The Silent Warnings: Recognising Early Deterioration in Paediatric Patients
Introduction
Paediatric patients can be some of the most rewarding and most challenging patients to assess in the pre-hospital setting. Children often compensate extremely well right up until they don’t, which means early warning signs of deterioration can be subtle. The key is understanding how small deviations in their vital signs can point to big physiological changes beneath the surface.
Our Paediatric Reference Card was designed to make those values instantly accessible, giving clinicians a visual cue to spot when “normal” isn’t really normal.
Why children deteriorate differently
Unlike adults, children maintain their cardiac output primarily through heart rate, not stroke volume. That means tachycardia is their first line of defence it’s how they maintain perfusion when things start to go wrong.
But when you see bradycardia, it’s usually late. It often indicates severe hypoxia or acidosis the point where compensation has failed.
In essence:
➡️ Tachycardia = early warning
➡️ Bradycardia = late, critical warning
The value of trending, not snapshots
A single set of paediatric observations can be misleading. Children’s vital signs fluctuate with fear, pain, and activity. What matters most is the trend is that heart rate climbing, is the respiratory rate settling, is capillary refill slowing?
In the pre-hospital world, trends can be hard to capture we’re often on scene for a short time. But even brief reassessments every few minutes can reveal early decompensation that might otherwise be missed.
Tip: Record a quick baseline the moment you make patient contact. Even if they’re crying, you’ll have a reference to compare later when they’re calmer.
When “normal” isn’t reassuring
A common pitfall is assuming that a normal heart rate or respiratory rate means stability. In reality, “normal” might mean they’ve just compensated successfully for now.
For example:
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A septic child may have a heart rate that’s normal for their age, but only because it was previously high and is now dropping a dangerous sign of exhaustion.
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A head-injured child with a “normal” blood pressure might actually be in the early stages of increased intracranial pressure, which hasn’t yet affected systemic output.
Always assess the context of the numbers, not just the range.
Early warning scores in the field
Paediatric Early Warning Scores (PEWS) are gaining traction in pre-hospital care. While they were originally designed for hospital settings, the principle holds true on-scene combining vital signs with clinical appearance to generate a risk level.
Using a PEWS or even a simplified “traffic light” approach (green = stable, amber = concern, red = high risk) helps standardise handovers and escalation decisions.
Our Paediatric Card aligns with this thinking colour-coded values make it easier to recognise when a child is trending outside of their expected range.
What to do when you see the early signs
When you identify a child who’s just beginning to deteriorate:
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Act early. Oxygen, warming, and fluid access if indicated.
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Escalate quickly. Early pre-alerts to hospital paediatric teams can save minutes that matter.
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Reassess often. Don’t wait for visible collapse; subtle changes are the earliest clues.
In summary
Children rarely crash without warning but the warnings are often silent. Recognising small shifts in their vital signs, behaviour, or perfusion can be the difference between a smooth handover and a life-threatening emergency.
That’s why our Paediatric Reference Card was created: a compact, durable tool designed to help you interpret those subtle signs with confidence, even under pressure.
