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Let’s look a little bit more at the initial assessment of the child

The paramedics discuss the importance of using the Paediatric Assessment Triangle when assessing children.
Just this way. Thank you. Is this young Charlotte? Yes. Morning. Hello sweet, how are you? So initial appearance she is fully alert and she is a good colour. Perhaps a bit flushed in appearance. So Grandma, can you tell me a little of what’s happened please? Well she took unwell about 24 hours ago, quite listless, feverish just really lethargic. So I rang 111 and they sent yourselves. Ok. Jordan, can you do some obs on her. So I’m just going through the Patient Assessment Triangle. Appearance is that she’s a bit flushed but fully alert and she’s responding to me. Resp rate appears normal and heart rate also appears normal. So we’ll get some observations now to see what they find.
So you said beforehand she was absolutely fine. Nothing at all, just flushed.
So it’s not a big sick at this point of time. So we’ll see what we find in the observations and go from there.
Just checking your temperature, sweet.
Does she take any regular medication from the doctor at all? No, no she’s had nothing.
Everything ok at school? No problem at school? No, this just happened in the last 24 hours.
Blood sugar is good at 5.4. She’s got sats of 100 and a heart rate of 90. Ok, resp rate is good.

So let’s explore that initial, ‘Are they big sick or little sick?’ concept. There is an excellent assessment tool for paediatrics known as the Paediatric Assessment Triangle (PAT). Have a look a the PAT attached to the bottom of this step as a guide.

The PAT is the initial ‘hands off from the doorway look at the child’, and is split down into three elements. Unless you need to immediately intervene, adopt an initial hands-off approach. Allow the child to look at you and decide if you are friend or foe. Let them see you interact with parents; if the parents trust you, the child is more likely to trust you.

Take your time, no sudden moves, approach cautiously and where possible use play/distraction. Leave undressing to later; removal of clothes can be un-nerving for the child. The appearance of the patient is probably one of the biggest clues to how sick a child is; a child doesn’t lie if they look sick then they tend to be.

A good mnemonic for assessing the appearance of a child is TICKLES.

  • Tone – Movement or resistance to examination. Good muscle tone? Limp/Flaccid. Remember floppy is bad.
  • Interaction – How alert are they? Will they grab a toy or follow a light? Are they uninterested in the carer or examiner?
  • Consolability – Can the carer or examiner console the child, or is the crying or agitation unrelieved with?
  • Knackered – Do they look worn out and tired? Children only have so much reserve.
  • Look/Gaze – Do they have a fixed gaze, or do they have a “nobody home” look?
  • Expression – Scared, not scared?
  • Speech/Cry – Is their speech or cry strong & spontaneous, weak, muffled or hoarse?

Remember the child’s overall appearance reflects the adequacy of oxygenation, ventilation and perfusion. Also remember ABC. Important points to consider are:


Remember a screaming child has a patent airway!

Look for:

  • Stridor. An inspiratory sound indicating potential upper airways obstruction.

Work of breathing

Look for:

  • Abnormal positioning (tri-pod, sniffing position, refusal to lie down)

  • Retractions (suprasternal, intercostal, subcostal)

  • Use of accessory muscles or head bobbing

  • Nasal flaring rate. Listen for: Stridor, wheezing, grunting


Inadequate perfusion of vital organs leads to compensatory vasoconstriction in non-essential anatomic areas, especially the skin. Therefore circulation to skin reflects overall adequacy of perfusion.

Look for:

  • Pallor white or pale skin / mucus membrane

  • Mottling patchy skin

  • Discolouration due to vasoconstriction

  • Cyanosis (bluish discolouration of skin & mucus membranes)

  • Skin temperature

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Emergency and Urgent Care for Children: a Survival Guide

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