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Pediatric vitals signs

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Blood Pressure

 

Blood pressure is measured by auscultation, palpation, Doppler or an oscillometric instrument such as the Dinamap. The blood pressure cuff should be long enough to encircle the arm completely, with slight overlap. The width should be about 2/3 the length of the arm. The lower limit of normal blood pressure in a child may be estimated by the formula: 70 + (2 x the age in years). Example: a three year old should have a systolic pressure above 76 mm Hg.

Shock

Hypovolemic Shock

Hypovolemic shock from dehydration caused by gastroenteritis is an important cause of shock in the pediatric age group. Hypovolemic shock may also be caused by blood loss from trauma. Dehydration is seen after continuous vomiting and/or diarrhea and by decreased fluid intake over several days. Signs and symptoms include tachycardia, tachypnea, decreased urinary output, altered mental status and dry mucous membranes. It is important to note that only in the final stages of shock does the blood pressure fall. Tachycardia is prevalent throughout all stages. The child is positively orthostatic if an increase in heart rate (>25 beats per minute rather than 30 as in the adult) or near-syncope occurs. A good early indicator of shock in infants is capillary refill. The fingernail bed is gently pressed and the time noted for the blanched nailbed to return to normal. Normal is less than 2 seconds. 2-3 seconds represents 5-10% dehydration. Longer than 3 seconds represents a greater than 10% deficit.

Treatment for dehydration:

1. The ABCs of resuscitation are followed;
2. Normal saline 20 cc/kg IV bolus x 2 is administered; then
3. D5.25NS IV as maintenance, plus extra fluid to compensate for hypovolemia and
4. Fluids are adjusted so that the urine output is maintained at 1 ml/kg/hour.

Hypovolemic shock from blood loss: signs and symptoms are similar to those in dehydration.
Treatment: the ABCs of resuscitation are followed, NS 20 cc/kg IV bolus x 2 is administered, the urine output is maintained at 1 cc/kg per hour, 10 cc/kg of type-specific warmed packed red blood cells (or O-negative RBCs if the need is urgent) is given, and a surgical consult is obtained as soon as possible.

Septic Shock

Septic shock is the last stage of a continuum from sepsis. Signs and symptoms include irritability, poor feeding and lethargy. Fever is present in the early stage, accompanied by tachycardia, tachypnea and warm and pink extremities. In later stages, inflammatory mediators are activated, pulses are weak, extremities are cool, mental status is decreased, capillary refill is prolonged, hypothermia may be present and the pulse pressure widens (hypotension is not seen until late, unlike the adult). The WBC may be high or low. Cultures are done on blood, urine and cerebrospinal fluid.
Treatment:
1. The ABCs of resuscitation are followed;
2. 20 cc/kg boluses of IV NS are administered to maintain a urine output of 1 cc/kg per hour;
3. If BP can not be maintained, dopamine 5 ug/kg/min is added and 4. For the neonate, cefotaxime (Claforan) is given 50 mg/kg IV every 6 hours, plus ampicillin 50 mg/kg every 6 hours. For the infant and child, ceftriaxone (Rocephin) is administered at 50 mg/kg IV every 12 hours. Antibiotics should be administered when blood cultures are drawn, before the lumbar puncture.

 


 
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