VITAL SIGNS IN CHILDREN

HEART RATE

                                                                  AWAKE                   SLEEPING

Newborn to 3 months                                 85-205                      80-160

3 months to 2 years                                  100-190                     75-160

2 to 10 years                                               60-140                     60-90

Over 10 years                                             60-100                     50-90

RESPIRATORY RATE

Infant to 1 year 30-60

Toddler 24-40

Preschooler 22-34

School Aged Child 18-30

Adolescent 12-16

BLOOD PRESSURE (SYSTOLIC BP ONLY)

10 years and over (double age in years) + 90

Under 10 yrs (double age in years) + 70

A 3 month old is 0 years. 0 + 0 = 0 + 70 systolic should be at least 70

A 12 year old. 12 + 12 = 24 + 90 systolic should be at least 114   

WHEN YOU FIND AN UNCONSCIOUS CHILD ( Age 1 to Puberty)

You are a lone rescuer:

STEP 1: Assess scene safety. Always assess scene safety first. If the scene is not safe, it is reasonable to withhold resuscitation efforts.

STEP 2: Tap and shout "Hey are you ok?"

STEP 3: Assess pulse and breathing simultaneously. Activate the Emergency Response System and get an AED. If others are around, send someone to get help.

STEP 4: Check a carotid pulse. Check for at least 5 seconds but no more than 10. If there is no pulse or you are not sure if you feel a pulse, begin chest compressions. The maximum time you should spend checking for a pulse is 10 seconds.

Compress at a depth of at least 2 inches or 5 cm (or 1/3 the anterior posterior diameter of the chest).

Compress at a rate of at least 100-120 compressions per minute. Push hard and fast.

Make sure you allow the chest to completely recoil between compressions.

After 30 compressions, give 2 breaths. If there is no suspected head or neck injury: Perform a "head tilt chin

lift" and give 2 breaths. If you suspect a neck injury: Perform a "jaw thrust" to open the airway and deliver 2 breaths.

Give each breath over 1 second watching for chest rise. Do not give large breaths. You want to see the chest just begin to rise. If you give breaths that are too large, all that extra air will go into the stomach. After several large breaths, the pressure will begin to increase in stomach which will then crush the lungs, heart and the diaphragm making it more difficult to save your patient.

Give cycles of 30 compressions and 2 breaths. 5 cycles = two minutes

STEP 5: If you are alone, and there is no one to get help, leave the child, activate the emergency response system, then return to the child. Reassess the pulse. If there is no pulse, resume chest compressions and breaths for 2 more minutes. Every two minutes check a pulse.

Continue to steps of 30 compressions and 2 breaths until more advanced help arrives.

ONCE THE AED ARRIVES

When an AED arrives, use it.

Step 1: Turn on the AED. It may take up to 5-15 seconds to warm up.

Step 2: Follow the instructions given by the AED. Continue chest compressions and breaths while listening to the AED.

STEP 3: Place the pads on the patient following the pictures on the pads for correct placement. If you are not alone, continue chest compressions and have someone else place the pads.

STEP 4: When the AED says "ANALYZING RHYTHM, DO NOT TOUCH THE PATIENT" make sure no one is touching the patient, not even the person giving breaths. If the AED says "SHOCK ADVISED, CHARGING" continue chest compressions while the AED is charging.

STEP 5: When the AED is charged, clear the patient and deliver the shock. Immediately resume chest compressions. Begin with 30 compressions and 2 breaths. Complete 5 cycles of 30 compressions and 2 breaths. When 2 minutes have passed, the AED will automatically reanalyze the rhythm. If the AED says: "NO SHOCK ADVISED" you do not check a pulse, you immediately resume CPR for 2 more minutes. Continue these steps until more advanced help arrives.

Always assess scene safety first. If the scene is not safe, it is reasonable to withhold resuscitation efforts. If you find someone unconscious in the middle of the street and run out to save them and get hit by a car, the situation just got worse and now there are two people needing to be saved.

The American Heart Association now recommends C.A.B. Instead of A.B.C. When a cardiac arrest happens, there is usually enough oxygen in the blood stream to sustain life, but it must circulate throughout the body. So the most important step to begin with is chest compressions, not rescue breaths. Beginning with chest compressions is the easiest step for bystanders to perform. It will only delay rescue breaths by about 18 seconds.

An AED only detects 2 particular heart rhythms. They are Ventricular Fibrillation or V-Fib and Pulseless Ventricular Tachycardia or Pulseless V-Tach. If the AED detects either of these rhythms it will deliver a shock.

The biggest misconception people have is that when you shock someone, you jump start the heart just like you would jump start a car. This is not true. When the heart is in Ventricular Fibrillation or Pulseless Ventricular Tachycardia the heart is quivering. The heart is getting told to contract too fast, from too many different cells that it can't possibly keep up and just begins to vibrate.

Almost like seeing someone on TV getting stunned with a taser. The heart just vibrates. The only way to correct all the overstimulation is to stop all of the electricity in the heart. For example: My computer gets a virus. The first thing I want to do is pull the cord from the wall and stop the virus. I don't want to start opening other programs and get them running too. The same goes for V-Fib and Pulseless V-Tach.

The shock stops the heart completely, giving it a chance to start over and hopefully produce a normal organized rhythm. So if defibrillating actually stops the heart, do you see why shocking someone in asystole doesn't make any sense? Why shock someone to stop the heart, when their heart is already stopped.

Always allow the chest to completely recoil when doing compressions. Say there was a small fire, and you had a water bottle full of water. Would it make sense to squeeze tiny amounts out really really fast? Or, would it make more sense to give the bottle a good squeeze and force out as much water as you can at one time, and repeat? When you compress the chest, it squeezes a small amount of blood out. By letting the chest completely recoil with each compression, more blood is squeezed out with every compression.

CHILD SPECIFIC

A CHILD is considered to be 1 year to puberty. (Puberty is not an age but rather physical signs)

Over puberty is treated as an adult. Puberty is not defined by age, but instead by physical appearance.

For boys: If there is any chest hair, or underarm hair present, they are considered an adult.

For girls: Look for signs of breast development. If any breast development is present they are considered an adult. So, if you had a 10 year old girl who happens to be pregnant, she has hit puberty and is treated as an adult.

For lone rescuers, to provide child CPR, use one hand instead of two and compress 2 inches = 5 cm (The same as an adult) or compress 1/3 the depth of the chest. Deliver 30 compressions and 2 breaths.

An INFANT is 0 to 1 year old.

For lone rescuers, to provide infant CPR, use two fingers on the lower half of the breastbone and compress 1 1/2 inches = 4 cm or 1/3 the depth of the chest. Deliver 30 compressions and 2 breaths.

MAJOR DIFFERENCES IN CHILD AND INFANT CPR:

When there are TWO RESCUERS, and the child us UNDER PUBERTY the compression to ventilation ratio changes to 15:2 (Now, 10 cycles is 2 minutes - Check the pulse every two minutes

For infant compressions with two rescuers, encircle your hands around the infant's chest and provide the compressions using your thumbs over the lower half of the breastbone. Compress at least 1 1/2 inches = 4 cm or 1/3 the depth of the chest. This is called the "Two thumbs technique" and is only used with 2 or more rescuers.

DIFFERENCES WITH AN AED USED ON CHILDREN AND INFANTS

Some AEDs have Adult and Pediatric pads. Pediatric pads should be used on anyone 8 yrs and under. If pediatric pads are not available you should use the adult pads on an infant or child. For a child, place the pads the same way you would on an adult. Make sure the pads do not touch, or overlap.

For an infant, place one pad in the center of the chest, and one pad on the back in the center. If you can remember, "baby sandwich". Pads used on infants under 1 year old are always placed front and back whether you are using pediatric or adult pads.

Adult pads can be used on an infant under 1 year old. A burned baby is better than a dead baby, and if a shock is needed it must be delivered.

Never cut the adult pads in half. This will leave a bare metal edge which will allow the shock to arc and shock someone else.

RESCUE BREATHING

For a child/infant, give 1 breath every 3-5 seconds this is 12-20 breaths/min.

If you can remember 1 breath every 3-5 seconds (then multiply each x 4) 3 x 4 = 12 and 5 x 4 = 20. This is 12-20 breaths per minute. Children run faster than adults, so they must breathe faster too.

If an advanced airway (ETT) is in place regardless of age deliver one breath every 6 seconds. If someone has an advanced airway in place, they will not be conscious. If the person is "sleeping" they will not need to breathe as fast as an adult or child and is the slowest rate of all. Only 1 breath every 6 seconds. This is only 10 breaths per minute. When an advanced airway is used, compressions must be stopped until the tube in placed in the airway. Once it is in place, provide continuous chest compressions without pauses for the breaths. (The tubes are very stiff and firm, slightly flexible. But they are firm enough and long enough to allow oxygen to pass through them effectively while someone is pushing down and compressing the chest.

WHEN TO CALL FOR HELP AND WHEN TO START COMPRESSIONS

If a child, check responsiveness, tap and shout "hey, are you ok ?"

Check for breathing: if no breathing, activate emergency response system and get an AED

Check for a pulse: if no pulse, begin chest compressions at a rate of 30:2

If the victim is UNDER PUBERTY, and there are 2 rescuers, begin 15:2

IF they are UNDER PUBERTY and the arrest is witnessed, GET HELP FIRST then return to the child and begin with compressions. Provide 2 minutes of CPR and check a pulse.

When you see a child collapse, (WITNESSED) you know their last breath and last heartbeat was just now. Their blood oxygen level should be pretty high. So get help first. If there are others around, send someone to get help and get and AED.

If you find a child who has collapsed and it was not witnessed, you have no idea if their blood oxygen level is adequate, so provide 2 minutes of CPR and get their blood oxygen level back up, then leave the child and go get help. If there are others around, send someone to get help and get and AED.

IF the arrest is NOT WITNESSED, Begin 2 minutes of CPR, go get help and an AED and return to the child. Begin cycles of 30 compressions and 2 breaths if you are alone. Check a pulse every 2 minutes.

If there are two rescuers and the child is under puberty, begin cycles of 15 compressions and 2 breaths. Check a pulse every 10 cycles or 2 minutes.

ONE MORE VERY IMPORTANT THING ABOUT KIDS

If the child is UNDER PUBERTY AND HAS A PULSE OF 60 or less (BEGIN VENTILATION WITH 100% OXYGEN, IF THERE IS NO IMPROVEMENT, BEGIN CHEST COMPRESSIONS.

Only perform chest compressions if they show signs of poor perfusion. (Do CPR and give Epi 0.01 mg/kg Not Atropine)

Are they cold, are their fingers or lips blue, does their color just not look right ? Are there any signs the child is not getting enough blood supply and oxygen? If you see these signs, BEGIN CHEST COMPRESSIONS. DO NOT DELAY.

CHOKING

For an adult or child, wrap your hands around the victim's waist and begin abdominal thrusts until the victim becomes unconscious or the foreign object is removed. For an infant, lay them over your forearm supporting the infant's head and neck and begin 5 back slaps (Be sure to cradle the infant face down with head lower than the rest of the body).

Turn the infant over and begin 5 chest thrusts (just as you would chest compressions). Continue with 5 back slaps and 5 chest compressions until the object is removed or the infant becomes unconscious.

Once an adult, child or infant becomes unconscious, do not continue to treat them as a chocking victim. Lay them on a hard flat surface and begin Basic Life Support.

Start by tapping and shouting "Hey, Are you Ok ?" Assess breathing, if no breathing or only gasping, activate emergency response and get an AED.

Begin chest compressions. Before giving breaths, look in the mouth for the obstructing object. If you can see the object, try to remove it. Do not perform a blind finger sweep.

Attempt to give 2 rescue breaths. If the chest does not rise, reposition the airway and attempt again. If the chest does not rise, begin chest compressions. Between chest compressions and rescue breath attempts, it is hoped that the back and forth motions will move the object one way or the other. Continue as long as you can and just know, that you cannot continue CPR forever. There may be a time when it is just not humanly possible to continue for hours and hours, nor would you want to continue CPR on someone for that length of time. The chances of successfully reviving someone without significant brain damage after an extended amount of time is very slim.

FOUR TYPES OF RESPIRATORY DISORDERS

UPPER AIRWAY OBSTRUCTION

These children will present with stridor, and/or increased INSPIRATORY effort and retractions. The most important INITIAL medication is Nebulized Epinephrine (also called racemic epi). Give steroids if the child has a history of asthma. Provide oxygenation. If the oxygen sat continues to drop despite oxygen administration, or if an infant or child is grunting, immediately begin bag mask ventilations and prepare for intubation.

LOWER AIRWAY OBSTRUCTION

This is bronchiolitis or asthma. You’ll hear wheezes and a prolonged expiratory phase. Provide nebulizer treatments, steroids and support the oxygen needs.

LUNG TISSUE DISEASE

This is pneumonia, or aspiration pneumonia. Expect to hear crackles. The child will have a low oxygen saturation and resp effort will be increased. Provide oxygenation, antibiotics and antipyretics. Obtain cultures if the fever is over 101.

DISORDERED CONTROL OF BREATHING

This is an example of a post dictal child, a brain injury or neuro child, or even a child that has been sedated and doesn’t have control over their breathing. As long as their V/S are stable, simply monitor. The resp rate may only be 6, but if their sat is 99% on room air, just monitor. However! If the respirations are shallow, the O2 sat is 94% with oxygen and the child has poor chest rise, snoring, and poor air entry, reposition them and insert and OPA or Oral Pharyngeal Airway. This is a hard plastic thing that looks like a question mark. To find the

correct size, measure from the corner of the mouth to the angle of the mandible (corner of the jaw). If breathing does not improve, administer bag mask ventilations.

FOUR TYPES OF SHOCK

The best way to determine the severity of any type of shock, is by the BLOOD PRESSURE.

If the blood pressure is normal, this is compensated shock.

CARDIOGENIC 

Defined as cold and dusky hands and feet, gallop on auscultation, palpable liver and crackles to lung bases as the heart struggles to preserve the core and circulate the blood volume.

Treatment includes antibiotics and fluids of ONLY 5-10ml/kg given very slowly. This will thin the blood and allow the sick heart to pump more efficiently clearing up the crackles in the lungs.

DISTRIBUTIVE/SEPTIC SHOCK

With septic shock, the child will have a very low BP, good cap refill, most likely a very high fever near or above 103. A child with a high fever who is on chemotherapy would be in septic shock with a very low BP. Treatment consists of supporting the airway, obtaining cultures, administering antibiotics and antipyretics and a fluid bolus of 20ml/kg given very quickly followed with vasopressors if the BP does not respond to the fluid bolus.

OBSTRUCTIVE SHOCK

This could be due to a tension pneumothorax. This will cause an increased pressure within the chest which will crush the vena cava, and the heart restricting or obstructing the blood flow leading to shock. Treatment consists of immediate correction of the pneumothorax with needle decompression and preparation of a chest tube. If the child is on a ventilator, and the oxygen saturation is 68%, Remember the D.O.P.E. mnemonic.

D.O.P.E.

D = Displacement (Check to see that the tube has not moved and is still at the previous cm marking at the lip.

This step should be performed FIRST.

O = Obstruction Listen for breath sounds. If any breath sounds are heard, the tube is not obstructed or you would hear no breath sounds at all.

P = Pneumothorax Check to see if breath sounds are equal. Is the trachea deviated (Very late sign in children) and check to see if there is equal rise and fall of the chest.

E = Equipment Disconnect the ventilator, attach BVM and bag the child. If the O2 sat does NOT rise, it is not an equipment problem.

HYPOVOLEMIC SHOCK (ALSO Called HYPOTENSIVE SHOCK) 

This can be due to volume depletion caused by blood loss or by dehydration. Administer rapid fluid bolus of 20ml/kg over 5 minutes up to 3 times. A low blood pressure is a very late sign of shock in children. Children can maintain a normal blood pressure until they have lost 25% of their total blood volume. If the Blood pressure is low, this is hypotensive, if the blood pressure is normal, this is COMPENSATED shock.

Always keep children’s O2 Sat between 94-99% to prevent hyperoxia. If the child is on oxygen and the sat is 100%, then turn the oxygen down to achieve a sat of 94-99%.

From the age of puberty and under. If the child has a pulse of 60 or less, begin chest compressions and treat them as though they have no pulse. Administer EPI. Do not give Atropine to a child for bradycardia unless the bradycardia is caused by vagal stimulation such as with suctioning.

If a child’s heart slows down or stops, it is because they can’t breathe. If a child has been in respiratory distress for a few days, and the heart rate begins to drop, and resp rate begins to drop it’s because they are getting tired and are going to stop breathing. If you do not fix this, the child will go into respiratory failure. Begin ventilations with a BVM device.

The same goes for a child in respiratory distress for a few days. If they have been struggling to breathe and you suction away what little bit of air they were able to get in, their heart rate will drop. Simply bag them and replace the oxygen you took away.

When you place a pulse ox on a child, make sure that the heart rate on the pulse ox correlates with the heart rate on the monitor. If the monitor shows a heart rate of 200, and your pulse ox says the heart rate is 99, the pulse ox is not reliable. So if it says the O2 sat is 98%, it is not reliable and the child must be given oxygen.

The best way to establish vascular access in a child is IO Intraosseous. In cases of cardiac arrest, do not attempt peripheral IV access, immediately go to IO access.

The preferred vagal maneuver in children is ice to the face.

When performing cardioversion for an unstable tachycardia, begin with ½ to 1J/kg.

When defibrillating, begin with 2J/kg, then 4J/kg, 6J/kg, 8J/kg and finally 10J/kg which is the maximum. Repeat 10J/kg as needed.

In children 1 year and under, check a brachial pulse.

When using an AED, if pediatric pads are not available, you may use adult pads. For a child, place them in the same place you would an adult. If it is an infant, always place one pad in the center of the chest, and one on the back directly behind the one on the chest.

As soon as an AED arrives, use it. Be sure to turn it on FIRST.

When performing CPR alone, everyone is 30 compressions and 2 breaths regardless of age.

If the child is under puberty, and there are 2 rescuers, the ratio changes to 15:2

Just remember that children are not small adults. If an adult wants to increase their cardiac output, their cardiac muscle fibers stretch to hold move blood volume, thus they can pump more blood with each heartbeat. Kids can't do that. Their muscle fibers are very short and don't stretch enough to change cardiac output. All they can do is increase their heart rate. Kids can compensate too !

Did you know, that if a 4 year old child's body can hold 4 liters of blood, that they can lose an ENTIRE LITER (or 25% of their total circulating volume) and still maintain a normal blood pressure !!!

Scary isn't it !!!! Kids can compensate for a while, but not forever. So if you notice a low blood pressure on a child, you have only a minute or two notice that the child is about to CODE ! If their blood pressure is low, that means their compensatory mechanisms are failing and in just a minute, they will completely stop ! Replace fluids quickly !!! Not over 20 min. They could be dead in 20 minutes.

The MOST IMPORTANT laboratory test for a child or infant is BLOOD SUGAR. Kids don't store glycogen like adults do. If their blood sugar drops, they have to burn their own tissue as a source of energy. Once this happens, they won't metabolize any medications you give them.

Any child that is in cardiac arrest, should have I/O placement attempted BEFORE peripheral IV access. Intraosseous access is a rapid and fairly simple method to establish immediate IV access.

Remember, children's heart rates often drop because of respiratory problems. For example, you have a child with a heart rate of 40, O2 sat is 60% and respirations are 6. For this child you should immediately start bag mask ventilations with 100% O2.

Respiratory distress VS respiratory failure

Respiratory distress could be increased effort, retractions, nasal flaring and head bobbing. However, if you are already giving 100% O2, and the oxygen saturation is still low, this is Failure. You cannot provide more than 100% oxygen. If the child needs to be intubated, this is failure.

Sinus Rhythm has a heart rate of 60-100 beats per minute

Sinus Bradycardia is a normal sinus rhythm with a HR less than 60 beats per minute

Sinus Tachycardia has p-waves and a heart rate of 101-150 per minute

Supraventricular Tachycardia (or SVT) has a heart rate over 150 (it's usually around 200 per minute)

PEA or Pulseless Electrical Activity is a normal sinus rhythm, or sinus bradycardia on the monitor, but there is no pulse.

TEAM DYNAMICS

IF you are a team member, and the team leader gives you an order that is outside your scope of practice (say you are a nurse, and the doctor tells you to intubate), then you should ask for another role.

IF the team leader gives an order for Epinephrine 0.1mg/kg you should say "I think the correct dose is 0.01mg/kg. Should I give that instead".

I hope this study guide has been helpful. If you have any questions or comments please let us know.