Vitals:

Vitals in paediatrics depend on the age of the individual. Here we will be covering: heart rate, blood pressure and respiratory rate.

Weight and height of patients should be plotted using a growth chart.

Quick way to calculate BP if in emergency setting is by:

Systolic Blood Pressure (SBP):

  • 1–10 years: Minimum SBP = 70+(2×age in years)

  • Over 10 years: Minimum SBP should generally be around 90 mmHg or more.

Diastolic Blood Pressure (DBP):

Diastolic blood pressure isn’t as commonly estimated in an emergency setting for children as it varies widely, but typically:

  • DBP for 1–10 years is about half to two-thirds of the systolic BP.

  1. Temperature:

    If a child in the ward has a fever, follow these steps to ensure a thorough assessment and effective management: Read about the case that you received, admission diagnosis, medications on, plan etc.

    1. Assess and Record Vital Signs:

      • Document the temperature, heart rate, respiratory rate, and oxygen saturation.

    2. Evaluate Symptoms and Severity:

      • Check for accompanying symptoms (e.g., cough, sore throat, rash, lethargy, vomiting, or difficulty breathing).

      • Determine if the child has any signs of distress or severe illness, like difficulty breathing, altered mental status, or signs of dehydration.

    3. Perform a Focused Physical Examination:

      • Examine for potential sources of infection, including the throat, lungs, ears, skin, and abdomen.

      • Look for signs of systemic infection or inflammation, such as rashes or swollen lymph nodes.

    4. Implement Symptomatic Treatment:

      • Antipyretics: Administer acetaminophen or ibuprofen, following age and weight dosing guidelines. Avoid aspirin in children due to the risk of Reye's syndrome.

      • Hydration: Encourage oral fluids or provide IV fluids if the child is unable to drink, to prevent dehydration..

    5. Investigate Underlying Causes:

      • Order blood tests, urinalysis, or chest X-rays if needed to identify bacterial or viral infections or other causes of fever if not already known

      • Consider specific tests for children with prolonged or very high fevers, such as blood cultures, CRP, and procalcitonin, especially if an invasive bacterial infection is suspected.

2. Oxygen saturation:

1. Assess Oxygen Saturation and Vital Signs

  • Confirm the desaturation with a reliable pulse oximeter and check other vital signs (heart rate, respiratory rate, blood pressure, and temperature).

2. Ensure Airway Patency

  • Position the child to maximize airflow, such as in the "sniffing" position for infants or sitting upright for older children.

  • Clear any secretions or obstructions from the airway by suctioning, if necessary.

3. Administer Supplemental Oxygen

  • Initiate supplemental oxygen, starting with a low flow via nasal cannula and increasing as needed, up to non-rebreather masks or high-flow nasal cannula for more severe desaturations.

  • Monitor oxygen levels closely to gauge the response to oxygen therapy.

4. Perform a Focused Clinical Assessment

  • Identify possible causes of desaturation by examining for signs of respiratory distress (e.g., wheezing, stridor, grunting, retractions) and performing a focused examination (lung auscultation, inspection for cyanosis, signs of infection).

  • Consider common causes of desaturation in children, such as:

    • Respiratory Causes: Asthma, bronchiolitis, pneumonia, aspiration, atelectasis

    • Cardiac Causes: Congenital heart disease, heart failure

    • Systemic Causes: Sepsis, anemia

5. Obtain Additional Support and Investigations

  • Notify senior staff or the on-call pediatrician if initial interventions don’t stabilize the child.

  • If needed, perform chest X-rays, blood gas analysis, or lab tests (e.g., blood count, blood cultures) to further investigate the underlying cause.

  • Consider an arterial or venous blood gas for detailed assessment of oxygenation and ventilation if indicated.

6. Consider Advanced Airway or Respiratory Support

  • If the child does not respond to supplemental oxygen or is showing signs of severe respiratory distress, prepare for potential advanced airway management (e.g., CPAP, BiPAP, or intubation).

  • Escalate to pediatric critical care if needed, particularly for intubation or mechanical ventilation.

3. Blood pressure

Hypertension:

If a child in the ward is found to have high blood pressure, prompt and systematic management is important. Here are key steps to follow:

  1. Repeat Blood Pressure Measurement:

    • Use an appropriate-sized cuff and ensure the child is calm.

    • Take multiple readings over 5–10 minutes to confirm the elevated pressure.

    • Measure blood pressure in all four limbs if there is concern about secondary causes (e.g., coarctation of the aorta).

  2. Assess Symptoms:

    • Check for symptoms associated with hypertensive emergencies, such as headache, visual disturbances, vomiting, chest pain, or altered mental status.

    • Look for signs of end-organ damage (e.g., neurological deficits, signs of heart failure).

  3. Identify the Severity:

    • Hypertensive Emergency: Severe elevation with symptoms or end-organ damage.

    • Hypertensive Urgency: Elevated blood pressure without symptoms.

    • Mild/Moderate Hypertension: Persistently elevated blood pressure above age-based norms but without acute symptoms.

  4. Immediate Treatment for Hypertensive Emergency:

    • If a hypertensive emergency is confirmed, initiate treatment to lower blood pressure gradually (e.g., 20–25% reduction over the first hour) to avoid sudden drops that could compromise organ perfusion.

    • IV Medications: Drugs such as labetalol or nicardipine are commonly used in children for rapid, controlled reduction.

  5. Evaluate Underlying Causes:

    • Consider secondary causes like renal disease, endocrine disorders, or coarctation of the aorta.

    • Order necessary investigations such as renal function tests, urinalysis, echocardiogram, and possibly imaging studies.

Hypotension

If a child in the ward is hypotensive, immediate assessment and treatment are necessary to prevent shock and other complications. Here’s a systematic approach:

1. Confirm Hypotension and Assess Vital Signs

  • Confirm hypotension by comparing blood pressure readings against age-appropriate norms. In general, a systolic blood pressure below 70 + (2 x age in years) mmHg indicates hypotension in children.

  • Assess other vital signs, including heart rate, respiratory rate, oxygen saturation, and capillary refill.

2. Evaluate for Symptoms of Shock

  • Check for signs of poor perfusion, such as cool extremities, delayed capillary refill, altered mental status, and decreased urine output.

  • Identify other signs of shock, including tachycardia, weak pulses, or pallor.

3. Identify and Treat Underlying Cause

  • Hypovolemic Shock: Common in dehydration, bleeding, or trauma. Provide fluid resuscitation (see below).

  • Distributive Shock (e.g., sepsis, anaphylaxis): Suspect if the child has fever, rash, or signs of infection. Begin fluid resuscitation, antibiotics, or treat anaphylaxis as indicated.

  • Cardiogenic Shock: Less common, often seen in heart disease or myocarditis. Use fluids cautiously and consider inotropes early.

4. Initiate Fluid Resuscitation

  • Administer a bolus of isotonic fluids, typically 10-20 mL/kg of normal saline or lactated Ringer's solution over 5-10 minutes.

  • Reassess after each bolus, monitoring blood pressure, heart rate, and signs of perfusion.

  • If there is no improvement, consider additional fluid boluses or escalate care.

5. Administer Medications if Needed

  • Vasopressors: If fluids are insufficient or contraindicated (e.g., cardiogenic shock), consider starting inotropes or vasopressors (e.g., dopamine, epinephrine) under specialist guidance.

  • Antibiotics: For suspected sepsis, give broad-spectrum antibiotics within the first hour.

  • Other Medications: If anaphylaxis is suspected, administer epinephrine intramuscularly.

6. Obtain Labs and Imaging

  • Order labs (e.g., CBC, electrolytes, blood gas, lactate, renal function, and blood cultures for suspected infection).

  • Consider imaging (e.g., chest X-ray, echocardiogram) if cardiogenic or septic shock is suspected.

7. Notify Pediatric Intensive Care Team

  • If the child is not stabilizing or requires advanced interventions (e.g., inotropes, respiratory support), escalate care to the pediatric intensive care team.

4. Heart rate:

Tachycardia

1. Confirm the Tachycardia and Assess Vital Signs

  • Measure the heart rate accurately and confirm it against age-based normal ranges (e.g., for infants, normal heart rate is 100–160 bpm; for children 1–10 years, it’s 70–120 bpm).

  • Assess other vital signs, including respiratory rate, blood pressure, oxygen saturation, and temperature.

2. Identify and Address Reversible Causes

  • Fever: Fever is a common cause of increased heart rate in children. Administer antipyretics (e.g., acetaminophen or ibuprofen) and encourage hydration.

  • Medications such as nebulisers like Ventolin, steroids, anti-epileptics, thyroid hormone replacements.

  • Pain or Anxiety: Address any sources of pain or anxiety, which can elevate heart rate. Treat pain as appropriate and provide reassurance.

  • Dehydration: Check for signs of dehydration (e.g., dry mucous membranes, poor skin turgor) and consider a fluid bolus if appropriate.

  • Hypoxia: If oxygen saturation is low, provide supplemental oxygen and investigate possible respiratory causes, such as pneumonia or asthma.

3. Perform a Focused Clinical Examination

  • Evaluate for signs of distress, such as altered mental status, cool extremities, delayed capillary refill, and weak pulses.

  • Assess for respiratory causes of tachycardia (e.g., wheezing, stridor) and any signs of infection, especially in febrile children.

4. Classify Tachycardia Type

  • Sinus Tachycardia: Often related to fever, pain, dehydration, or anxiety and usually resolves with treatment of the underlying cause.

  • Supraventricular Tachycardia (SVT): A more concerning form of tachycardia with rapid, regular rhythm, often above 220 bpm in infants or above 180 bpm in children. SVT requires urgent management.

5. Intervene Based on Severity

  • If Sinus Tachycardia: Continue managing underlying causes and monitor the heart rate to ensure it decreases as the cause is addressed.

  • If SVT or Unstable Tachycardia:

    • Vagal Maneuvers: Attempt vagal maneuvers, such as ice to the face or the Valsalva maneuver, if the child is stable.

    • Medication or Cardioversion: If unstable or unresponsive to vagal maneuvers, consult a pediatric cardiologist and consider adenosine or synchronized cardioversion.

6. Order Investigations if Needed

  • ECG: Perform an ECG to help differentiate between sinus tachycardia and arrhythmias such as SVT.

  • Blood Tests: If an underlying metabolic or infectious cause is suspected, consider checking electrolytes, blood counts, and possibly cultures if infection is a concern.

7. Notify the Pediatric Team for Escalation if Needed

  • If the tachycardia is persistent or the child appears unstable, consult a senior pediatrician or cardiologist for additional guidance, especially if arrhythmias are suspected.

Bradycardia:

1. Confirm Bradycardia and Assess Vital Signs

  • Measure the heart rate accurately and compare it with age-based normal values (e.g., for newborns, <100 bpm may be considered bradycardic; for children 1–10 years, <60 bpm may indicate bradycardia).

  • Assess other vital signs, including respiratory rate, blood pressure, oxygen saturation, and temperature, to get a full picture of the child’s clinical status.

2. Evaluate the Severity and Stability

  • Check for signs of poor perfusion, such as low blood pressure, weak or thready pulses, cold extremities, and delayed capillary refill.

  • Assess mental status for any alterations, such as lethargy or confusion, and watch for respiratory distress.

3. Identify Potential Causes

  • Hypoxia: One of the most common causes of pediatric bradycardia, so ensure the airway is clear and provide supplemental oxygen if needed.

  • Hypothermia: In cold conditions or if exposed to cold, the child’s heart rate may slow. Gradually rewarm the child if hypothermia is suspected.

  • Increased Intracranial Pressure (ICP): Bradycardia may indicate raised ICP, especially if accompanied by irregular breathing and hypertension (Cushing’s triad). This requires urgent evaluation.

  • Vagal Stimulation: Bradycardia may be caused by vagal reflexes triggered by suctioning, intubation, or severe pain.

4. Initiate Immediate Interventions Based on Severity

  • If Stable: Closely monitor and address the underlying cause (e.g., hypoxia or hypothermia).

  • If Unstable or Symptomatic: Begin resuscitative measures:

    • Airway and Breathing Support: Ensure airway patency and initiate high-flow oxygen.

    • Chest Compressions: If the heart rate drops below 60 bpm with signs of poor perfusion, initiate CPR and chest compressions per Pediatric Advanced Life Support (PALS) guidelines.

    • Medications: If bradycardia persists despite resuscitation efforts, administer epinephrine as per pediatric dosing protocols. Atropine may also be considered, particularly in cases due to vagal stimulation or AV block.

5. Order Investigations if Necessary

  • ECG: An ECG can help identify the type and cause of bradycardia (e.g., sinus bradycardia vs. AV block).

  • Blood Tests: If metabolic causes are suspected, check electrolytes, glucose, and thyroid function tests.