wheezing, and changes in voice or speech Observation should include assessment of patient positioning, the presence and location of chest wall retractions, and nasal flaring TABLE 6.3 TICLS MNEMONIC Tone Interactivity Consolability Look/gaze Speech/cry Moves spontaneously, sits or stands as age appropriate Interacts with people, environment, objects Stops crying with comfort by caregiver Tracks objects, makes eye contact Age-appropriate speech or strong cry Adapted from APLS: The Pediatric Emergency Medicine Resource 5th ed American College of Emergency Physicians & Jones and Bartlett; 2012 TABLE 6.4 TRIAGE “RED FLAGS” Airway Breathing Circulation Disability Exposure Apnea, stridor, hoarse voice/cry, drooling, choking, gurgling, sniffing position, hypoxemia Increased work of breathing, retractions, grunting, nasal flaring, seesaw respirations, head bobbing, adventitious breath sounds, tripod positioning Tachycardia, bradycardia, hypotension, capillary refill >3 sec or 105.1°F, rash (petechial, purpura), signs of abuse Circulation to the Skin Assessment of circulation to the skin reflects the integrity of vital organ perfusion The child’s skin should be exposed by the parent in a warm environment and visual examination performed, evaluating for pallor, mottling, cyanosis, and visible active bleeding