Tørisen et al.

BMC Emergency Medicine (2024) 24:158 BMC Emergency Medicine

https://doi.org/10.1186/s12873-024-01068-w

RESEARCH Open Access

Emergency pediatric patients and use

of the pediatric assessment triangle tool (PAT):
a scoping review
Tore A. G. Tørisen1, Julie M. Glanville2, Andres F. Loaiza3,4 and Julia Bidonde5*

Abstract
Background We conducted a scoping review of the evidence for the use of the Pediatric Assessment Triangle (PAT)
tool in emergency pediatric patients, in hospital and prehospital settings. We focused on the psychometric prop-
erties of the PAT, the reported impact, the setting and circumstances for tool implementation in clinical practice,
and the evidence on teaching the PAT.
Methods We followed the Joanna Briggs Institute methodology for scoping reviews and registered the review pro-
tocol. We searched MEDLINE, PubMed Central, the Cochrane Library, Epistemonikos, Scopus, CINAHL, Grey literature
report, Lens.org, and the web pages of selected emergency pediatrics organizations in August 2022. Two reviewers
independently screened and extracted data from eligible articles.
Results Fifty-five publications were included. The evidence suggests that the PAT is a valid tool for prioritizing emer-
gency pediatric patients, guiding the selection of interventions to be undertaken, and determining the level of care
needed for the patient in both hospital and prehospital settings. The PAT is reported to be fast, practical, and use-
ful potentially impacting overcrowded and understaff emergency services. Results highlighted the importance
of instruction prior using the tool. The PAT is included in several curricula and textbooks about emergency pediatric
care.
Conclusions This scoping review suggests there is a growing volume of evidence on the use of the PAT to assess
pediatric emergency patients, some of which might be amenable to a systematic review. Our review identified
research gaps that may guide the planning of future research projects. Further research is warranted on the psycho-
metric properties of the PAT to provide evidence on the tool’s quality and usefulness. The simplicity and accuracy
of the tool should be considered in addressing the current healthcare shortages and overcrowding in emergency
services.
Review registration: Open Science Framework; 2022. https://​osf.​io/​vkd5h/
Keywords Pediatrics or paediatric, Pediatric assessment triangle, Children; emergency medicine; review

*Correspondence:
Julia Bidonde
[email protected]
Full list of author information is available at the end of the article

© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or
parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To
view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Tørisen et al. BMC Emergency Medicine (2024) 24:158 Page 2 of 14

Background to deliver timely effective emergency treatment. EHWs

Emergency medical services (EMS) are crucial to emer- also need to reassure patients and caregivers and bring
gency care systems providing effective emergency order to potentially chaotic situations. EHWs who lack
medical care to people in need [1]. The World Health specialized training in pediatric emergencies may unin-
Organization (WHO) Emergency Care System Frame- tentionally exacerbate stressful situations [13]. Emer-
work [2] (see Additional file 1) notes that effective emer- gency pediatric training for healthcare professionals
gency care involves a coordinated and integrated system inside and outside of the hospital is essential to ensure
of care, including the provision of prehospital care, trans- the best outcomes for critically ill or injured pediatric
portation, and emergency department (ED) services. patients [14, 15].
The WHO framework emphasizes the importance of Emergency triage involves quickly identifying patients
early recognition of health issues and the timely provi- who require medical attention to prioritize treatment
sion of appropriate interventions to reduce morbidity efficiently for those in greatest need [14]. Triage tools
and decrease the incidence of death and illness. Pediat- such as the Manchester Triage System and the Emer-
ric emergencies, particularly acute injuries and illnesses, gency Severity Index are helpful [16]. The Paediatric
generate considerable numbers of ambulance calls and Canadian Triage and Acuity Scale (PaedCTAS) was
ED visits in developed countries [3, 4]. developed specifically for pediatric patients [17], using
There is a general understanding that lack of pediatric the Pediatric Assessment Triage (PAT) tool as the first
emergency flow (or crowding) may lead to adverse out- step in assessing emergency patients. It includes the “gen-
comes for the child. However, the prevalence of pediatric eral impression” stage using the PAT, primary assessment
emergencies poses significant challenges to emergency with the airway, breathing, circulation, disability, and
healthcare providers [5, 6]. In the UK, pediatric emer- exposure (ABCDE) approach [18], secondary assessment,
gencies represent 5–10% of all emergencies [7] and in the diagnostic assessment, and reassessment.
USA, children represent 20% of ED patients [8]. Injuries
are the leading cause of morbidity and mortality among The Pediatric Assessment Triangle (PAT)
children and adolescents [9, 10]. The PAT is used to quickly identify critically ill or injured
Caring for critically ill or injured pediatric patients children needing immediate medical attention. It focuses
can be challenging for emergency healthcare workers on three presenting components (“arms”): appear-
(EHWs) [11]. Patients’ histories may be difficult to obtain ance, work of breathing, and circulation (Fig. 1). It can
if the patient cannot provide verbal information or has be used in prehospital or hospital settings for efficient
been found alone without a caregiver [12]. Taking vital rapid assessment of the patient’s level of consciousness,
signs can be difficult and may not provide accurate infor- breathing, and circulation, without requiring hands-
mation due to normal age-based variations [12]. Fur- on assessment or equipment [5, 19]. It can help identify
thermore, some EHWs may have not received training in key pathophysiological problems and whether urgent
pediatric emergencies, which can be stressful [13]. transport or resources are needed. The PAT assessment
Despite these challenges, EHWs need to conduct a takes 30–60 s [5, 19] and it can be performed remotely (a
rapid and accurate assessment of the pediatric patient “through the room” assessment).

Fig. 1 The Pediatric Assessment Triangle components (arms). Figure adapted from Fuchs S and McEvoy M [20]]
Tørisen et al. BMC Emergency Medicine (2024) 24:158 Page 3 of 14

Methods and CINAHL, from 1995 to July 2022, to include publi-

Scoping review aim and design cations before the introduction of the PAT in the curric-
Give the current shortage of healthcare personnel world- ula of Pediatric Education for Prehospital Professionals
wide, and overcrowding of emergency departments, (PEPP) and Advanced Pediatric Life Support (APLS) in
gathering of the PAT’s evidence is essential. This review 2000 [24]. The database searches were conducted from
aimed to identify the available scientific evidence about 24 to 28 July 2022. Fourteen websites of organizations
the PAT and its use by EMS. Our objective was to com- involved in policy making in emergency pediatrics were
plete a scoping review within the pre-and-hospital care to searched between 6 and 10 August 2022. We searched
synthesize: for unpublished (grey) literature using Grey Literature
Report (http://​www.​greyl​it.​org/) and Lens.org (https://​
• What are the psychometric properties of the PAT www.​lens.​org/). Full searches are presented in additional
(e.g., validity, reliability, applicability)? file 3.
• What are the reported impact(s) of the PAT? (e.g.,
improved triage, cost, better clinical outcomes)
• What are the requirements or circumstances for PAT Study selection process
implementation in clinical practice? We deduplicated records in EndNote and conducted
• What is the evidence on the value of teaching EMS double independent screening (TT, AFL-B) in Covidence
workers about PAT? (Veritas) against the eligibility criteria (Table 1). Con-
flicts were resolved by consensus or arbitrated by a third
We followed the Joanna Briggs Institute framework for reviewer (JB). Additional file 4 lists records excluded
scoping reviews [21]. The review protocol was registered at full text with reasons. Records reporting the same
[22]. The review is reported according to the PRISMA study were grouped and we cite the earliest publication
extension for scoping reviews [23] (Additional file 2). while presenting relevant data from any of the related
publications.
Eligibility criteria
Eligible publications (Table 1) reported the use of the
PAT with pediatric populations in prehospital, hospital Data collection process
or training settings. Eligible outcomes matched our spe- Data were extracted from eligible studies into a Microsoft
cific aims as follows: 1) psychometric performance, 2) 365 Excel form which was piloted on a random sample
impact(s), 3) implementation of PAT utilization, and 4) of five included studies, and modified as required based
evidence on teaching the PAT. on feedback from the team [22]. One reviewer (TT) com-
pleted data extraction and a second reviewer (AFL-B)
Searches verified the extracted data. Disagreements were resolved
We searched MEDLINE (PubMed), PubMed Central (via by consensus or arbitrated by a third reviewer (JB). Risk
LitSense), the Cochrane Library, Epistemonikos, Scopus of bias was not assessed [21].

Table 1 Scoping review inclusion and exclusion criteria

Inclusion Exclusion

• Participants/population: Emergency pediatric patients. ‘Emergency’ defined Exclusions:

as any medical condition or trauma that requires contact with the health care • Non-English language literature unless there was an English abstract,
system, prehospital and/or hospital. Pediatric means any patient from 0 to 18 in which case the abstract was data extracted
years of age. Emergency health care workers. Pediatric Assessment Triangle • Podcasts, recorded lectures etc.
(PAT) trainers • Incomplete records (i.e., those with no abstracts or where the full text
• Concept: The PAT for clinical assessment was unavailable after exhausting all possible routes)
• Context: Prehospital and hospital use. Prehospital includes, but is not limited
to, Emergency Medical Services, out of hours clinics, search and rescue
services, doctors’ offices, “walk in” clinics, or ambulance services. Hospital use
is not limited to emergency departments. In training settings
• Outcomes: Psychometric properties of the PAT (e.g., validity, reliability, appli-
cability), reported impact(s), requirements for PAT implementation, reported
conditions of PAT utilization, and evidence on teaching/instructing people
to use the PAT
• Any publication status. Documents at all stages of publication were eligible
(e.g., “in review”, “accepted”, “in press”, “published”)
Tørisen et al. BMC Emergency Medicine (2024) 24:158 Page 4 of 14

Knowledge user (KU)/patient engagement Additional file 5) of which three were books. Sixteen pub-
and methodological appraisal lications were in non-English languages, but with English
We defined KU/ patient engagement as individuals who abstracts, and of these we retrieved 14 full text publica-
may be affected by the research findings. Since this tions (Spanish (n = 9), German (n = 2), French (n = 1),
review was time sensitive, we did not recruit knowledge Turkish (n = 1), and assumed Taiwanese Mandarin
users or patients. (n = 1)). Of these, there were seven papers that described
We did not appraise methodological quality or risk the psychometric properties of the PAT, 18 were about
of bias of the included articles, which is consistent with the PAT’s impact, 38 described implementation pros and
guidance on scoping review conduct. cons, and 30 provided references to the PAT used in edu-
cational/training environments. The publication dates
Synthesis ranged from 1999 to 2022, representing 18 countries with
The synthesis included quantitative (e.g. psychometric the majority classified as "high income" (World Bank
properties) and qualitative analyses (e.g. content analysis) classification) [25] (see Additional file 6). Study designs
of the components of the impact, implementation and were diverse: primary research (n = 27, 49.1%), second-
teaching. A word cloud was drawn for the impact of the ary research (n = 4, 7.3%), and "other" (n = 24, 43.6%). We
PAT using the online program WordClouds. The team identified no randomized controlled trials, systematic
members identified, coded, and charted relevant units reviews, or scoping reviews.
of text from the articles using a framework established a
priori as a guide. The framework was developed through Psychometric properties
team discussions upon reviewing the preliminary results. The seven papers reporting psychometric properties
Data were grouped by question and overviews are pro- were as follows. Four studies (Table 2) reported sensi-
vided using charts and tables generated using Microsoft tivity and specificity, measuring test accuracy [26–29],
365 Excel. of which one study reported an area under the receiver
operating characteristic curve (AUROCC) [29] and four
Results studies reported likelihood ratios (LR) [26–28, 30].
Search results and publication characteristics PAT sensitivity (Fig. 3) ranged from 77.4% to 97.3%
The searches identified 548 records (Fig. 2). Fifty- (four studies) suggesting it can accurately identify a
five publications were included (full citations listed in large proportion of patients with the targeted condition

Fig. 2 PRISMA flow chart

Table 2 Psychometric properties of the Pediatric Assessment Triangle (7 studies)
Author (number of Sensitivity Specificity Positive Negative likelihood Odds Ratio Area under the Reliability
participants) % (95% CI) % (95% CI) likelihood ratio (95% CI) (95%CI) receiver operating (95% CI)
ratio (95% CI) curve

Aviles-Martinez 2016 81 (78–84) 87 (84–90) 5.2 (5–7.8) 0.22 (0.18–0.26) 111 (73–168.6) p < 0.001 NR NR
[26]
N = 1120 children
Fernandez 2010 NR (NR) NR (NR) NR (NR) NR (NR) NR (NR) NR 93.6% (Kappa index 0.77
N = 57,617 cases (0.75–0.79)
Tørisen et al. BMC Emergency Medicine

Fernandez 2017 [24] NR (NR) NR (NR) NR (NR) NR (NR) Abnormal PAT findings NR NR
N = 302,103 episodes at triage increased hos-
pitalization probability
5.14 (4.97–5.32) p < 0.01
Age adjusted
autonomous risk factors
for hospitalization:
(2024) 24:158

abnormal PAT findings

and urgent triage levels
I-III: 2.21 (2.13–2.29);
triage levels 6.01
(5.79–6.24) p < 0.01
Abnormal appearance
or 1 + components
of the PAT were associ-
ated with admissions:
3.99 (3.63–4.38) p < 0.01;
14.99 (11.99–18.74)
p < 0.001
Adjusted age and triage
were independent risk
factor for intensive care
unit admission 4.44
(3.77–5.24) P < 0.001
and longer stay 1.78
(1.72–1.84) P < 0.001
in the pediatric emer-
gency department
Page 5 of 14
Table 2 (continued)
Author (number of Sensitivity Specificity Positive Negative likelihood Odds Ratio Area under the Reliability
participants) % (95% CI) % (95% CI) likelihood ratio (95% CI) (95%CI) receiver operating (95% CI)
ratio (95% CI) curve

Gausche-Hill 2014 [27] 77.4 (72.6–81.5) (insta- 90 (87.1–91.5) 7.7 (5.9–9.1) NR NR NR Paramedics used
N = 1168 PAT study bility) (instability) (instability) of the PAT in the three
forms arms and formed a gen-
eral impression with high
consistency k = 0.93
(0.91–0.95)
Tørisen et al. BMC Emergency Medicine

κ = 0.62 (0.57–0.66) (PAT

paramedic’s impres-
sion and investigators’
retrospective chart
review on final diagnosis
and disposition)
(2024) 24:158

κ = 0.66 (0.62–0.71) (PAT

paramedics’ impression
and investigator’s impres-
sion: stability)
Horeczko 2013 [28] Children deemed Children deemed Children Instability (n = 58): 0.12 NR NR Fleiss’ κ (n = 38, 3 raters)
N = 528 children instable (n = 58): 97.3 instable(n = 58): 22.9 deemed stable: (0.06–0.25) Appearance = 0.7,
(94.6–98.8) (17–30) 0.12 (0.06–0.25) Respiratory dis- (0.51–088) p < 0.001
Respiratory dis- Respiratory dis- Instability tress (n = 290): 0.11 Work of breathing = 0.24
tress (n = 290): 91.1 tress (n = 290): 76.6 (n = 58): 1.2 (0.078–0.17) (0–0.48) p 0.01
(86.6–94.2) (71.1–81.3) (1.2–1.3) Respiratory failure Circulation to skin = 0.32
Respiratory failure Respiratory failure Respiratory dis- (n = 14): 0.8 (0.55–1.06) (0–0.49) p < 0.001
(n = 14): 25.0 (6.7–57.2) (n = 14): 97.9 (96.1–98.9) tress (n = 290): Shock (n = 109): 0.32 Categories of pathophysi-
Shock (n = 109): 74.1 Shock (n = 109): 82.2 4 (3.1–4.8) (0.17–0.60) ology
(53.4–88.1) (78.5–85.4) Respiratory CNS/ metabolic Stable = 0.70 (0.51–0.88)
CNS/ metabolic CNS/ metabolic failure (n = 14): disorder (n = 49): 0.58 p < .001
disorder (n = 49): 46.0 disorder (n = 49): 93.5 12 (4–37) (0.43–0.78) Respiratory distress = 0.16
(30.0–62.9) (90.8–95.4) Shock (n = 109): Cardiopulmonary (0 to 0.49) p 0.08
Cardiopulmonary Cardiopulmonary 4.2 (3.1–5.6) failure (n = 11): 0.25 Respiratory failure = 0.74
failure (n = 11): 75 failure (n = 11): 98.5 CNS/ metabolic (0.046–1.39) (0–1) p < .001
(21.9–98.7) (96.9–99.3) disorder Shock = 0.32 (0–0.49)
(n = 49): 7 p < .001
(4.3–11) CNS/metabolic distur-
Cardiopulmo- bances = 0.68, (0.51–0.88)
nary failure p < .001
(n = 11): 49.1
(20–120)
Page 6 of 14
Table 2 (continued)
Author (number of Sensitivity Specificity Positive Negative likelihood Odds Ratio Area under the Reliability
participants) % (95% CI) % (95% CI) likelihood ratio (95% CI) (95%CI) receiver operating (95% CI)
ratio (95% CI) curve
Tørisen et al. BMC Emergency Medicine

Lugo 2012 NR (NR) NR (NR) NR (NR) NR (NR) NR NR Trained observer

N = 157 children and nurse agreement
150/157: k 0.90 (0.91)
Concordance ­Indexa
Stable and non-urgent
patients: k.0.83 (0.85)
Stable and semi-urgent:
(2024) 24:158

κ: 0.95 (0.96)
Respiratory distress
and compensated shock
with urgencies: κ: 0.79
(0.81)
Emergency and respira-
tory failure or decompen-
sated shock: κ: 0.5 (0.6)
Ma 2021 [29] 93.24 (NR) 99.15 (NR) NR (NR) NR (NR) NR AUROCC 0.96 Rate of agreement
N = 1608 children AUROCC PAT vs PWES: between the PAT
0.96 vs 0.99 x­ 2 0.10 p and the actual situa-
0.74 tion of the sick child
The PAT performed bet- was 93.24%
ter in assessing non-res-
piratory critical diseases
(vs. respiratory critical
diseases), with values
of AUROCC of 0.986
vs 0.930, YI of 0.969 vs
0.858, respectively
CI confidence interval, CNS central nervous system, PAT pediatric assessment triangle, PEWS pediatric early warning score, YI Yorden index
*Concordance Index – is not typically considered a measure of reliability. In this context it has been used to predict or classify outcomes, the concordance index has been used to evaluate the accuracy of the test’s
predictions
Kappa interpreted as < 0.20 weak k 0.21 – 0.40, moderate k 0.41 – 0.60, good k 0,61- 0,80 very good
Fleiss k coefficient <0.00 poor, 0.00-0.20 slight 0.21-0.40 fair 0.41-0.60 moderate, 0.61-0.80 substantial 0.81-1.00 almost perfect.
Page 7 of 14
Tørisen et al. BMC Emergency Medicine (2024) 24:158 Page 8 of 14

Fig. 3 PAT sensitivity and specificity

[26–29]. Specificity, measuring a test’s ability to correctly to correctly identify and classify initial severity of disease
identify patients without the condition, ranged from during triage. A second study reported a LR + of 7.7 (95%
22.9% to 99.15% (four studies) [26–29]. CI 5.9–9.1) [27]. A third study triaged 1002 children using
One study evaluated the PAT’s validity and reliability the PAT, reporting a LR + of 0.12 (95% CI 0.06–0.25) for
[31] by collecting data for 157 patients triaged by a single children deemed stable by the PAT (n = 200) [28]. This
trained observer and an “enfermera clasificadora” (classi- study’s results for categories of pathophysiology (respira-
fying nurse). This single pair showed high inter-observer tory distress, respiratory failure, shock, central nervous
agreement in applying the PAT and no errors associated system/metabolic disorder, and cardiopulmonary fail-
with polypnea, pre-existing pallor, or irritability. ure) highlighted the need to consider the clinical scenario
Likelihood ratios (LR) measure a test’s diagnostic accu- when interpreting the PAT in EMS. However, the mod-
racy which are less likely to change with the prevalence of erate LR- value (0.22, 95% CI 0.18–0.26) indicated that
a disorder. A positive LR (LR +) indicates a positive test the test is less able to correctly identify children who do
result is more likely in people with the condition and a not need urgent care. The study reported a LR- of 0.12
negative LR (LR-) indicates that a negative test result is (95% CI 0.06–0.25) for children found to be stable by the
more likely in people without the condition of interest. PAT (n = 802) [28]. The LR- values for children with the
One study reported LR + of 5.2 (95% CI 5–7.8) [26] with five specified categories of pathophysiology suggest the
a statistically significant high odds ratio (OR 111, 95% CI PAT has relatively low LR for identifying respiratory dis-
73–168.6; p < 0.001), indicating the PAT has a high ability tress and shock, indicating it is better at ruling out those
Tørisen et al. BMC Emergency Medicine (2024) 24:158 Page 9 of 14

conditions. However, the relatively high LR- for respira- Reported impacts of the PAT
tory failure and cardiopulmonary failure suggests the Eighteen publications reported on impacts after PAT
PAT is less effective at ruling out those conditions. implementation; the word cloud of impact names is dis-
One study (2017) found that abnormal PAT results play in Fig. 4. Terms most used were “triage –communi-
were associated with an increased risk of admission to cation -vocabulary and care”.
the hospital (OR 5.14, 95% CI 4.98–5.32; p < 0.01) [30]. Impact reported were on mortality, safety, effectiveness
Abnormal appearance (OR 3.99, 95% CI 3.63–4.38) or of care, timeliness of care, triage, and communication
having one or more components of the PAT (OR 14.99, [27–31, 33–44]. Three studies showed the ability of the
95% CI 11.99–18.74) were significantly associated with PAT to correctly assess critical cases (e.g. higher risk of
hospital admission [30]. The study identified adjusted mortality in patients with sepsis with an altered or unsta-
age (OR 4.44, 95% CI 3.77–5.24; p < 0.001) and triage ble PAT) [33, 34, 36]. Two studies found that PAT helped
(OR 1.78, 95% CI 1.72–1.84; p < 0.001) as independent to avoid unnecessary interventions or potential harm to
risk factors for intensive care unit admission and longer patients [27, 35]. One study reported that a normal PAT
stays in the pediatric ED [30]. One study reported the result did not exclude severe infections, and a proper
PAT performed similarly to the Pediatric Early Warning examination was still necessary to diagnose emergency
Score (PEWS) (AUROCC 0.963 (PAT) and 0.966 (PEWS); pediatric patients [33]. One study reported that the PAT
x2 = 0.10; p = 0.74) [29]. was timely and rapid to apply (mean 32.4 s) [31] and two
Four studies reported high levels of reliability in PAT studies reported that the PAT was equally effective, but
results [27–29, 32]. One study reported 93.6% reliability faster and easier to use, than the PEWS in predicting crit-
(Kappa index 0.7, 95% CI 0.5–0.8) [29]. A second study ical illness in pediatric patients [29, 38].
found paramedics used the PAT highly consistently Communication and documentation were another
across its three arms (Kappa 0.93, 95% CI 0.91–0.95) [32] way the PAT’s impact were reported. The PAT’s “general
and the paramedics’ impression, completed using PAT on impression” aided in care communication and helped
first contact with the patient, showed substantial agree- prioritize management options. The specific vocabu-
ment with the investigators’ retrospective chart review on lary to describe a patient’s vital signs and physical find-
diagnosis and disposition (Kappa 0.62, 95% CI 0.57–0.66) ings allowed for easy documentation and transfer/flow
and categorization of stable versus unstable (Kappa 0.66, of information between EHWs [27, 28, 37]. Two studies
95% CI 0.62–0.71). A third study reported substantial highlighted the power of a common vocabulary in EMS
inter-rater reliability agreement on PAT scores (n = 1002, replacing subjective comments with specific assessments
two pediatric emergency physicians and a pediatric nurse [27, 28].
practitioner) (Fleiss’ κ 0.7, p < 0.001) [28]. A fourth study Studies offered insights into achieving optimal triage
reported an agreement rate of 93.24% between the PAT outcomes using the PAT. One study demonstrated the
and the condition of sick children [29]. PAT’s usefulness when classifying non-urgent patients

Fig. 4 The PAT reported impact

Tørisen et al. BMC Emergency Medicine (2024) 24:158 Page 10 of 14

[40] and a second noted the importance of setting sever- patients [29]. In a study of the Advanced Pediatric Life
ity and prioritization criteria (1 to 5 depending on sever- Support (APLS) course, attendees considered the system-
ity) and using the PAT to ensure proper attention [45]. atic assessment approach incorporating the PAT crucial
Abnormal PAT findings helped to identify patients to their clinical practice, highlighting the importance of
with a higher risk of hospitalization [30] and enabled ear- training prior implementation [54]. Studies acknowl-
lier interventions for high-risk patients [42]. One study edged that applying the PAT with young infants (7–89
used the PAT for children experiencing secondary com- days old) was challenging [33], implementing the PAT
plications to hematopoietic cell transplantation [44] and requires skills, on-site senior emergency pediatric care
reported that an unstable PAT, along with other factors, providers, and a pediatric-friendly environment [59] and
accurately predicted the need for admission (relative risk that the feasibility of the PAT is promising, but further
3.4, 95% CI 2.6–4.6; p < 0.001). A study investigated fea- research for “clinical validation” (not further defined) was
tures of 17,243 cases referred from in-hospital areas to needed [30].
the pediatric ED (median age 42 months (range: 0–120)); We found no information about the implementation of
65% of transferred patients were PAT-assessed as sta- PAT in clinical guidelines, requirements for recertifica-
ble [41]. One study assessed the PAT as a discriminator tion after PAT implementation, cost of implementation,
in the triage classification system and assessed the cor- or sustainability.
relation between pathophysiological diagnosis and triage
classification [31]. Four studies suggested the PAT was Teaching the PAT
considered practical and helpful in identifying emergency Thirty studies presented data on teaching PAT to EHWs
pediatric patients in need of intervention and identifying as follows: an early report suggested that the PAT was
the probable underlying cause of illness [26, 28, 38, 46]. ideal for pediatric life support courses in all settings,
Treatment priorities were met in children with fever, and based on its simplicity and reproducibility for both
to a lesser extent for pain, respiratory distress, and oxy- teachers and clinicians [60]. The PAT is included in one
gen needs. textbook of general emergency pediatrics [61] and two
One study concluded that an abnormal PAT and a textbooks for emergency pediatric care in the prehospi-
more severe triage level (I-III) were independent factors tal environment [20, 62]. Courses for EHWs on pediat-
in identifying asthmatic children requiring hospitaliza- ric life support have incorporated the PAT for the “first
tion and longer stays [43]. One study suggested that the impression” assessment, as well as training on the use of
PAT did not perform well for patients with anaphylaxis the PAT tool itself [29, 30, 63].
and as a result patients did not receive timely interven- Methods for teaching the PAT tool included classroom-
tions [39]. based, use of simulation, use of virtual reality and video
We found no data for impacts on pediatric readmis- for case training [54, 64, 65]. The PAT has been recom-
sion, patient/caregiver experience, or provider burnout. mended as a teaching tool for the goal-directed manage-
ment of shock in children [66].
Setting and circumstances for PAT implementation The number of people who have received PAT training
Ten studies evaluated pre-hospital triage using the PAT is unknown, but more than 170,000 EHWs had received
[6, 20, 27, 30, 38, 47–50] and 28 evaluated hospital tri- formal training up to 2010 (worldwide) [63]. The num-
age [24, 26, 28–36, 39–46, 50–58]. No studies reported bers of EHWs trained in the studies ranged from 30 to
PAT use in emergency call centers or telemedicine ser- 1520 [29, 54].
vices. One study noted that the PAT may be implemented Eighteen studies reported the care of emergency pedi-
by midwives working in hospitals or prehospital settings atric patients and provide insights into best practices for
[37]. A study of 391 admissions reported PAT was con- care which can, in turn, inform educational programs
sidered a useful triage tool in resource-poor hospitals or be used to develop evidence-based protocols [30, 37,
[52]. 48–50, 56, 57, 59, 67–76]. Four publications describe how
Four studies recommended formal training on using emergency care providers use the PAT to assess emer-
the PAT as necessary for effective use [27, 28, 45, 47]. gency pediatric patients generally or with specific medi-
One study (n = not reported) found that a low utilization cal problems [30, 49, 59, 67].
rate for the PAT (patient report forms collected over a
three-month period) following its introduction increased Discussion
significantly following training in PAT use (12% vs 63.3%) We identified 55 documents reporting the use of the
[47]. After implementation, one study reported that the PAT in hospital and pre-hospital emergency pediatric
30 emergency nurses involved preferred using the PAT care. Research indicates that the PAT is a valid and reli-
over the PEWS when assessing emergency pediatric able tool for evaluating emergency pediatric patients,
Tørisen et al. BMC Emergency Medicine (2024) 24:158 Page 11 of 14

prioritizing interventions, and determining the appro- using simulation-based approaches, should review
priate level of care. EHWs found the PAT is fast and these sources of evidence-based training [78].
practical, akin to the intuitive ‘gut feeling’ of experi- The main challenges to PAT instruction noted to date
enced clinicians., but they should complete formal are the limited provision of hands-on experience (i.e.
training before implementing the PAT. Several emer- real-life emergency situations), limited feedback on site
gency pediatric care course curricula and key textbooks to the EHW on their performance (to enable them to
include the PAT. identify and correct areas of weakness in their assess-
We found only seven publications on the PAT’s psycho- ment skills) and lack of standardization in the training
metric properties, which suggest that the PAT has good programs. Skill decay is problematic as EHWs may for-
sensitivity and some variability in specificity. The low get the PAT steps without regular use. Re-certification
research volume may reflect ethical challenges around requirements depend on the EHW’s professional organ-
research involving children, the unique and unpredict- ization and any employer’s certification requirements.
able nature of emergency situations, the impossibility of Although research evidence seems to show that the
controlling all variables and difficulties in obtaining fund- PAT is considered a valuable tool for rapid assessment
ing [77]. Research on psychometric properties can be of the status of a distressed patient, and its simplicity
expensive and funding for pediatric-focused psychomet- makes it easy to implement across a range of settings,
ric research may not be a priority for research funders. we identified limited evidence on using the PAT in
The PAT’s ease of use may have contributed to its rapid low-income settings [52, 79]. Resource-limited settings
adoption in practice before adequate psychometric test- may lack coordinated emergency systems including at
ing was conducted and published. Implementing the PAT the scene aid, a system of triage, emergency medical
may still be challenging in terms of training or resist- care and critical care [80]. In these situations, different
ance to change [47]. Despite the challenges of research approaches to pediatric assessments may be adopted,
in the emergency setting, a third of the included stud- limited data may be recorded on the frequency and
ies reported positive impacts when using the PAT, sug- quality of PAT assessments [81] and access to PAT
gesting its potential for triaging and improving patient training may be limited. Workforce shortages can
outcomes in clinical settings which merits further inves- impact the availability of trained EHWs to provide PAT
tigation in an era of emergency department overcrowd- instruction. Despite the limited evidence, we anticipate
ing and shortages of healthcare personnel. that the PAT is still a feasible tool for EHWs with lim-
Other tools are also used for emergency pediatric ited resources [52]. The PAT’s simplicity can be helpful
assessment (e.g., the Pediatric Glasgow Coma Scale, the in rural areas, remote communities, and resource-lim-
PEWS, and the Pediatric Vital Sign Score) and each has ited clinics. Based on evidence from this review, the
its strengths and limitations. Choosing a tool depends on PAT provides a practical and effective way for EHWs
the specific circumstances and the healthcare provider’s to assess children in emergency situations and make
expertise. Based on the included comparative studies, the informed decisions about their care.
PAT is often favored for its simplicity, rapidity, and ease
of use in remote or face-to-face emergency settings, since
it does not require hands-on assessment or the use of Limitations
specialized equipment. The available research and com- This scoping review has limitations. Firstly, we focused
parative studies merit further investigation. on English language articles and there may be additional
Evidence was identified on training EHWs to use the full text publications in non-English languages that might
PAT to assess accurately a child’s appearance, work of have provided information on low- and middle-income
breathing, and circulation. Proficiency is needed in countries’ experiences of the PAT, its impact, or its psy-
using the tool and there is a need to use it regularly, to chometric properties. This scoping review was prag-
maintain their knowledge. While the PAT can provide matic, but a follow up review may identify additional
a quick snapshot of a child’s overall condition, it is only studies in languages other than English. Secondly, the
one part of a comprehensive assessment, and EHWs search for grey literature was conducted on 14 websites,
should use additional tools and techniques to assess a was hampered by the varying quality (and sometimes
child’s condition. Online courses, in-person workshops, absence) of website search engines and the list of web-
and continuing education courses offered by profes- sites was prepared by one author (TT). A full systematic
sional organizations as well as guides or manuals with review would ideally search a larger number of websites
step-by-step instructions on how to use the PAT are and other sources of grey literature to potentially identify
all available. Healthcare providers who are consider- further research, particularly for LMICs. and might have
ing preparing or updating their PAT training, perhaps been enhanced by suggestions from experts in the field.
Tørisen et al. BMC Emergency Medicine (2024) 24:158 Page 12 of 14

Options for a future systematic review and other areas

Additional File 6. Appendix A – WHO Emergency Care System Framework
of research
A full systematic review would likely focus on those
Acknowledgements
research questions for which there are most data follow- This work was submitted as a thesis requirement for the Master in Pre-Hospital
ing the scoping review and would also include detailed Critical Care, University of Stavanger, Norway in December 2022. We thank
data extraction as well as the grouping of studies by out- the Norwegian Institute of Public Health for supporting this publication open
access fees.
comes of interest to provide summaries of the evidence
for each outcome. Scoping reviews typically do not con- Authors’ contributions
duct risk of bias assessments or evaluate publication bias. Project conceptualization was done by TT, JB, JG, and AFL. TT and JB were
primarily responsible for the methodology and resources, while TT, JB, and AFL
A future systematic review could include these steps to carried out the data extraction and validation process, and TT led the analysis
assess the strength and quality of the evidence for the use and synthesis. TT and JB wrote the original draft, with input and feedback
of the PAT. from JG and AFL during the review and editing process. The visualization was
primarily handled by TT and AFL. TT and JB supervised the project, and TT
Other areas for research identified are how the PAT managed project administration. JB was responsible for software acquisition.
affects pediatric readmissions, patient/caregiver experi-
ence, and provider burnout. This scoping review did not Funding
This work had no financial support.
find evidence of implementation, that is requirements of
recertification and costs or data on utilization for exam- Availability of data and materials
ple use of the PAT by emergency call centers, assess- All data generated or analysed during this study are included in this published
article [and its additional information files].
ments by videoconference or other telemedicine services.
Evidence on the utilization of the PAT specific to differ-
Declarations
ent emergency transport services such as air medical ser-
vices, disaster response, etc. was not found. Ethics approval and consent to participate
Not applicable.

Consent for publication

Conclusion Not applicable.
In summary, this scoping review shows that the PAT has
Competing interests
been used in clinical settings for over 20 years. There is Tore A. G. Tørisen is an instructor and medical supervisor for courses in “Pedi-
some evidence of its validity and reliability, impacts and atric Education for Prehospital Professionals” (PEPP) and he is registered with
that the tool is broadly accepted by EHWs. Although the the American Academy of Pediatrics (AAP). The remaining authors declare no
conflict of interest.
PAT condenses years of experience into a practical and
useful assessment suitable for use by less experienced Author details
1
personnel, the need for prior training and certification University of Stavanger, P.O. Box 8600, NO‑4036 Stavanger, Norway. 2 Glanville.
Info, 38 Moorgate, York YO24 4HR, UK. 3 Instituto Universitario de Educación
was highlighted. Although there are gaps in the litera- Física, Universidad de Antioquia. , Medellín, Colombia. 4 Grupo de Investi-
ture, the evidence has increase in recent years. Scoping gación en Entrenamiento Deportivoy, Actividad Física Para La Salud (GIEDAF),
reviews are used to inform research agendas and identify Universidad Santo Tomás. , Tunja, Colombia. 5 School of Rehabilitation Science,
College of Medicine, University of Saskatchewan, 107 Wiggins Rd, Saskatoon,
implications for policy or practice. As such, psychomet- SK S7N 5E5, Canada.
ric tool data are imperative. Further research on impact
and implementation is warranted, and in particular, there Received: 19 July 2023 Accepted: 8 August 2024
is a need to standardize the teaching of PAT teaching
and its certification. The simplicity, friendliness and low
resources requirement of the tool should be considered
in addressing the current healthcare shortages and over- References
crowding in emergency services. 1. Kobusingye OC, Hyder AA, Bishai D, Joshipura M, Hicks ER, Mock C.
Emergency medical services. In: Jamison DT, Breman JG, Measham AR,
et al, editors. Disease control priorities in developing countries 2nd ed.
Supplementary Information Washington, DC: International Bank for Reconstruction and Development
The online version contains supplementary material available at https://​doi.​ / The World Bank; 2006. https://​www.​ncbi.​nlm.​nih.​gov/​books/​NBK11​744/.
org/​10.​1186/​s12873-​024-​01068-w. 2. World Health Organization (WHO). WHO Emergency care system frame-
work infographics Geneva: World Health Organization; 2018. Available
from: https://​www.​who.​int/​publi​catio​ns/i/​item/​who-​emerg​ency-​care-​
Additional File 1: Appendix B. PRISMA-ScR
system-​frame​work. Updated 2 May 2018; cited 2023 11 April.
Additional File 2. Appendix C. Search Strategy 3. Andersen K, Mikkelsen S, Jørgensen G, Zwisler ST. Paediatric medical
Additional File 3. Appendix D. Excluded studies with reasons for exclusion emergency calls to a Danish emergency medical dispatch centre: a
retrospective, observational study. Scand J Trauma Resusc Emerg Med.
Additional File 4. Appendix E. Included studies 2018;26(1):2.
Additional File 5. Tables 4. Lee LK, Porter JJ, Mannix R, Rees CA, Schutzman SA, Fleegler EW,
et al. Pediatric traumatic injury emergency department visits and
Tørisen et al. BMC Emergency Medicine (2024) 24:158 Page 13 of 14

management in US children’s hospitals from 2010 to 2019. Ann Emerg 28. Horeczko T, Enriquez B, McGrath NE, Gausche-Hill M, Lewis RJ. The pediat-
Med. 2022;79(3):279–87. ric assessment triangle: accuracy of its application by nurses in the triage
5. Fuchs S. The origins and evolution of emergency medical services for of children. J Emerg Nurs. 2013;39(2):182–9.
children. Pediatr Ann. 2021;50(4):e150–4. 29. Ma X, Liu Y, Du M, Ojo O, Huang L, Feng X, et al. The accuracy of the
6. Fuchs S, Yamamoto L, editors. APLS: the pediatric emergency medicine pediatric assessment triangle in assessing triage of critically ill patients in
resource. 5th ed. Burlington: Jones & Bartlett Learning; 2012. p. 538. emergency pediatric department. Int Emerg Nurs. 2021;58.
7. Houston R, Pearson GA. Ambulance provision for children: a UK 30. Fernández A, Ares MI, Garcia S, Martinez-Indart L, Mintegi S, Benito J.
national survey. Emerg Med J. 2010;27(8):631–6. The validity of the pediatric assessment triangle as the first step in the
8. McDermott KW, Stocks C, Freeman WJ. Overview of pediatric emer- triage process in a pediatric emergency department. Pediatr Emerg Care.
gency department visits, 2015: Statistical Brief #242. Rockville: Agency 2017;33(4):234–8.
for Healthcare Research and Quality; 2018. 31. Lugo S, Pavlicich V. Application of the pediatric assessment triangle to the
9. Nesje E, Valoy NN, Kruger AJ, Uleberg O. Epidemiology of paediatric triage classification system in an emergency department. Rev Bol Ped.
trauma in Norway: a single-trauma centre observational study. Int J 2014;53(2):88–93.
Emerg Med. 2019;12(1):18. 32. Fernández A, Pijoan JI, Ares MI, Mintegi S, Benito FJ. Canadian paediatric
10. United Nations Children’s Fund (UNICEF). Levels and trends in child triage and acuity scale: assessment in a European pediatric emergency
mortality. Report 2022. New York: UNICEF; 2023. Available from: https://​ department. Emergencias. 2010;22(5):355–60.
data.​unicef.​org/​resou​rces/​levels-​and-​trends-​in-​child-​morta​lity/. 33. Ecclesia FG, Alonso Cadenas JA, Gómez B, Gangoiti I, Hernández-Bou S,
11. Jeruzal JN, Boland LL, Frazer MS, Kamrud JW, Myers RN, Lick CJ, et al. de la Torre EM. Late-onset group B streptococcus bacteremia evaluated
Emergency medical services provider perspectives on pediatric calls: a in the pediatric emergency department and risk factors for severe infec-
qualitative study. Prehosp Emerg Care. 2019;23(4):501–9. tion. Pediatr Infect Dis J. 2022;41(6):455–9.
12. Nordén C, Hult K, Engström Å. Ambulance nurses’ experiences of nurs- 34. Gomez B, Hernandez-Bou S, Garcia-Garcia JJ, Mintegi S. Bacteremia in
ing critically ill and injured children: a difficult aspect of ambulance previously healthy children in emergency departments: clinical and
nursing care. Int Emerg Nurs. 2014;22(2):75–80. microbiological characteristics and outcome. Eur J Clin Microbiol Infect
13. Hansen M, Meckler G, Dickinson C, Dickenson K, Jui J, Lambert W, et al. Dis. 2015;34(3):453–60.
Children’s safety initiative: a national assessment of pediatric educa- 35. Sánchez IA, Cotanda CP, Casas MM, de la Maza VTS, Cubells CL. Profile of
tional needs among emergency medical services providers. Prehosp the child seen in the resuscitation room. Rev Esp Salud Publica. 2019;93.
Emerg Care. 2015;19(2):287–91. 36. Shiva GS, Kumar VS, Kumar PR, Subramanian SB. A study on the role of
14. Li J, Roosevelt G, McCabe K, Preotle J, Pereira F, Takayesu JK, et al. Criti- paediatric assessment triangle, clinical scoring and serum lactate in
cally ill pediatric case exposure during emergency medicine residency. the management of septic shock in children. Int J Contemp Pediatr.
J Emerg Med. 2020;59(2):278–85. 2019;6(5):2037.
15. Ralston ME, Zaritsky AL. New opportunity to improve pediatric emer- 37. Macnab AJ. Objective assessment and communication of the physiologic
gency preparedness: pediatric emergency assessment, recognition, status of the sick infant. Can J Midwif Res Pract. 2004;3(2):7–12.
and stabilization course. Pediatrics. 2009;123(2):578–80. 38. Mierek C, Nacca N, Scott JM, Wojcik SM, D’Agostino J, Dougher K, et al.
16. Roukema J, Steyerberg EW, van Meurs A, Ruige M, van der Lei J, Moll View from the door: making pediatric transport decisions based on first
HA. Validity of the manchester triage system in paediatric emergency impressions. JEMS. 2010;35(7):68–9, 71, 3, 5, 7, 9, 81.
care. Emerg Med J. 2006;23(12):906. 39. Arroabarren E, Alvarez-Garcia J, Anda M, de Prada M, Ponce MC, Palacios
17. Yates MT, Ishikawa T, Schneeberg A, Brussoni M. Pediatric Canadian M. Quality of the triage of children with anaphylaxis at the emergency
Triage and Acuity Scale (PaedsCTAS) as a measure of injury severity. Int department. Pediatr Emerg Care. 2021;37(1):17–22.
J Environ Res Public Health. 2016;13(7):659. 40. Alp EE, Dalgic N, Yilmaz V, Altuntas Y, Ozdemir HM. Evaluation of patients
18. Thim T, Krarup NH, Grove EL, Rohde CV, Lofgren B. Initial assessment with suspicion of COVID-19 in pediatric emergency department. Sisli Etfal
and treatment with the Airway, Breathing, Circulation, Disability, Expo- Hastan Tip Bul. 2021;55(2):179–87.
sure (ABCDE) approach. Int J Gen Med. 2012;5:117–21. 41. Derİnöz-Güleryüz O. In-hospital pediatric patient transfers to the pediatric
19. Shah MN. The formation of the emergency medical services system. emergency department. Cukurova Med J. 2022;47(1):332–40.
Am J Public Health. 2006;96(3):414–23. 42. Kawai R, Nomura O, Tomobe Y, Morikawa Y, Miyata K, Sakakibara H,
20. Fuchs S, McEvoy M, editors. Pediatric education for prehospital profes- et al. Retrospective observational study indicates that the paediatric
sionals. 4th ed. Burlington: Jones & Bartlett Learning; 2021. p. 490. assessment triangle may suggest the severity of Kawasaki disease. Acta
21. Peters MDJ, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil H. Paediatr. 2018;107(6):1049–54.
Chapter 11: scoping reviews. In: JBI manual for evidence synthesis. 43. Paniagua N, Elosegi A, Duo I, Fernandez A, Mojica E, Martinez-Indart L,
Joanna Briggs Institute; 2020. Available from: https://​synth​esism​anual.​ et al. Initial asthma severity assessment tools as predictors of hospitaliza-
jbi.​global. tion. J Emerg Med. 2017;53(1):10–7.
22. Tørisen TAG, Glanville J, Loaiza-Betancur AF, Bidonde J. Emergency 44. Alonso Cadenas JA, Corredor Andrés B, Andina Martínez D, et al. Charac-
pediatric patients and use of the pediatric assessment triangle (PAT) teristics and risk factors for admission in children undergoing hematopoi-
tool. Protocol for a scoping review. Charlottesville: Open Science etic cell transplantation in a pediatric emergency department. Authorea.
Framework; 2022. https://​www.​osf.​io/​vkd5h. 2021. https://​doi.​org/​10.​22541/​au.​16325​3914.​42579​466/​v1.
23. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. 45. Rodríguez Borbolla FJ, Sancha Herrera ML, Ortiz Angulo E, Pulido PP.
PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and Implementación del sistema de clasificación en la Unidad de Urgencias
explanation. Ann Intern Med. 2018;169(7):467–73. Pediátricas del Hospital Marqués de Valdecilla. Fundacion de Enfermeria
24. Fernandez A, Benito J, Mintegi S. Is this child sick? Usefulness of the de Cantabria. 2013;2(9):26–31.
pediatric assessment triangle in emergency settings. J Pediatr (Rio J). 46. Suárez M, Jaime M. Utilidad del triángulo de evaluación pediátrica en
2017;93(Suppl 1):60–7. un servicio de emergencia pediátrica. Boletin Medico de Postgrado.
25. World Bank. New World Bank country classifications by income 2018;34(2):39–45.
level: 2022-2023. The World Bank Group; 202. Available from: https://​ 47. Ogden K. The use of the paediatric assessment triangle in the manage-
blogs.​world​bank.​org/​opend​ata/​new-​world-​bank-​count​r y-​class​ifica​ ment of the sick child. Emerg Med J. 2016;33(9):e4.
tions-​income-​level-​2022-​2023. 48. Romig LE. PREP for peds-patient physiology, rescuer responses, equip-
26. Avilés-Martinez KI, López-Enríquez A, Luévanos-Velázquez A, ment, protocols. Size-up & approach tips for pediatric calls. JEMS.
Jiménez-Pérez BA, García-Armenta MB, Ceja-Moreno H, et al. Triage, 2001;26(5):24–33.
priorization tools of pediatric emergency room. Acta Pediatr de Mex. 49. Horeczko T, Gausche-Hill M. The paediatric assessment triangle: a power-
2016;37(1):4–16. ful tool for the prehospital provider. J Paramed Pract. 2011;3(1):20–5.
27. Gausche-Hill M, Eckstein M, Horeczko T, McGrath N, Kurobe A, Ullum L, 50. Walker A, Hanna A. Kids really are just small adults: utilizing the pediatric
et al. Paramedics accurately apply the pediatric assessment triangle to triangle with the classic ABCD approach to assess pediatric patients.
drive management. Prehosp Emerg Care. 2014;18(4):520–30. Cureus. 2020;12(3): e7424.
Tørisen et al. BMC Emergency Medicine (2024) 24:158 Page 14 of 14

51. Morilla L, Morel Z, Pavlicich V. Clinical characteristics of pediatric patients 78. Grant D. The future of paediatric simulation. In: Cheng A, Grant V, editors.
with COVID-19 in an emergency department. Pediatría (Asunción). Comprehensive healthcare simulation: Pediatric Edition: Springer Interna-
2020;47(3):124–31. tional Publishing. 2016. p. 401.
52. Akindolire AE, Tongo OO. Paediatric critical care needs assessment in a 79. Hansoti B, Jenson A, Keefe D, De Ramirez SS, Anest T, Twomey M, et al.
tertiary facility in a developing country. Niger J Paediatr. 2018;45(1):10–4. Reliability and validity of pediatric triage tools evaluated in low resource
53. Anitha GF, Velmurugan L, Sangareddi S, Nedunchelian K, Selvaraj V. Effec- settings: a systematic review. BMC Pediatr. 2017;17(1):37.
tiveness of flow inflating device in providing Continuous Positive Airway 80. Slusher T, Bjorklund A, Aanyu HT, Kiragu A, Philip C. The assessment,
Pressure for critically ill children in limited-resource settings: a prospective evaluation, and management of the critically ill child in resource-limited
observational study. Indian J Crit Care Med. 2016;20(8):441–7. international settings. J Pediatr Intensive Care. 2017;6(1):66–76.
54. Benito J, Luaces-Cubells C, Mintegi S, Manrique Martínez I, De la Torre EM, 81. Muttalib F, González-Dambrauskas S, Lee JH, Steere M, Agulnik A, Murthy
Miguez Navarro C, et al. Evaluation and impact of the “advanced pediatric S, et al. Pediatric emergency and critical care resources and infrastruc-
life support” course in the care of pediatric emergencies in Spain. Pediatr ture in resource-limited settings: a multicountry survey. Crit Care Med.
Emerg Care. 2018;34(9):628–32. 2021;49(4):671–81.
55. Guerrero-Márquez G, Míguez-Navarro MC. The physiological diagno-
sis missing in the pediatric assessment triangle. Pediatr Emerg Care.
2021;37(11). Publisher’s Note
56. Jayashree M, Singhi SC. Initial assessment and triage in ER. Indian J Pedi- Springer Nature remains neutral with regard to jurisdictional claims in pub-
atr. 2011;78(9):1100–8. lished maps and institutional affiliations.
57. Gonzalez Brabin A, Martín Rivada Á, Cabrero Hernández M, Cañedo Villar-
roya E. MIR clinical case. Make your diagnosis: a newborn with decreased
intake and lethargy. Pediatr Integ. 2019;23(3):162–5.
58. Simon Junior H, Schvartsman C, Sukys GA, Farhat SCL. Pediatric emer-
gency triage systems. Rev Paul Pediatr. 2022;41:e2021038.
59. Gehri M, Flubacher P, Chablaix C, Pediatrics Curchod P. The PAT: a simple
and rapid tool for the assessment of the severely ill or injured child. Rev
Med Suisse. 2011;3(277):64–5.
60. Dieckmann RA. New assessment model saves critical time in pediatric
emergencies. AAP News. 1999;15(2):22.
61. Mendes M, McCormick T. Pediatric resuscitation. In: Rose E, editor.
Pediatric emergencies: a practical, clinical guide. United kingdom: Oxford
Oxford University Press; 2020. p. 67–74.
62. Fuchs S. The special needs of children. In: Cone D, Brice JH, Delbridge
TR, Myers JB, editors. Emergency medical services: clinical practice and
systems oversight. 3rd ed. Hoboken: Wiley-Blackwell; 2021. p. 379–85.
63. Dieckmann RA, Brownstein D, Gausche-Hill M. The pediatric assessment
triangle: a novel approach for the rapid evaluation of children. Pediatr
Emerg Care. 2010;26(4):312–5.
64. Chiu Y-C, Liu S-Y, Yen T-A, Chen Y-Y, Yang C-W, Chu T-S, et al. Application
of high-fidelity patient simulation in the teaching of pediatric primary
assessment and management - is it feasible for medical students? J Med
Educ. 2018;22(1):17–27.
65. Hansen M, Spiro DM. Teaching the pediatric assessment triangle using
online video cases. Ann Emerg Med. 2013;62(5):S172.
66. Patten J. Goal-directed management of shock in children [thesis]. Zagreb:
University of Zagreb School of Medicine; 2015.
67. Tagg A. Paediatric Assessment Triangle [internet]: Don’t forget the bub-
bles; 2019 [updated 06/02/2023. Available from: https://​dontf​orget​thebu​
bbles.​com/​the-​paedi​atric-​asses​sment-​trian​gle/.
68. Furmick J, Malburg L, Leetch A. Pediatric airway management. Pediatr
Emerg Med Rep. 2017;22(10):1–17.
69. Khouli M. Injuries in children and general principles of management.
Mexican J Med Res ICSA. 2015;3(5). https://​doi.​org/​10.​29057/​mjmr.​v3i5.​
1835.
70. Pérez LFT, Bouza MR, Valle AML, Hoyos JB, Vera CV. Emergency manage-
ment: introduction. Revista Infancia y Salud. 2019;1(2). Available from:
http://​rinsad.​uca.​es/​ojs3/​index.​php/​rinsad/​artic​le/​view/​20.
71. Rochat MK, Gehri M. Pediatric emergencies - the essential, briefly, for
general practitioners. Ther Umsch. 2013;70(11):653–60.
72. Yock Corrales A, Starr M. Assessment of the unwell child. Aust Fam Physi-
cian. 2010;39(5):270–5.
73. Agbim CA, Wang NE, Lee M. Respiratory distress in pediatric patients.
Pediatr Emerg Med Rep. 2018;23(4):41–55.
74. Güler E, Özkaya AK. Recognition of shock in children: review. Turkiye
Klinikleri Pediatri. 2015;24(2):45–50.
75. Ramser M. The febrile child in respiratory distress. Praxis.
2017;106(4):201–7.
76. Singh A, Frenkel O. Evidence-based emergency management of the
pediatric airway. Pediatr Emerg Med Pract. 2013;10(1):1–25.
77. Neumar RW, Blomkalns AL, Cairns CB, D’Onofrio G, Kuppermann N, Lewis
RJ, et al. Emergency medicine research: 2030 strategic goals. Acad Emerg
Med. 2022;29(2):241–51.