Pediatric emergency medicine trisk 0132 0132
Bạn đang xem bản rút gọn của tài liệu. Xem và tải ngay bản đầy đủ của tài liệu tại đây (127.99 KB, 1 trang )
wheezing, and changes in voice or speech. Observation should include
assessment of patient positioning, the presence and location of chest wall
retractions, and nasal flaring.
TABLE 6.3
TICLS MNEMONIC
Tone
Interactivity
Consolability
Look/gaze
Speech/cry
Moves spontaneously, sits or stands as age appropriate
Interacts with people, environment, objects
Stops crying with comfort by caregiver
Tracks objects, makes eye contact
Age-appropriate speech or strong cry
Adapted from APLS: The Pediatric Emergency Medicine Resource . 5th ed. American College of Emergency
Physicians & Jones and Bartlett; 2012.
TABLE 6.4
TRIAGE “RED FLAGS”
Airway
Breathing
Circulation
Disability
Exposure
Apnea, stridor, hoarse voice/cry, drooling, choking,
gurgling, sniffing position, hypoxemia
Increased work of breathing, retractions, grunting, nasal
flaring, seesaw respirations, head bobbing, adventitious
breath sounds, tripod positioning
Tachycardia, bradycardia, hypotension, capillary refill >3
sec or <1 sec, decreased pulses, bounding pulses,
cyanosis, mottling, uncontrolled bleeding
Altered level of consciousness, inconsolable crying,
abnormal pupillary reaction, hypoglycemia
Hypothermia, hyperthermia >105.1°F, rash (petechial,
purpura), signs of abuse
Circulation to the Skin
Assessment of circulation to the skin reflects the integrity of vital organ
perfusion. The child’s skin should be exposed by the parent in a warm
environment and visual examination performed, evaluating for pallor, mottling,
cyanosis, and visible active bleeding.
