If you know me, you know that I’m a sucker for good, useful mnemonics for prehospital care. Since we’ve been discussing pediatric assessment lately, I thought it might be a good time to review an excellent mnemonic tool for pediatric assessment. That tool is the tickles (TICLS) mnemonic. The tickles assessment is a cornerstone of the PEPP (Pediatric Emergencies for Prehospital Professionals) pediatric assessment triangle. It’s also strongly endorsed by the American Academy of Pediatrics. (APP)
When you make initial contact with a pediatric patient, think about the five elements of the TICLS mnemonic as part of your initial assessment. They will give you a solid stating point when developing an initial impression. Here they are:
T is for Tone
Is the child active or listless? Does the child physically engage with you or do they remain limp and allow you to move them like a puppet or a doll. When you place a finger or object in the child’s hand, do they attempt to grab it or do they allow it to lie in their open hand? Babies normally lose their head-lag by three months. Does the child support the weight of their own head when picked up or do they allow their head to fall back against a supporting object?
I is for Interactiveness
Does the child want to play and interact with you? Does the child primarily want their eyes open or closed? If they are frightened of you, do they attempt to actively avoid you? Can you gain the child’s interest and engage them in play or activity. Do they desire a toy or instrument when offered? How do they respond to unusual sounds in their environment? Will they turn to investigate and unknown sound or auditory stimuli?
C is for Consolability
Can the child be appropriately agitated and calmed by caregivers and clinicians? Are they behaving as we would predict to external stimuli? For instance, we would expect a child who is normally calm in a parents arms to be calm when properly consoled and comforted in the arms of a familiar caregiver. We would also expect that a child who normally exhibits stranger anxiety to become agitated when taken from familiar caregivers and removed from their presence. Is the child’s temperament consistent with what we might normally expect for their environment?
L is for Look (or Gaze)
Does the infant or child fix their gaze on your face or other appropriately interesting object or do they gaze off into space? Infants find their world fascinating and should actively look toward new and interesting stimuli. Look for signs of active looking and be concerned about the “lights-are-on-but-nobody’s-home” type gaze.
S is for Speech (or Cry)
When the infant or child uses their voice is it a strong expression, a weak cry or absent of sound? Is the child’s speech spontaneous and self-initiated or does the child only use their voice when prompted or stimulated? Is this the volume and tone that you would expect from a child or infant in this age range?
The TICLS mnemonic can help you decide in the first few minutes of evaluation if you need to move fast or if you have time to stay on scene and do a more in depth evaluation. Notice that none of the points of the “tickles” evaluation involve taking vital signs or even touching the child. Most of this exam can be completed while the child is in a caregivers arms.
You can check through your “tickles” mental checklist while you are still warming up your hands. Once you do start touching and feeling the patient, work of breathing and skin signs should be the next priorities in your physical evaluation.
Also keep in mind that all of the parameters of the “tickles’ assessment need to be compared with the infants baseline behavior and his or her environment. If the child has been awake all afternoon and is late for nap time, their interactiveness, look and tone may be naturally depressed. If the child hasn’t been fed, their consolability may be understandably abnormal.
Use the parents as a guide for what is baseline for a given child. Trust their input and trust your gut.