Paediatric Red Flags

Using the paediatric assessment triangle

Identification of the critically ill child is a crucial skill every paramedic should have in their tool kit. Moreover, the swift recognition of these patients is paramount to effectively treat and optimise their physiological state. For this reason, we have to become experts in subtly. In essence, our priority is to clinically determine the ‘sick’ vs ‘well’ child.

The paediatric assessment triangle (PAT) is a robust tool for the emergency clinician to quickly assess and formulate an initial impression to guide treatment priorities.

The paediatric assessment triangle:

Initially developed some twenty years ago as a part of education for prehospital providers to assist with quick identification of the ‘sick’ child. This tool employs three components 1. Appearance, 2. Work of breathing, and 3. Circulation. It has stood the test of time and is now used by many emergency physicians. Not only does it identify the ‘sick’ child, but it can direct the clinician to the underlying pathology affecting the patient.

Physiologic StatesAppearanceWOBCirculation to the skin
Respiratory distressNormalAbnormalNormal
Respiratory failureAbnormalAbnormalNormal-abnormal
Compensated ShockNormalNormalAbnormal
Decompensated shockAbnormalNormal-abnormalAbnormal
Brain injury or dysfunctionAbnormalNormalNormal
Cardiorespiratory failureAbnormalAbnormalAbnormal


Observing from a distance enables the paramedic to gain insight to the patient’s overall status without potentially upsetting the child. The mnemonic TICLS summarizes the overall appearance.




                        Look & gaze

                        Speech and cry

Close attention to how the child interacts with family will give clues to their status. Allowing to assess if they are alert versus reactions from tactile stimuli. The vacant gaze or motionless child is more concerning than that of the moving child screaming. Irritability is an early sign of inadequate brain perfusion. Attention to the pitch of a child cry may also be helpful as it may be signifying their level of irritability.

Work of Breathing

Initially this should be assessed visually prior to getting hands on, as frequently children can become upset with a stranger in their space, which just makes the assessment harder. Note their breathing posture. For example, the tripod or the sniffing positions are portentous signs. However, this assessment is not complete without the chest being unclothed.

Signs of respiratory compromise include:


Audible wheeze



Snoring respirations

Nasal flaring

Signs of impending respiratory failure:

Head bobbing

Seesaw breathing

Respiratory rates are inversely related to age due to the metabolic demands and lower tidal volumes of younger children. Kids function near the maximal tidal volume capacity, so small increases in metabolic demands can elevate breathing rates. Hence, why you can add ~5 breaths per minute for every 1°C above baseline temperatures and be considered appropriate.

Non-respiratory illnesses are identifiable in the character of the child’s breathing. Effortless tachypnoea may be a sign of any shock; deep rapid respirations with normal chest sounds may be compensation for metabolic acidosis. Others include irregular respiratory patterns, which can relate to neurological diseases.


Inspection of the perfusion to the skin provides clues to the child’s cardiovascular performance. Compensated shock is characterized by peripheral vasoconstriction, diverting blood from the skin to the brain and vital organs. The skin will appear pale but warm to touch with a delayed capillary refill time (>2seconds – tip: assess this centrally). If not treated, the patient will become mottled with cold extremities. Do not confuse mottling (random pattern of vasoconstriction) with Cutis marmorata (lacy pattern on the skin caused by vascular irritability in cold environments). The difference being kids will appear well with cutis marmorata, and when the patient is placed in a warm environment, the skin findings will disappear.

Cyanosis may be present normally in kids with congenital heart disease. However, if it is a new finding it is usually predictive of respiratory failure or decompensated shock.

To hear more about this, listen to Episode 20: Pearls of paediatric assessment.


Dieckmann R, Brownstein D, Gausche-Hill M, editors: Pediatric education for prehospital professionals, Sudbury, MA, 2013, Jones & Bartlett.

Ron M. Walls MD, Robert S. Hockberger MD and Marianne Gausche-

Rosen’s Emergency Medicine: Concepts and Clinical Practice

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