Pediatric Emergencies and Resuscitation

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