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1.4 Primary & Secondary Pediatric Emergency Assessment

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BCEN CPEN Certified Pediatric Emergency Nurse Exam

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1 Chapter 1: Exam Overview, Triage Process & Initial Emergency Assessment

1.1 CPEN Exam Logistics, Blueprint & Certification Overview 1.2 Pediatric Triage Systems & Acuity Categorization 1.3 Pediatric Assessment Triangle (PAT) & Initial Impression 1.4 Primary & Secondary Pediatric Emergency Assessment 1.5 Age-Specific Vital Signs, Developmental Considerations & Pain Scales

2 Chapter 2: Pediatric Respiratory Emergencies

2.1 Upper Airway Obstruction 2.2 Lower Airway Emergencies 2.3 Respiratory Distress vs. Respiratory Failure & Airway Management

3 Chapter 3: Pediatric Cardiovascular Emergencies

3.1 Pediatric Dysrhythmias & ECG Analysis 3.2 Congenital Heart Defects 3.3 Acquired Heart Disease & Heart Failure

4 Chapter 4: Pediatric Neurological Emergencies

4.1 Pediatric Seizures, Status Epilepticus & Febrile Seizures 4.2 Altered Mental Status, Increased ICP & Head Trauma 4.3 Pediatric Central Nervous System Infections

5 Chapter 5: Pediatric Gastrointestinal & Genitourinary Emergencies

5.1 Pediatric GI Surgical Emergencies 5.2 Pediatric Dehydration, Gastroenteritis & Fluid Resuscitation Protocols 5.3 Pediatric GU & Renal Emergencies

6 Chapter 6: Pediatric Endocrine, Metabolic & Hematologic/Oncologic Emergencies

6.1 Diabetic Ketoacidosis (DKA) & Hypoglycemia in Pediatric Emergency Patients 6.2 Electrolyte Imbalances & Inborn Errors of Metabolism 6.3 Sickle Cell Disease Crisis & Pediatric Oncologic Emergencies

7 Chapter 7: Pediatric Musculoskeletal, Integumentary & ENT/Ophthalmic Emergencies

7.1 Pediatric Musculoskeletal Injuries & Fractures 7.2 Pediatric Dermatologic Emergencies & Rashes 7.3 Pediatric ENT & Ocular Emergencies

8 Chapter 8: Pediatric Trauma Emergencies

8.1 Pediatric Trauma Resuscitation & Anatomical Vulnerabilities 8.2 Head, Spinal & Thoracic Trauma in Children 8.3 Abdominal, Pelvic & Extremity Trauma in Pediatric Patients

9 Chapter 9: Child Maltreatment, Toxicology & Behavioral Emergencies

9.1 Child Abuse, Neglect, Non-Accidental Trauma & Mandatory Reporting 9.2 Pediatric Toxicology, Toxidromes & Emergency Antidotes 9.3 Pediatric Behavioral & Mental Health Crisis Management

10 Chapter 10: Pediatric Multi-System Emergencies, Shock & Thermal Injuries

10.1 Pediatric Shock Recognition & Classification 10.2 Pediatric Sepsis, Septic Shock & Multiple Organ Dysfunction Syndrome 10.3 Pediatric Anaphylaxis & Severe Allergic Reactions 10.4 Submersion Injuries, Drowning & Thermal/Burn Emergencies

11 Chapter 11: Professional Practice, Legal, Ethical & Safety Standards

11.1 Legal & Ethical Considerations 11.2 Patient Safety, Medication Error Prevention & Weight-Based Dosing 11.3 Family-Centered Care, Communication & Disaster/Surge Preparedness

1.4 Primary & Secondary Pediatric Emergency Assessment

Key Takeaways Explain This Topic AI

In infants, an exaggerated occiput causes neck flexion when supine; placing a small roll under the shoulders establishes a neutral 'sniffing' position to maintain airway patency.

Hypotension is a late, catastrophic sign of shock in pediatric patients; compensated shock presents with normal blood pressure maintained by compensatory tachycardia and vasoconstriction.

Neonatal hypoglycemia is defined as a bedside blood glucose less than 45 mg/dL, whereas in infants and children, hypoglycemia is defined as less than 60 mg/dL.

Intraosseous (IO) access should be established after two unsuccessful peripheral IV attempts or immediately within 90 seconds in a critically ill, unstable pediatric patient.

Last updated: July 2026

  • 1.4 Primary & Secondary Pediatric Emergency Assessment
  • Overview of Emergency Assessment Frameworks

Once the Pediatric Assessment Triangle (PAT) establishes the initial general impression, the emergency nurse immediately executes a systematic, hands-on clinical evaluation. Pediatric emergency assessment is divided into two sequential phases:

Primary Assessment (ABCDE Framework): A rapid, hands-on physical evaluation designed to identify and treat immediate life-threatening abnormalities in vital organ functions.

Secondary Assessment (FGHI Framework): A comprehensive head-to-toe physical examination, full vital sign collection, diagnostic testing, and detailed history gathering (SAMPLE / CIAMPESS). +-------------------------------------------------------------------------+

  • | PRIMARY ASSESSMENT (ABCDE) |
  • | A - Airway Patency, positioning, suctioning, adjuncts |
  • | B - Breathing Rate, effort, breath sounds, SpO2, EtCO2 |
  • | C - Circulation Pulses, cap refill, BP, heart rate, skin perfusion |
  • | D - Disability AVPU, pGCS, pupils, bedside blood glucose |
  • | E - Exposure Full exposure, injury inspection, thermoregulation |
  • +-------------------------------------------------------------------------+
  • |
  • v
  • +-------------------------------------------------------------------------+
  • | SECONDARY ASSESSMENT (FGHI) |
  • | F - Full Vitals / Family Presence |
  • | G - Give Comfort Measures (Non-pharm & Pharmacologic) |
  • | H - History (SAMPLE/CIAMPESS) & Head-to-Toe Exam |
  • | I - Inspect Posterior Surfaces (Log-roll with spinal stability) |
  • +-------------------------------------------------------------------------+
  • Systematic Primary Assessment (ABCDE)
  • A — Airway (Patency & Positioning)

Assess whether the airway is clear , maintainable with simple maneuvers, or unmaintainable requiring advanced interventions.

Anatomical Positioning Nuance: Infants have a large, prominent occiput. When placed supine on a flat surface, the heavy head flexes the neck forward, causing anatomical airway occlusion. Nurses must place a small towel roll under the shoulders to achieve a neutral "sniffing position" .

Manual Airway Maneuvers: Use the Head-Tilt/Chin-Lift for medical cases. Use the Jaw-Thrust maneuver without head tilt if cervical spine trauma is suspected.

Airway Adjuncts:

Oropharyngeal Airway (OPA): Used ONLY in unconscious patients with absent gag reflex. Measure from corner of mouth to angle of mandible. In children, insert directly over the tongue using a tongue depressor; do NOT rotate 180 degrees as in adults to avoid lacerating the soft palate.

Nasopharyngeal Airway (NPA): Used in conscious/semi-conscious patients with intact gag reflex. Measure from tip of nose to tragus of ear. Contraindicated in basilar skull fracture or severe facial trauma.

B — Breathing (Ventilatory Status & Oxygenation)

Evaluate respiratory rate, respiratory effort, chest expansion, breath sounds, and gas exchange monitors.

Auscultation: Listen in mid-axillary lines and anterior/posterior chest fields. Transmitted upper airway sounds easily mimic lower airway adventitious sounds in small chest cavities.

Capnography ( E t C O 2 EtCO_2 EtC O 2 ​ ): Continuous end-tidal C O 2 CO_2 C O 2 ​ monitoring is the gold standard for verifying endotracheal tube placement and monitoring hypoventilation ( E t C O 2 > 45 EtCO_2 > 45 EtC O 2 ​ > 45 mmHg) or hyperventilation.

Oxygenation Modalities:

Nasal Cannula: 0.5 to 4 L/min ( F i O 2 FiO_2 F i O 2 ​ 24%–38%).

Non-Rebreather Mask (NRB): 10 to 15 L/min ( F i O 2 FiO_2 F i O 2 ​ 80%–95%). Reservoir bag must be fully inflated prior to placement.

High-Flow Nasal Cannula (HFNC): Provides heated, humidified gas up to 2 L/kg/min, delivering low-level positive airway pressure.

Bag-Valve-Mask (BVM) Ventilation: Indicated for hypoventilation, severe respiratory depression, or apnea. Deliver 1 breath every 2 to 3 seconds (20–30 breaths/min for infants/children). Ensure visible chest rise.

C — Circulation (Perfusion & Hemodynamic Stability)

Assess central versus peripheral pulses, capillary refill time, skin temperature, blood pressure, and cardiac rhythm.

Pulse Assessment: Compare central pulses (brachial/femoral in infants; carotid/femoral in children) with peripheral pulses (radial/dorsalis pedis). Loss of peripheral pulses with weak central pulses indicates severe shock.

Capillary Refill Time (CRT): Depress sternum or forehead for 5 seconds. Normal CRT is < 2 < 2 < 2 seconds . Delayed CRT ( > 3 > 3 > 3 seconds) indicates poor peripheral perfusion.

Blood Pressure Standards: Hypotension is a LATE sign of pediatric shock. Compensated shock preserves normal blood pressure through profound vasoconstriction and tachycardia.

Formula for Minimum Acceptable Systolic BP (5th Percentile):

  • Term Neonates (0–28 days): > 60 > 60 > 60 mmHg
  • Infants (1–12 months): > 70 > 70 > 70 mmHg

Children 1 to 10 years: 70 + ( 2 × age in years ) 70 + (2 \times \text{age in years}) 70 + ( 2 × age in years ) mmHg

Children > 10 > 10 > 10 years: > 90 > 90 > 90 mmHg

Vascular Access Protocol: Attempt peripheral IV placement twice. If peripheral access fails or is impossible in a critically ill patient, immediately establish Intraosseous (IO) access (proximal tibia or distal femur) within 90 seconds.

D — Disability (Neurological Status)

AVPU Scale: Alert (A), Responds to Voice (V), Responds to Pain (P), Unresponsive (U).

Pediatric Glasgow Coma Scale (pGCS): Scored from 3 to 15, modified for non-verbal infants (evaluates best eye, verbal, and motor responses).

Pupillary Reflexes: Size, equality, and light reactivity.

Bedside Blood Glucose: Must be checked immediately in any child with altered mental status. Hypoglycemia thresholds:

Neonates: < 45 < 45 < 45 mg/dL (treat with 2 mL/kg D 10 W D_{10}W D 10 ​ W )

Infants & Children: < 60 < 60 < 60 mg/dL (treat with 2 mL/kg D 10 W D_{10}W D 10 ​ W or 1 mL/kg D 25 W D_{25}W D 25 ​ W )

E — Exposure & Environmental Control

Fully undress the child to inspect for hidden trauma, rashes, petechiae, or signs of abuse. Prevent Hypothermia: Infants have high body surface area-to-mass ratios. Utilize radiant warmers, warm blankets, and warmed IV fluids immediately after exposure.

  • Secondary Assessment Framework (FGHI)
  • F — Full Vitals & Family Presence

Collect a complete set of baseline vital signs (HR, RR, BP, S p O 2 SpO_2 Sp O 2 ​ , temp). Support family-centered care by maintaining primary caregivers at the bedside during resuscitation.

G — Give Comfort Measures

Implement non-pharmacologic comfort (sucrose pacifiers for infants, swaddling, distraction) and prompt pharmacologic analgesia.

H — History & Head-to-Toe Physical Exam

Obtain a detailed clinical history using standardized mnemonics:

  • SAMPLE History Mnemonic CIAMPESS History Mnemonic
  • S - Signs & Symptoms C - Chief Complaint
  • A - Allergies I - Immunizations & Isolations
  • M - Medications A - Allergies
  • P - Past Medical History M - Medication history
  • L - Last Oral Intake P - Past medical history
  • E - Events Leading to Illness/Injury E - Events leading to ED visit
  • S - Special care needs / technology
  • S - Social environment / Safety

Perform a systemic head-to-toe examination inspecting fontanelles, ears, throat, chest, abdomen (palpate for tenderness/masses), extremities, and skin integrity.

I — Inspect Posterior Surfaces

Log-roll the patient while maintaining manual in-line cervical spine stabilization to inspect the back, spine, buttocks, and posterior skin surfaces for bruising, bony deformity, or tenderness.