Nor

mal

Ped

iatr

ic V

ital S

igns

Age

Estim

ated

W

eigh

tN

orm

al

Hea

rt

Rat

e R

ange

Aver

age

HR

Nor

mal

R

espi

-ra

tory

R

ate

Ran

ge

Hyp

oten

-si

on le

vel

(sys

tolic

B

P)

1 m

onth

4 kg

110-

180

145

40-6

0<7

0

6 m

onth

s8

kg11

0-17

013

525

-40

<70

12

mon

ths

10 k

g11

0-17

013

522

-30

<72

2 ye

ars

12 k

g90

-150

120

22-3

0<7

4

3 ye

ars

14 k

g 75

-135

120

22-3

0<7

6

4 ye

ars

16 k

g75

-135

110

22-2

4<7

8

5 ye

ars

18 k

g65

-135

110

20-2

4<8

0

6 ye

ars

20 k

g60

-130

100

20-2

4<8

2

8 ye

ars

26 k

g60

-130

100

18-2

4<8

6

10 y

ears

32 k

g60

-110

8516

-22

<90

12 y

ears

42 k

g60

-110

8516

-22

<90

14 y

ears

50 k

g60

-110

8514

-22

<90

≥15

year

s60

-100

8012

-18

<90

Hem

odyn

amic

Ass

essm

ent

Para

met

ers

Stab

le

Circ

ulat

ion

Com

pens

ated

sh

ock

Hyp

oten

sive

sh

ock

Con

scio

us

leve

lC

lear

and

luci

d C

lear

and

luci

dR

estle

ss,

com

bativ

e

Cap

illar

y re

fill t

ime

Bris

k (<

2 se

c)P

rolo

nged

(>

2 se

c)Ve

ry p

rolo

nged

, m

ottle

d sk

in

Extr

emiti

esW

arm

and

pin

kC

ool p

erip

herie

sC

old,

cla

mm

y

Perip

hera

l pu

lse

vo

lum

e

Goo

d vo

lum

e W

eak

& th

read

yFe

eble

or a

bsen

t

Hea

rt ra

teN

orm

al h

eart

rate

for a

geTa

chyc

ardi

aS

ever

e ta

chyc

ardi

a or

br

adyc

ardi

a in

la

te s

hock

Blo

od

pres

sure

Nor

mal

blo

od

pres

sure

for

age

Nor

mal

pul

se

pres

sure

for

age

Nor

mal

sys

tolic

pr

essu

re b

ut ri

s-in

g di

asto

lic

pres

sure

Nar

row

ing

puls

e pr

essu

reP

ostu

ral h

ypot

en-

sion

Nar

row

ed p

ulse

pr

essu

re (<

20

mm

Hg)

Hyp

oten

sion

(s

ee d

efini

tion)

Unr

ecor

dabl

e bl

ood

pres

sure

Res

pira

tory

ra

teN

orm

al re

spira

-to

ry ra

te fo

r age

Tach

ypno

eaH

yper

pnoe

a or

Kus

smau

l’s

brea

thin

g (M

eta-

bolic

aci

dosi

s)

Urin

e ou

tput

Nor

mal

R

educ

ing

trend

Olig

uria

or a

nuria

1

2

3

4

5

6

7

8

9

10

40

Shoc

kB

leed

ing

Day

s of

Illn

ess

Tem

pera

ture

Pote

ntia

lcl

inic

al is

sues

Labo

rato

ry

chan

ges

Sero

logy

and

viro

logy

Febr

ile

Crit

ical

Re

cove

ry Ph

ases

Deh

ydra

tion

Rea

bsor

ptio

nFl

uid

over

load

Hem

atoc

rit

Vira

emia

Plat

elet

IgM

/lgG

Org

an Im

pairm

ent

Dia

gnos

tic

Test

ing

• V

irus

det

ecte

d fo

r up

to 5

day

s po

st o

nsetɯÖÍɯÚàÔ×ÛÖÔÚ

· V

irem

ia c

oinc

ides

with

feve

r ·

Det

ectio

n by

PC

R hi

ghes

t in

first

3 d

ays

of il

lnes

s•

Alw

ays

send

acu

te a

nd

conv

ales

cent

sam

ples

· U

nles

s 1s

t sam

ple

posi

tive

fo

r den

gue

by P

CR

pair

ed

sam

ples

, acu

te (0

-5 d

ays)

an

d co

nval

esce

nt (6

-21

days

), ne

eded

for d

iagn

osis

• Ig

M d

etec

ted

for u

p to

3m

onth

s · N

o Ig

M in

20-

30%

of s

econ

din

fect

ions

Dengue Case ManagementASSESSMENT

Presumptive Diagnosis: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

Warning Signs:• 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

Group A Group B Group C

For patients with any of:• Severe plasma leakage

with shock and/ or fluid accumulation with respiratory distress

• Severe bleeding• Severe organ impairment

For patients with warning signs of severe dengue OR co-existing conditions• pregnancy• infancy• diabetes mellitus• poor social situation• old age• renal failure

No warning

signs

CS 125085

U.S. Department of Health and Human Services Centers for Disease Control and Prevention

National Center for Zoonotic, Vector-Borne, and Enteric Diseases

Cou

rse

of d

engu

e ill

ness

:C

ours

e of

den

gue

illne

ss:

Ada

pted

from

: Yip

WC

L. D

engu

e H

aem

orrh

agic

Fe

ver:

Cur

rent

App

roac

hes

to M

anag

emen

t.

Med

ical

Pro

gres

s O

ctob

er 1

980.

Group A Outpatient Management

Obtain daily CBC Follow patient daily for:

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 do the following:

Get adequate bed rest • Let patient rest as much as they are able.

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 patient’s skin with tepid water when temperature is high

despite Tylenol.

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

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.

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

Gro

up C

Em

erge

ncy

Man

agem

ent

For p

atie

nts

with

any

of:

• Se

vere

pla

sma

leak

age

with

sho

ck a

nd/ o

r flui

d ac

cum

ulat

ion

with

resp

irat

ory

dist

ress

• Se

vere

ble

edin

g

• S

ever

e or

gan

impa

irm

ent

Com

pens

ated

Sho

ckH

ypot

ensi

ve S

hock

Giv

e cr

ysta

lloid

or c

ollo

id b

olus

of 2

0 m

l/kg

in 1

5 m

inG

ive

isot

onic

flui

d at

5-1

0 m

l/kg/

hour

ove

r 1 h

our

Red

uce

IV Flu

ids*

• 5

-7 m

l/kg/

hour

x 1

-2 h

our

then

reas

sess

clin

ical

sta

tus,

if

impr

ovin

g th

en •

3-5

ml/k

g/ho

ur x

2-4

hou

rs

and

reas

sess

Hct

and

clin

ical

st

atus

, if c

ontin

ued

impr

ove-

men

t the

n •

2-3

ml/k

g/ho

ur x

2-4

hou

rs,

reas

sess

Hct

and

clin

ical

st

atus

and

• D

isco

ntin

ue IV

flui

ds when

in

take

and

uri

ne o

utpu

t

ade

quat

e an

d he

mat

ocri

t

bel

ow b

asel

ine

valu

e

Impr

oved

Not

Impr

oved

Dec

reas

ing

If im

prov

ed,

• R

educ

e IV

flui

ds to

7-1

0ml/

kg/h

our x

1-2

hou

rs•

Con

tinue

ste

pwis

e*

redu

ctio

n in

IV fl

uids

Che

ck H

emat

ocrit

Tran

sfus

e 5-

10 m

l/kg

PRBC

or 1

0-20

ml/k

g w

hole

blo

od A

SAP,

re

asse

ss

Incr

easi

ng

Incr

easi

ng

Giv

e co

lloid

10-

20 m

l/kg

bolu

s ov

er ½

to 1

hou

r, re

asse

ss

If im

prov

ed,

• R

educ

e co

lloid

to 7

-10m

l/kg

for 1

-2 h

our,

then

•

Con

tinue

ste

pwis

e*

redu

ctio

n us

ing

crys

tallo

ids

If no

t im

prov

ed,

Rech

eck

he

mat

ocri

t

Giv

e cr

ysta

lloid

10-

20 m

l/kg

bolu

s ov

er 1

hou

rȮɯÙÌÈÚÚÌÚÚ

Impr

oved

REA

SSES

SR

EASS

ESS

If st

ill im

prov

ing,

• C

ontin

ue s

tepw

ise*

redu

ctio

n of

IV fl

uids

•

If n

ot im

prov

ed re

chec

k ɯɯɯɯh

emat

ocri

tȮɯÈÕËɯÙÌÈÚÚÌÚÚ

• G

ive

crys

tallo

id o

r co

lloid

in

fusi

on a

t 10m

l/kg/

hour

for

1 ho

ur, t

henɯÙÌÈÚÚÌÚÚ

Obt

ain

base

line

CBC

and

or

gan

func

tion

test

s an

d as

sess

hem

odyn

amic

sta

tus

Gro

up B

Inpa

tient

Man

agem

ent

For p

atie

nts

with

war

ning

sig

ns o

f sev

ere

deng

ue O

R c

o-ex

istin

g co

nditi

ons

• pr

egna

ncy

• po

or s

ocia

l situ

atio

n •

liver

enl

arge

men

t >2c

m•

old

age

• le

thar

gy/ r

estle

ssne

ss

• pe

rsis

tent

vom

iting

• in

fanc

y •

rena

l fai

lure

•

incr

ease

d he

mat

ocri

t•

diab

etes

mel

litus

•

tend

er/ p

ainf

ul a

bdom

en

• flu

id a

ccum

ulat

ion

•

muc

osal

ble

edin

g

Inad

equa

te

Inta

ke

Con

tinue

IV F

luid

s @

2-3

ml/k

g/ho

ur fo

r 2-4

hou

rs

then

REA

SSES

S H

emat

ocri

t and

Clin

ical

Sta

tus

Red

uce

IV F

luid

s gr

adua

lly w

hen

plas

ma

leak

de

crea

sing

as

indi

cate

d by

• A

dequ

ate

inta

ke a

nd u

rine

out

put

• H

ct d

ecre

ases

bel

ow b

asel

ine

in p

atie

nt w

ith s

tabl

e cl

inic

al s

tatu

s

Incr

ease

IV F

luid

s to

5-1

0 m

l/kg/

hour

x 1

-2 h

ours

th

en R

EASS

ESS

HC

T an

d cl

inic

al s

tatu

sIf

Uns

tabl

e

Vita

l Sig

ns a

t any

Poi

nt

Gro

up C

Em

erge

ncy

M

anag

emen

t

Obt

ain

Base

line

CBC

on

Adm

issi

on

Mon

itorin

g G

roup

B• V

itals

signs

and a

nd pe

riphe

ral p

erfus

ion ch

ecks

(at le

ast e

very

1-2 h

ours

until

out o

f cri

tical

phas

e – m

ore f

requ

ently

if pa

tient

is re

quirin

g flui

d bolu

ses o

r is in

ICU)

• Tem

pera

ture c

urve

(watc

h for

defer

vesc

ence

)• F

ollow

urine

outpu

t clos

ely (r

ecor

d volu

me an

d fre

quen

cy at

leas

t eve

ry 4 h

ours)

• Volu

me of

fluid

intak

e and

loss

es (“

strict

I/O’s”

) at le

ast e

very

4 hou

rs• F

requ

ent h

emato

crits

(befo

re an

d afte

r flui

d bolu

ses)

and a

t leas

t eve

ry 6-

8 hou

rs• M

onito

r bloo

d gluc

ose a

t leas

t eve

ry 6-

12 ho

urs

• Dail

y com

plete

blood

coun

ts• O

ther o

rgan

func

tion t

ests

(rena

l pan

el, liv

er pr

ofile,

coag

ulatio

n pro

file) a

s ind

icated

by

patie

nt sta

tus

Obt

ain

Base

line

Hem

atoc

rit b

efor

e St

artin

g IV

Flu

ids

Ade

quat

e In

take

$nco

urag

e

Ora

l Flu

id In

take

Dis

char

ge C

riter

ia -

All

of th

e fo

llow

ing

mus

t be

met

:• N

o fev

er fo

r at le

ast 2

4-48

hour

s• I

mpro

veme

nt in

clinic

al sta

tus (g

ener

al we

ll bein

g, ap

petite

, he

mody

nami

c stat

us, u

rine o

utput,

no re

spira

tory d

istre

ss)

• Stab

le he

matoc

rit off

IV flu

ids• I

ncre

asing

tren

d of p

latele

t cou

nt (u

suall

y pre

cede

d by r

ising

WBC

)

Star

t Iso

toni

c So

lutio

ns (N

S, L

R)

•

5-7m

l/kg/

hour

x 1

-2 h

ours

then

•

3-5

ml/k

g/ho

ur x

2-4

hou

rs th

en R

EASS

ESS

Hct

and

clin

ical

sta

tus

If W

orse

ning

Vi

tal S

igns

and

Rap

idly

In

crea

sing

Hct

If C

linic

ally

Sta

ble

an

d H

ct re

mai

ns s

ame

or

chan

ges

min

imal

ly