Recognising the seriously ill child and paediatric assessment triangle — formative SAQs

1. PAT interpretation and immediate response

“This infant has abnormal Appearance, Work of Breathing and Circulation to Skin. This is a PEPP-derived cardiopulmonary-failure pattern. I will treat the infant as critically unwell. Breathing may be ineffective from fatigue, and perfusion is impaired, until reassessment shows otherwise.” [1] [3]

I would call the senior paediatric and resuscitation teams now. I would name a leader, allocate roles and begin ABCDE while observations, history and equipment arrive. [12] [18]

PAT is an equipment-free first impression from the AAP PEPP framework. It records what I see at that moment. It is not a diagnosis, score, complete examination, PEWS or disposition rule. [1] [2] [3]

2. Immediate age-adapted ABCDE stabilisation

A — Airway. I would assess patency, position, abnormal sounds or silence, secretions and the ability to cry. I would also assess whether the infant can maintain and protect the airway. I would position the airway and clear an immediately remediable obstruction or secretions. I would avoid unnecessary agitation. If the airway is threatened or cannot be maintained, I would call paediatric airway expertise early. I would prepare age- and weight-appropriate equipment rather than use adult assumptions. [1] [5]

B — Breathing. I would assess respiratory rate under stated conditions, work, effectiveness, symmetry, air entry and fatigue. I would check a technically reliable saturation trend. The infant’s quieter phase is not reassuring by itself. Improvement requires easier breathing with better air entry, interaction and perfusion. Less effort with poor air entry or reduced responsiveness suggests exhaustion. [1] [5] [11] [12]

I would support oxygenation and ventilation through the active age-, condition- and jurisdiction-specific pathway. I would move early to skilled assisted support if breathing remains ineffective. I would check the probe, site, signal and agreement between the displayed pulse and the infant’s pulse. Pulse oximetry may overestimate oxygenation, including in children with darker skin. It does not measure ventilation. [11] [12]

C — Circulation. I would assess pulse rate and quality, skin colour and temperature, blood pressure, mental state and urine output. I would measure capillary refill with the technique and conditions stated. I would look for bleeding and follow the response over time. A normal blood pressure or capillary refill would not exclude shock. [7] [12]

I would control obvious loss and obtain timely vascular access. I would not allow repeated failed attempts to delay care. I would consider hypovolaemic, distributive, cardiogenic, obstructive or mixed shock. I would follow the current pathway for the likely pattern and available local support. Before each action, I would state the expected response. I would then check for benefit, no response or harm. I would not give one universal fluid or vasoactive regimen. [7] [12]

D — Disability. I would assess interaction, age-appropriate consciousness, pupils, posture, tone, movement and seizure activity. Reduced feeding and responsiveness make a bedside glucose important. I would confirm an unexpected result when feasible, but not delay correction of a clinically dangerous low. I would use the active age- and context-specific pathway, then recheck the glucose. [23]

E — Exposure. I would expose only enough to look for rash, injury, bleeding and device problems. I would preserve warmth and dignity. I would also preserve possible safeguarding evidence. [20]

3. Prioritised differential and parallel checks

My first respiratory threats are upper-airway obstruction and lower-airway, lung or pleural disease. I would also consider impaired respiratory drive and neuromuscular failure. [12]

My circulatory threats are hypovolaemic, distributive, cardiogenic, obstructive or mixed shock. Other urgent causes include serious infection, seizure, intracranial disease, clinically dangerous low glucose and other metabolic disorders. I would also consider toxin or medication exposure, trauma and safeguarding. [12] [20] [23]

Without delaying support, I would ask about onset and direction of change, apnoea, cyanosis, intake and urine. I would ask about fever or temperature change, collapse, seizure, exposure, ingestion, medicines and previous disease. I would ask the caregiver what changed and what worries them most. [15]

I would select bedside glucose, reliable oximetry, ECG, gas or lactate, focused samples and imaging only for a clear question. Each test must identify a reversible threat or change the immediate plan or destination. No test should delay airway, breathing or circulation support. [4] [12] [23]

4. Reassessment, escalation and evidence limits

After every intervention or important change, I would repeat PAT and ABCDE from A. I would compare the actual response with the result I expected. I would document benefit, adverse effects and remaining threats. I would revise the differential and name the next sign of failure. There is no fixed universal reassessment interval. [1] [12]

I would contact PICU or retrieval early if an ABCDE threat persists, worsens or responds only briefly. I would also escalate if the infant may need monitoring, airway, ventilation or circulatory support unavailable locally. I would not wait for arrest or diagnostic certainty. [21]

I would tell the team that no single normal finding proves safety. This includes PAT, blood pressure, capillary refill, saturation, temperature, PEWS and an individual test. PAT studies are heterogeneous. Several complex and remote paediatric groups are under-represented. [3] [4] [7] [21]

The Resuscitation Council UK 2025 Paediatric Life Support guidance is the named UK source for immediate ABCDE care, treatment of threats and reassessment. The ANZCOR 2026 PALS guideline is the binational Australian and Aotearoa New Zealand resuscitation source. Their operational details remain specific to their populations, phases and jurisdictions. My answer stops at first stabilisation, response assessment and activation of the relevant local pathway. [12] [21] [23]