As we know, the pediatric assessment triangle is often used, rightfully so, as a tool to quickly identify sick kids who may require rapid, lifesaving intervention. While certainly effective for pediatrics, we can apply the same principles to the adult population to identify sick vs. not sick, and to rapidly form our initial impression and begin to form our differential diagnosis.
The three sides of the triangle: appearance, work of breathing and circulation, can be quickly assessed as you walk through the door to great your patient.
Appearance
As you enter the room, does your patient acknowledge you? When you say, 鈥淗ello sir/ma鈥檃m, my name is John, what鈥檚 going on today?,鈥� any response other than, 鈥淗ey John, this is my chief complaint鈥� is potentially a clue.
- Do they look at you and track you as you walk in the door?
- Is their speech slurred?
- Do they have facial droop?
- Is someone who is normally articulate and alert now slumped over and barely answering?
- No response is even more of a clue
Appearance refers to the patient鈥檚 tone and level of activity, or level of consciousness. More than just traditional AVPU, you can begin to assess orientation and capacity. Remember that orientation and capacity are more than just name, date, president and event. This is more than just how the patient looks, as well.
Look for clues in the patient鈥檚 vicinity, such as recent hospital discharge paperwork, drug paraphernalia or medications. It is also important to keep in mind scene safety when assessing a patient鈥檚 appearance. Move couch cushions and bed pillows, look at coffee tables and bedside tables. Be proactive in noticing firearms, knives or anything else that may be used as a weapon. You may be able to glean additional information from the contents of trash cans nearby, whether it be noting the bloody or coffee ground emesis in them, or the multiple empty OTC medication boxes.
Going into a scene, be nosy, not intrusive, but be truly aware.
Work of breathing
What is the patient鈥檚 respiratory rate and effort? A respiratory rate of 16 is considered 鈥渘ormal,鈥� but not without adequate tidal volume. Minute volume matters.
- Is the patient tripoding?
- Can they speak in full sentences?
- Can you hear them wheezing as you enter the house?
- Do you note rales from the doorway?
- Are they sitting up truly working to breath?
- Are there retractions?
- Are they using accessory muscles?
Rapid recognition of and intervention in severe respiratory distress is vital. You do not need a pulse oximeter to tell when a patient is short of breath. Do not delay treatment for a 鈥渞oom air sat.鈥�
We are limited on the amount of objective information available during prehospital care; don鈥檛 ignore this vital piece of the puzzle
Circulation
Skin condition is a relatively reliable predictor of perfusion. As a partner told me once, you can鈥檛 fake sweat. If someone is diaphoretic for no obvious environmental reason, it is time to investigate. In , in the presence of typical or atypical chest pain, the presence of sweating predicted the probability of STEMI even before clinical confirmation.
The eyes can tell a story, as well, with jaundiced sclera or pale conjunctivae possibly indicating liver disease, gastrointestinal bleeding or other blood loss.
- Are the patient鈥檚 pupils equal?
- Pinpoint?
- Dilated?
- Is the patient looking at you and tracking you with their eyes?
Rapidly reading a room and performing a quick visual evaluation of a patient from the doorway helps to identify potential life threats, to you and your patient. This, coupled with attention to detail makes narrowing down a differential diagnosis more accurate, which leads to better patient outcomes.
