Use appearance, breathing, and skin circulation for a rapid first impression.
OCEMS source summary · Updated 2026-09-16
First impression
Use visual and auditory observations. The triangle is particularly useful in children younger than 5.
Continue assessment and use the applicable pediatric standing order for treatment.
1. Appearance
Tone: observe movement and posture.
Interaction: look for alertness and engagement with people or surroundings.
Consolability: assess response to a caregiver.
Look/gaze: observe eye contact and tracking.
Speech/cry: listen to the strength and character of the voice or cry.
2. Work of breathing
Observe breathing effort and listen for abnormal respiratory sounds.
3. Circulation to skin
Observe skin color for pallor, mottling, or cyanosis.
Turn the impression into a focused assessment
Use the triangle as a rapid visual/auditory impression, then assess airway, ventilation, perfusion, and mental status. It does not supply a stand-alone diagnosis or treatment order.
When documenting depressed consciousness, use the age-appropriate GCS components; PR-002 has separate scoring for age 2 and younger.
Find the next pathway
For respiratory distress, use SO-P-035 and reassess the response to oxygen, airway support, and the specific treatment. For altered mental status, SO-P-065 includes a glucose check and treatment of poor perfusion.
310.00 identifies pediatric respiratory distress and circulatory compromise as base-contact triggers, with a pediatric-capable base preferred. A reassuring momentary appearance does not cancel the source’s BRUE contact criteria.