Primary Survey (ABCDE) with (FG) – Assess and Treat Emergencies/Injuries
A. Airway and Alertness
i. Is the child alert? AVPU assessment (Alert, responds to verbal stimulation, responds to painful stimulation, unresponsive)
ii. Airway sounds like stridor, snoring, gurgling
iii. Airway or facial swelling, drooling
iv. Keep neck in neutral position with padding under shoulders
B. Breathing and Ventilation
i. Is the child breathing?
ii. Audible respiratory sounds like wheezing or grunting
iii. Increased work of breathing – tachypnea, accessory muscle use, retractions
iv. ET tube size = uncuffed (age in years/4) + 4; cuffed (+3.5)
v. Decompress the stomach with a gastric tube
C. Circulation and Control of Breathing
i. Is the heart rate normal for age?
1. Tachycardia is early sign of distress. Bradycardia is an ominous sign.
ii. Is the blood pressure normal for age? Hypotension is a late sign of shock.
iii. Are peripheral pulses normal? Bounding pulses is a sign of early (warm) septic shock.
iv. Normal capillary refill is 2 seconds or less.
1. Flash capillary refill (< 1 second) is a sign of warm septic shock.
v. Skin color and temperature
vi. Hydration status – no tears when crying, dry mucus membranes, sunken fontanelles
vii. Treatment of shock - 20 ml/kg fluid bolus over 5-10 minutes for severe shock
1. Pull-push technique (20 cc syringe) with 3-way stopcock
2. 5-10 ml/kg over 10-20 minutes for suspected cardiogenic shock
viii. Packed RBC’s at 10 ml/kg after 2 boluses if hemorrhagic shock
D. Disability “Da Brain”
i. Caregiver describes child as “fussy”, “irritable”, or “inconsolable”
ii. Alterations in pupillary response
iii. Bulging fontanelle may indicate increased intracranial pressure (ICP)
iv. Seizure activity
v. Hypo or hyperglycemia
E. Exposure and Environmental Control
i. Any signs of trauma or child maltreatment?
ii. Presence of petechiae (tiny non-blanchable) or purpura (larger non-blanchable)
iii. Hives or urticaria
iv. Keep warm during assessment
F. Full set of vitals and Family Presence
i. Hypotension = < 60 SBP in neonate, < 70 in infant, 70 + (2 x age in years) for 1-10 age
ii. Widened pulse pressure is seen in early septic shock or increased ICP
iii. Narrow PP in early hypotensive shock
iv. Weight in kg’s only, lock scales in kilograms
v. Assess the needs of the family, taking into consideration their cultural practices and religious affiliations.
G. Get adjuncts and Give comfort
i. L = Labs (bedside glucose)
ii. M = Monitor
iii. N = Nasogastric (contraindicated in head and facial injury) or Orogastric tube consideration
iv. O = Oxygenation (pulse oximetry) and ET CO2 capnography
v. P = Pain assessment and management
Secondary Survey (HI)
i. SAMPLE – Symptoms, Allergies, Medications, Past medical history, Last oral intake/Last output, Events and Environmental factors related to the illness/injury
ii. Chronic illness or immunosuppression
iii. Threat to self or others
B. Head-to-toe assessment – inspection, palpation, auscultation
C. Inspect Posterior
1. American Heart Association. Textbook of Pediatric Life Support, 2016.
2. Deboer, Scott. Certified Pediatric Emergency Nurse, Putting it all Together, 3rd edition, 2015.
3. Emergency Nurses Association. Emergency Nurses Pediatric Course Provider Manual, 5th edition, 2020.
4. ENA. Sheehy, S. Sheehy’s Manual of Emergency Care, 7th ed. Elsevier, 2013.