Triage of the Acutely Ill Child

Assessment of Vital Signs

Assessment of vital signs is critical in all pediatric visits for acute illness, including temperature, heart rate, respiratory rate, and blood pressure. Normal vital signs vary with age. Although there have been increasing efforts to build evidence-based vital sign cutoffs for different age-groups, most institutions use nonempirically derived cutoffs such as those in Pediatric Advanced Life Support (PALS). Tachycardia is common in children presenting for acute care and can result from benign (fever, pain, dehydration) to life-threatening (septic shock, hemorrhage) conditions. An abnormal heart rate should prompt a full history and physical examination, as described later, and careful reassessment (often multiple times) after the presumed cause is identified and treated. The vast majority of children will improve after initiation of simple interventions such as antipyretics or analgesia. Tachycardia that persists after fever, pain, and dehydration have been treated must be evaluated further, particularly if the child appears ill or has deficit in perfusion or altered mental state.

Tachypnea is also common and has many causes, including fever, respiratory conditions (bronchiolitis, asthma, pneumonia), cardiac disease (e.g., heart failure), and metabolic acidosis (shock, poisoning, diabetic ketoacidosis). Similar to tachycardia, tachypnea often resolves with antipyretics in febrile children, and should be reassessed to ensure resolution once fever has been managed. In cases where bronchiolitis and asthma have been ruled out, persistent tachypnea and fever can be a sign of pneumonia, even in the absence of focal lung findings on examination. Consider evaluation for metabolic acidosis in cases of significant tachypnea without apparent pulmonary or cardiac causes. Apnea is a sign of respiratory failure and should be treated emergently with bag-valve-mask ventilation and immediate ED evaluation.

Hypotension is rare in children, and when present, it is a sign of critical illness. Children with hypotension should be evaluated in an ED. Hypotension is evidence of decompensated circulatory shock and can result from severe dehydration, sepsis, hemorrhage, neurogenic spinal shock, or cardiogenic shock.

Pulse oximetry (oxygen-hemoglobin saturation, Sp o ₂ ) should be assessed in children with respiratory or cardiac illness/compromise and also in children with underlying abnormalities of oxygenation. Healthy children have Sp o ₂ >95%. The practitioner should consider evaluating for any underlying respiratory or cardiac causes in children with Sp o ₂ <93–95%. For children with underlying abnormalities, the child's baseline Sp o ₂ should be assessed and alterations from that baseline should be investigated further.

The combination of bradycardia, hypertension, and altered breathing known as Cushing triad can be a sign of life-threatening increased intracranial pressure (ICP) and should be evaluated in an ED. Anisocoria and a 6th cranial nerve palsy are other signs of increased ICP. Toxidromes should also be considered in children with abnormal combinations of vital signs (see Chapter 77 ).