P E D I AT R I C P R I O R I T I E S
Reference Information
Fluid management
1. Initial Assessment
(and assess need for decontamination)
Pediatric Assessment Triangle
First Impression
Appearance Triage
Unresponsive
Limp / Apathetic
Inconsolable
Weak or hoarse cry
Mild distress /
Intermittently consolable
Alert / Tracking with eyes / Strong
muscles / Appropriate interactions
(may include crying)
Airway / Breathing Triage
Appearance
Breathing
Mental status
Rate
Activity
Effort / Work
Muscle tone
Sounds (stridor,
wheezing, etc.)
Circulation
Color
Capillary refill
Temperature of extremities
Obstructed
(stridor, blood/vomit/foreign body)
Circulation Triage
Normal respiratory effort and rate
Pallid or mottled
Central cyanosis
Absent or labored
Excess secretions
Wheezing / Accessory muscle use
Cyanotic
Mild delay in capillary refill or cool digits
Pink, normal
2. High Risk Features? *
• Hypoxia or respiratory distress
• Multiple injuries or high-energy
mechanism
• Signs of hypoperfusion / shock
(only sign may be tachycardia)
• Altered mental status
*Consider consultation age <5
or underlying complex medical
problems
Yes
Arrange transportation - Ask
clerk or other personnel to
request/arrange appropriate
transport to referral center
(helicopter, road, etc.)
Weight Estimate
Equipment Estimate
• Estimate ONLY if actual weight or
length-based calculation unavailable
ET size = (age/4) + 4
• Infant - (Months/2) + 4 = kg
2x ET = Foley or suction catheter size
• Child - (Years times 2) + 10 = kg
3x ET = Nasogastric / orogastric tube size
No
ET depth 3x tube size = depth in cm
4x ET = Chest tube size
3. Primary Interventions
Airway – Position and ventilate as needed with Bag-Valve-Mask initially. Intubate if required; narrowest part of child’s
airway is below cords.
Breathing – Provide oxygen, bronchodilators (e.g., albuterol, epinephrine, heliox); monitor breathing over time.
Circulation - Treat signs of hypoperfusion aggressively with intravenous fluids and/or blood (per table at right). Fall in
blood pressure is late and end-stage.
Disability – Assess neurologic status (including sensation and motor) and need for cervical spine protection.
Expose - Remove clothing, jewelry and contact lenses. Protect from heat loss; hypothermia is common.
4. Secondary Survey and Interventions
Normal Vital Signs
Age (years)
Respiration Rate
(per minute)
Heart Rate
(per minute)
Infant
Birth to 1 year
30 - 60
100 - 160
Toddler
1 to 3 years
24 - 40
90 - 150
Preschooler
3 to 6 years
22 - 34
80 - 140
School age
6 to 12 years
18 - 30
70 - 120
5. Disposition and Consultation
Analgesia – Titrated opioids and non-opioid analgesia (and antipyretics); consider ibuprofen 10 mg/kg (> 3 months of
age without renal compromise), acetaminophen 15 mg/kg, oral oxycodone 0.1mg/kg, intravenous/oral/nasal morphine 0.1 mg/kg (or equivalent agents).
Fluids – Obtain IV or IV access, including second access if critically ill, see table at right.
Family – Keep family/guardian with patient to degree possible, including on lap for toddlers. Identify / notify caregivers as required.
Genitourinary – Target urine output to 0.5 - 1 ml/kg/hour. Indwelling urinary cathether as needed.
Gastrointestinal - Orogastric tube for all intubated patients to decompress stomach.
Glucose – Monitor fingerstick glucose in all significantly ill/injured children. Correct hypoglycemia according to table
at right.
History – Mechanism and time of injury, treatments pre-hospital, underlying diseases, medications / allergies, social
history, immunization history.
Refer to Pediatric Resource Card in Scarce Resources cardset for mass casualty situation
2012.10.31
• Initial fluid for resuscitation – Normal Saline
• Initial bolus 20 ml/kg, repeat as needed
• Hemorrhagic shock - initiate packed red blood cells (PRBC) 10ml/kg if not
responding to initial 40ml/kg of crystalloid
• May use O neg initially (or O pos for males) until type-specific or crossmatched
available
• Maintenance fluid rate
• 4 ml/kg/hr first 10 kg (40 ml/hour)
• 2 ml/kg/hr second 10 kg (20+40 = 60 ml/hour)
• 1 additional ml/kg/hr for each kg over 20 kg (e.g., 40 kg = 60 ml/hr for first 20
kg plus 20 ml/hr = 80 ml/hr)
• Fluids
• Neonate with BG < 45, administer D10W, 3 ml/kg IV / IO
• < 4 years with BG < 60, administer D25 W, 2 ml/kg IV / IO
• > 4 years with BG < 60, administer D50W, 1 ml/kg IV / IO
• Goals – normal vital signs, improved signs of perfusion, urine output 0.5-1 ml/kg/
hour
• Carefully immobilize IV / IO site to allow for easy visualization of the IV / IO and
assessment of circulation of the limb
• Review child’s illness / injuries
• Determine need for referral - consultation if unsure
• Arrange appropriate admit / transfer
Pediatric Referral Facility Name
M I N N E S OTA D E PA R T M E N T O F H E A LT H
OFFICE OF EMERGENCY PREPAREDNESS
www.health.state.mn.us/oep/healthcare
Pediatric Referral Facility Phone
Orville L. Freeman Building / PO Box 64975
625 Robert Street N. / St. Paul MN 55164
TEL: 651 201.5700 / TDD: 651 215.8980