Normal Pediatric Vital Signs Hemodynamic Assessment

Age Estimated Normal Average Normal Hypoten- Parameters Stable Compensated Hypotensive
Weight Heart HR Respi- sion level Circulation shock shock
Rate ratory (systolic
Range Rate BP) Conscious Clear and lucid Clear and lucid Restless,
Range level combative

1 month 4 kg 110-180 145 40-60 <70 Capillary Brisk (<2 sec) Prolonged Very prolonged,
refill time (>2 sec) mottled skin
6 months 8 kg 110-170 135 25-40 <70
Extremities Warm and pink Cool peripheries Cold, clammy
12 10 kg 110-170 135 22-30 <72
months Peripheral Good volume Weak & thready Feeble or absent
pulse
2 years 12 kg 90-150 120 22-30 <74 volume
3 years 14 kg 75-135 120 22-30 <76 Heart rate Normal heart Tachycardia Severe
rate for age tachycardia or
4 years 16 kg 75-135 110 22-24 <78 bradycardia in
5 years 18 kg 65-135 110 20-24 <80 late shock

6 years 20 kg 60-130 100 20-24 <82 Blood Normal blood Normal systolic Narrowed pulse
pressure pressure for pressure but ris- pressure (<20
8 years 26 kg 60-130 100 18-24 <86 age ing diastolic mmHg)
Normal pulse pressure Hypotension
10 years 32 kg 60-110 85 16-22 <90 pressure for Narrowing pulse (see definition)
12 years 42 kg 60-110 85 16-22 <90 age pressure Unrecordable
Postural hypoten- blood pressure
14 years 50 kg 60-110 85 14-22 <90 sion

≥15 years 60-100 80 12-18 <90 Respiratory Normal respira- Tachypnoea Hyperpnoea or
rate tory rate for age Kussmaul’s
breathing (Meta-
bolic acidosis)
Urine output Normal Reducing trend Oliguria or anuria

Days of Illness 1 2 3 4 5 6 7 8 9 10 Diagnostic

Testing
40 
• Virus detected for up to 5 days
post onset
Temperature · Viremia coincides with fever
·D etection by PCR highest in
Shock Reabsorption first 3 days of illness
Dehydration Bleeding • ALWAYS SEND ACUTE AND
Fluid overload
Potential CONVALESCENT SAMPLES
clinical issues Organ Impairment · Unless 1st sample positive
for dengue by PCR paired
Platelet samples, acute (0-5 days)
Laboratory and convalescent (6-21 days),
changes Hematocrit needed for diagnosis
• IgM detected for up to 3
Viraemia IgM/lgG months
· No IgM in 20-30% of
Serology and secondary infections
virology

Course of dengue illness:

rse of dengue illness: Febrile Critical Recovery Phases

No

signs
warning

Group A
• Rash
• Aches and pains

• old age
• infancy
• pregnancy
• Anorexia and nausea

• renal failure
• Mucosal bleed

• diabetes mellitus
of platelet count

co-existing conditions

• poor social situation

• Persistent vomiting

Group B
• Lethargy; restlessness

For patients with warning

signs of severe dengue OR
• Liver enlargement >2cm
Warning Signs:
ASSESSMENT

• Clinical fluid accumulation

• Laboratory: Increase in HCT

Presumptive Diagnosis:

• Abdominal pain or tenderness

concurrent with rapid decrease

• Leucopenia

Centers for Disease Control and Prevention

• Warning signs

U.S. Department of Health and Human Services

National Center for Zoonotic, Vector-Borne, and Enteric Diseases

• Tourniquet test positive
Dengue Case Management

• Severe bleeding
with shock and/ or

respiratory distress

Group C
Live in / travel to endemic area plus Fever and two of the following:

• Severe plasma leakage

For patients with any of:
CS 125085

fluid accumulation with

• Severe organ impairment



into house.
Control the fever
Obtain daily CBC

• Sunken eyes
platelet level

• Vomiting blood
despite Tylenol.
Get adequate bed rest

• Black, tarry stools

Follow patient daily for:

• Difficulty breathing
• Drowsiness or irritability
• Sunken fontanel in infant
• Dry mouth, tongue or lips

• Pale, cold, or clammy skin

following warning signs appear:

• Bleeding from nose or gums

• Red spots or patches on the skin
• Few or no tears when child cries

• Cold or clammy fingers and toes

• Fast heart beat (more than 100/min)

Prevent spread of dengue within your house

• Let patient rest as much as they are able.
 warning signs (until out of critical phase)

• Listlessness or overly agitated or confused

 defervescence (beginning of critical phase)

Advise patient or their family to the the following:

• Severe abdominal pain or persistent vomiting

to clinic or emergency room if any of the following signs develop:
Prevent dehydration which occurs when a person loses too much
fluid (from high fevers, vomiting, or diarrhea with poor oral intake).
ibuprofen (Motrin, Alleve) aspirin, or aspirin containing drugs.
• Sponge patient’s skin with tepid water when temperature is high

Give plenty of fluids and watch for signs of dehydration. Bring patient

to avoid infecting mosquitoes that can infect others within 2 weeks.

Group A Outpatient Management

• Give Tylenol every 6 hours (maximum 4 doses per day). Do not give

• Put screens on windows and doors to prevent mosquitoes from coming

 decreasing white blood cell level, increasing hematocrit and decreasing

Watch for warning signs as temperature declines 3 to 7 days after symptoms

began. Return IMMEDIATELY to clinic or emergency department if any of the
• Place patient under bed net or have patient use insect repellent while febrile

• KILL all mosquitoes in house and empty containers that carry water on patio.
• Decrease in urination (check number of wet diapers or trips to the bathroom).

Group B Inpatient Management

For patients with warning signs of severe dengue OR co-existing conditions Monitoring Group B
• pregnancy • poor social situation • liver enlargement >2cm • Vitals signs and and peripheral perfusion checks (at least every 1-2 hours until out of
critical phase – more frequently if patient is requiring fluid boluses or is in ICU)
• old age • lethargy/ restlessness • persistent vomiting • Temperature curve (watch for defervescence)
• infancy • renal failure • increased hematocrit • Follow urine output closely (record volume and frequency at least every 4 hours)
• Volume of fluid intake and losses (“strict I/O’s”) at least every 4 hours
• diabetes mellitus • tender/ painful abdomen • fluid accumulation • Frequent hematocrits (before and after fluid boluses) and at least every 6-8 hours
• mucosal bleeding • Monitor blood glucose at least every 6-12 hours
• Daily complete blood counts
• Other organ function tests (renal panel, liver profile, coagulation profile) as indicated
by patient status
Obtain Baseline CBC on Admission Encourage
Oral Fluid Intake

Adequate Obtain Baseline Hematocrit before Starting IV Fluids Inadequate

Intake Intake

If Clinically Stable Start Isotonic Solutions (NS, LR) If Worsening

and Hct remains same or • 5-7ml/kg/hour x 1-2 hours then Vital Signs and Rapidly
changes minimally Increasing Hct
• 3 -5 ml/kg/hour x 2-4 hours then REASSESS
Hct and clinical status

Continue IV Fluids @ 2-3 ml/kg/hour for 2-4 hours Increase IV Fluids to 5-10 ml/kg/hour x 1-2 hours
then REASSESS Hematocrit and Clinical Status If Unstable
Vital Signs at any Point
then REASSESS HCT and clinical status

Discharge Criteria - All of the following must be met:

Reduce IV Fluids gradually when plasma leak • No fever for at least 24-48 hours
decreasing as indicated by • Improvement in clinical status (general wellbeing, appetite,
• Adequate intake and urine output Group C hemodynamic status, urine output, no respiratory distress)
• Hct decreases below baseline in patient with stable Emergency • Stable hematocrit off IV fluids
clinical status Management • Increasing trend of platelet count (usually preceded by rising WBC)

Group C Emergency Management

For patients with any of:
• severe plasma leakage with shock and/ or fluid accumulation with respiratory distress • severe bleeding • severe organ impairment

Obtain baseline CBC and

organ function tests and
assess hemodynamic status
Compensated Shock Hypotensive Shock

Give isotonic fluid at 5-10 ml/kg/hour over 1 hour Give crystalloid or colloid bolus of 20 ml/kg in 15 min

Improved REASSESS Not Improved REASSESS Improved

Increasing Check Hematocrit Increasing

Reduce IV fluids* • Give crystalloid or colloid
• 5-7 ml/kg/hour x 1-2 hour infusion at 10ml/kg/hour for
then reassess clinical status, Decreasing 1 hour, then
if improving then
• 3-5 ml/kg/hour x 2-4 hours Give crystalloid 10-20 ml/kg Transfuse 5-10 ml/kg Give colloid 10-20 ml/kg bolus
and reassess Hct and clinical bolus over 1 hour PRBC or 10-20 ml/kg over ½ to 1 hour, reassess
status, if continued improve- whole blood ASAP,
ment then reassess
• 2-3 ml/kg/hour x 2-4 hours,
reassess Hct and clinical If still improving,
status and If improved, If improved, • Continue stepwise* reduction
• Discontinue IV fluids • Reduce IV fluids to 7-10ml/ • Reduce colloid to 7-10ml/kg
kg/hour x 1-2 hours If not improved, of IV fluids
when intake and urine o for 1-2 hour, then
• Continue stepwise* Recheck • Continue stepwise* • If not improved
utput adequate and hemat-
reduction in IV fluids hematocrit reduction using crystalloids (recheck hematocrit)
ocrit below baseline value