Primary assessment algorithm / Initial emergency assessment

Written by Jessica Munoz DPN, RN, CEN

In adults, sudden cardiac death caused by ventricular fibrillation is the most frequent cause of cardiac arrest. In infants and children, cardiopulmonary arrest is most likely secondary to another condition such as respiratory failure or trauma, causing hypovolemia. The primary assessment in pediatrics is very important because it focuses on detecting issues that may lead to cardiac arrest before they occur.

Vital signs in children

Vital signs in children: heart rate (per minute) is defined by age and whether the child is awake or asleep.

• In newborns up to 3 months old, the heart rate is 85–205 while awake and 80–160 while asleep.
• At ages 3 months to 2 years old, the heart rate ranges from 100–190 while awake and 75–160 while asleep.
• Heart rate begins to fall between ages 2 and 10, reaching 60–140 while awake and 60–90 while asleep.
• Falling further, children aged 10 years and above become 60–100 while awake and 50–90 while asleep.

Respiratory rate (breath per minute) has a similar progression.

• Infant, 30–60
• Toddler, 24–40
• Preschooler, 22–34
• School-aged, 18–30
• Adolescent, 12–16

Hypotension in children is determined by age and systolic blood pressure (BP), measured in mmHg.

• Term neonates (0 to 28 days): The systolic BP is < 60 mmHg
• Infants (1 to 12 months): Systolic BP is < 70 mmHg
• Children 1 to 10 years (5th BP percentile): Systolic BP is < 70 mmHg + (age in years x 2)
• Children > 10 years: Systolic BP is < 90 mmHg

For example, you use the following calculation to determine hypotension by systolic blood pressure for a 7-year-old:

Modifications in Glasgow Coma Scale for infants and children: eye opening

• For spontaneous eye opening, the score is 4 in both children and infants.
• If eye opening involves speech, the score is 3 for both.
• If eye opening is painful, the score is 2 in both eyes.
• If there is no eye opening, the score is 1 in both.

Scoring pattern for verbal response:

• The score is 5 if the verbal response is oriented and appropriate in children, and is 5 with coos and babbles in infants.
• The score becomes 4 for confusion in children and irritable cries in infants.
• The score is 3 if children respond with inappropriate words and infants cry in response to pain.
• Making incomprehensible sounds by children and moaning in response to pain by infants lowers the score to 2.
• If there is no verbal response, the score becomes 1 in both.

Scoring pattern for motor response:

• The score is 6 in children obeying commands and in infants showing purposeful and spontaneous movements.
• The score is 5 for children who localize pain to painful stimuli and for infants who withdraw from touch.
• The score is 4 in both children and infants who withdraw due to pain.
• The score is 3 in children whose flexion is in response to pain and in infants showing abnormal flexion posture due to pain.
• The score is 2 for children who show extension during pain and for infants with abnormal extension posture due to pain.
• The score is 1 in the absence of any motor response.

The following should be assessed in all children who are suspected of having any grave illness.

1. Abnormal vital signs (see normal vital sign chart)
2. Irregular respirations
3. Slow or fast heart rate for age
4. Signs of poor perfusion
   1. Check for the presence or absence of distal pulses
   2. Poor skin color
   3. Delayed capillary refill
5. Cyanosis or oxygen saturation less than 94%
6. Altered level of consciousness
7. Seizures
8. Fever with petechiae
9. Significant trauma
10. Burns of >10% of body surface area

A positive answer to any of the above may indicate the need for cardiopulmonary support.

PALS systematic approach algorithm

The PALS systematic approach outlines the steps required to care for a critically injured or ill child.

The initial assessment includes color, breathing, and consciousness. If the child is unresponsive, with only gasping and no breathing, then the caregiver should immediately shout for help and activate emergency response. If there is a pulse, the airway should be opened and the child provided with oxygen and ventilation support as needed. If the pulse is <60/min, and the patient shows signs of poor perfusion despite adequate oxygenation and ventilation, CPR should be immediately initiated.

Also, if there is no pulse, CPR (C-A-B) should be initiated, followed by the pediatric cardiac arrest algorithm. Following ROSC, the evaluate-identify-intervene sequence should be initiated—the evaluation stage includes primary and secondary assessments and diagnostic tests. If the child shows signs of breathing during the initial assessment, the evaluate-identify-intervene sequence should be initiated thereafter. If cardiac arrest is identified at any point during this process, then CPR should be started.