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title: "Paediatric Emergencies"
Paediatric Emergencies
Recognition of the sick child, paediatric resuscitation, and common emergency presentations.
Recognition of the Sick Child
Paediatric Assessment Triangle (PAT)
Quick initial assessment without touching the child:
| Component | What to Assess |
|---|---|
| Appearance | Tone, interactivity, consolability, look/gaze, speech/cry |
| Work of Breathing | Abnormal sounds (stridor, wheeze, grunting), positioning, retractions, nasal flaring |
| Circulation to Skin | Pallor, mottling, cyanosis |
Abnormal PAT = Sick child: Any abnormality in PAT indicates potential serious illness. Trust your instincts - a child who "doesn't look right" warrants careful assessment.
Red Flags - Do Not Miss
Critical Red Flags:
- Purpuric/petechial rash → Meningococcaemia
- Bulging fontanelle → Raised ICP (meningitis, SAH)
- Biphasic stridor → Glottic/subglottic lesion
- High-pitched scream → Meningitis
- Bile-stained vomiting → Surgical emergency (malrotation)
- Grunting respiration → End-stage respiratory failure
Primary Assessment (ABCDE)
A - Airway:
- Patency, positioning, drooling, secretions
- Noisy breathing (stridor, stertor)
- See-saw chest movement (obstruction)
B - Breathing:
- Effort: Rate, recession, nasal flaring, accessory muscles
- Efficacy: SpO2, air entry
- Effect: Mental state, colour, heart rate
Stridor localisation:
- Inspiratory stridor = Upper airway pathology
- Expiratory wheeze = Lower airway pathology
- Biphasic stridor = Fixed lesion at glottis/subglottis
- Grunting = Airspace pathology (pneumonia, pulmonary oedema)
C - Circulation:
- Heart rate (tachycardia often first sign of [[shock]])
- Capillary refill time (>2 seconds = poor perfusion)
- Blood pressure (hypotension is PRE-TERMINAL)
- Peripheral pulses, skin colour, temperature
Hypotension is a pre-terminal sign in children: Children compensate for [[shock]] with tachycardia and peripheral vasoconstriction. When BP drops, decompensation is imminent.
D - Disability:
- AVPU (Alert, Voice, Pain, Unresponsive)
- Pupils (size, reactivity, symmetry)
- Posture (decorticate/decerebrate)
- Blood glucose (always check!)
E - Exposure:
- Full examination looking for rash, bruising
- Temperature
- Consider non-accidental injury if mechanism doesn't fit
Fluid Status Assessment
| Sign | Mild (3-5%) | Moderate (6-9%) | Severe (>10%) |
|---|---|---|---|
| Appearance | Alert | Irritable | Lethargic/drowsy |
| Eyes | Normal | Sunken | Very sunken |
| Mucous membranes | Slightly dry | Dry | Parched |
| Capillary refill | Normal | 2-3 seconds | >3 seconds |
| Pulse | Normal | Rapid | Rapid, weak |
| Urine output | Slightly reduced | <1 mL/kg/hr | Minimal/none |
Reduced intake markers: Less than half usual fluid intake, <4 wet nappies in 24 hours in infants.
Paediatric Life Support
[[basic-life-support|Basic Life Support]] - DRSABCD
D - Danger: Check for environmental hazards R - Response: "Are you alright?" + shake arm S - Send for help: Call for help, activate emergency response
A - Airway:
- Head tilt-chin lift (neutral position in infants)
- Jaw thrust if cervical spine injury suspected
B - Breathing:
- Look, listen, feel for 10 seconds
- 2 initial rescue breaths
C - Circulation:
- Check for pulse (brachial in infants, carotid in children)
- If no pulse or HR <60 with poor perfusion → start compressions
D - Defibrillation:
- Attach AED/monitor
- Shockable rhythms (VF/pVT) are RARE in children
CPR Technique
| Age | Compression Depth | Compression Point | Ratio |
|---|---|---|---|
| Infant (<1 year) | 1/3 chest depth (~4 cm) | Lower sternum | 15:2 |
| Child (1-8 years) | 1/3 chest depth (~5 cm) | Lower sternum | 15:2 |
| Adolescent | ~5-6 cm | Lower sternum | 30:2 (single rescuer) |
Compression rate: 100-120/minute
Infant Compression Techniques
- Two-finger technique (single rescuer): Two fingers on lower sternum
- Encircling technique (two rescuers): Thumbs on sternum, hands encircling chest - preferred
Paediatric Cardiac Arrest
Most paediatric arrests are respiratory in origin: Hypoxic arrest from respiratory failure (60%) or circulatory failure (30%). Primary cardiac causes rare unlike adults.
Source: ANZCOR paediatric life support guidance; APLS.
[[adrenaline|Adrenaline]]: 10 mcg/kg (0.1 mL/kg of 1:10,000) IV/IO every 3-5 minutes
Amiodarone: 5 mg/kg IV/IO for shockable rhythms
Defibrillation: 4 J/kg for shockable rhythms
Choking Child
Conscious child with effective cough: Encourage coughing
Conscious child with ineffective cough:
- Up to 5 back blows
- 5 chest thrusts (infant) or abdominal thrusts (child > 1 year)
- Repeat cycle
Unconscious child: Start CPR (DRSABCD)
Blind finger sweeps are contraindicated: Only remove visible foreign bodies. Blind sweeps may push object further in.
Upper Airway Emergencies
Croup (Laryngotracheobronchitis)
Aetiology: Parainfluenza virus (most common), RSV, adenovirus
Age: 6 months to 3 years (peak 1-2 years)
Pathophysiology: Subglottic oedema causing airway narrowing
Clinical Features:
- Low-grade fever
- Barking "seal" cough
- Inspiratory stridor (worse at night)
- Hoarse voice
- Symptoms worsen at night, recur over 3-5 days
Severity Assessment:
| Mild | Moderate | Severe |
|---|---|---|
| Occasional barking cough | Frequent barking cough | Frequent cough |
| No stridor at rest | Stridor at rest | Stridor at rest |
| No chest wall recession | Mild recession | Moderate-severe recession |
| Happy child | Some distress | Distressed, agitated or lethargic |
Management:
| Severity | Treatment |
|---|---|
| Mild | Dexamethasone 0.15-0.6 mg/kg PO single dose |
| Moderate | Dexamethasone + nebulised adrenaline if distressed |
| Severe | Dexamethasone + nebulised adrenaline, consider ICU |
Nebulised adrenaline: 0.5 mL/kg of 1:1000 (max 5 mL). Effect lasts 2 hours - observe for rebound. Not a substitute for steroids.
Source: RCH Clinical Practice Guidelines (croup); local ED guideline.
Epiglottitis
Aetiology: Haemophilus influenzae type b (now rare with vaccination), other bacteria
Clinical Features (rapid onset over hours):
- High fever
- Severe sore throat
- Dysphagia, drooling
- Muffled "hot potato" voice
- Tripod position (leaning forward, neck extended)
- Minimal cough (unlike croup)
Do not examine throat: Risk of complete airway obstruction. Do not lie child flat. Call senior help immediately.
Management:
- Keep child calm with parent
- Call anaesthetist and ENT
- Prepare for emergency airway in theatre
- IV antibiotics after airway secured (ceftriaxone)
Lower Airway Emergencies
Bronchiolitis
Aetiology: RSV (most common), human rhinovirus, metapneumovirus
Age: Peak 3-6 months, 80% <1 year
Pathophysiology: Small airway inflammation and obstruction
Clinical Features:
- URTI prodrome (coryza, low-grade fever)
- Gradual onset respiratory distress
- Tachypnoea (RR 60-100)
- Subcostal/intercostal recession
- Expiratory wheeze
- Crackles on auscultation
- Poor feeding
Risk Factors for Severe Disease:
- Age <6 weeks
- Prematurity
- Chronic lung disease
- Congenital heart disease
- Immunodeficiency
Investigations:
- Usually clinical diagnosis
- CXR only if uncertain: hyperinflation, atelectasis
Management:
| Supportive Care | Details |
|---|---|
| Oxygen | Target SpO2 >92% |
| Fluids | NG or IV if unable to feed |
| Respiratory support | High-flow nasal cannula, then CPAP if needed |
| Suction | Nasal suction if secretions obstructing |
What doesn't work in bronchiolitis: Bronchodilators (no benefit, may cause harm), corticosteroids, antibiotics (unless secondary bacterial infection), hypertonic saline (ED setting).
[[asthma-acute|Acute Asthma]]
Severity Assessment:
| Feature | Mild-Moderate | Severe | Life-threatening |
|---|---|---|---|
| Talks in | Sentences | Words | Unable |
| SpO2 | >92% | 90-92% | <90% |
| PEF (if able) | >50% | 33-50% | <33% |
| HR | Normal | Tachycardia | Bradycardia |
| Respiratory distress | Mild | Moderate | Exhaustion |
| Chest | Wheeze | Loud wheeze | Silent chest |
Management:
| Step | Treatment |
|---|---|
| 1 | Oxygen to maintain SpO2 >94% |
| 2 | Salbutamol 6 puffs via spacer (or nebulised 2.5-5mg) every 20 min x 3 |
| 3 | Prednisolone 1-2 mg/kg (max 50mg) or IV hydrocortisone |
| 4 | Ipratropium bromide 250 mcg nebulised with salbutamol if poor response |
| 5 | Magnesium sulphate 50 mg/kg IV over 20 min if severe |
| 6 | Consider IV salbutamol if no improvement |
| 7 | ICU for intubation if deteriorating |
Salbutamol via spacer: As effective as nebulised in most children and avoids treatment delay. Use 6 puffs per dose in children 6+ years, 4 puffs for younger.
Fever and [[sepsis|Sepsis]]
Fever in Children - Approach by Age
Neonates (<28 days) with fever (>38°C) or hypothermia (<36°C): Presume serious bacterial infection until proven otherwise. Full septic workup + empiric antibiotics.
Source: RCH Clinical Practice Guidelines (fever in children); local neonatal sepsis pathway.
| Age | Approach |
|---|---|
| 0-28 days | Full septic workup (blood, urine, LP), empiric antibiotics |
| 1-3 months | High risk - careful assessment, consider workup, close observation |
| 3-36 months | Assess for focus, consider UTI (urine MC&S), observe if well |
| >36 months | Treat as adults - guided by history and examination |
Toxic Signs (Markers of Serious Bacterial Infection)
- Pallor
- Drowsiness, decreased responsiveness
- Irritability (inconsolable)
- Poor feeding
- Poor tone
- Mottled skin
- Prolonged capillary refill
Common Serious Bacterial Infections in Children
- Urinary tract infection - especially in undifferentiated fever in young children
- Pneumonia
- Meningitis
- Osteomyelitis/septic arthritis
- Occult bacteraemia
UTI in children: Common cause of fever without focus. Always obtain urine in young febrile children. Clean catch or catheter specimen for culture.
Seizures
Febrile Seizures
Definition: Seizure occurring with fever in children 6 months to 5 years without CNS infection or other cause
Types:
| Simple | Complex |
|---|---|
| Duration <15 minutes | Duration >15 minutes |
| Generalised | Focal features |
| Single seizure | Multiple in 24 hours |
| Complete recovery | Incomplete recovery/Todd's paresis |
Management:
- Protect airway (recovery position)
- Treat fever (paracetamol after seizure stops)
- Identify source of fever
- Reassurance - not epilepsy, low recurrence risk
When to investigate further:
- Complex features
- First afebrile seizure
- Meningism
- Prolonged post-ictal state
- New neurological signs
Status Epilepticus
Definition: Seizure lasting >5 minutes OR multiple seizures without recovery between
Management Algorithm:
| Time | Action |
|---|---|
| 0-5 min | Airway, oxygen, check BSL, IV access |
| 5-10 min | Midazolam 0.15 mg/kg IV/IM or Diazepam 0.2 mg/kg IV |
| 10-15 min | Repeat benzodiazepine if still seizing |
| 15-20 min | Phenytoin 20 mg/kg IV over 20 min OR Levetiracetam 40 mg/kg IV |
| >20 min | Consider RSI and ICU |
Buccal midazolam dose (no IV access) is 0.3 mg/kg.
Source: RCH Clinical Practice Guidelines (seizures/status epilepticus); local paediatric guideline.
Rectal diazepam dose (no IV access) is 0.5 mg/kg.
Source: RCH Clinical Practice Guidelines (seizures/status epilepticus); local paediatric guideline.
Common Rashes in Emergencies
Meningococcal Septicaemia
Clinical Features:
- Non-blanching petechial or purpuric rash
- May start as blanching maculopapular rash
- Rapid deterioration
- Shock (tachycardia, poor perfusion, hypotension)
- Altered consciousness
Petechial rash + unwell child = Meningococcal disease until proven otherwise. Give IV/IM benzylpenicillin or ceftriaxone immediately. Do not delay for LP.
Differentiating Petechiae:
| Concerning | Less Concerning |
|---|---|
| Spreading | Static |
| Associated with fever and unwellness | Well child |
| Below nipple line | Above nipple line only (pressure from vomiting/coughing) |
| Purpuric (larger, darker) | Pinpoint only |
[[anaphylaxis|Anaphylaxis]] in Children
Recognition: Acute onset (minutes to hours) of:
- Skin/mucosal involvement (urticaria, angioedema) AND
- Respiratory compromise OR cardiovascular compromise
Adrenaline Doses (IM):
| Age | Dose (1:1000) |
|---|---|
| <6 months | 0.05 mL (50 mcg) |
| 6 months-6 years | 0.15 mL (150 mcg) |
| 6-12 years | 0.3 mL (300 mcg) |
| >12 years | 0.5 mL (500 mcg) |
Management:
- Remove trigger if possible
- IM adrenaline (anterolateral thigh)
- Lie flat with legs elevated (unless respiratory distress)
- High-flow oxygen
- IV fluids 20 mL/kg if hypotensive
- Repeat adrenaline every 5 minutes if no improvement
- Antihistamines and steroids (not first-line, for symptom relief)
Sources
- ANZCOR paediatric life support guidance
- APLS
- RCH Clinical Practice Guidelines (common paediatric emergencies)
- ASCIA anaphylaxis guidelines