PEDIATRIC ASSESSMENT TRIANGLE (PAT)
The Pediatric Assessment Triangle (PAT) is a rapid, visual assessment tool used to quickly evaluate a child’s condition within seconds, without the need for equipment or vitals. It is an essential first step in pediatric emergency care and helps determine the severity of illness or injury before conducting a more detailed examination.
PAT is based on three key observations that allow healthcare providers to immediately recognize life-threatening conditions and prioritize interventions.
Why Use PAT?
- Fast & Non-Invasive: Takes only seconds to assess.
- No Need for Equipment: Based entirely on observation.
- Guides Immediate Management: Helps determine if the issue is respiratory, circulatory, or both.
THE THREE COMPONENTS OF THE PEDIATRIC ASSESSMENT TRIANGLE
PAT focuses on Appearance, Work of Breathing, and Circulation to Skin.
Appearance – “Is the child acting normally?”
Appearance reflects neurological function and overall condition. A child’s mental status and interaction can indicate whether the issue is primarily respiratory, circulatory, or metabolic in nature.
Key Features of Normal Appearance (TICLS mnemonic):
- Tone: Is the child moving normally or limp?
- Interactiveness: Is the child alert and engaging?
- Consolability: Can they be comforted by a caregiver?
- Look/Gaze: Is the child making eye contact or staring off?
- Speech/Cry: Is it strong and appropriate for age?
Abnormal Findings:
- Lethargy, irritability, or unresponsiveness → Suggests shock, sepsis, or metabolic issues.
- Poor tone, weak cry, or lack of eye contact → Can indicate hypoxia, brain injury, or severe illness.
Clinical Implications:
If the child has abnormal appearance, immediate intervention is needed. Altered mental status often means hypoxia or shock is worsening.
Work of Breathing – “How hard is the child trying to breathe?”
This assesses respiratory effort and effectiveness. Since respiratory failure is the leading cause of cardiac arrest in children, early recognition is critical.
Key Observations:
- Visible retractions (subcostal, intercostal, suprasternal)
- Abnormal breath sounds (stridor, wheezing, grunting)
- Nasal flaring (sign of distress)
- Head bobbing (late sign of fatigue in infants)
- Irregular or absent breathing (apnea, gasping)
Abnormal Findings:
- Stridor → Suggests upper airway obstruction (e.g., croup, epiglottitis).
- Wheezing → Suggests lower airway obstruction (e.g., asthma, bronchiolitis).
- Grunting → Suggests alveolar collapse or lung disease (e.g., pneumonia, ARDS).
- Diminished breath sounds → May indicate severe respiratory distress or failure.
Clinical Implications: If abnormal, provide immediate oxygenation and ventilatory support. Respiratory distress that progresses to fatigue means impending failure!
Circulation to Skin – “Is perfusion adequate?”
This evaluates the child’s circulatory status by checking for early signs of shock. Poor circulation leads to decreased oxygen delivery and can rapidly progress to cardiac arrest.
Key Observations:
- Pallor (pale skin): Early sign of poor perfusion.
- Mottling (patchy skin discoloration): Suggests vasoconstriction or poor circulation.
- Cyanosis (bluish skin): Indicates severe hypoxia or shock.
- Cool extremities, weak pulses, delayed capillary refill (>2 seconds): Sign of decompensated shock.
Abnormal Findings:
- Pallor + tachycardia → Early sign of shock (hypovolemic or distributive).
- Mottling or cold extremities → Worsening circulatory failure.
- Cyanosis (especially central cyanosis) → Critical hypoxia or shock.
Clinical Implications: Pallor and prolonged capillary refill suggest early shock—treat immediately! If cyanosis is present, urgent oxygenation and fluid resuscitation are required.
INTERPRETING THE PAT RESULTS
Once the three components are assessed, PAT helps determine the likely underlying problem:
| PAT Findings | Likely Condition | Examples |
|---|---|---|
| Abnormal Appearance + Normal Breathing + Normal Circulation | CNS or Metabolic issue | Sepsis, hypoglycemia, poisoning |
| Normal Appearance + Abnormal Breathing + Normal Circulation | Respiratory issue | Asthma, croup, pneumonia |
| Normal Appearance + Normal Breathing + Abnormal Circulation | Circulatory (shock) issue | Dehydration, sepsis, anaphylaxis |
| Abnormal in 2 or More Categories | Critical, combined failure | Impending arrest, severe shock |
Key Actions Based on PAT Findings: Respiratory distress? → Support ventilation (oxygen, nebulizers, airway adjuncts). Shock symptoms? → IV fluids, vasopressors, treat underlying cause. Altered mental status? → Consider hypoxia, sepsis, or metabolic causes.
Why PAT is a Game-Changer in Pediatric Emergencies
Immediate Triage: Quickly identifies critical vs. stable patients. No Equipment Needed: Can be used in pre-hospital and emergency settings. Guides Treatment Priorities: Helps determine whether the issue is respiratory, circulatory, or metabolic. Improves Team Communication: Provides a structured, universal assessment language.
Summary: PAT in Action
PAT is a rapid, first-line assessment tool that allows providers to categorize pediatric emergencies into respiratory, circulatory, or neurological/metabolic causes.
Appearance: Is the child acting normally? Work of Breathing: Is the child struggling to breathe? Circulation to Skin: Is perfusion adequate?
By using PAT, healthcare providers can rapidly assess, prioritize care, and intervene early, improving survival and outcomes in pediatric emergencies.
Takeaway: In pediatrics, seconds matter. PAT helps make life-saving decisions—fast. 