Pediatric Vitals: Why “Normal” Can Still Mean Sick

Why “Normal” Can Still Mean Sick

There is nothing more terrifying for a medic than a sick kid. They are small, they cannot tell you what is wrong, and their physiology seems designed to hide how sick they truly are until it is too late. The biggest lie a sick child will ever tell you is with their blood pressure.

Understanding Compensated Shock

Children are masters of compensation. Unlike adults, whose blood pressure often drops early in shock, kids have incredibly resilient cardiovascular systems. They can maintain a normal blood pressure for a dangerously long time by aggressively increasing their heart rate and clamping down their peripheral blood vessels.

This is compensated shock. They are maintaining blood pressure, but at a huge metabolic cost. Their vital organs are still not getting enough oxygenated blood. When they can no longer compensate, they crash—and they do it fast and hard. Decompensated shock (with hypotension) is a pre-arrest finding in a child. If you wait for the blood pressure to drop, you have already lost.

The Vital Signs That Lie (and the Ones That Do Not)

• The Liar: Blood Pressure. A normal BP in a child means almost nothing by itself. Do not be reassured by it.
• The Truth-Tellers: Heart Rate and Perfusion. Tachycardia is often the very first sign of trouble. A heart rate that is persistently high for their age, especially at rest, is a major red flag. Pair this with your perfusion assessment:
  • Skin: Are they pale, mottled, or ashen? Are their hands and feet cool to the touch compared to their core?
  • Capillary Refill: A cap refill of >2 seconds is a sign of poor perfusion.
  • Mental Status: Are they listless, irritable, or have a weak cry? Are they not interacting with their parents normally? A change in mental status is a sign of poor brain perfusion.

The Pediatric Assessment Triangle (PAT)

This is your best friend on every pediatric call. Before you even touch the child, you can assess the PAT from the doorway in 30 seconds.

1. Appearance: Tone, Interactiveness, Consolability, Look/Gaze, Speech/Cry. This is your “sick or not sick” gut check.
2. Work of Breathing: Look for nasal flaring, retractions, abnormal airway sounds, and tripod positioning.
3. Circulation to Skin: Assess skin color—pallor, mottling, cyanosis.

A child with a “bad” PAT is a sick child, regardless of what the vitals say.

Parental Instinct is a Diagnostic Tool

No one knows the child better than their parent or caregiver. “He’s just not acting right” is one of the most important things you can hear. Trust it. Ask specific questions:

• “How many wet diapers have they had today?” (Fewer than 4-5 in 24 hours is a sign of dehydration).
• “Is this their normal cry?”
• “Are they drinking fluids?”

A parent’s concern should always elevate your own.