Synopsis
Detect paediatric deterioration before collapse by combining first-impression physiology, repeated ABCDE assessment, age-specific observations, National PEWS trends, family concern and decisive senior escalation.
- Use the paediatric assessment triangle on first sight: appearance, work of breathing and circulation to skin; any abnormal arm means the child needs prompt hands-on assessment.
- Move immediately to ABCDE, treat each life threat before proceeding and repeat the whole sequence after intervention or change.
- Interpret heart rate, respiratory rate and blood pressure against age, temperature, pain, medication and trend; a single adult threshold is unsafe.
- Respiratory deterioration usually precedes cardiac arrest in children; bradypnoea, exhaustion and reduced effort are late and dangerous.
- Hypotension is a late sign of paediatric shock; assess perfusion using mental state, pulse quality, capillary refill, skin, urine output and lactate in context.
- Bradycardia in a critically ill child often reflects severe hypoxia and demands ventilation-focused resuscitation, not observation for a lower PEWS.
- National PEWS standardises age-specific observations and escalation, but it complements clinical judgement and never cancels clinician or family concern.
- Trend matters: rising oxygen need, repeated tachycardia, falling urine output or increasingly frequent interventions may be more important than the current total score.
- Escalate on any single extreme parameter, acute concern or required care beyond the setting's capability; do not wait for a composite score threshold.
- Use an explicit SBAR call that states the immediate concern, current ABCDE findings, trajectory, treatment given and the response you need by what time.
- If the response is inadequate, repeat the concern using graded assertiveness, contact the next senior or critical-care team and remain with the child.
- Document the escalation time, named responder, agreed action and review deadline; ‘doctor informed’ is not a completed safety process.
Key red flags
Apnoea, gasping, central cyanosis, silent chest, severe stridor, exhaustion or decreasing respiratory effort indicates impending respiratory arrest.
Bradycardia with poor perfusion, weak pulses, mottling, prolonged capillary refill, altered consciousness or hypotension indicates decompensated shock or peri-arrest physiology.
A falling respiratory rate in a child who remains distressed is not improvement when consciousness, air entry or effort is worsening.
Non-blanching rash, meningism, reduced consciousness, focal neurology or a prolonged seizure requires immediate senior assessment and time-critical treatment.
A parent saying their child is markedly different, worsening or difficult to wake requires reassessment and escalation even when the numerical PEWS is low.
Repeated staff concern, unexpected re-attendance, failure to respond to treatment or rapid change over minutes overrides a reassuring earlier observation set.
Investigation priorities
Quantify age-specific physiology, oxygen requirement and consciousness and activate standard escalation.
Detect rapid change in a child with airway, breathing or circulation compromise.
Management branches
Any child appears unwell, behaves abnormally or is flagged by family or staff.
- Assess appearance, work of breathing and circulation to skin within seconds and call early help if any arm is abnormal.
- Perform ABCDE with age-appropriate observations, treating each threat before moving on.
- Repeat from airway after every intervention and record response, trend and the next review interval.