# Seminar 08: Pediatric Emergencies ## Year 3: Emergency Medicine Clerkship --- ## Learning Objectives By the end of this seminar, students will be able to: 1. Apply age-appropriate vital signs and assessment 2. Manage pediatric respiratory emergencies 3. Recognize and treat pediatric shock 4. Evaluate the febrile infant 5. Identify non-accidental trauma 6. Perform pediatric resuscitation --- ## Seminar Outline ### I. Pediatric Assessment Pediatric vital signs vary dramatically by age, and understanding normal ranges is essential for recognizing pathology in children. Newborns maintain heart rates between 100-160 beats per minute with respiratory rates of 30-60, while infants have heart rates of 100-150 with respiratory rates of 25-40. Toddlers show heart rates of 90-140 and respiratory rates of 20-30, school-age children have rates of 70-120 with respirations of 15-25, and adolescents approach adult values with heart rates of 60-100 and respiratory rates of 12-20. Blood pressure also varies by age, with the fifth percentile systolic pressure estimated by the formula 70 plus twice the age in years for children between one and ten years. Recognition that hypotension is a late and ominous finding in pediatric shock emphasizes the importance of detecting earlier signs of cardiovascular compromise. The Pediatric Assessment Triangle (PAT) provides a rapid, hands-off initial evaluation that guides the urgency of intervention. Appearance assessment evaluates tone, interactiveness, consolability, look or gaze, and speech or cry, remembered through the mnemonic TICLS. Work of breathing is assessed by observing body position, retractions, nasal flaring, and audible respiratory sounds. Circulation to skin is evaluated by noting pallor, mottling, or cyanosis without touching the patient. This brief assessment, performed in seconds, identifies children requiring immediate intervention and categorizes the type of physiologic abnormality present. Weight estimation is critical for accurate medication dosing, fluid administration, and equipment sizing. Actual measured weight is always preferred when time and clinical stability permit. The Broselow tape provides length-based weight estimation with color-coded zones that correspond to precalculated medication doses and equipment sizes. When tape is unavailable, the formula of age in years multiplied by two plus eight gives approximate weight in kilograms for children over one year. These weight estimations must be available immediately during resuscitation, as all pediatric medications are weight-based and errors in dosing can have serious consequences. Equipment sizing follows established formulas and should be prepared based on estimated weight or Broselow color zone. Uncuffed endotracheal tube size is calculated as age in years divided by four plus four, while cuffed tubes use age divided by four plus 3.5. Laryngoscope blade selection progresses from size 0-1 for infants, size 2 for young children, and size 3 for older children and adolescents. Nasogastric tube size follows the same formula as endotracheal tubes. Having equipment prepared and readily accessible before attempting procedures improves success rates and reduces delays in critical situations. Panel A: Age-based normal vital signs table with heart rate, respiratory rate, and blood pressure ranges. Panel B: Pediatric Assessment Triangle showing appearance, work of breathing, and circulation to skin components. Panel C: Broselow tape demonstration with color-coded zones and equipment. Panel D: Equipment sizing formulas for endotracheal tubes, laryngoscope blades, and related supplies. --- ### II. Pediatric Respiratory Emergencies Croup, or laryngotracheobronchitis, is the most common cause of stridor in children aged six months to three years. Parainfluenza virus causes most cases, producing inflammation and edema of the subglottic airway. Children present with the characteristic barking seal-like cough, inspiratory stridor, and hoarseness, often worse at night. Anteroposterior neck radiograph may show the steeple sign of subglottic narrowing, though imaging is rarely necessary for diagnosis. Treatment includes dexamethasone 0.6 mg/kg as a single dose, which reduces airway edema and decreases the need for return visits. Severe croup with stridor at rest warrants nebulized racemic epinephrine, with observation for at least two hours following administration due to potential rebound effect. Bronchiolitis affects infants under two years of age, with peak incidence at three to six months. Respiratory syncytial virus (RSV) causes the majority of cases, though other viruses including rhinovirus and influenza contribute. The typical presentation begins with upper respiratory infection symptoms, progressing to cough, wheezing, and increased work of breathing. Treatment is primarily supportive, including nasal suctioning to relieve obstruction, supplemental oxygen for hypoxia, and hydration support. Importantly, multiple studies have demonstrated that albuterol, inhaled corticosteroids, and antibiotics do not improve outcomes and should not be routinely administered. Admission is indicated for hypoxia, significant dehydration, apnea risk in infants under two months or those born prematurely, and inadequate home support. Pediatric asthma shares pathophysiology with adult disease but requires age-appropriate dosing and special attention to delivery devices. Mild exacerbations are treated with albuterol via nebulizer or metered-dose inhaler with spacer every 20 minutes for three doses, along with systemic corticosteroids. Moderate exacerbations warrant continuous nebulized albuterol, ipratropium bromide, and corticosteroids. Severe exacerbations not responding to initial therapy may require intravenous magnesium sulfate at 25-50 mg/kg, with maximum dose of 2 grams. Corticosteroid dosing is typically prednisone or prednisolone 1-2 mg/kg with a maximum of 60 mg. Children with severe exacerbations unresponsive to maximal medical therapy may require non-invasive ventilation or intubation, though intubation should be avoided if possible due to the risks of bronchospasm during laryngoscopy. Foreign body aspiration occurs most commonly in children under three years who explore their environment by placing objects in their mouths. Presentation ranges from witnessed choking episode with acute respiratory distress to subtle persistent cough or wheezing when the aspiration was unwitnessed. Physical examination may reveal unilateral decreased breath sounds or wheezing. Chest radiograph may be normal, particularly with radiolucent objects, but may show unilateral hyperinflation from air trapping or atelectasis. Complete airway obstruction in a conscious child is managed with back blows in infants and abdominal thrusts in older children, while partial obstruction with adequate air exchange should prompt avoidance of intervention that might convert partial to complete obstruction. Definitive treatment is rigid bronchoscopy for foreign body removal. Panel A: Steeple sign on AP neck radiograph with comparison to normal subglottic airway. Panel B: Bronchiolitis clinical presentation and supportive care measures. Panel C: Pediatric asthma severity classification with corresponding treatment escalation. Panel D: Foreign body aspiration management including back blows and abdominal thrusts technique. --- ### III. Febrile Infant The approach to the febrile infant varies dramatically by age due to differing risk of serious bacterial infection and ability to localize infection. Neonates aged 0-28 days have incompletely developed immune systems and are at highest risk for serious bacterial infection including bacteremia and meningitis. Any fever (temperature 38 degrees Celsius or higher) in this age group mandates a full sepsis workup and admission for empiric intravenous antibiotics. Infants aged 29-60 days have intermediate risk and require careful evaluation with risk stratification to guide management. Infants aged 61-90 days have lower risk and may be managed based on clinical assessment, while those over 90 days are typically evaluated based on apparent source of infection. The workup for a febrile neonate includes comprehensive testing to identify bacterial infection. Complete blood count assesses for leukocytosis or leukopenia, which may indicate bacterial infection. Blood culture is obtained to evaluate for bacteremia. Urinalysis and urine culture are essential as urinary tract infection represents the most common source of serious bacterial infection in febrile infants. Lumbar puncture with cerebrospinal fluid analysis and culture evaluates for meningitis and should not be deferred in neonates. Chest radiograph is indicated when respiratory symptoms are present. Herpes simplex virus testing and empiric acyclovir should be considered in neonates, particularly those with maternal risk factors, vesicular lesions, or seizures. Empiric antibiotic selection covers the pathogens most likely to cause serious infection in young infants. For neonates 0-28 days, ampicillin provides coverage for Listeria monocytogenes and enterococcus, while gentamicin or cefotaxime covers gram-negative organisms including Escherichia coli and group B streptococcus. For infants 29-60 days, ampicillin plus ceftriaxone is commonly used, providing similar coverage with once-daily ceftriaxone dosing. Acyclovir should be added when herpes simplex virus infection is considered based on risk factors or clinical presentation. Antibiotics are continued until culture results are available, typically 24-48 hours for blood and urine cultures and 48-72 hours for cerebrospinal fluid. Low-risk criteria have been developed to identify febrile infants who may be safely observed without hospitalization. The Rochester, Boston, and Philadelphia criteria include factors such as well appearance, normal white blood cell count, normal urinalysis, and normal cerebrospinal fluid. Infants meeting all low-risk criteria may be candidates for outpatient observation with close follow-up, though practices vary by institution. These criteria apply primarily to infants 29-60 days old who have reliable caregivers and access to follow-up care. Recent studies and protocols such as the Step-by-Step approach have refined risk stratification using inflammatory markers including procalcitonin to further identify low-risk infants. Panel A: Age-stratified approach to febrile infant showing risk categories and required workup. Panel B: Components of full sepsis workup with rationale for each test. Panel C: Empiric antibiotic regimens by age with pathogen coverage. Panel D: Low-risk criteria comparison across Rochester, Boston, and Philadelphia protocols. --- ### IV. Pediatric Shock Recognition of pediatric shock requires understanding that children compensate for hypovolemia more effectively than adults, making early signs subtle. Tachycardia is often the first and only sign of compensated shock, making age-appropriate heart rate interpretation essential. Capillary refill time exceeding 2-3 seconds indicates poor peripheral perfusion, though this finding can be affected by ambient temperature. Mottled or pale skin indicates shunting of blood away from the periphery to preserve vital organ perfusion. Weak peripheral pulses with preserved central pulses suggest moderate volume depletion, while weak central pulses indicate severe shock. Mental status changes including irritability followed by lethargy reflect cerebral hypoperfusion. Hypotension represents a late finding indicating decompensated shock, with blood pressure being maintained until approximately 30% of blood volume is lost. The types of shock in pediatrics parallel adult categories with some unique pediatric considerations. Hypovolemic shock from dehydration or hemorrhage is common and responds to fluid resuscitation. Distributive shock includes sepsis, which is a leading cause of pediatric mortality, and anaphylaxis. Cardiogenic shock occurs with congenital heart disease, myocarditis, and cardiomyopathy, requiring careful fluid administration to avoid exacerbating pulmonary edema. Obstructive shock from tension pneumothorax, cardiac tamponade, or pulmonary embolism requires treatment of the underlying obstruction rather than fluid alone. Distinguishing between shock types guides appropriate treatment and avoids potentially harmful interventions. Fluid resuscitation in pediatric shock follows a bolus approach with reassessment between doses. Normal saline or lactated Ringer's solution is administered in 20 mL/kg boluses over 5-20 minutes, with faster infusion for more severe shock. After each bolus, the child is reassessed for improvement in heart rate, capillary refill, mental status, and urine output. Up to 60 mL/kg may be required in the first hour for septic shock. However, excessive fluid administration in cardiogenic shock can worsen pulmonary edema, so smaller aliquots (5-10 mL/kg) with careful reassessment are appropriate when cardiac function is impaired. Point-of-care ultrasound can help assess fluid responsiveness and cardiac function. Septic shock management in children follows time-sensitive protocols emphasizing early recognition and aggressive intervention. Vascular access should be obtained within five minutes, with intraosseous access placed if peripheral access fails. Broad-spectrum antibiotics should be administered within one hour of recognition, with coverage based on age and likely source. Fluid boluses of 20 mL/kg are administered up to 60 mL/kg in the first hour. If shock persists despite adequate fluid resuscitation (fluid-refractory shock), vasoactive medications are indicated, with epinephrine as first-line in pediatric septic shock due to its inotropic and vasopressor effects. Source control, including drainage of abscesses, is essential when applicable. The goal is restoration of normal perfusion parameters including mental status, capillary refill, and urine output. Panel A: Early versus late signs of pediatric shock with physiologic progression. Panel B: Classification of pediatric shock types with characteristic findings and causes. Panel C: Fluid resuscitation algorithm with reassessment parameters. Panel D: Pediatric septic shock management timeline with intervention targets. --- ### V. Pediatric Cardiac Emergencies Congenital heart disease may present at different ages depending on the specific lesion. Neonates with ductal-dependent lesions present with cyanosis or shock when the ductus arteriosus closes in the first days to weeks of life. Infants with significant left-to-right shunts develop congestive heart failure symptoms including poor feeding, diaphoresis with feeds, tachypnea, and failure to thrive as pulmonary vascular resistance falls and shunting increases. Older children with less severe lesions may present with murmurs detected on examination, exercise intolerance, or arrhythmias. Recognition of the age-related presentation patterns helps identify children with previously undiagnosed congenital heart disease. Ductal-dependent lesions require prostaglandin E1 to maintain ductal patency and preserve systemic or pulmonary blood flow. Cyanotic ductal-dependent lesions include transposition of the great arteries, pulmonary atresia, tricuspid atresia, and critical pulmonary stenosis, where the ductus provides the only source of pulmonary blood flow. Acyanotic ductal-dependent lesions include coarctation of the aorta, critical aortic stenosis, hypoplastic left heart syndrome, and interrupted aortic arch, where the ductus provides systemic blood flow. Prostaglandin E1 is administered at 0.05-0.1 mcg/kg/min as continuous infusion. A major side effect is apnea, so preparation for intubation is essential when starting prostaglandin infusion. Additional side effects include fever, hypotension, and flushing. Pediatric arrhythmias are managed according to Pediatric Advanced Life Support (PALS) guidelines. Supraventricular tachycardia (SVT) is the most common pathologic tachycardia in children, presenting with rates often exceeding 220 beats per minute in infants. Stable SVT is initially treated with vagal maneuvers, including ice application to the face in infants, followed by adenosine 0.1 mg/kg (maximum 6 mg) with rapid push technique. Ventricular tachycardia with pulses is treated with amiodarone or synchronized cardioversion. Ventricular fibrillation and pulseless ventricular tachycardia are treated with immediate defibrillation at 2 J/kg, followed by CPR and medications. Asystole and pulseless electrical activity are managed with high-quality CPR, epinephrine, and treatment of reversible causes. Pediatric basic and advanced life support follows protocols modified from adult guidelines. Compression rate is 100-120 per minute with depth of one-third the anteroposterior chest diameter. The compression-to-ventilation ratio is 30:2 for single rescuer and 15:2 for two-rescuer CPR with advanced airway. Epinephrine dosing is 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration) given every 3-5 minutes during arrest. Initial defibrillation energy is 2 J/kg, increasing to 4 J/kg for subsequent shocks. Emphasis on minimizing interruptions to chest compressions and ensuring adequate compression depth and full chest recoil improves outcomes. Unlike adults, pediatric cardiac arrest more commonly results from respiratory failure or shock, making prevention of arrest through early recognition and intervention paramount. Panel A: Age-based presentation of congenital heart disease from neonate to older child. Panel B: Ductal-dependent lesions classified by cyanotic and acyanotic with prostaglandin management. Panel C: Pediatric arrhythmia recognition and treatment algorithm. Panel D: Pediatric BLS and PALS key differences from adult protocols with dosing. --- ### VI. Pediatric Trauma Pediatric trauma differs from adult trauma due to anatomic and physiologic differences that affect injury patterns. The head is proportionally larger in children, resulting in higher incidence of traumatic brain injury. The chest wall is more compliant, allowing transmission of force to internal structures without rib fractures, so internal thoracic injury can occur without external evidence of trauma. The abdomen is less protected by the pelvis and rib cage, making solid organ injuries to liver and spleen more common. Bones are more pliable, resulting in greenstick and buckle fractures rather than complete fractures. Children have relatively larger blood volume per kilogram (80 mL/kg) but smaller absolute volumes, meaning that what appears to be small blood loss can represent significant hemorrhage. Fluid resuscitation in pediatric trauma follows principles similar to adult trauma with weight-based dosing. Initial resuscitation uses 20 mL/kg crystalloid boluses, with reassessment after each bolus. If there is no response to the first bolus, a second 20 mL/kg bolus is administered. Persistent hemodynamic instability after 40 mL/kg of crystalloid suggests ongoing hemorrhage requiring blood transfusion. Packed red blood cells are administered at 10-20 mL/kg. Massive transfusion protocols with balanced ratios of blood products are activated for children requiring large-volume resuscitation. Permissive hypotension strategies used in adult trauma are not well-established in children, particularly given the late manifestation of hypotension in pediatric shock. Pediatric head trauma evaluation balances the need to identify significant injury against radiation exposure from computed tomography. The Pediatric Emergency Care Applied Research Network (PECARN) decision rule helps identify children at very low risk for clinically important traumatic brain injury who do not require CT imaging. High-risk findings mandating CT include Glasgow Coma Scale under 15, signs of basilar skull fracture, and altered mental status. Intermediate-risk factors include severe mechanism, loss of consciousness, vomiting, and severe headache, for which observation versus imaging is considered based on clinical judgment. The Glasgow Coma Scale has been modified for preverbal children, with verbal response assessed based on age-appropriate vocalizations. Scalp hematomas, particularly those in non-frontal locations in young children, increase the risk of underlying skull fracture. Non-accidental trauma (child abuse) must be considered in any pediatric injury. Red flags include history inconsistent with injury pattern or developmental ability, changing or conflicting histories, delay in seeking care, and injuries in various stages of healing. Specific injury patterns concerning for abuse include rib fractures in infants (highly specific), metaphyseal corner fractures, multiple fractures of different ages, retinal hemorrhages, and bruising in non-mobile infants. The adage "those who don't cruise rarely bruise" emphasizes that bruising in infants who are not yet pulling to stand is highly suspicious for inflicted injury. When abuse is suspected, mandatory reporting to child protective services is required, and skeletal survey radiography helps identify occult fractures. Panel A: Anatomic differences between pediatric and adult trauma with injury pattern implications. Panel B: Pediatric trauma fluid resuscitation algorithm with blood transfusion triggers. Panel C: PECARN head injury decision rule with risk stratification. Panel D: Non-accidental trauma red flags with specific injury patterns concerning for abuse. --- ### VII. Common Pediatric Emergencies Febrile seizures are the most common seizure type in childhood, occurring in children aged six months to five years during febrile illness. Simple febrile seizures are generalized, last less than 15 minutes, and occur only once during a 24-hour illness period. Complex febrile seizures are focal, prolonged beyond 15 minutes, or recur within 24 hours. Simple febrile seizures in well-appearing children with identified fever source do not require extensive workup, lumbar puncture, or electroencephalography. Complex febrile seizures warrant consideration of lumbar puncture and possibly neuroimaging to evaluate for central nervous system infection or structural abnormality. Treatment is supportive, and antiepileptic medications are not indicated for simple febrile seizures due to their benign prognosis. Parent education regarding the benign nature of simple febrile seizures and fever management is important. Pediatric dehydration is graded by clinical assessment and estimated percentage of body weight lost. Mild dehydration (3-5% weight loss) presents with slightly dry mucous membranes and mildly decreased urine output. Moderate dehydration (6-9% weight loss) shows decreased tears, sunken eyes, delayed capillary refill, and decreased skin turgor. Severe dehydration (10% or greater weight loss) manifests as lethargy, very sunken fontanelle in infants, absent tears, and poor perfusion. Oral rehydration solution is appropriate for mild to moderate dehydration in children who can tolerate oral intake. Intravenous fluids are indicated for severe dehydration, persistent vomiting, or inability to tolerate oral intake, with initial 20 mL/kg boluses followed by maintenance plus deficit replacement. Pediatric hypoglycemia requires age-appropriate definition and treatment. Neonates are considered hypoglycemic below 40 mg/dL, while infants and older children are hypoglycemic below 60 mg/dL. Symptoms include jitteriness, poor feeding, irritability, seizures, and lethargy. Treatment in neonates uses D10W at 2-4 mL/kg (providing 200-400 mg/kg of glucose) to avoid osmotic complications from more concentrated dextrose solutions. Older children receive D25W at 2-4 mL/kg or D50W at 1-2 mL/kg. Glucagon 0.03 mg/kg intramuscularly is an alternative when intravenous access is unavailable. Following acute treatment, continuous dextrose infusion and investigation for underlying cause are important, particularly in neonates where hypoglycemia may indicate metabolic disease or sepsis. Brief resolved unexplained events (BRUE), formerly called apparent life-threatening events (ALTE), are episodes involving some combination of apnea, color change, tone change, or altered responsiveness that resolve spontaneously or with minimal intervention. Lower-risk BRUE is defined by age over 60 days, gestational age over 32 weeks, first event, duration under one minute, no CPR by medical provider required, and no concerning history or physical findings. Lower-risk BRUE may require minimal workup with observation and caregiver education. Higher-risk BRUE warrants more extensive evaluation for underlying causes including infection, cardiac disease, metabolic disorders, and non-accidental trauma. The key principle is identifying children at risk for recurrent events or with serious underlying conditions while avoiding excessive testing in low-risk patients. Panel A: Simple versus complex febrile seizure characteristics with management approach. Panel B: Dehydration severity assessment with clinical findings and treatment. Panel C: Pediatric hypoglycemia treatment by age with dextrose concentrations and dosing. Panel D: BRUE risk stratification with lower-risk criteria and evaluation approach. --- ### VIII. Pediatric Infectious Emergencies Pediatric meningitis requires high suspicion and prompt treatment given the potential for rapid deterioration. Presentation varies by age, with infants showing nonspecific signs including fever, irritability, lethargy, poor feeding, and bulging fontanelle. Older children develop the classic triad of fever, headache, and neck stiffness with photophobia and vomiting. Kernig and Brudzinski signs may be present but are less reliable in young children. Diagnosis requires lumbar puncture with cerebrospinal fluid analysis and culture, though empiric antibiotics should not be delayed if lumbar puncture cannot be performed immediately. Empiric treatment for bacterial meningitis includes vancomycin and ceftriaxone with dexamethasone to reduce inflammation and improve outcomes, particularly for Haemophilus influenzae and pneumococcal meningitis. Neonatal meningitis has a different pathogen spectrum requiring modified empiric coverage. Common organisms include group B streptococcus, Escherichia coli, and Listeria monocytogenes. Empiric regimen includes ampicillin plus cefotaxime or gentamicin. Herpes simplex virus causes meningoencephalitis in neonates and requires empiric acyclovir when there is any suspicion based on maternal history, vesicular lesions, or seizures. HSV meningoencephalitis can cause devastating neurologic outcomes if treatment is delayed. Cerebrospinal fluid in HSV infection may initially appear benign, so empiric acyclovir should be started based on clinical suspicion rather than waiting for abnormal CSF findings. Pediatric sepsis is a leading cause of pediatric mortality worldwide, and early recognition with prompt treatment improves outcomes. Early signs include tachycardia, fever or hypothermia, and subtle behavioral changes such as irritability or decreased responsiveness. As sepsis progresses, signs of poor perfusion develop including mottled skin, weak pulses, prolonged capillary refill, and oliguria. Late signs include hypotension and obtundation. Source evaluation should assess for urinary tract infection, pneumonia, meningitis, and bacteremia without focus. Time to antibiotics is a critical quality metric, with goal administration within one hour of sepsis recognition. Antibiotic selection is based on age and likely source, with broad coverage that can be narrowed once culture results are available. Kawasaki disease is an acute vasculitis affecting medium-sized arteries, most importantly the coronary arteries, in children typically under five years old. Diagnosis requires fever for five or more days plus four of the following five criteria: bilateral conjunctival injection without exudate, oral changes including red cracked lips or strawberry tongue, polymorphous rash, extremity changes including edema or desquamation, and cervical lymphadenopathy greater than 1.5 cm. Incomplete Kawasaki disease may present with fewer criteria and requires high suspicion, particularly in young infants. The major complication is coronary artery aneurysm, which can lead to myocardial infarction. Treatment with intravenous immunoglobulin (IVIG) plus aspirin within the first ten days of illness significantly reduces coronary artery complications. Echocardiography is performed to evaluate for coronary involvement. Panel A: Meningitis presentation by age group with clinical findings and empiric treatment. Panel B: Neonatal meningitis pathogen spectrum with antibiotic coverage including HSV considerations. Panel C: Pediatric sepsis recognition timeline with progression from early to late signs. Panel D: Kawasaki disease diagnostic criteria with images of clinical findings and coronary artery involvement. --- ### IX. Pediatric Pain and Sedation Pain assessment in children requires age-appropriate tools that account for developmental stage and communication ability. Non-verbal infants and young children are assessed using behavioral observation scales such as the FLACC scale, which evaluates Face, Legs, Activity, Cry, and Consolability. Children aged three to seven years can use the Wong-Baker Faces Pain Scale, selecting a face that represents their pain level. Children over seven years can typically use numeric rating scales similar to adults. Self-report remains the gold standard when developmentally appropriate, but behavioral indicators provide essential information in preverbal children and those with communication impairments. Pain assessment should be documented and reassessed following intervention. Analgesic dosing in pediatrics requires weight-based calculations with attention to maximum doses. Acetaminophen is dosed at 15 mg/kg orally or rectally every four hours, with maximum single dose of 1 gram and maximum daily dose of 75 mg/kg or 4 grams. Ibuprofen is dosed at 10 mg/kg orally every six hours, with maximum single dose of 400-600 mg. Opioids for moderate to severe pain include morphine 0.1 mg/kg intravenously every two to four hours and fentanyl 1-2 mcg/kg intravenously. Intranasal fentanyl at 1.5 mcg/kg provides rapid onset non-invasive analgesia and is particularly useful for procedural pain or when intravenous access is not available. Combination of acetaminophen and ibuprofen provides synergistic effect and is often more effective than either agent alone. Procedural sedation in children requires careful agent selection, monitoring, and preparation for complications. Ketamine provides dissociative anesthesia with preservation of airway reflexes and is widely used in pediatric emergency departments at doses of 1-2 mg/kg intravenously. Ketamine side effects include emergence reactions (reduced with benzodiazepine pretreatment), hypersalivation, and vomiting. Propofol provides rapid onset and offset for brief procedures but causes hypotension and respiratory depression, requiring careful monitoring. Midazolam provides anxiolysis and amnesia, useful as an adjunct or for less painful procedures. Nitrous oxide is appropriate for mild to moderate procedural pain and anxiety. All procedural sedation requires monitoring with pulse oximetry, end-tidal capnography, and blood pressure monitoring. Sedation safety requires attention to fasting status, equipment preparation, and monitoring protocols. Traditional NPO guidelines recommend clear liquids up to two hours and solids up to six to eight hours before elective sedation, though emergency procedures may proceed with appropriate risk-benefit consideration. Age-appropriate resuscitation equipment including bag-valve-mask, suction, and appropriately sized airway equipment must be immediately available. Continuous monitoring during sedation and recovery includes oxygen saturation, end-tidal carbon dioxide, heart rate, and blood pressure. Discharge criteria include return to baseline mental status, stable vital signs, adequate hydration, and appropriate supervision at home. Documentation includes informed consent, pre-procedure assessment, medications administered, continuous monitoring record, and discharge criteria met. Panel A: FLACC and Wong-Baker Faces pain assessment scales with scoring interpretation. Panel B: Pediatric analgesic dosing chart with acetaminophen, ibuprofen, and opioid doses. Panel C: Procedural sedation agent comparison with ketamine, propofol, and midazolam properties. Panel D: Sedation safety checklist including equipment, monitoring, and discharge criteria. --- ### X. Pediatric Resuscitation Pediatric airway management requires equipment appropriately sized for the child and techniques modified for pediatric anatomy. Mask selection should ensure coverage of nose and mouth with minimal leak, using transparent masks when possible to detect vomiting. Oral airways are sized from corner of mouth to angle of mandible. Laryngoscope blade selection follows age guidelines, with Miller blades (straight) often preferred in infants for lifting the epiglottis. Endotracheal tube size is calculated using formulas, with cuffed tubes increasingly used even in young children. The laryngeal mask airway provides supraglottic airway management and is sized based on weight. Video laryngoscopy improves visualization and success rates, particularly for trainees. The anterior and superior position of the pediatric larynx and relatively large tongue require modified positioning with neutral head alignment in infants. Vascular access during pediatric resuscitation prioritizes speed and reliability. Peripheral intravenous access should be attempted first but should not delay treatment. If peripheral access is unsuccessful within 90 seconds or after two attempts, intraosseous access should be placed without delay. The proximal tibia is the preferred intraosseous site in young children, with the distal femur as an alternative. In older children and adolescents, the proximal humerus is also used. Intraosseous access provides reliable delivery of all resuscitation medications and fluids. Central venous access may be considered in stabilized patients requiring prolonged access but is not a priority during active resuscitation. The femoral vein is most accessible for emergent central access if needed. Medication dosing during pediatric resuscitation follows weight-based protocols with emphasis on accuracy. Epinephrine is dosed at 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration) every 3-5 minutes during cardiac arrest. Amiodarone for ventricular fibrillation or pulseless ventricular tachycardia is dosed at 5 mg/kg, with maximum 300 mg. Lidocaine is an alternative at 1 mg/kg. Adenosine for supraventricular tachycardia is 0.1 mg/kg for the first dose (maximum 6 mg) and 0.2 mg/kg for subsequent doses (maximum 12 mg). Dextrose for hypoglycemia is administered as D10W 5 mL/kg in neonates or D25W 2 mL/kg in children. Calcium chloride 20 mg/kg is indicated for hypocalcemia, hyperkalemia, or calcium channel blocker overdose. Broselow tape or pre-calculated weight-based dosing references reduce calculation errors during resuscitation. Post-resuscitation care aims to optimize neurologic outcome and prevent secondary injury. Temperature management is essential, with avoidance of hyperthermia and consideration of targeted temperature management in comatose patients following cardiac arrest. Glucose monitoring and treatment of hypoglycemia support cerebral metabolism. Hemodynamic support with fluids and vasopressors maintains adequate perfusion pressure. Seizure monitoring and treatment prevents additional neurologic injury. Mechanical ventilation should target normal oxygenation and carbon dioxide levels, avoiding both hyperoxia and hypocapnia which can worsen neurologic outcomes. Transfer to a pediatric intensive care unit with expertise in post-cardiac arrest care improves outcomes, and early involvement of pediatric critical care specialists guides ongoing management. Panel A: Pediatric airway equipment sizing with endotracheal tube formulas and blade selection by age. Panel B: Intraosseous access sites including proximal tibia, distal femur, and proximal humerus landmarks. Panel C: Resuscitation medication dosing chart with epinephrine, amiodarone, adenosine, and dextrose. Panel D: Post-resuscitation care priorities including temperature management, hemodynamics, and neurologic monitoring. --- ## Summary - Pediatric vital signs: age-specific normal ranges; hypotension is a late sign indicating decompensated shock - Pediatric Assessment Triangle (PAT): rapid assessment of appearance, work of breathing, and circulation to skin guides urgency - Croup: barking cough and stridor; dexamethasone 0.6 mg/kg single dose; racemic epinephrine for severe cases - Bronchiolitis: supportive care with suctioning, oxygen, and hydration; albuterol and steroids are not effective - Febrile neonate (0-28 days): full sepsis workup including lumbar puncture, admission, and intravenous antibiotics required - Pediatric shock: recognize early with tachycardia and poor perfusion; 20 mL/kg fluid boluses; epinephrine for fluid-refractory septic shock - Ductal-dependent congenital heart disease: prostaglandin E1 to maintain ductal patency; prepare for apnea - Non-accidental trauma: recognize inconsistent history, unusual injury patterns, and bruising in non-mobile infants - Kawasaki disease: five days fever plus four criteria; IVIG and aspirin; coronary artery aneurysm is major complication - Pediatric resuscitation: intraosseous access if IV fails within 90 seconds; epinephrine 0.01 mg/kg; defibrillation 2 J/kg --- ## Key Terms | Term | Definition | |------|------------| | PAT | Pediatric Assessment Triangle; rapid visual assessment of appearance, breathing, and circulation | | Broselow tape | Length-based system for weight estimation and equipment/medication sizing | | PECARN | Pediatric Emergency Care Applied Research Network; provides head injury decision rule | | BRUE | Brief Resolved Unexplained Event; episode of apnea, color change, tone change, or altered responsiveness | | SBI | Serious Bacterial Infection; includes bacteremia, meningitis, and urinary tract infection | | NAT | Non-Accidental Trauma; injuries resulting from child abuse | | IO | Intraosseous; vascular access through bone marrow cavity | | FLACC | Face, Legs, Activity, Cry, Consolability; behavioral pain assessment scale | --- *This content is subject to the [MIT License](https://opensource.org/licenses/MIT). © 2024–2026 Hibbert School of Medicine.*