Vital Signs in Children

Heart Rate (per minute) Respiratory Rate

(breaths/min)

Sleeping Age Rate

Age Awake Rate Rate infant 30 to 60
Newborn to 3 months 85 to 205 80 to 160 toddler 24 to 40
3 months to 2 years 100 to 190 75 to 160 preschooler 22 to 34
2 to 10 years 60 to 140 60 to 90 school-agen child 18 to 30
> 10 years 60 to 100 50 to 90 adolescent 12 to 16

Definition of Hypotension by Systolic Blood Pressure and Age

Age Systolic Blood Pressure (mm Hg)

Term neonates (0 to 28 days) <60

Infants (1to 12 months) <70

Children 1 to 10 years (5th BP percentile) <70 + (age in years x 2)

Children >10 years < 90

Modified Glasgow Coma Scale for Infants and Children

child Infant Score

Eye Spontaneous Spontaneous 4

opening to speech to speech 3

to pain to pain 2

none none 1

best oriented, apropriate coos and babbles 5

verbal confused irritable, cries 4

response inappropriate words cries in response to pain 3

incomprehensible sounds moans in response to pain 2

none none 1
Best obeys commands moves spontaneously and purposely 6

Motor localizes painful stimulus withdraws in response to touch 5

Response withdraws in response to pain withdraws in response to pain 4

Flexion in response to pain abnormal flexion posture to pain 3

Extension in response to pain abnormal extemsion posture to pain 2

None none 1
Summary of Steps of CPR for Adults, Children, and Infants

Component Recommendations
Adults Children Infants
Unresponsive (for all ages)

No breathing
Recognition Or no normal No breathing or only gasping
(ie, only gasping)

No pulse felt within 10 seconds

CPR sequence Chest compressions, Airway, Breathing (C-A-B)
Compression rate At least 100/min

Compression depth At least At least At least

2 inches 1/3 AP diameter 1/3 AP diameter
(5 cm) About 2 inches About 1 ½ inches
(5 cm) (5 cm)
Chest wall recoil Allow complete recoil between compressions
Rotate compressors every 2 minutes
Compressions Minimize interruptions in chest compressions
interruptions Attempt to limit interruptions to <10 seconds
airway Head tilt-chin lift (suspected trauma: jaw thrust)
Compression- 30:2
To-ventilation ratio 30:2 Single rescuer
(until advanced 1 or 2 rescuers 15:2
airway placed) 2 rescuers
Ventilations with 1 breath every 6-8 seconds (8-10 breaths/min)
advanced airway Asynchronous with chest compressions
About 1 second per breath
Visible chest rise
Defibrillation Attach and use AED as soon as available.
Minimize interruptions in chest compressions before and
After shock; resume CPR beginning with compressions
Immediately after each shock
Abbreviations: AED, automated external defibrillator; anterior-posterior; CPR, cardiopolmonary resuscitation.
Pediatric Septic Ahock Algorithm

Recognize altered mental status and perfusion

Give oxygen and support ventilation; establish vascular acces

And begin resuscitation according to PALS guidelines

Consider VBG or ABG, lactete, glucose, ionized calcium, culturesm, CBC

FIRST HOUR

First hour: Push repeared 20 mL/kg boluses of isotonic crystalloid to treat shock. Give up to 3, 4, or more boluses unless reles,
respiratory distress, or hepatomegaly develops

Additional therapies;

 Correct hypoglycemia and hypocalcemia

 Administer first-dose antiboditics STAT
 Consider ordering STAT vesopressor drip and stress-dose hydrocortisone*
 Establish second vascular access site if vasoactive infusion anticipated

YES NO
Fluid responsive (ie, normalized perfusion/hemodynamics)?

Consider ICU Begin vasoactive drug therapy and titrate to

monitoring correct
Hypotension/poor perfusion; consider
establishing
Arterial and central venous acces
 Normotensive: begim dopamine
 Hypotensive vasodilated (warm) shock:
Begin norepinephrine
 Hypotensive vasocontstricted (cold) shock:
Begin epinephrine rather than norepinephrine

Evaluate ScvO2; goal ScvO2 sat 70%?

ScvO2 >70%, low ScvO2< 70%, normal ScvO2 <70%, low BP and
BP (“warmshock”) BP but poor perfusion Poor perfusion (cold shock”)

Additional fluid Transfuse to Hgb >10g/dl Transfuse to Hgb >10g/dl

Boluses Optimize arterial oxygen Optimize arterial oxygen
Norephinephrine Saturation Saturation
Additional fluid boluses Additional fluid boluses
vasopressin
Consider milrinone or Consider epinephrine or
nitroprisside dobutamine + norepinephrine
Consider dobutamine

*Fluid-refractoru and dopamine- or norepinephrine-dependent shock defines patient at risk for adrenal
insufficiency.

Draw baseline cortisol;consider

ACTH stimulation test if unsure
If adrenal insufficiency is suspected give
hydrocortisone – 2 mg/kg bolus IV; maximum Of need for steroid
100 mg
Drugs Used in PALS

Drug Indications/Dosages
Adenosine SVT
 0.1 mg/kg IV/IO rapid push (max 6 mg), second dose 0.2 mg/kg IV/IO rapid push
(max 12 mg)
Albumin Shock, trauma, burns
 0.5 to 1 g/kg (10 to 20 mL/kg of 5% solution)IV/IO rapid infusion
Albuterol Asthma, anaphylaxis (bronchospasm), hyperkalemia
 MID: 4 to 8 puffs via inhalation q 20 minutes PRN with scaper (OR ET if intubated)
 Nebulizer: 2.5 mg/dose (wt <20 kg) OR 5 mg/dose (wt > 20kg) via inhalation q 20
minutes PRN
 Continous nebulizer: 0.5 mg/kg per hour via inhalation (max 20 mg/h)
Amiodarone Svt, vt (with pulses)
 5 mg/kg IV/IO load over 20 to 60 minute (max 300 mg), repeat to daily max 15 mg/kg
(2.2 g in adolestcents)
Pulseless arrest (ie, VF/pulseless VT)
 5 mg/kg 5 IV/IO bolus (max 300 mg), repeat to daily max 15 mg/kg (2.2 g in
adolestencents)
Atropine sulfate Bradicardia (symptomatic)
 0.02 mg/kg IV/IO (min dose 0.1 mg, max single dose child 0.5 mg, max single dose
adolescent 1 mg), may repeat dose once, max total dose child 1 mg, max total dose
adolescent 3 mg
 0.04 to 0.06 mg/kg ET
Toxins/overdose (eg, organopnosphate, carbamate)
 <12 years: 0.02 to 0.05 mg/kg IV/IO initally, then repeat IV/IO q 20 to 30 minutes until
muscarinic symptoms revarse
 >12 years: 2 mg/kg IV/IO initally, then 1 to 2 mg/kg IV/IO q 20 to 30 minutes until
muscarinic symptoms revarse

Calcium chloride 10% Hypocalcemia, hyperkalemia, hypermagnasemia, calcium channel blocker overdose
 20 mg/kg (0.2 mL/kg) IV/IO slow push during arrest, repeat PRN
Dexamethasone Croup
 0.6 mg/kg PO/IM/IV max 16 mg)
Dextrose (glucose) Hypoglycemia
 0.5 to 1 g/kg IV/IO (D25 W 2 to 4 mL/kg; D10W 5 to 10 mL/kg
Diphen-hydramine Anaphylatic shock
 1 to 2 mg/kg IV/IO/IM q 4 to 6 hours (max single dose 50 mg)
Dobutamine Congestive heart failure, cardiogenic shock
 2 to 20 mcg/kg per minute IV/IO infusion; titrate to desired effect
Dopamine Cardiogenic shock, distributive shock
 2 to 20 mcg/kg per minute IV/IO infusion; titrate to desired effect
Epinephrine Pulseless arrest, bradycardia (symptomatic)
 0.01 mg/kg (0.1 mL/kg of 1:10 000 standart concentration) IV/IO q 3 to 5 minutes (max
single dose 1 mg).
 0.01 mg/kg (0.1 mL/kg of 1:1000 hight concentration) IV/IO q 3 to 5 minutes
Hipotensive shock
 0.1 mcg/kg per minute IV/IO infusion (consider higher doses if needed)
Anaphylaxis
 IM autoinjector 0.3 mg (for patient weighing >30 kg) or IM junior autoinjector 0.15 mg
(for patient weighing 10 to 30 kg)
 .01 mg/kg (0.1 mL/kg of 1:1000 hight concentration) IM q 15 minutes PRN (max single
 dose 0.3 mg)
 0.01 mg/kg (0.1 mL/kg of 1:10 000 standart concentration) IV/IO q 3 to 5 minutes (max
single dose 1 mg) if hypotensive
 0.1 to 1 mcg/kg per minute IV/IO infusion if hypotension parsists despite fluids and IM
injection
Asthma
 0.01 mg/kg (0/01 mL/kg) 1:1000 subcutaneously q 15 minutes (max 0.3 mg or 0.3 mL)
Croup
 0.25 to 0.5 mg recemic solution (2.25%) mexed in 3 mL NS via inhalation
 3 mL of 1:1000 epinephrine mixed with 3 mL NS (which yields 0.25 mL recamic
epinephrine solution) via inhalation
Drugs Used in PALS (continued)

Drug Indications/Dosages
Etomidate RSI
 0.2 to 0.4 mg/kg IV/IO infused over 30 to 60 second (max 20 mg) will produce rapid
sedation that lasts for 10 to 15 minutes
Hydrocortisone Adrenal
 2 mg/kg IV bolus (max 100 mg)
Ipratropium bromide Asthma
 250 to 500 mcg via inhalation q 20 minutes PRN x 3 doses
Lidocaine VF/pulseless VT, wide-complex tachycardia (with pulses)
 1 mg/kg IV/IO bolus
 Maintence: 20 to 50 mcg/kg per minute IV/IO infusion (repeat bolus dose if infusion
initiated>15 minutes after initial bolus)
 2 to 3 mg/kg ET
Magnesium sulfate Asthma (refractory status asthmaticus), torsades de pointes, hyhypomagnesemia
 25 to 50 mg/kg IV/IO bolus (max 2 g) (pulselessVT) OR over 10 to 20 minutes (VT with
pulses) OR slow infusion over 15 to 30 minutes (status asthmaticus)
Methyl-prednisolone Asthma (status asthmaticus), anaphylatic shock
 Load: 2 mg/kg IV/IO/IM (max 60 mg); only use acetate salt IM
 Maintence: 0.5 mg/kg IV/IO q 6 hours (max 120 mg/d)
Milrinone Myocardial dysfunction and increased SVR/PVR
 Loading dose: 50 mcg/kg IV/IO over 10 to 60 minutes followed by 0.25 to 0.75 mcg/kg
per minutes IV/IO infusion
Naloxone Narcotic (opiate) reversal
 Total reversal reqruited (for narcotic toxicity secondary to overdose): 0.1 mg/kg
IV/IMO/IM subcutanteous bolus q 2 minutes PRN (max 2 mg)
 Total reversal not reqruited (eg, for respiratory depression associated with therapeutic
narcotic use): 1 to 5 mcg/kg IV/IO/IM subcutaneously: titrate to desired effect
 Maintain reversal: 0.002 to 0.16 mg/kg per hour IV/IO infusion
Nitroglycerin Congestive heart failure, cardio genic shock
 Initiate at 0.25 to 0.5 mcg/kg per minute IV/IO infusion; titrate by1 mcg/kg per minute q
15 to 20 minutes as tolerated. Typical dose range 1 to 5 mcg/kg per minute (max dose 10
mcg/kg per minute)
 In adolescent, start with 5 to 10 mcg per minute (not per kg per minute) and increase to
max 200 mcg per minute
Nitroprusside Cardiogenic shock (ie, associated with high SVR), severe hypertension
 0.3 to 1 mcg/kg per minute initial dose; then titrate uo to 8 mcg/kg per minute as needed
norepinephrine Hypotensive (usually distributive) shock (ie, low SVR and fluid refractory)
 0.1 to 2 mcg/kg per minute IV/IO infusion; titrate to desired effect
procainamide SVT, atlrial flutter, VT (with pulses)
 15 mcg/kg IV/IO load over 30 to 60 minutes (do not use routinely with amiodarone)
Prostagladin E1 (PGE1) Ductal-dependent congenital hearth disease (all forms)
 0.05 to 0.1 mcg/kg per minute IV/IO infusion initialy, then 0.001 to 0.005 mcg/kg per
minute IV/IO
Sodium bicarbonate Metabolic acidosis (severe), hyperkalemia
 1 mEq/kg IV/IO slow bolus
Sodium chanel blocker overdose (eg, tricyclic antidepressant)
 1 to 2 mEq/kg IV/IO bolus until serum pH is>7.45 (7.50 to 7.55 for severe poisoning
followed by IV/IO infusion of 150 mEq NaHCO3/L solution titrated to maintain alkalosis
Terbutaline Asthma (status asthmaticus), hyperkalemia
 0.1 to 10 mcg/kg per minute IV/IO infusin intially; consider 10 mcg/kg IV/IO load over 5
 minute
 10 mcg/kg subcutaneously q 10 to 15 minutes until IV/IO infusion is initiated (max single
dose 0.4 mg)
Vasopressin Cardiac arrest
 0.4 to 1 unit/kg bolus (max 40 units)
Cathecolamine-resistant hypotension
 0.0002 to 0.002 unit/kg per minute (0.2 to 2 milliunits/kg per minutes) continous infusion

Indications/Dosages Indications/Dosages Indications/Dosages

 Equipment GRAY* PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN
3-5 kg Small Infant Infant Toddler Small Child Child Child Large Child Adult
6-7 kg 8-9 kg 10-11 kg 12-14 kg 15-18 kg 19-23 kg 24-29 kg 30-36 kg

Resuscitation Infant/child Infant/child Child Child Child Child Child Adult

bag
Oxygen mask Pediatric Pediatric Pediatric Pediatric Pediatric Pediatric Pediatric Pediatric/adult
(NRB)
Oral airway 50 50 60 60 60 70 80 80
(mm)
Laryngoscope 1 Straight 1 Straight 1 Straight 2 Straight 2 Straight 2 Straight or 2 Straight or 3 Straight or
blade (size) curved curved curved
ET tube 3.5 Uncuffed 3.5 Uncuffed 4.0 Uncuffed 4.5 Uncuffed 5.0 Uncuffed 5.5 Uncuffed 6.0 Cuffed 6.5 Cuffed
(mm)+ 3.0 Cuffed 3.0 Cuffed 3.5 Cuffed 4.0 Cuffed 4.5 Cuffed 5.o Cuffed
ET tube 3 kg 9-9.5 10.5-11 10.5-11 11-12 13.5 14-15 16.5 17-18 18.5-19.5
insertion 4 kg 9.5-10
length (cm) 5 kg 10-10.5
Suction 8 8 10 10 10 10 10 10-12
catheter (F)
BP cuff Nenonatal Infant/child Infant/child Child Child Child Child Child Small adult
#5/infant
IV catheter 22-24 22-24 20-24 18-22 18-22 18-20 18-20 16-20
(ga)
IO (ga) 18/15 18/15 15 15 15 15 15 15
NG tube (F) 5-8 5-8 8-10 10 10 12-14 14-18 16-18
Urinary 8 8 8-10 10 10-12 10-12 12 12
catheter (F)
Chest tube (F) 10-12 10-12 16-20 20-24 20-24 24-32 28-32 32-38
Abbreviations: BP, blood pressure; ET, endotracheal; F, French; IO, intraosseous; IV, intravenous; NG, nasogastric; NRB, nonrebreathing.

*For Gray column, use Pink or Red equipment if no size is listed

Per 2010 AHA Guidelines, in the hospital cuffed or uncuffed tubes may be used (see below for sizing of cuffed tubes).

Adapted from Broselow Pediatric Emeregency Tape. Distributed by Armstrong Medical Industries, Lincolnshire,IL. Copyright 2007 Vital Signs, Inc.