A. Capillary refill time > 4 seconds – Explanation
Normal capillary refill time is usually less than 2 seconds. Prolonged capillary refill time
is a sign of clinical shock. Intravenous fluid should be started immediately.
A 2 year old child can have a heart rate anywhere between 80 to 120 beats per minute
and so option B is wrong.
It is also normal to have a respiratory rate between 20 to 30 breaths per minute in a 2
year old child thus option C is wrong.
Passing large amount or increased frequency of watery stool is not a clinical sign of
dehydration.
Weight has no role as an indication for IV fluids and has no relation as a clinical sign of
dehydration.
| No clinically detectable dehydration |
Clinical dehydration |
Clinical shock | |
|---|---|---|---|
| Symptoms (remote and face-to-face assessments) |
Appears well | Red flagAppears to be unwell or deteriorating |
|
| Alert and responsive |
Red flag Altered responsiveness (for example irritable, lethargic) |
Decreased level of consciousness |
|
| Normal urine output | Decreased urine
output |
||
| Skin colour unchanged |
Skin colour unchanged |
Pale or mottled skin | |
| Warm extremities | Warm extremities | Cold extremities | |
| Signs (face-to-face assessments) |
Alert and responsive |
Red flag Altered responsiveness (for example, irritable, lethargic) |
Decreased level of consciousness |
| Skin colour unchanged |
Skin colour unchanged |
Pale or mottled skin | |
| Warm extremities | Warm extremities | Cold extremities | |
| Eyes not sunken | Red flag Sunken
eyes |
– | |
| Moist mucous membranes (except after a drink) |
Dry mucous membranes (except for ‘mouth breather’) |
– | |
| Normal heart rate | Red flag Tachypnoea |
Tachycardia | |
| Normal breathing pattern |
Red flag Tachypnoea |
Tachypnoea | |
| Normal peripheral pulses |
Normal peripheral pulses |
Weak peripheral pulses |
|
| Normal capillary refill time |
Normal capillary refill time |
Normal capillary refill time |
|
| Normal skin turgor | Red flag Reduced skin turgor |
– | |
| Normal blood pressure |
Normal blood pressure |
Hypotension (decompensated shock) |
