Introduction

Pediatric emergencies require prompt recognition and intervention to prevent morbidity and mortality. Children are not simply small adults; they have unique anatomical, physiological, and developmental characteristics that influence their response to illness and injury. This document provides a comprehensive overview of common pediatric emergencies and the principles of pediatric resuscitation, with an emphasis on evidence-based management strategies.

Basic Life Support (BLS) in Pediatrics

Effective BLS is the foundation of successful resuscitation. Key components include:

1. Early Recognition of Cardiopulmonary Arrest

• Check responsiveness
• Assess breathing: look, listen, and feel for no more than 10 seconds
• Check pulse (brachial in infants, carotid or femoral in children) for no more than 10 seconds

2. High-Quality CPR

• Start compressions within 10 seconds of recognition of arrest
• Push hard (≥1/3 anterior-posterior diameter of the chest) and fast (100-120/min)
• Allow complete chest recoil between compressions
• Minimize interruptions (aim for chest compression fraction >80%)
• Avoid excessive ventilation

3. Compression-to-Ventilation Ratio

• 30:2 for single rescuer
• 15:2 for two healthcare provider rescuers
• Continuous compressions with asynchronous ventilations (1 breath every 6 seconds) if an advanced airway is in place

Advanced Life Support in Pediatrics

Airway Management

Securing and maintaining a patent airway is critical in pediatric resuscitation. Considerations include:

• Positioning: Shoulder roll for infants, neck extension and jaw thrust for children
• Appropriate sizing of equipment (e.g., masks, oral airways, endotracheal tubes)
• Rapid sequence intubation (RSI) when indicated, with appropriate drug selection and dosing
• Continuous waveform capnography to confirm and monitor endotracheal tube placement
• Anticipation of difficult airway scenarios (e.g., craniofacial abnormalities, cervical spine injury)

Breathing and Ventilation

Effective oxygenation and ventilation strategies include:

• High-flow nasal cannula (HFNC) or non-invasive positive pressure ventilation (NIPPV) in appropriate cases
• Lung-protective ventilation strategies for intubated patients (tidal volume 6-8 mL/kg ideal body weight, PEEP titration)
• Recognition and management of tension pneumothorax
• Careful monitoring of exhaled CO2 and oxygen saturation

Circulation and Shock Management

Shock is a state of inadequate tissue perfusion and oxygenation. Early recognition and aggressive management are essential:

• Establish vascular access (intraosseous if intravenous access is difficult)
• Fluid resuscitation: 20 mL/kg boluses of isotonic crystalloid, reassessing after each bolus
• Early initiation of vasoactive medications if fluid-refractory shock (e.g., epinephrine for cold shock, norepinephrine for warm shock)
• Blood product transfusion for hemorrhagic shock (target hemoglobin ≥7 g/dL, higher in certain conditions)
• Consider echocardiography for assessing cardiac function and volume status

Medications in Pediatric Resuscitation

Common medications used in pediatric resuscitation include:

• Epinephrine: First-line medication for cardiac arrest (0.01 mg/kg of 1:10,000 solution IV/IO every 3-5 minutes)
• Amiodarone or Lidocaine: For shock-refractory VF/pVT
• Atropine: For symptomatic bradycardia due to increased vagal tone or primary AV block
• Calcium: In cases of proven hypocalcemia, hyperkalemia, or calcium channel blocker overdose
• Glucose: For documented hypoglycemia (0.5-1 g/kg)
• Sodium bicarbonate: Consider only in prolonged arrest with metabolic acidosis, hyperkalemia, or tricyclic antidepressant overdose

Specific Pediatric Emergencies

1. Respiratory Emergencies

Bronchiolitis

• Supportive care (hydration, oxygenation, nasal suctioning)
• Consider HFNC for moderate to severe cases
• Bronchodilators and corticosteroids generally not recommended

Asthma Exacerbation

• Oxygen to maintain SpO2 94-98%
• Inhaled short-acting beta-2 agonists (e.g., salbutamol) with or without ipratropium bromide
• Systemic corticosteroids (oral preferred if tolerated)
• Consider IV magnesium sulfate for severe exacerbations
• Prepare for intubation and mechanical ventilation if clinical deterioration

2. Neurological Emergencies

Status Epilepticus

• First-line: Benzodiazepines (buccal midazolam, rectal diazepam, or IV/IM lorazepam)
• Second-line: Phenytoin/fosphenytoin, valproate, or levetiracetam
• Refractory status: Consider RSI and continuous infusion of midazolam, propofol, or barbiturates with continuous EEG monitoring

Raised Intracranial Pressure

• Elevation of head to 30°, midline positioning
• Analgesia and sedation
• Osmotherapy (mannitol or hypertonic saline)
• Target PaCO2 35-40 mmHg (unless signs of impending herniation)
• Early neurosurgical consultation

3. Cardiac Emergencies

Supraventricular Tachycardia (SVT)

• Vagal maneuvers
• Adenosine (first dose 0.1 mg/kg, maximum 6 mg; second dose 0.2 mg/kg, maximum 12 mg)
• Consider electrical cardioversion if hemodynamically unstable

Ventricular Fibrillation (VF) / Pulseless Ventricular Tachycardia (pVT)

• Immediate defibrillation (2 J/kg, then 4 J/kg for subsequent shocks)
• High-quality CPR between shocks
• Epinephrine every 3-5 minutes
• Amiodarone or lidocaine after the second shock

4. Metabolic Emergencies

Diabetic Ketoacidosis (DKA)

• Fluid resuscitation (calculate deficit and replace over 48 hours with isotonic fluids)
• Insulin infusion (0.05-0.1 units/kg/hour) after initial fluid bolus
• Potassium replacement
• Careful monitoring for cerebral edema

Inborn Errors of Metabolism

• Stop protein intake
• Provide high glucose infusion rate (8-10 mg/kg/min) to promote anabolism
• Correct metabolic acidosis
• Initiate ammonia scavengers if hyperammonemic

Trauma Resuscitation in Children

Trauma is a leading cause of morbidity and mortality in children. Key principles include:

• Adherence to ATLS (Advanced Trauma Life Support) principles
• Recognition that compensatory mechanisms may mask shock until late stages
• Low threshold for blood product transfusion in hemorrhagic shock
• Rapid identification and management of tension pneumothorax and cardiac tamponade
• Appropriate cervical spine immobilization
• Early involvement of pediatric surgery and/or neurosurgery

Post-Resuscitation Care

After return of spontaneous circulation (ROSC), focus on:

• Targeted temperature management (avoid hyperthermia, consider therapeutic hypothermia for selected cases)
• Careful hemodynamic monitoring and support
• Lung-protective ventilation strategies
• Seizure prophylaxis and management
• Glycemic control (avoid both hyper- and hypoglycemia)
• Prognostication (multi-modal approach, avoiding premature withdrawal of care)

Family Presence During Resuscitation

Current guidelines support offering family members the opportunity to be present during resuscitation, provided that:

• A dedicated staff member is assigned to support and guide the family
• The family's presence does not interfere with resuscitation efforts
• The team is comfortable with family presence

Ethical Considerations

Resuscitation of children involves complex ethical issues:

• Decision-making capacity and the role of parental authority
• Futility and limits of intervention
• Organ donation after cardiac death
• Resource allocation in mass casualty events

Simulation and Team Training

Regular simulation-based training is essential for maintaining competence in pediatric resuscitation. Focus areas should include:

• Crisis resource management
• Effective communication
• Role clarity and task delegation
• Debriefing and reflective practice

Further Reading

• American Heart Association Pediatric Advanced Life Support Guidelines
• Paediatric cardiac arrest and resuscitation provided by physician-staffed emergency medical teams in Germany: a prospective epidemiological study
• Pediatric Shock
• Epidemiology and Outcomes From Out-of-Hospital Cardiac Arrest in Children
• European Resuscitation Council Guidelines for Resuscitation: Section 6. Paediatric life support