CPEN/ENPC Initial Assessment

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)

A. History

i. SAMPLESymptoms, 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.