SPECIAL ARTICLE
Supplemental Information
DEFINITIONS AND ASSESSMENT
APPROACHES FOR EMERGENCY
MEDICAL SERVICES FOR CHILDREN
Severity Classification of
Respiratory Disease
Respiratory distress and respiratory
failure are key concepts in PLS
but have not been applied in a
consistent manner across courses
and programs. The task force
adopted a severity classification
of respiratory symptoms for PLS
courses and programs to help guide
appropriate therapy. Specifically, PLS
courses should build on the general
impression and primary, secondary,
and diagnostic (tertiary) assessments
of the child to identify severity,
followed by defining the specific
etiology of the child’s respiratory
abnormality.
• “Respiratory distress” is a clinical
state characterized by increased
respiratory rate, effort, and
work of breathing.8 Children can
have respiratory distress, which
spans a spectrum from mild
tachypnea with increased effort
to severe distress with impending
respiratory failure. A description of
the severity of respiratory distress
typically includes respiratory rate
and effort, quality of breath sounds,
and mental status.
• “Respiratory failure” is a clinical
state of inadequate oxygenation,
ventilation, or both.8 Respiratory
failure is recognized typically by
abnormal appearance (particularly
an altered level of consciousness,
which may be characterized by
agitation or a depressed level of
consciousness), poor color, and
reduced responsiveness. Although
PEDIATRICS Volume 138, Number 6, December 2016
respiratory failure is thought to
be the end stage of respiratory
distress, it may occur with little
or no respiratory effort. At
times, recognition of respiratory
failure requires capnography or
laboratory data (eg, blood gas)
to confirm the diagnosis. In other
patients, the clinical examination
is sufficient to identify respiratory
failure.
• “Respiratory arrest” is the absence
of respirations with detectable
cardiac activity.
• “Apnea” is the cessation of
breathing, typically defined as
longer than 15 seconds. Apnea
may be further classified as
“central” or “obstructive.” Central
apnea indicates that the child
is making no respiratory effort,
whereas obstructive apnea is when
ventilation is impeded, resulting in
hypoxemia, hypercapnia, or both.8
Etiologic Classification of
Respiratory Disease8*
• "Upper airway obstruction": the
major clinical signs typically occur
during the inspiratory phase of the
respiratory cycle, such as stridor,
hoarseness, or a change in voice
or cry. Inspiratory retractions,
use of accessory muscles, and
nasal flaring are often present.
The respiratory rate is often only
mildly elevated because upper
airway obstruction is worse with
faster breathing. Examples include
foreign body obstruction, croup,
and epiglottitis.
*A patient may exhibit symptoms
consistent with more than one class
of respiratory abnormality.
• "Lower airway obstruction": the
major clinical signs typically occur
during the expiratory phase of the
respiratory cycle. The child often
has wheezing and a prolonged
expiratory phase requiring
increased expiratory effort. The
respiratory rate is usually elevated,
particularly in infants. Inspiratory
retractions become prominent
when the lower airway obstruction
impairs inspiration and exhalation,
requiring increased respiratory
effort. Examples include asthma
and bronchiolitis.
• "Parenchymal (tissue) lung
disease": this etiologic condition is
used to describe disease involving
the substance (ie, parenchyma or
tissue) of the lung. In this state,
the child’s lungs become stiff
because of fluid accumulation in
the alveoli, interstitium, or both,
requiring increased respiratory
effort during inspiration and
exhalation. Therefore, retractions
and accessory muscle use are
common. Hypoxemia is often
marked due to alveolar collapse
or reduced oxygen diffusion
caused by pulmonary edema
fluid and inflammatory debris in
alveoli. Tachypnea is common and
often quite marked. The patient
frequently attempts to counteract
alveolar and small airway collapse
by increasing efforts to maintain an
elevated end-expiratory pressure.
This is often manifested by
grunting respirations.
• "Disordered control of breathing":
In this state, there is inadequate
respiratory effort. Often the
parent will state that the child is
“breathing funny.” There may be
periods of increased respiratory
rate, effort, or both followed by
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 decreased rate, effort, or both;
or the child’s respiratory rate
or effort may be continuously
inadequate. Often the net effect
is hypoventilation leading to
hypoxemia and hypercarbia.
Disordered control of breathing
may result from a host of
conditions, such as traumatic
injury to the brain or brain
stem, drug overdose, metabolic
abnormalities, or neuromuscular
disorders.
Treatment of Airway and Breathing
Problems
Treatment of airway and breathing
problems is a critical component
of PLS. However, the identification
and description of physiologic
impairments are complicated by
variable definitions of hypoxemia,
hypoxia, and hyperventilation. The
task force adopted the following
definitions of these pathologic states:
• “Hypoxemia” is defined as
a decreased arterial oxygen
saturation detected by pulse
oximetry or direct measurement
of oxygen saturation in an arterial
blood gas sample. Hypoxemia
is generally defined as arterial
oxygen saturation <94% in a
normal child breathing room air.8 A
variety of conditions may lower the
threshold, such as altitude or the
presence of cyanotic heart disease.
• “Permissive hypoxemia” is a pulse
oximetry level of <94%, which
may be appropriate in certain
circumstances (eg, some case of
congenital heart disease).
• “Hyperoxia” is an increased arterial
oxygen saturation detected by
direct measurement of oxygen
saturation in an arterial blood gas
sample. This has been associated
with worse outcomes, such as after
return of spontaneous circulation,
in the newly born, and in some
forms of cyanotic heart disease.
Because of the uncertainty of
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measuring hyperoxia without
arterial blood gases, administering
oxygen to achieve a pulse
oximetry reading of 100% is not
recommended in these conditions.9
• “Hypoxia” is a pathologic condition
in which the body as a whole
(generalized hypoxia) or a region
of the body (tissue hypoxia) is
deprived of an adequate oxygen
supply. Note that hypoxemia does
not necessarily lead to tissue
hypoxia and that tissue hypoxia
may occur when arterial oxygen
saturation is normal. For example,
compensatory increases in blood
flow often can maintain tissue
oxygenation even when hypoxemia
is present. Conversely, if tissue
perfusion is poor or the patient has
severe anemia, tissue hypoxia may
occur with normal arterial oxygen
saturations.
• “Hyperventilation” refers to
increased alveolar ventilation
resulting in a decrease in PaCO2
to <35 mm Hg.10 This may be
caused by an increased respiratory
rate, increased tidal volume, or
combination of both. To ensure
that PaCO2 does not decrease below
30 mm Hg, hyperventilation must
be guided by capnography or blood
gas measurements.
• “Drug-assisted intubation”
(formerly called rapid
sequence intubation) is the
use of pharmacologic agents to
facilitate urgent or emergent
endotracheal intubation, which
generally includes sedation and
neuromuscular blockade.11
Shock
Shock is defined as a physiologic
state characterized by inadequate
tissue perfusion to meet metabolic
demand and tissue oxygenation.
• “Compensated shock” refers to
a clinical state in which there
are clinical signs of inadequate
tissue perfusion, but the patient’s
blood pressure is in the normal
range. Clinical findings include
tachycardia, delayed capillary refill,
and decreased urine output.12,13
• “Hypotensive (decompensated)
shock” can result from a variety
of etiologies and is characterized
by evidence of impaired perfusion
that will rapidly progress to
cardiac arrest if not corrected. It
is characterized by an abnormal
clinical appearance and evidence
of severely impaired perfusion
(ie, absent distal pulses and weak
central pulses, cool extremities,
mottled skin, or altered level
of consciousness).12,13 Shock
represents a continuum of severity,
and the presence of signs and
symptoms of shock should prompt
immediate action rather than
waiting for direct measurement of
hypotension.
Classification of Shock by
Etiology12,13
Assessment of circulation is an
important element of PLS because
identification and characterization
of the etiology (Supplemental Table
2) and severity of shock is critical
to early recognition, successful
treatment, and prevention of
cardiovascular collapse.
• “Hypovolemic shock” refers to a
clinical state of reduced intravascular
volume. It is the most common type
of shock in pediatric patients. It can
be caused by extravascular fluid
loss (eg, diarrhea) or intravascular
volume loss (eg, hemorrhage) and
results in decreased preload and
cardiac output.
• “Cardiogenic shock” refers to
reduced cardiac output secondary
to abnormal cardiac function
or pump failure. This results
in decreased systolic function
and cardiac output. This can be
due to congenital heart disease,
myocarditis, cardiomyopathy, or
arrhythmia.

• “Distributive shock” refers to
a clinical state characterized
by reduced systemic vascular
resistance leading to
maldistribution of blood volume
and blood flow. This group
includes septic, anaphylactic,
and neurogenic shock. In septic
and anaphylactic shock, there
may also be increased capillary
permeability, leading to loss of
volume from the intravascular
space (ie, decreased preload).
In neurogenic shock, there is
loss of sympathetic tone leading
to vasodilation and lack of
compensatory mechanisms
(ie, tachycardia and peripheral
vasoconstriction).
• “Obstructive shock” refers to
conditions that physically impair
blood flow by limiting venous
return to the heart or the pumping
of blood from the heart. This
results in decreased cardiac output.
Conditions causing obstructive
shock include pericardial
tamponade, tension pneumothorax,
pulmonary embolism, and ductal-
dependent congenital heart
defects, such as coarctation of the
aorta and hypoplastic left ventricle.
Classification of Dehydration by
Severity
Dehydration is defined as a loss
of water with varying loss of
electrolytes, leading to a hypertonic
(hypernatremic), isotonic, or
hypotonic (hyponatremic) state. The
losses can be from some combination
of the interstitial, intracellular, and
intravascular compartments; the
relative loss from each component
helps determine clinical symptoms.
Severity of dehydration is generally
related to the percentage of total
body water loss (ie, percent
dehydration), but the percentage is
not consistent across all age groups
because the relative proportion of
fluid loss based on total body weight
is size dependent. The task force
PEDIATRICS Volume 138, Number 6, December 2016
agreed that severity and clinical
signs of dehydration may be defined
according to the clinical signs in
Supplemental Table 3.14
Sepsis
Sepsis represents an important cause
of shock in infants and children.
Sepsis, severe sepsis, septic shock,
and systemic inflammatory response
syndrome (SIRS) are terms used to
characterize the host response to
an infectious agent or inflammatory
stimulus. These terms were based
on 1992 consensus definitions for
SIRS, sepsis, severe sepsis, and septic
shock in adult patients.15 Pediatric
definitions were introduced in
2001.16 There is national attention to
providing more consistent treatment
of pediatric sepsis and septic shock,
17 and an ad hoc consensus group
provided updated definitions and
treatment guidelines for pediatric
sepsis and septic shock in 2005.18
• "Infection" is a pathologic process
caused by invasion of normally
sterile tissue, fluid, or a body
cavity by pathogenic or potentially
pathogenic microorganisms.
Infection may be suspected or
proven by positive result of a
culture, tissue stain, or polymerase
chain reaction test. In the absence
of these tests, evidence of infection
includes positive findings on
clinical examination, imaging, or
laboratory tests consistent with
tissue invasion by a pathogenic
organism leading to a host
response (eg, white blood cells
in normally sterile body fluid,
perforated viscus, chest radiograph
consistent with pneumonia,
petechial or purpuric rash, purpura
fulminans).18
• "SIRS" is the host’s response to an
inflammatory stimulus, whether
caused by infection or some other
stimulus. The definition of SIRS
requires at least 2 of the following
characteristics (1 of which must
SPECIAL ARTICLE
be an abnormal temperature or
abnormal white blood cell count):
1. Core temperature above
38.5°C (101.3°F) or below 36°C
(96.8°F)
2. Tachycardia, defined as a
mean heart rate >2 SD above
normal for age in the absence
of external stimulus, chronic
drugs, or painful stimuli,
or otherwise unexplained
persistent heart rate elevation
over a 0.5- to 4-hour period;
or for infants aged <1 year,
bradycardia, defined as a
mean heart rate below the
10th percentile for age in
the absence of external vagal
stimulus, β-blocker drugs,
or congenital heart disease;
or otherwise unexplained
persistent depression of the
heart rate over a 0.5-hour
period
3. Mean respiratory rate >2
SD above normal for age or
mechanical ventilation for an
acute process not related to
an underlying neuromuscular
disease or the receipt of
general anesthesia
4. Leukocyte count elevated
or depressed for age (not
secondary to chemotherapy-
induced leukopenia) or >10%
immature neutrophils.18
• "Sepsis" is defined by SIRS in
the presence of or as a result of
suspected or proven infection.18
• "Severe sepsis" is sepsis plus 1 of
the following: cardiovascular organ
dysfunction or acute respiratory
distress syndrome, or ≥2 other
organ dysfunctions. Note that
there is no generally recognized
consensus on how to define organ
dysfunction. A set of definitions
is recommended in the pediatric
sepsis consensus document.18
• "Septic shock" is defined
by the presence of sepsis
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 and cardiovascular organ
dysfunction.18
Disability Assessment
Disability assessment is part of the
primary ABCDE approach, but how
to perform this component of the
evaluation sequence is especially
ill defined. Disability assessment
is often repeated during the
secondary assessment and ongoing
reassessment to help identify
changes in the patient’s neurologic
status. Many questions remain
about the evidence for and against
different methods of evaluation
of disability, including the GCS
(Supplemental Table 4)19 and its
pediatric modification, the pediatric
GCS (PGCS) (Supplemental Table 5),
20 and the AVPU scale. Interobserver
reliability of the GCS or PGCS has
been inconsistent. Also, none of these
scales has undergone validation
in a wide variety of children with
altered levels of consciousness not
related to trauma. Data suggest
that the PGCS may not perform
as well in nontraumatic patients
as an assessment that includes
examination of brainstem reflexes.21
The task force suggests that a
consistent method be used to assess
disability. If the GCS score is used,
each component of the GCS or PGCS
should be recorded.
The task force also recognizes
that the best disability scale for an
individual child may be site specific.
For example, the AVPU scale may
be appropriate in the prehospital
setting, whereas the GCS (particularly
the motor component) or PGCS
may be better in the emergency
department and hospital. The
differences between the AVPU scale
and GCS or PGCS do not appear
significant when associated with
neurologic outcome. Each component
of the AVPU scale generally
correlates with the GCS scores shown
in Supplemental Table 6.22
SI4 FUCHS et al
Health care providers also should
assess and record the pupillary size
and response to light for each eye
in any patient with altered level of
consciousness.
“Altered mental status” refers to the
range of mental states from agitation
to coma. The previous terminology,
altered level of consciousness, was
felt to be confusing because it often
is used to suggest and describe a
depressed level of consciousness or a
loss of consciousness.
Trauma
Trauma is an important component
of PLS training because it is the
most important cause of morbidity
and mortality in children beyond
the neonatal period. Traumatic
brain injury (TBI) often determines
outcome; thus, terms to describe
the nature and severity of TBI are
important assessment and treatment
guideposts.
• Motor vehicle collision or crash
should be used instead of motor
vehicle accident because accident
implies that the event could not be
prevented.
• TBI, which was formerly called
head trauma or head injury, is
now the preferred term for head
trauma. The term does not imply a
specific level of severity. Severity
is often based on the GCS, with GCS
score 13 to 15 reflecting mild, 9 to
12 moderate, and 3 to 8 severe TBI.
Of note, recent pediatric studies
have used a GCS score of 14 or 15
to represent mild TBI.23 Various
terms are used to describe injuries
that result from TBI.
Brain injury may be described as
primary, resulting from the direct
effects of the trauma, or secondary
to complications from the injury (eg,
hypotension, hypoxia).
• "Primary brain injury" results
from the biomechanical effects of
the impact, which result in direct
impact or sudden movement
causing shear stress of the brain.
• "Secondary brain injury" refers
to brain injury resulting from
factors occurring after the initial
biomechanical effects of the
primary injury. It includes brain
insults resulting from hypoxemia,
hypotension, hyperthermia,
hypoglycemia, and increased
intracranial pressure.
• "Open TBI" refers to an injury that
results in communication between
the skull contents and external
environment.
• "Closed TBI" refers to a brain
injury with no communication
between the skull contents and
external environment.
Either type (open or closed) of
TBI may be mild, moderate, or
severe. Open injury poses a risk of
developing infectious complications,
such as secondary meningitis. The
mechanism of open injury often
has different injury patterns and
pathophysiology from the more
common closed TBI; for example,
gunshot wounds may result in
significant vascular injuries not seen
in blunt head trauma.
• There is still controversy regarding
the ideal definition of concussion.
The task force chose to use the
definition resulting from the
Fourth International Conference
of Concussion in Sport, Zurich,
November 2012.24
- Concussion may be caused by
a direct blow to the head, face,
neck, or elsewhere on the
body with an impulsive force
transmitted to the head.
- Concussion typically results in
the rapid onset of short-lived
impairment of neurologic
function that resolves
spontaneously. However, in
some cases, symptoms and signs
may evolve over a number of
minutes to hours.

- Concussion may result in
neuropathologic changes, but the
acute clinical symptoms largely
reflect a functional disturbance
rather than a structural injury;
as such, no abnormality is
seen on standard structural
neuroimaging studies.
- Concussion results in a graded
set of clinical symptoms that
may or may not involve loss of
consciousness. Resolution of the
clinical and cognitive symptoms
typically follows a sequential
course. However, it is important
to note that in some cases,
symptoms may be prolonged.24
• “Postconcussion syndrome” is a
constellation of symptoms that
have been related to TBI, which may
vary between individuals. There
are numerous definitions, but the
symptoms fall into 4 major domains.
5. Physical, including headache,
phonophobia/photophobia,
disturbances of vision and
balance, nausea/vomiting, and
dizziness
6. Sleep, including problems with
insomnia, sleeping too much,
fatigue, and drowsiness
7. Cognitive, including memory
difficulties, slow processing,
“feeling foggy,” and
concentration or attention
problems
8. Emotional, including problems
with irritability, anxiety,
depression, and mood or
personality changes24
• “Herniation syndrome” refers
to the combination of clinical
symptoms seen with shifts and
compression of various cerebral
components caused by mass
lesions and/or cerebral edema.
Common findings in herniation
syndrome include depressed level
of consciousness, asymmetric or
bilateral dilated, and unresponsive
pupils. With central herniation,
Cushing's triad (bradycardia,
PEDIATRICS Volume 138, Number 6, December 2016
hypertension, and an irregular
respiratory pattern) may be seen.
Role of Hyperventilation
The task force suggests that PLS
courses discourage hyperventilation
in the patient who is hypovolemic
or in cardiac arrest because
hyperventilation can depress cardiac
output by impairing venous return.
Hyperventilation must be used
cautiously in the child with TBI
because excessive hyperventilation
may cause cerebral vasoconstriction,
leading to brain ischemia and a
worse outcome.10,25,26 In patients
with severe TBI, hyperventilation is
indicated only when there are acute
signs of cerebral herniation and must
be guided by capnography or blood
gas measurements to ensure PaCO2
does not fall below 30 mm Hg.
Spinal Injury
Injury to the spine confers the
potential for lifelong morbidity.
Various terms are used to describe
methods for minimizing the risk of
spinal injury. The task force endorses
the following term:
• “Spinal motion restriction” refers
to the preferred practice of
maintaining the spine in anatomic
alignment to minimize gross
movement, without mandating
the use of specific adjuncts. True
spinal immobilization is difficult
to achieve. The use of a backboard
should be judicious, so that the
potential benefits outweigh the
risks.27
MEDICAL CONDITIONS
Seizures
Seizures are common medical
emergencies in children. PLS courses
SPECIAL ARTICLE
and programs use a variety of
classification schemes.
• “Status epilepticus” is defined
as ≥5 minutes of continuous
clinical and/or electrographic
seizure activity or recurrent
seizure activity without recovery
(returning to baseline) between
seizures.28 In emergency settings,
therapy for status epilepticus
should be initiated when seizure
activity exceeds 5 minutes.
• “Nonconvulsive status epilepticus”
may be caused by absence or
atonic seizures or by incomplete
treatment of convulsive status
epilepticus. In the latter case,
nonconvulsive status epilepticus
should be suspected when
the patient continues to have
a markedly impaired level of
consciousness after visible
convulsive activity has ceased
because most patients will awaken
relatively soon after effective
therapy for convulsive status
epilepticus.29
“Hypoglycemia” refers to blood sugar
≤60 mg/dL in a child and ≤40 mg/
dL in the newborn and may result
in brain injury if not recognized
and effectively treated. Treatment
decisions should be based on patient
symptoms and can include oral
glucose.
“Drowning” is the process of
experiencing respiratory impairment
from submersion or immersion in
liquid.30 The terms “near drowning”
and “secondary drowning” have
become obsolete.
Hypothermia
Hypothermia may occur secondary
to environmental exposure or be
induced for therapeutic purposes.
The range of temperatures associated
with exposure-induced (accidental)
hypothermia is classified differently
from the range of hypothermia
induced therapeutically. The
following definitions are used
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to classify exposure-induced
hypothermia.31 Pronouncement of
death after recent environmental
exposure should not occur until core
temperatures of at least 32°C have
been achieved.
• Mild (environmental) hypothermia
(stage 1) is defined as a core
temperature from 32°C (89.6°F) up
to 35°C (95°F). The patient is often
alert and shivering.
• Moderate (environmental)
hypothermia (stage 2) core
temperature is from 28°C (82.4°F)
up to 32°C (89.6°F). The patient
is typically somnolent and not
shivering.
• Deep (environmental)
hypothermia (stage 3) core
temperature is below 28°C
(82.4°F). The patient is typically
unresponsive.
• "Therapeutic hypothermia"
refers to intentional core cooling
of a patient by using active
interventions. A recent pediatric
study did not find significant
benefit in children who survived
out-of-hospital cardiac arrest.32
Special Pediatric Issues
The task force identified a number
of other special terms for PLS
training and adopted the following
definitions:
• "Sudden infant death syndrome"
is the sudden death of an infant <1
year that cannot be explained after
a thorough investigation, including
a complete autopsy, examination of
the death scene, and review of the
clinical history.33
• "Sudden unexpected infant death"
is the sudden death of an infant
<1 year that cannot be explained
because a thorough investigation
was not conducted and cause of
death could not be determined.33
• "Brief resolved unexplained event
(BRUE)", formerly called apparent
life-threatening event, is an event
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occurring in an infant <1 year
in which the observer reports a
sudden, brief, and now resolved
episode of ≥1 of the following:
cyanosis or pallor; absent,
decreased, or irregular breathing;
marked change in tone (hypertonia
or hypotonia); or altered level
of responsiveness. Health care
providers should diagnose a BRUE
only when there is no explanation
for a qualifying event after
conducting an appropriate history
and physical examination.34
• "Child maltreatment" (sometimes
referred to as child abuse and
neglect) includes all forms
of physical and emotional ill
treatment, sexual abuse, neglect,
and exploitation that result in
actual or potential harm to the
child’s health, development,
or dignity. Within this broad
definition, 5 subtypes can be
distinguished: physical abuse,
sexual abuse, neglect and negligent
treatment, emotional abuse, and
exploitation.
• For children with special health
care needs, the Maternal and Child
Health Bureau uses the following
broad definition: “Children with
special health care needs are those
who have or are at increased
risk for a chronic physical,
developmental, behavioral, or
emotional condition and who also
require health and related services
of a type or amount beyond that
required by children generally.”35
• "Technology-assisted children"
are those children who require
the use of medical devices without
which, if they fail or were to be
discontinued, adverse health
consequences and hospitalization
would likely follow.36
• "Patient- and family-centered
care" is an approach to the
planning, delivery, and evaluation
of health care that is grounded in
a mutually beneficial partnership
among patients, families, and
health care professionals.37 This
approach to care recognizes that
the perspectives and information
provided by families, children,
and young adults are essential
components of high-quality clinical
decision-making and that patients
and family are integral partners
with the health care team.
• "Family presence" is a practice
that allows the patient and family
members to choose whether to be
present for procedures, including
resuscitation.
• The “medical home” refers to the
medical care of infants, children,
and adolescents, which ideally
should be accessible, continuous,
comprehensive, family centered,
coordinated, compassionate, and
culturally effective. It should be
delivered or directed by well-
trained physicians who provide
primary care and help to manage
and facilitate essentially all aspects
of pediatric care. The physician
should be known to the child
and family and should be able to
develop a partnership of mutual
responsibility and trust with them.
These characteristics define the
medical home.38
CONCLUSIONS
PLS courses are taught to a diverse
community of medical providers,
integrating previous medical training
with specialized information on
pediatric resuscitation. Some
medical providers complete or
instruct different PLS courses,
presenting possible conflicts among
course information. The goal of the
Emergency Medical Services for
Children Task Force is to minimize
confusion among learners and
instructors by providing common
terminology and core concepts.
Course materials and instructors
can then focus on the application
of these concepts to improve

recognition and treatment of critical
conditions in pediatric patients. The
task force recognizes that different
providers may have learned slightly
different definitions and models,
but by recognizing and reinforcing
consensus definitions, it hopes to
focus attention on learning objectives
rather than slight differences in
underlying concepts or terms.
A summary of the task force
suggestions follows.
Suggestions of the Task Force†
1. The PAT should be the initial
component of all emergency
pediatric assessments to form
an observational general
impression.
2. Primary assessment (primary
survey) should include ABCDE,
vital signs, and pulse oximetry.
This guides immediate
correction of life-threatening
conditions.
3. Secondary assessment
(secondary survey) should
consist of a focused history,
focused examination, ongoing
reassessment of physiologic
status, and response to
treatment and is an essential
part of the trauma evaluation.
This guides correction of
underlying conditions that lead
to life threats.
4. Diagnostic (tertiary) assessment
should be a key component of
patient evaluation that relies
on laboratory and radiologic
tests, usually in the emergency
department or hospital setting,
but also occurring at the point
of care in the out-of-hospital
setting.
5. Use of a length-based tape to
determine weight and drug
dosing, as well as appropriate
equipment sizing, is preferable
†These do not reflect AAP policy.
PEDIATRICS Volume 138, Number 6, December 2016
when a child’s weight cannot be
obtained.
6. To avoid excessive dosing in
children who are overweight,
the weight provided on the
length-based tape should not
be adjusted based on presumed
increased body mass.
7. PLS courses and programs
should classify respiratory
disease by severity and etiology
because these categorizations
drive emergency treatment.
8. Provider-induced
hyperventilation is harmful,
should be guided by
capnography or blood gas
measurements, and should only
be used if the child has signs of
cerebral herniation.
9. Capnography should be used as
an important adjunct to physical
assessment of the adequacy of
ventilation.
10. It is important to realize that
shock can occur without
hypotension.
11. For optimal therapy, shock
assessment should lead to
classification of shock into 1 of
4 etiologic classes: hypovolemic,
cardiogenic, distributive, or
obstructive.
12. Dehydration is a common and
important clinical entity with
specific identifiable clinical
stages and pitfalls in assessment.
13. To improve communication and
classification of children with
SIRS, sepsis, severe sepsis, and
septic shock, consensus terms
should be used.
14. Consistent application of the GCS,
PGCS, or AVPU scale is key to
reduce interobserver variability
in disability assessment.
15. Appropriateness of the GCS or
PGCS versus the AVPU scale as
a disability measurement is site
SPECIAL ARTICLE
specific, and both methodologies
appear to have similar predictive
value.
16. The term altered mental status
is preferred over altered level of
consciousness.
17. Motor vehicle collision or crash
is the preferred term for injury
mechanisms involving vehicle
crashes.
18. TBI is the preferred term for
all forms of head injury of all
degrees of severity.
19. Primary and secondary brain
injury are key terms that allow
distinction in timing, treatability,
and prevention options after TBI.
20. The definition of concussion
involves impact, impairment of
neurologic function, and clinical
symptoms.
21. Spinal motion restriction
refers to the preferred practice
of maintaining the spine in
anatomic alignment to minimize
gross movement, without
mandating the use of specific
adjuncts.
22. Status epilepticus is defined
as ≥5 minutes of continuous
clinical and/or electrographic
seizure activity or recurrent
seizure activity without recovery
(returning to baseline) between
seizures. Therapy should be
initiated when seizure activity
exceeds 5 minutes.
23. Hypoglycemia refers to blood
sugar ≤60 mg/dL in a child and
≤40 mg/dL in the newborn and
may result in brain injury if
not recognized and effectively
treated. Treatment decisions
should be based on patient
symptoms and can include oral
glucose.
24. Drowning is the preferred term
for submersion or immersion
in a liquid medium (usually
water) causing any degree of
SI7
 respiratory impairment, whether during infancy involving death of pediatric and other physician
the patient lives or dies. or resuscitation from life- services and should extend to the
threatening events. prehospital setting.
25. Identification of hypothermia
requires measurement of 27. Child maltreatment is the 30. Family presence is strongly
core body temperature and is preferred general term for the encouraged during assessment
often difficult to establish in broad categories of neglect and and treatment of almost
emergency settings. Therapeutic abuse of children. every emergency in children
hypothermia refers to the 28. Children with special health and during every procedure,
induction of hypothermia. care needs and technology- whenever possible.
26. Sudden infant death syndrome, assisted children are prevalent 31. The medical home concept
sudden unexpected infant death, in communities and require of accessible, continuous,
and brief resolved unexplained specialized assessment and comprehensive, family centered,
event (formerly apparent life- treatment techniques. coordinated, compassionate, and
threatening event) are preferred 29. Patient- and family-centered culturally effective care should
terms for characteristic events care are essential components extend to the prehospital setting.

SUPPLEMENTAL TABLE 2 Types of Shock by Etiology

Type Etiology
Hypovolemic Gastroenteritis, burns, hemorrhage, inadequate fluid intake, increased body fluid losses,
osmotic diuresis
Cardiogenic Congenital heart disease, myocarditis, cardiomyopathy, arrhythmia
Distributive Sepsis, anaphylaxis, spinal cord injury
Obstructive Tension pneumothorax, cardiac tamponade, pulmonary embolism, ductal-dependent
lesions (eg, coarctation, hypoplastic left ventricle) when the ductus closes

SUPPLEMENTAL TABLE 3 Stages and Signs of Dehydration

Severity of Infant EWL and mL/ Adolescent EWL and Clinical Signs Pitfalls in Assessment
Dehydration kga mL/kga
Mild 5% 50 3% 30 Dry mucus membranes; Oral mucosa may be dry in chronic mouth breathers.
oliguria Frequency and amount of urine are difficult to assess
during diarrhea, especially in toilet-trained toddlers.
Moderate 10% 100 5%–6% 50–60 Poor skin turgor; sunken Affected by sodium concentration; increased sodium
fontanel; marked oliguria; concentration better maintains intravascular volume.
tachycardia; quiet Fontanel is only open in infants. Oliguria is affected by
tachypnea fever, sodium concentration, and underlying disease.
Severe 15% 150 7%–9% 70–90 Marked tachycardia; weak Clinical signs are affected by fever, sodium
to absent distal pulses; concentration, and underlying disease.
narrow pulse pressure;
quiet tachypnea;
hypotension and altered
mental status (late
findings)
Adapted from Roberts.14
aMilliliters per kilogram is the estimated corresponding fluid deficit normalized to body weight.

SI8 FUCHS et al
 SPECIAL ARTICLE

SUPPLEMENTAL TABLE 4 GCS SUPPLEMENTAL TABLE 6 Alert, Verbal, Painful,

Eye Opening Best Motor Response Best Verbal Response Unresponsive, and
GCS Equivalents
4 Spontaneous 6 Obeys commands 5 Oriented
3 To speech 5 Localizes pain 4 Confused Response GCS Score
2 To pain 4 Withdraws from pain 3 Inappropriate words Alert 15
1 No response 3 Abnormal flexion 2 Incomprehensible words Verbal 13
2 Abnormal extension 1 No response Painful stimulation 8
1 No response Unresponsive to noxious 6
From Schutzman.19 stimulation

SUPPLEMENTAL TABLE 5 PGCSa

Score Child Infant
Eye opening
4 Spontaneously Spontaneously
3 To verbal command To shout, speech
2 To pain To pain
1 No response No response
Best motor response
6 Obeys commands Spontaneous movements
5 Localizes pain Withdraws to touch
4 Flexion-appropriate withdraw Flexion-appropriate withdraw
3 Flexion-abnormal (decorticate Flexion-abnormal (decorticate rigidity)
rigidity)
2 Extension (decerebrate rigidity) Extension (decerebrate rigidity)
1 No response No response
Best verbal response
5 Oriented and converses Smiles, coos, and babbles
4 Disoriented, confused Cries but is consolable
3 Inappropriate words Persistent, inappropriate crying and/
or screaming
2 Incomprehensible sounds Moans, grunts to pain
1 No response No response
Total = 3 to 15
a Score is the sum of the individual scores from eye opening, best motor response, and best verbal response, by using

age-specific criteria. GCS score of 13 to 15 indicates mild head injury; GCS score of 9 to 12 indicates moderate head injury;
and GCS score of ≤8 indicates severe head injury. Modified from James, Anas, and Perkin.20

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