EDAITUTOR
ED Briefs · Paediatrics v1.0 Educational use only

Assessing
a Sick Child

Look first. Triangle always. Reassess relentlessly. — a structured approach to spotting the child who is sick, or about to be.

LOOKTriangleABCDEReassess
Full reference →
Paediatric retrieval — PIPER (VIC)

Call early when a child is critically unwell or beyond local capability. Confirm destination and pathway with local protocols and retrieval services.

Children compensate — then crash

A child holds a normal blood pressure until they are peri-arrest. Tachycardia, work of breathing and altered behaviour come first; hypotension is a late, pre-terminal sign. Trust the triangle, use age-based numbers, and escalate on your gut.

First principles — and a rapid assessment flow

Think this way

  • Look before you touch — the doorway impression frames everything.
  • Sick or not sick? — appearance and interaction beat any single number.
  • Physiology is age-dependent — interpret vitals against the right band.
  • Weight drives everything — drugs, fluids and equipment sizing.
  • Reassess after every intervention — children change fast.
End-of-bed impression — well vs unwell, before disturbing the child
Paediatric Assessment Triangle — appearance · WOB · circulation
ABCDE + glucose + temperature, treating as you go
Interpret age-based vitals & screen the red flags
Focused Hx & exam (SAMPLE) · targeted investigations
Reassess · escalate · disposition — sick / not sick / uncertain
◯ the spineLOOK → TRIANGLE → ABCDE → REASSESS. A hands-off impression frames severity before you lay hands on the child; an abnormal triangle is associated with a markedly higher risk of ICU admission.
The Paediatric Assessment Triangle — hands-off, in seconds

Appearance

TICLS
  • Tone — moving, or floppy?
  • Interactivity — alert, engaging?
  • Consolability — settles with carer?
  • Look / gaze — fixing, or vacant?
  • Speech / cry — strong, or weak?
abnormal = concern

Work of breathing

effort
  • Abnormal airway sounds — stridor, grunting, wheeze
  • Abnormal positioning — tripod, sniffing
  • Recession — intercostal, subcostal, tracheal tug
  • Nasal flaring, head bobbing
silent chest = pre-arrest

Circulation to skin

colour
  • Pallor
  • Mottling
  • Cyanosis (central)
2 sides abnormal → critical
◯ expert consensusThe triangle is an observational tool — it drives your first management decision (well / respiratory / shock / CNS / critical) before the first hands-on measurement.
The structured primary survey — assess and treat in parallel

AAirway

patency
  • Patent, maintainable, or obstructed?
  • Added sounds · positioning · secretions
  • Open with positioning / suction / adjuncts
stridor + drooling → don't distress

BBreathing

oxygenation
  • Rate, effort, SpO₂, air entry
  • Recession, grunting, symmetry
  • Oxygen · support as needed
apnoea / exhaustion → help now

CCirculation

perfusion
  • HR, central & peripheral pulses
  • Cap refill, skin temp, mottling
  • BP is a late sign — don't wait for it
compensated shock is invisible on BP

DDisability

neuro
  • AVPU / GCS, pupils, posture
  • Glucose — never forget it
  • Seizure? Consider causes early
check glucose

EExposure

head-to-toe
  • Temperature — fever or hypothermia
  • Rash — look for non-blanching
  • Expose fully — don't forget the nappy; avoid heat loss
non-blanching rash = act

HHistory

SAMPLE +
  • Feeds, output (wet nappies), activity
  • Onset, associated symptoms, exposures
  • Immunisations, PMHx / complexity, meds, allergies
  • Social & safeguarding concerns
the carer's instinct matters
Age-based vital signs — indicative APLS ranges, verify against the local chart
Age bandHeart rate (bpm)Resp rate (/min)Systolic BP (mmHg)
< 1 year110–16030–4070–90
1–4 years100–15025–3580–95
5–11 years80–12020–2590–110
12+ years60–10015–20100–120
🔴 the trapMinimum acceptable SBP ≈ 70 + (2 × age in years) — but a falling BP is late and pre-terminal. A "normal" heart rate in a mottled, drowsy child is still a sick child: numbers guide, they don't diagnose.
◯ fever & ageAny fever in an infant < 3 months is a red flag — the well-appearing febrile young infant still needs a structured septic screen and risk stratification (age, appearance, urinalysis, inflammatory markers).
Serious illness not to miss
Sepsis / septic shock Meningococcaemia DKA Severe bronchiolitis / asthma Intussusception / volvulus Non-accidental injury Unwell neonate Poisoning

Sepsis

time-critical

Fever or hypothermia with an abnormal triangle or poor perfusion — activate the paediatric sepsis pathway.

sepsis pathway

Meningococcaemia

rash

Non-blanching rash in an unwell child — treat, don't wait for the full picture.

antibiotics now

DKA

metabolic

Deep tachypnoea, dehydration, drowsiness — check glucose & ketones.

glucose + ketones

Unwell neonate

< 28 days

Poor feeding, lethargy, temperature instability — low threshold, full screen.

admit & screen

Intussusception

surgical

Intermittent pain, drawing up legs, redcurrant stool, lethargy.

surgical review

Safeguarding (NAI)

social

History that doesn't fit the injury, pattern marks, delayed presentation.

consider & escalate
◯ escalate earlyThe safest move with any sick child is early senior and paediatric involvement. Confirm destination and retrieval (PIPER, VIC) with local protocols.
Disposition — where does this child go?

Discharge low risk

  • Well-appearing, normal triangle & vitals
  • Feeding & hydrated, clear diagnosis
  • Reliable carer & safety-net advice
  • Able to return / follow-up arranged

Admit / observe uncertain

  • Uncertain diagnosis or trajectory
  • Needs scheduled reassessment & obs
  • Borderline vitals or partial response
  • Social / safeguarding concern

PICU / retrieval critical

  • Abnormal triangle / compensated shock
  • Not responding to initial treatment
  • Airway threat, apnoea, altered GCS
  • Activate retrieval (PIPER) early
◯ reassess before you decideRepeat the triangle and vitals before every disposition decision — and again before discharge. Document clear review points and what should prompt return.
Immediate red flags — call for help now
  • Apnoea or irregular breathing
  • Stridor with drooling / obstruction
  • Silent chest or exhaustion
  • Altered consciousness or seizure
  • Poor perfusion — mottled, cool, prolonged cap refill
  • Bradycardia in a sick child (pre-arrest)
  • Non-blanching rash / petechiae / purpura
  • Bulging fontanelle in an infant
  • Unwell neonate (< 28 days)
  • Suspected poisoning, trauma or safeguarding
🔴 priorityAny single crossed threshold plus a gut feeling of "unwell" → escalate and reassess. Deteriorating despite treatment? Escalate now — don't wait for the next set of obs.
Pearls & pitfalls

Do

  • Form your impression from the doorway
  • Check glucose in every unwell child
  • Interpret vitals against the age band
  • Estimate weight early for drugs & kit
  • Reassess after every intervention
  • Escalate on trend and gut, not just numbers

Don't

  • Don't be reassured by a normal BP
  • Don't dismiss the worried carer
  • Don't forget the nappy, rash and temperature
  • Don't miss compensated shock or hypoglycaemia
  • Don't delay antibiotics for a non-blanching rash
  • Don't discharge without a documented safety net

ED AI Tutor · Paediatric Essentials · for clinicians and trainees. Always follow local protocols and senior clinician oversight.