Amy Romashko, MD Medical Director - PowerPoint Presentation

1. Amy Romashko, MD Medical DirectorChildren’s Hospital of Wisconsin Urgent CareThe Importance of Vital Signs

2. ACCME Accreditation Statement:The Medical College of Wisconsin is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.AMA Credit Designation Statement:The Medical College of Wisconsin designates this  for a maximum of 1.0 AMA PRA Category 1 Credits™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.Nurse Practitioner:The Medical College of Wisconsin, Inc. is approved as a provider of nurse practitioner continuing education by the American Association of Nurse Practitioners: AANP Provider Number 150930. This program has been approved for up to 1.0 contact hours of continuing education (which includes 0.0 hours of pharmacology). Nurse Practitioners should claim only those hours actually spent participating in the CME activity.Hours of Participation for Allied Health Care Professionals:The Medical College of Wisconsin designates this activity for up to 1.0 hours of participation for continuing education for allied health professionals.

3. DisclosureI have no actual or potential conflict of interest in relation to this presentation/program

4. Learning objectives: Recognize the importance of measuring accurate vital signs in every pediatric patient presenting for care.Understand the importance of recognizing abnormal vital signs based on patient age.Recognize the clinical importance of an unexplained abnormal vital sign.

5. Sophisticated technologic advances in medicine have proved to be remarkably beneficial in the diagnostic process, yet the well-performed history and the physical examination remain the clinician's most important tools. They are venerated elements of the art of medicine, the best series of diagnostic tests we have.(Sackett DL, Rennie D. The science of the art of the clinical examination. JAMA 1992; 267:2650)

6. Vital Signs are Important!Vital signs are measurements of the body's most basic functions.Normal values are very reliable across populations.They change when our body’s physiology significantly changes.They can give us early clues before more significant symptoms present during an illness.

7. Pediatric Early Warning Scores (PEWS)Use information including vital signs to detect the early deterioration of pediatric inpatients with the goal of reducing in-hospital morbidity and mortality.Have become widespread in Western health systems and are being modified for resource limited settings around the world due to their efficacy.Just the use of vital signs alone has shown a sensitivity of 44% in detecting early deterioration in pediatric patients.

8. Pre-hospital Transport and Emergency CarePediatric vital signs have been shown to be documented at variable rates by non-pediatric specific transport teams responding to emergency calls. National standards for pediatric emergency care have been developed that include the importance of obtaining vital signs (and understanding normal variance by age) in pediatric patients in non-pediatric specific hospital EDs.

9. What about vital signs during acute care visits?In non-emergent clinical situations outside of our Urgent Cares, I have observed that vital signs are not always obtained or documented.This does not seem to be a focus of study in the current literature.

10. Obtaining Vital Signs: A Quick and Easy Assessment ToolThey are quick to obtain and can be repeated over time.After treatments or medications given:AntipyreticsBreathing treatmentsO2After other interventions performed:Hydration providedPain controlledChild comforted

11. Sick Kids Can Be SneakySick kids can’t always tell us what is happening in their bodies, so we need to use all the information we have at our disposal!

12. Challenges to Appreciating Abnormal Vital Signs:Normal values vary by age.Our solution: Badge Buddies for all providers and nursesNormal values adapted from 2017 PALS guidelines

13. Challenges to obtaining and interpreting pediatric vital signs in an acute or primary care setting

14. Challenges to Appreciating Abnormal Vital Signs:Not all abnormal vitals are indicative of a serious medical problem:FeverPainCryingFearMeasurement errorsAthletes

15. Challenges to Appreciating Abnormal Vital Signs:Type of “Repetition Blindness”Vital signs in well appearing patients are not usually abnormal.When obtained on every patient, they can easily become “background noise”, especially on busy shifts.

16. Challenges to Appreciating Abnormal Vital Signs:Electronic med recordsProviders often have to make a concerted effort to look for them. Charting has become more complicated in many ways. All of those “clicks” can make it easier to get distracted. They often pull automatically into our charting.

17. Documentation of Actual Vital Signs is Important!Afebrile, Vital Signs Stable

18. What conditions in an acute care setting might CAUSE abnormal vital signs?

19. Hyperthermia (Fever)Hypothermia100.5 and abovePossible causes: External heat stressInfectionNeonatal SepsisDrug UseInflammationRheumatologic ConditionsCancerEndocrine Disorders97.5 or belowPossible causes: Neonatal sepsisIntracranial hemorrhageDrug withdrawalExternal cold stressTemperature

20. Tachycardia: Possible CausesSinus TachycardiaFever/Pain/Anxiety/ActivityDehydrationMedications/Drugs/IngestionsHyperthyroidismHypoxemiaElectrolyte imbalanceHypocalcemiaHyperkalemiaAnemiaSepsisAnaphylaxisShockArrhythmiasSVTVentricular TachycardiaAtrial FlutterAtrial FibrillationMyocarditisKawasaki DiseaseFeverPericardial effusionCoronary artery aneurysmHeart failure

21. Bradycardia: Possible CausesSinus BradycardiaHypothermiaHypothyroidismHypokalemiaHypoxiaMalnutritionEating DisordersMedicationsCardiac CardiomyopathiesCongenital heart defectsIschemiaKawasaki’s DiseaseLupusIncreased Vagal Tone

22. Tachypnea: Possible CausesFeverAnxietyDehydrationRespiratory InfectionEx: Pneumonia, BronchiolitisPneumothoraxUpper Airway ObstructionEx: Croup, Epiglottitis, Laryngomalacia, Nasal congestionLower Airway Foreign BodyCardiac CausesPulmonary EmbolismAcidosis (with respiratory attempt to compensate by blowing off CO2)Ex: Sepsis, DKAHypercapnea (obstructive airway disease)HypoxiaPoisoningIngestionEnvenomationRespiratory Failure

23. Decreased Respiratory Rate: Possible CausesPneumoniaAsthmaRespiratory FailureCarbon Monoxide PoisoningDrugs/IngestionsElectrolyte abnormalitiesNeurologic Causes:Guillain-Barre SyndromeAmyotropic Lateral SclerosisHead InjuryHypothyroidism

24. Causes of low blood pressure in kids:Common causes of hypertension in kids: Orthostatic (temporary)Alcohol/other medsShock: SepsisAnaphylaxisHypovolemiaArrhythmiasHeart FailurePain/stressHeart defectsKidney diseaseEndocrine problemsGenetic ConditionsObesity (idiopathic)Drugs/ingestionsWhat About Blood Pressure?

25. Blood PressureAcute care conditions where obtaining a BP can be especially helpful: Severe headachesPregnancyEdema or suspected or known kidney disease (hematuria, proteinuria)Dizziness, weakness, or or syncopeHead or or neck injuriesSuspected allergic reactionsAltered mental statusDehydrationSuspected sepsis

26. 13 yo male with vomiting and diarrheaCase #1

27. 13 yo male with vomiting and diarrhea2 day history of vomiting and diarrhea, taking fluids well despite illness, no obvious symptoms of dehydration in history, no reported decrease in UO.“No cough or nasal symptoms, Does report some mild trouble breathing today”No hx wheezing/asthma in pastExam: Lungs CTA, no retractions, mild generalized belly tendernessVS: T-37.1, P-124, R-32 Pox- 100%Normal values for age: P-60-100R-12-20Sent home with diagnosis of GE

28. 13 yo male with vomiting and diarrheaPresented to ED later that evening with worsening breathing symptoms, slurred speech, and hypertension (165/91)Additional Hx obtained in the ED: Significant weight loss over the past 2 years. Polyuria, polydipsia and polyphagia x 1 year. Gets up during the night to drink and urinate almost every night x 1 year. This history not mentioned by family to UC because issues were so longstandingThe “difficulty breathing” he was having turned out to be Kussmal breathing. Pt diagnosed with DKA.pH of 6.83, glucose of 430 mg/dL, HbA1C >14%

29. 4 yo male with sore throat and 4 days of feverCase #2

30. 4 yo with sore throat and fever x 4 days4 day history of fever over 100.5Tmax 103 day prior to visitSore throat Since fever started, seen by PMD 1 day prior, rapid strep and confirmatory PCR negative.Emesis day one of symptomsNo emesis since. Decreased energy, sleeping more than usual Especially yesterday and today.Intermittent complaints of back and leg pain past few days.No cough, runny nose, increased work of breathing or GI symptoms.

31. 4 yo with sore throat and fever x 4 daysExam: General: Alert, awake, nontoxic, smiling, sitting up in chair, no resp distress.HEENT: Significant OP erythema, enlarged tonsils, mild ant and post cervical LAD bilaterally, otherwise unremarkable.Lungs CTA, no signs of increased WOB or respiratory distressRest of exam unremarkable.VS: Temp-100 , RR-38, P-124Normal vitals for age: RR: 20-28, P: 80-120VS rechecked to confirm, RR-40 on recheck, P-130

32. 4 yo with sore throat and fever x 4 daysMom was a nurse, concerned about fever duration and continued/worsening malaise.No lab or CXR available on-site. Patient sent to lab for a CBC and Monospot for reassurance due to predominant pharyngitis symptoms, LAD, and persistence of fever.Monospot and CBC orderedCBC: WBC 29.4K, with left shift , Monospot negativeChild sent for CXR due to unexplained tachypnea and abnormal CBC

33. 4 yo with sore throat and fever x 4 daysCXR revealed a focal LLL pneumoniaPatient afebrile and feeling much better after 24 hours of amoxicillin.

34. 16 yo with anxiety and pneumoniaPresented with chest pain, trouble breathing, cough and fever x24 hoursSeen by PMD previous afternoon and diagnosed with sinusitis, started on z-pakSince that time complaining of dizziness, numbness in fingers and toes, increased WOB, chest discomfort and emesis x 2PMhx significant for:Takes Xanax daily as needed for anxietyRecent eval by cardiology for recurrent complaints of palpitations and dizziness (attributed to anxiety)Mild asthma

35. 16 yo with anxiety and pneumoniaObtaining accurate pox difficult due to cold hands, best read obtained 91-92%Vital signs: RR-28, P-124, T-98.4Normal values for age: R: 12-20, P: 60-100Exam notable for:Patient sitting up on exam table looking at her phone and loudly arguing with her parents during the entire visit, appeared to be anxious and possibly hyperventilating to care team.Shallow breathing and reported inability to take deep breaths when asked to do so (making auscultation difficult) Very mild retractions present, no nasal flaring, decreased AE appreciated on R compared to LLF mildly erythematous OP

36. 16 yo with anxiety and pneumoniaContinued to complain about dizziness and trouble breathing, worsened after trial of albuterol neb.No significant improvement in exam, vitals, or pox after neb, HR increased to 140’s.Focal pneumonia suspected, but due to difficulty assessing how sick she really was she was sent to radiology at the main hospital for CXR.

37. 16 yo with anxiety and pneumoniaCXR demonstrated a focal RUL pneumonia without effusion

38. 16 yo with anxiety and pneumoniaBefore leaving radiology at CHW she collapsed.She was intubated for ARDS and admitted to the PICU on pressors for septic shock within four hours of her presentation in UC.Rapid decompsensation thought to be due to her hx of treatment for childhood leukemia and resultant diminished cardiac reserve.

39. 16 yo with anxiety and pneumoniaAfter review of the chart: Nursing in UC did a blood pressure when she complained of dizziness but did not communicate that to the provider seeing the patient: 82/47 Newly live on EPIC, provider never saw this BP as it was entered after the initial vitals were reviewed.Other lessons learned: Cold hands likely due to diminished perfusion (early shock) leading to difficulty obtaining a pulse ox.Tachypnea possibly due to early acidosis in addition to her pneumonia.Patient recovered fully from this illness after a 2 week PICU course.

40. 5 yo male with croupCase #4

41. 5 yo male with croup5 yo male presented to UC around 6:30 pm with croup symptoms (barky cough, hoarse voice, fever, sore throat). Symptoms had started the night prior and had continued to worsen since that time. General Appearance: Tired and ill-appearing, but responsive and interactive with the care team.Physical exam demonstrated moderate respiratory distress, with stridor at rest but otherwise clear lung fields. Vitals: T- 39.1 C /102.4 F (two hours after last tylenol dose)RR- 30 P-140Pox- 95%Normal values per age: RR: 20-28, P: 80-120

42. 5 yo male with croupPatient treated with racemic epi, given dexamethasone and ibuprofen prior to transfer to ED via ambulance.Still with retractions after treatment, but reassessment documents: no stridor at restimproved air entry bilaterallySignificant improvement in respiratory statusIn ED: BP: 113/55 | Pulse 152 | Temp 38.6 °C (101.5 °F) (Oral) | Resp 26 | SpO2 96%Normal values for age: P:80-120, R:20-28Initial exam: No stridor, mild retractions, diffusely coarse breath sounds.

43. 5 yo male with croupED Course: “He was observed for 2 hours during which he continued to improve. At the time of discharge the patient was in no respiratory distress and non-toxic or acutely ill appearing.”No mention of vitals on discharge.ED Automated Pox Recordings19:18 (taken in triage)- Pox 97%19:50 - Pox 96%21:02- Pox 93%21:22- Pox 92%21:35 Discharged Home

44. 5 yo male with croupPt brought back to ED by parents three hours later (around midnight).Significant resp distress, stridor at restPox: 83% on RA.Treated with: O2 initiated via facemaskRacemic epi neb #2 givenDuoneb given for possible RAD component.1:12 AM: CXR demonstrated shaggy looking and narrow trachea.Lateral neck film showed edema and narrowing in the subglottic space, normal looking epiglottis.

45. 5 yo male with croup1:49 AM: Patient alert, reporting feeling better, still O2 dependent.Still having moderate to severe supraclavicular and subcostal retractions that worsen when he attempts to talk. Unable to speak as he has no voice. No stridor heard or auscultated. Course breath sounds throughout.CBC: WBC 23.4 (H), H/H 15.1(H)/42.8, platelet 2252:00 am: Stridor and increased WOB returned againRacemic epi #3 given

46. 5 yo male with croup2:26 AM O2 weaned off. Patient sleeping. WOB improved. Mild supraclavicular and subcostal retractions, no stridor, coarse BS. RR-28. Very congested cough, SaO2 dropped to 84% on RA with significantly increased work of breathing. O2 restarted, within 5 minutes, patient fell back to sleep, work of breathing returned to mild retractions and SaO2 96% on 2L simple mask. 3:45 AMPatient asleep. On 2L oxygen via face mask, still having mild retractions. Much more comfortable when asleep and calm. Arrangements for admission to gen med floor initiated.

47. 5 yo male with croup4:30 AM Patient started coughing, reporting that he couldn't breathe. Started to gasp for air. Lips blue, cyanotic throughout. Patient bagged with BVM, ET tube placedCPR initiated due to lack of perfusing rhythm, continued for about 5 minutes.1 dose of epinephrine given with return of normal sinus rhythm. Admitted to PICU around 5 am, intubated and sedated, body temp cooled, broad spectrum antibiotics started.

48. Bacterial TracheitisDuring course in PICU:Required intermittent pressor support.Tested positive for Influenza A. (likely initial cause of croup sx)Grew out MSSA, Strep pneumo, and Hflu from his tracheal culture. (Secondary bacterial trachietis)Was extubated 8 days later and discharged home with a PICC line to complete antibiotic therapy.

49. Take Home MessagesVital signs are IMPORTANT, especially when assessing sick kiddos!BUT: They only help you if you pay attention to them.Think twice before dismissing an abnormal vital sign. Why might it be abnormal? TO YOUR VITAL SIGNS

50. Take Home MessagesGood communication between nurses and providers is essential, especially if an abnormal vital sign is discovered!Do not be afraid to use cheat sheets! There is no prize for memorization or guessing normal values for age groups!

51. ReferencesDrutz J. The pediatric physical examination: General principles and standard measurements. In: UpToDate, Duryea T (Ed), UpToDate, Waltham, MA. Mazor S, Mazor R. Approach to the child with tachycardia. In: UpToDate, Woodward G, Drutz J (Ed), UpToDate, Waltham, MA.Silva J. Bradycardia in children. In: UpToDate, Triedman JK (Ed), UpToDate, Waltham, MA. Mattoo TK. Definition and diagnosis of hypertension in children and adolescents. In: UpToDate, Stapleton FB, Fulton DR, (Ed), UpToDate, Waltham, MA.Schroeder L, et al. Assessing structural quality elements of pediatric emergency care. Pediatric Emergency Care. 2016; 32(2):63-68.Romgopal S, et al. Differences in prehospital patient assessments for pediatric versus adult patients. J of Pediatrics. 2018; 199:200-5.Tucker KM, et al. Prospective evaluation of a pediatric inpatient early warning scoring system. J Spec Pediatr Nurs. 2009; 14(2): 79-85.Rosman SL, et al. Provisional validation of a pediatric early warning score for resource-limited settings. DraynaPediatrics. 2019;143(5): 1-8Drayna PC, et al. Prehosptial pediatric care: Opportunities for training, treatment, and research. Prehospital Emergency Care. 2015; 19:441-7.2017 PALS Manual and Guidelines