He most likely has an upper respiratory infection. Because of the fever, labs and blood cultures will be drawn. His appearance is abnormal, but only in that he is tired and appears ill. His tone and alertness on stimulation are within normal limits. His work of breathing is normal. His circulation is also normal, as the face flushing is secondary to the fever. He is an ESI level 3. He will be treated and released with antibiotics and medications for symptom control.
  17. A 10 year old girl is brought to the ER after being sick for 2 days at home with a cough.
    Her mother states the cough is worse at night. The mother states, She sounds like she is barking when she coughs. Her vital signs are WNL. She is eating and drinking well. She is sitting up and talking with the ED staff. She does exhibit some mild chest retractions and some expiratory wheezes. Her capillary refill is brisk and her color is pink.What is the overall impression?

    What are the PAT findings?
    What is the ESI level?

    Rationale: Croup is usually treated at home with Tylenol, and cool moist air with a humidifier. It usually resolves within 3-7 days. In the absence of fever, no antibiotics are needed. This is most likely viral croup. This school age girl is alert and talking, without distress. The retractions and wheezing with the classic barking cough are the telltale signs of croup. Even though her work of breathing is abnormal, she will be treated and released. Her ESI level is 5.
  18. An 18 month old male is brought to the ER for the 3rd time in one month with a complaint of an ear infection. He has a runny nose. He is on zyrtec. He has been on augmentin at home. He was referred to the ENT and Eustachian tube placement was recommended. His mother states he is fussy at times, but is eating and playing normally. His vital signs are stable. His throat is clear, but his ears are red with fluid noted behind them. The doctor orders Rocephin 250mg IM and recommends following up with the pediatrician.

    What is the most likely treatment?
    What does the PAT formula indicate?
    What is the ESI level?

    Rationale: In light of failed outpatient antibiotic treatment, the doctor has ordered an IM antibiotic injection. The infant has already seen an ENT with a recommendation for tube placement to alleviate fluid buildup and drainage. The infants appearance is normal, as is his work of breathing and circulation. The ESI level is 4 due to the IM injection.
  19. An 11 year old boy with a rash on his face is brought to the ED by his father. The rash is blister like with a honey like fluid draining from the open blisters. Some of the blisters appear to be crusting over. His father states he has had the rash for 3 days. His vital signs are within normal limits. He was sent home from school by the school nurse. He is afebrile. His father states he is eating and drinking normally. The rash is limited to his face. His lungs are clear and his capillary refill is brisk.

    What is the general finding indicative of?
    What is the result of the PAT?
    What is the ESI level?

    Rationale: Impetigo is a common childhood rash. It is caused by strep or staph bacteria and is contagious. The infection will spread to other areas of the skin if the fluid that oozes from the blisters touches another open area on the skin. It is treated by gentle washing of the skin and an antibiotic cream. A culture of the weeping fluid may be ordered. The assessment findings of the child are normal except for the rash. School age children are kept at home until the rash is cleared and no drainage is noted for 24 hours due to being highly contagious. The ESI level is a 4 secondary to the wound culture.
  20. A 14 year old girl is brought to ED in tears by her mother with the complaint of a headache. The mother states, I have been giving her Tylenol and Motrin, but she still has a headache. She probably has a brain tumor the mother exclaims! The past medical history reveals treatment approximately 10 days ago for a cold. Her vital signs are T 98.9, HR 106, RR 18, B/P 106/72. She is pink, warm and dry, but remains tearful. She has orbital tenderness on exam. She has a runny nose with clear drainage.

    Are headaches common in children?
    Is any part of the PAT abnormal?
    What is the ESI level?

    Rationale: Children get headaches for the same reasons adults get headaches. Tension, migraines and sinus headaches are the most common causes. Most headaches in children are due to an illness, infection, cold or allergies. Do not let the slightly elevated vital signs alter your treatment modalities as they are most likely related to anxiety and pain. In light of the recent cold and current runny nose with orbital tenderness the headache is most likely related to a latent sinus infection and will require antibiotic treatment and NSAIDS. In the absence of muscle weakness, vision problems or nuchal rigidity, the culprit is not meningitis or brain tumor. The ESI level is 5. The patient will be discharged to home with oral NSAIDS and antibiotics.


It is vitally important that after rapidly initiating an across the room assessment using PAT to determine the level of distress, or emergency, move on to the hands on assessment to initiate emergency decision and treatment modalities. When performing vital signs do the least invasive first as crying, fear and anxiety will alter the normal vital signs. Look for danger zone vital signs. Follow the chief complaint and obtain a past medical history if parent or caregiver is available including the events precipitating the emergency room visit. Include immunizations, allergies, and current medications in past medical history (Newberry & Criddle, 2005).


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