Prehospital PRAM Score Use

As you may know, the Pediatric Respiratory Assessment Measure (PRAM) is used to assess the severity of asthma exacerbations in pediatric patients. It provides a common language for communicating severity—similar to the Glasgow Coma Scale (GCS)—and helps guide treatment decisions while tracking patient progress over time.

Hospitals categorize PRAM scores into mild, moderate, severe, and impending respiratory failure to determine treatment approaches. For your reference, I’ve attached an algorithm and order set, supported by TREKK. The score can also easily be calculated in MDCalc.

While calculating the PRAM score is generally straightforward, there are challenges in the prehospital setting. Firstly, paramedics are not routinely trained to assess suprasternal indrawing or scalene retractions, though these skills can be learned. The more difficult aspect is assessing air entry, as even experienced pediatric nurses can struggle to differentiate between "decreased at the bases" (score of 1), "widespread decrease" (score of 2), and "absent/minimal" (score of 3). Inaccuracies here can significantly impact scoring and subsequent treatment. It’s also important to note that the PRAM score can be somewhat subjective, and different clinicians may arrive at slightly different scores.

With respect to wheezing, another factor to consider is that if a patient has minimal air entry, it can be challenging to detect wheezes accurately. A strategy to overcome this is to ask patients to take a deep breath and rapidly exhale (“like you’re trying to make me smell your breath”). This often elicits more wheezing sounds than standard respiratory auscultation, which can provide a more accurate reflection of the patient's condition.

For paramedics new to using the PRAM scoring system, try it out! However, be sure to let the triage nurses know that you're still getting comfortable with the scoring process. Ask them to perform their own PRAM assessment and compare it with yours for accuracy.

For further insights, paramedics were introduced to PRAM as part of the 2022 Spring CME module on pediatric respiratory illnesses. We encourage you to review it here: https://mediclearn.rppeo.ca/course/view.php?id=607.

We also have an elective CME that speaks to pediatric respiratory illnesses as well if you’re interested in learning more: https://mediclearn.rppeo.ca/course/view.php?id=400.