Normal Pediatric Vital Signs

Age
Parameters Stable Circulation Clear and lucid Brisk (<2 sec) Warm and pink Good volume Prolonged (>2 sec) Cool peripheries Weak & thready Clear and lucid Compensated shock Conscious level Capillary refill time Extremities

Hemodynamic Assessment
Hypotension level (systolic BP) <70 <70 <72 <74 <76
Heart rate Peripheral pulse volume Normal heart rate for age Hypotensive shock Restless, combative Very prolonged, mottled skin Cold, clammy Feeble or absent

Estimated Weight

Normal Heart Rate Range 110-180 110-170 110-170 90-150 75-135 75-135 65-135 60-130 60-130 60-110 60-110 60-110 60-100 80 12-18 <90 85 14-22 <90
Respiratory rate Normal respiratory rate for age

Average HR

Normal Respiratory Rate Range 40-60 25-40 22-30 22-30 22-30 22-24 20-24 20-24 18-24 16-22 16-22 <90 <90 <86 <82
Blood pressure

1 month 6 months 12 months 2 years 3 years 4 years 5 years 6 years 8 years 10 years 12 years 14 years 15 years 50 kg 42 kg 85 32 kg 85 26 kg 100 20 kg 100 18 kg 110 <80
Normal blood pressure for age Normal pulse pressure for age

4 kg 8 kg 10 kg 12 kg 14 kg 16 kg 110 <78 120 120 135 135

145

Tachycardia

Severe tachycardia or bradycardia in late shock Normal systolic pressure but rising diastolic pressure Narrowing pulse pressure Postural hypotension Tachypnoea Narrowed pulse pressure (<20 mmHg) Hypotension (see definition) Unrecordable blood pressure Hyperpnoea or Kussmauls breathing (Metabolic acidosis)

Urine output

Normal

Reducing trend

Oliguria or anuria

Days of Illness
40

10

Diagnostic Testing
Virus  detected for up to 5 days

Temperature Shock Dehydration Bleeding Organ Impairment Platelet Laboratory changes Hematocrit Viraemia Serology and virology Course of dengue illness: rse of dengue illness: Febrile IgM/lgG Reabsorption Fluid overload

Potential clinical issues

post onset Viremia coincides with fever D  etection by PCR highest in first 3 days of illness  ALWAYS SEND ACUTE AND CONVALESCENT SAMPLES  Unless 1st sample positive for dengue by PCR paired samples, acute (0-5 days) and convalescent (6-21 days), needed for diagnosis  IgM detected for up to 3 months  No IgM in 20-30% of

secondary infections

Critical

Recovery Phases

No warning signs

Group A Group B Group C

U.S. Department of Health and Human Services Centers for Disease Control and Prevention National Center for Zoonotic, Vector-Borne, and Enteric Diseases

Dengue Case Management

Live in / travel to endemic area plus Fever and two of the following: Anorexia and nausea Warning signs Rash Tourniquet test positive Aches and pains Leucopenia

Abdominal pain or tenderness Persistent vomiting Mucosal bleed Liver enlargement >2cm Clinical fluid accumulation Lethargy; restlessness  Laboratory: Increase in HCT concurrent with rapid decrease of platelet count

For patients with warning signs of severe dengue OR co-existing conditions  pregnancy  infancy  diabetes mellitus  poor social situation  old age  renal failure For patients with any of:  Severe plasma leakage with shock and/ or fluid accumulation with respiratory distress Severe bleeding Severe organ impairment

ASSESSMENT

Presumptive Diagnosis:

Warning Signs:
CS 125085

 Obtain daily CBC Follow patient daily for:

Get adequate bed rest  Let patient rest as much as they are able. defervescence (beginning of critical phase) warning signs (until out of critical phase)  decreasing white blood cell level, increasing hematocrit and decreasing platelet level

Advise patient or their family to the the following:

Group A Outpatient Management

Control the fever  Give Tylenol every 6 hours (maximum 4 doses per day). Do not give ibuprofen (Motrin, Alleve) aspirin, or aspirin containing drugs.  Sponge patients skin with tepid water when temperature is high despite Tylenol.

For patients with warning signs of severe dengue OR co-existing conditions  pregnancy  poor social situation  liver enlargement >2cm  old age  lethargy/ restlessness  persistent vomiting  infancy  renal failure  increased hematocrit  diabetes mellitus  tender/ painful abdomen  fluid accumulation  mucosal bleeding Obtain Baseline CBC on Admission Encourage Oral Fluid Intake

Reduce IV Fluids gradually when plasma leak decreasing as indicated by Adequate intake and urine output  Hct decreases below baseline in patient with stable clinical status

For patients with any of: severe plasma leakage with shock and/ or fluid accumulation with respiratory distress Obtain baseline CBC and organ function tests and assess hemodynamic status Compensated Shock Give isotonic fluid at 5-10 ml/kg/hour over 1 hour

 5-7 ml/kg/hour x 1-2 hour then reassess clinical status, if improving then  3-5 ml/kg/hour x 2-4 hours and reassess Hct and clinical status, if continued improvement then  2-3 ml/kg/hour x 2-4 hours, reassess Hct and clinical status and  Discontinue IV fluids when intake and urine o utput adequate and hematocrit below baseline value

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 following warning signs appear:  Severe abdominal pain or persistent vomiting  Red spots or patches on the skin  Bleeding from nose or gums  Vomiting blood  Black, tarry stools  Drowsiness or irritability  Pale, cold, or clammy skin  Difficulty breathing

Prevent spread of dengue within your house  Place patient under bed net or have patient use insect repellent while febrile to avoid infecting mosquitoes that can infect others within 2 weeks.  KILL all mosquitoes in house and empty containers that carry water on patio.  Put screens on windows and doors to prevent mosquitoes from coming into house.

Group B Inpatient Management

 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)  Temperature curve (watch for defervescence)  Follow urine output closely (record volume and frequency at least every 4 hours)  Volume of fluid intake and losses (strict I/Os) at least every 4 hours  Frequent hematocrits (before and after fluid boluses) and at least every 6-8 hours  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

Adequate Intake
If Clinically Stable and Hct remains same or changes minimally

Obtain Baseline Hematocrit before Starting IV Fluids Start Isotonic Solutions (NS, LR) 5-7ml/kg/hour x 1-2 hours then 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 then REASSESS Hematocrit and Clinical Status

Group C Emergency Management

severe bleeding severe organ impairment

Prevent dehydration which occurs when a person loses too much fluid (from high fevers, vomiting, or diarrhea with poor oral intake). Give plenty of fluids and watch for signs of dehydration. Bring patient to clinic or emergency room if any of the following signs develop:  Decrease in urination (check number of wet diapers or trips to the bathroom).  Few or no tears when child cries  Dry mouth, tongue or lips  Sunken eyes  Listlessness or overly agitated or confused  Fast heart beat (more than 100/min)  Cold or clammy fingers and toes  Sunken fontanel in infant
Monitoring Group B

Inadequate Intake
If Worsening Vital Signs and Rapidly Increasing Hct

If Unstable Vital Signs at any Point

Increase IV Fluids to 5-10 ml/kg/hour x 1-2 hours then REASSESS HCT and clinical status
Discharge Criteria - All of the following must be met:

Group C Emergency Management

No fever for at least 24-48 hours  Improvement in clinical status (general wellbeing, appetite, hemodynamic status, urine output, no respiratory distress)  Stable hematocrit off IV fluids  Increasing trend of platelet count (usually preceded by rising WBC)

Hypotensive Shock Give crystalloid or colloid bolus of 20 ml/kg in 15 min

Improved

REASSESS

Not Improved Increasing

Reduce IV fluids* Check Hematocrit
Decreasing Give crystalloid 10-20 ml/kg bolus over 1 hour Transfuse 5-10 ml/kg PRBC or 10-20 ml/kg whole blood ASAP, reassess

REASSESS

Improved Increasing

 Give crystalloid or colloid infusion at 10ml/kg/hour for 1 hour, then Give colloid 10-20 ml/kg bolus over to 1 hour, reassess

If improved,  Reduce IV fluids to 7-10ml/ kg/hour x 1-2 hours  Continue stepwise* reduction in IV fluids

If not improved, Recheck hematocrit

If improved,  Reduce colloid to 7-10ml/kg for 1-2 hour, then  Continue stepwise* reduction using crystalloids

If still improving,  Continue stepwise* reduction of IV fluids  If not improved (recheck hematocrit)