Acutely Ill

  • Core 1 (Pre-Clerkship)
    • MDTI: Acute Inflammation, Chronic Inflammation, Mediators of Inflammation, Wound Repair 
    • Brain & Behavior: CSF, CNS Infections 1-2, The Mental Status Exam, AMS, Stimulant Use Disorder, Opioid Use Disorder, Alcohol and BZD Use Disorders, Cannabis and Adol Substance Use, Head Trauma
    • Cardiology: Shock and Other Inadequate States
    • Endocrinology: Pituitary Physiology, Pituitary Pathophysiology, Adrenal Physiology, Adrenal Pathophysiology, Thyroid Pathology, DM Type 1, DM Type 2, Diabetes Complications, Hypoglycemia 
    • Gastroenterology: Acute and Chronic Diarrhea
    • Renal: Metabolic Acidosis, Metabolic Alkalosis, Water Balance and Control of Osmolality, Sodium Balance and Control of ECF Volume, Disorders of Water Balance 1: Hyponatremia, Disorders of Water Balance 2: Hypernatremia, Potassium Balance and Transport, Hyperkalemia, Hypokalemia
  • Core 2 (Clerkships)
    • Pediatric Clerkship Didactics on the Acutely Ill Child
    • Pediatric Emergency Medicine didactics on Pediatric Trauma: Differences in Care
      • Optional reading - CDEM Approach to: Altered Mental Status, Cardiac Arrest, Crying Child, Headache, Ingestion, Pediatric Shock
  • Core 3 (Post-Clerkship)
    • Electives that may further knowledge: PEM SubI, Pediatric Cardiology, PICU, NICU

  • Pediatric Vital Signs

    • In pediatrics, interpretation of vital signs requires a nuanced, age-specific approach. Unlike in adult medicine, where normal ranges are relatively fixed, pediatric vital signs vary significantly with age and developmental stage. For example, a heart rate of 160 beats per minute or a respiratory rate of 40 breaths per minute may be completely normal for an infant, but in a school-aged child or adolescent, these same values could suggest serious distress or a patient in extremis. This variation underscores the importance of contextualizing vital signs within the appropriate age-specific norms. A single value taken out of context can lead to misinterpretation—either underestimating a child's acuity or overreacting to a normal finding. Table 1 provides reference ranges for heart rate, respiratory rate, and blood pressure by age and can be used as a bedside tool for quick reference.

    • Table 1. Reference range for pediatric vital signs including heart rate, respiratory rate, and systolic/diastolic blood pressure.  

       

      Age 

      Heart Rate (beats/min) 

      Respiratory Rate (breaths/min) 

      Blood pressure (mmHg) 

      Awake 

      Asleep 

      Normal 

      Systolic 

      Diastolic 

      MAP 

      Neonate 

      (<28 days) 

      100-205 

      90-160 

      30-53 

      67-84 

      35-53 

      45-60 

      Infant  

      (1-12 mo) 

      100-180 

      90-160 

      30-53 

      72-104 

      37-56 

      50-62 

      Toddler  

      (1-2 y) 

      98-140 

      80-120 

      22-37 

      86-106 

      42-63 

      49-62 

      Preschool 

      (3-5y) 

      80-120 

      65-100 

      20-28 

      89-112 

      46-72 

      58-69 

      School age 

      (6-11y) 

      75-118 

      58-90 

      18-25 

      97-115 

      57-76 

      66-72 

      Adolescent(12-15y) 

      60-100 

      50-90 

      12-20 

      102-120 

      61-80 

      71-79 

    • Outside of the immediate postnatal period or congenital heart disease, oxygen saturation is typically 95-100% and should be >90%. Similarly, fever is defined as a temperature over 38°C (>100.4°F). These values do not have specific age-specific ranges and are constant in pediatric and adult medicine. Over time, as you gain more clinical experience, you will begin to develop a heuristic or “gut sense” for what normal vital signs look like across different pediatric age groups. However, in the early stages of training, it’s essential to refer to standardized norms and consider the patient’s overall clinical picture when interpreting vital signs.

    • Always remember vital signs are only one part of the story. Their interpretation must always be integrated with the rest of the clinical exam and the trajectory of the patient’s illness. 

The AMPLE mnemonic is commonly used in emergency and trauma settings to guide a focused patient history. It helps clinicians quickly gather relevant background information, especially when time is limited.

  • A - Allergies
  • M - Medications
  • P - PMH
  • L - Last Meal
  • E - Events leading up to the illness/injury

  • When approaching a patient with acute decompensation or critical illness, it is important to employ a systematic approach to identify primary problems and associated complications. The initial approach, whether in the emergency department, intensive care unit, or other settings, is centered around the primary survey. The goal of the primary survey is to rapidly identify life-threatening injuries or problems and intervene quickly before proceeding to a more detailed investigation. We will employ a primary survey to assess ABCDE’s as follows:
  • Primary Survey: Rapidly identify life-threatening injuries or problems.
    • Airway: Assess for airway patency (is the patient speaking/crying, are they hoarse, is there an obvious foreign body) and ability to protect the airway (is the patient able to swallow their secretions, do they have emesis or blood in the mouth and airway, are there any injuries threatening the airway).
    • Breathing: Inspect and auscultate the chest. Assess for bilateral breath sounds, appropriate chest rise and fall, respiratory rate, work of breathing, and oxygen saturation.
    • Circulation: Inspect and palpate. Assess central pulses (for infants <1 years old, brachial pulse in the arm; if older, the carotid or femoral), heart rate, measure blood pressure. Capillary refill time is a critical tool in determining tissue perfusion and should be assessed on every patient. Obtain vascular access (aka IV) if necessary.
    • Disability: Assess consciousness and cognitive ability. There are various scales like the Glasgow Coma Scale (GCS), but it is most important to determine if the patient is awake and alert, awakening only to verbal stimuli, awakening only to painful stimuli, or unconscious (AVPU). It is also critical to assess pupillary size and response to light. It is also a good point to check a bedside point of care blood glucose.
    • Exposure: Finally, clothing should be removed to assess for concealed injury, care taken to maintain normothermia, and if there is chemical injury, decontamination is required.
  • Any identified issue requires rapid intervention in the order it is identified. If there is an emergent concern with A/airway, this is addressed before moving on the B/breathing. This framework is used frequently in the trauma bay for rapid evaluation but is also helpful in other contexts for rapidly identifying life threatening issues. Using a framework can help make sure that you do not miss anything.

When approaching a critically ill child, it is also important to maintain a broad differential diagnosis and consider a wide range of possible etiologies. Structure mnemonics can help improve diagnostic accuracy and guide timely interventions; these serve as a comprehensive framework to assess for potential causes of illness. The VITAMINS mnemonic is helpful for expanding a differential diagnosis but here we present a different mnemonic - “THE-MISFITS” - that is helpful in the work up of acutely ill infants but can also be generalized to older children. 

The MISFITS

  • Trauma (both accidental and non-accidental)
    • Consider injuries to the head, chest wall, and less protected internal organs
  • Heart disease/Hypovolemia/Hypoxia
    • Consider congenital heart disease, hypovolemia from dehydration or severe illness
    • It is important to check for hepatomegaly and heart murmur in all patients
  • Endocrine disorders (including congenital adrenal hyperplasia) 
  • Metabolic disturbances including electrolyte imbalances
    • Don't forget to evaluate for hypoglycemia
  • Inborn errors of metabolism
    • Can screen with ammonia level/blood glucose and metabolic acidosis
    • Calculate the anion gap (normal 4-12). Common causes of an elevated anion gap acidosis can be remembered by the mnemonic MUDPILES.
  • Sepsis
    • This is the leading cause of critical illness in children
    • Important to quickly obtain labs and blood, urine, and/or CSF cultures, administer broad spectrum antibiotics, and support hemodynamics
  • Formula errors or Feeding problems
    • Consider hypo/hypernatremia if incorrectly mixing formula
    • Consider hypoglycemia if not feeding appropriately
  • Intestinal surgical emergencies including volvulus and necrotizing enterocolitis
  • Toxins
    • Always assess medications at home and potential ingestions
  • Seizures

  • By approaching a critically ill patient systematically, using a primary survey, and a broad differential diagnosis, you can ensure that no potential cause is overlooked. Incorporating mnemonics and structured evaluations can facilitate a comprehensive evaluation and timely management of any life-threatening condition.