Is a dehydrated child's life possibly in danger?
Use these assessment tips
Severely dehydrated children are "in imminent danger" due to cardiovascular collapse, increased acidosis, and metabolic abnormalities, all of which can lead to significant morbidity and in some cases mortality, warns P. Jamil Madati, MD, director of emergency medical services at Rady Children's Hospital in San Diego.
If your assessment shows a dehydrated child is not alert, has poor color, is not consolable, or has abnormal breath sounds, retractions, nasal flaring, cool skin, delayed capillary refill, poor pulse strength, or poor muscle tone, then "this is a child that needs immediate intervention," according to Kerry Gold, RN, CCRN, CEN, MICN, the pediatric liaison nurse for the ED at University of California — Los Angeles Medical Center.
"More information, such as low blood pressure, is considered a late finding and should be treated immediately as well," she says.
Assess weight loss, whether eyes appear sunken, mucous membranes, skin color, skin turgor, anterior fontanelle in infants, pulse, blood pressure, urine output, and mental status, says Gold. If the child's dehydration is severe, perform these interventions immediately, she says:
- Open the child's airway if needed.
- Assist with ventilations as needed.
- Initiate circulatory support as needed.
- Place oxygen and/or initiate rapid fluid replacement. Give an initial fluid bolus of normal saline at 20cc/kg. "Reassess after the initial bolus and repeat as warranted," says Gold.
- Initiate cardiac, pulse oximetry, and blood pressure monitoring.
- Anticipate the need for labs and diagnostic tests: blood glucose, complete blood count (CBC), electrolytes, urinalysis, stool cultures, and X-rays.
In cases that are mild to moderate, you'll need to consider oral or intravenous (IV) fluid replacement. (See Clinical Tip, below, with a solution for difficult IVs.)
"There has been a push recently for fluid replacement via nasogastric tube," says Gold. She points to a study that compared the use of rapid nastrogastric tube rehydration with rapid IV rehydration in cases on uncomplicated, acute, moderate dehydration in pediatric patients ages 3-36 months with suspected viral gastroenteritis.1 The study found that a nastrogastric tube was as effective with fewer side effects.
Many signs and symptoms, such as breathing too fast or too slow, also can be seen "at a glance" before you even check a child's vital signs, Gold says. When you assess the child's appearance, consider alertness, distractibility, eye contact, speech or crying, motor activity, consolability, and color, she adds.
Gold also says to assess breathing for abnormal audible breath sounds, retractions, and nasal flaring. Assess circulation for skin temperature, pulse strength, and capillary as part of your "at-a-glance assessment." She recommends asking these questions at triage:
- What time was the onset of symptoms?
- What is the frequency of stool and emesis? What is the consistency and color? Is there any blood or mucous present? What is the child's fluid intake and urine output?
- Is there any weight loss?
- Is the child taking any necessary medications that they are unable to keep down, such as anti-rejection medications for a transplant patient?
- Are there any other associated findings: fever, vomiting, abdominal pain, rashes, rhinitis, or cough?
- If the child is crying, are tears present?
- Has the child been in contact with any illness?
- Has the child had any recent travel?
"The ED nurse typically spends much more time at the bedside with the patient and family members and are therefore often the ones to pick up on any changes in the patient's status," says Gold.
She once overheard a new resident commenting to the nurse how "good" a 22-month-old trauma patient was being by holding still and not crying for his IV start. "The nurse tactfully explained that while this made her task easier, it was definitely an abnormal and concerning finding in a child of this age group," says Gold.
- Nager A, Wang V. The comparison of NG and IV methods of rehydration in pediatric patients with acute dehydration. Pediatrics 2002; 109:566-572.
Consider intraosseous line for difficult IVs
In severe cases where an intravenous (IV) line is unable to be started, an intraosseous line can be placed to initiate immediate fluid resuscitation, says Kerry Gold, RN, CCRN, CEN, MICN, the pediatric liaison nurse for the ED at University of California — Los Angeles Medical Center. To secure placement of the intraosseous needle, use a paper drinking cup, cut to fit and taped in place or with gauze padded on the sides.
"This can help to keep the needle from being dislodged," says Gold. "For fluid replacement, use a syringe and stopcock and manually push fluids, as these lines often do not flow without some pressure. A pressure bag can also be used."
Gold, who works in a tertiary care center with a large population of special needs children, also has used gastrostomy-tube rehydration in this population when viral gastroenteritis was suspected and peripheral IV access proved to be a problem.
"This is a route that many do not think of to use," says Gold. "ED nurses tend to think of IV hydration first. Other routes are often overlooked as we have been taught in the past to focus on the IV route."