Chapter 36: Emergency Care

Pediatric resuscitation · Airway, Breathing, Circulation (ABC) · Shock recognition · Status epilepticus · Anaphylaxis · Diabetic ketoacidosis · Trauma · Sepsis · Toxic ingestion · Acute airway obstruction
🔥 Core principles: Early recognition of compensated shock, high-flow oxygen, vascular access, weight‑based drug dosing (Broselow). ABC – C spine control in trauma. Hypoglycemia and DKA management. Status epilepticus protocol (benzodiazepines, second‑line phenytoin/levetiracetam). Anaphylaxis IM adrenaline.

🚨 Summary: Pediatric Emergency Care – ABCDE, shock, seizures, DKA, anaphylaxis

🫁 ABCDE approach
Airway (patency), Breathing (oxygenation, ventilation), Circulation (perfusion, BP, pulses), Disability (GCS, pupils), Exposure (temperature, rashes, trauma).
⚠️ Shock recognition
Compensated: tachycardia, cool extremities, delayed capillary refill. Hypotensive: decreased BP, altered mental status. Septic, hypovolemic, cardiogenic.
🧠 Status epilepticus
Seizure >5 min or recurrent without recovery. 1st line: IV lorazepam (0.1 mg/kg) or buccal midazolam. 2nd line: IV phenytoin/levetiracetam. Refractory: phenobarbital, midazolam infusion.
🩸 Anaphylaxis
Rapid onset, respiratory compromise, hypotension, urticaria. IM adrenaline 0.01 mg/kg (1:1000). Adjuncts: oxygen, fluids, antihistamines, steroids.
📉 Diabetic ketoacidosis (DKA)
Fluid resuscitation (0.9% NaCl 10-20 mL/kg over 1h). Insulin infusion 0.05-0.1 U/kg/h, replace K+, monitor cerebral edema.
🧪 Toxic ingestion & Trauma
Activated charcoal within 1h for selected ingestions. Trauma: C‑spine immobilization, rapid sequence intubation, chest decompression for tension pneumothorax.
📊 Evidence-based pearls: Early IV/IO access, weight‑based epinephrine, use of Broselow tape. Fluid resuscitation in septic shock: 20 mL/kg boluses reassessing for hepatomegaly/rales. Avoid excessive fluids in DKA to reduce cerebral edema risk.

🔍 Clinical approach – emergency presentations

1
Acute respiratory distress / stridor – Assess airway patency, oxygen saturation. Croup (dexamethasone, nebulized adrenaline), anaphylaxis (IM adrenaline), foreign body (Heimlich if conscious, back blows <1y).
2
Altered mental status + fever – Meningitis? Encephalitis? Sepsis? ABC, blood glucose, IV antibiotics (ceftriaxone + ampicillin) after blood cultures. Lumbar puncture unless contraindicated (shock, focal signs, coagulopathy).
3
Shock (tachycardia, poor perfusion) – Identify type: hypovolemic (trauma, dehydration), distributive (sepsis, anaphylaxis), cardiogenic (heart failure). 20 mL/kg bolus crystalloid, reassess. Vasoactive support if fluid refractory.
4
Seizure >5 min (status epilepticus) – Airway, O2, IV access, blood glucose. Lorazepam IV (0.1 mg/kg) or midazolam IM/buccal. Second-line: phenytoin (20 mg/kg) or levetiracetam (60 mg/kg).
5
Poisoning / overdose – Stabilize ABC, identify substance (history, tox screen). Activated charcoal (1 g/kg) if recent ingestion and no airway compromise. Naloxone for opioid, flumazenil for benzodiazepine (caution in seizure risk).

📋 Stepwise management protocols (emergency)

1
Pediatric BLS/ALS algorithm – Check responsiveness, open airway (jaw thrust if trauma), look/listen/feel for breathing. No breathing → 15:2 compression:ventilation (2 rescuer 15:2, single rescuer 30:2). Depth 4 cm (infant 4 cm, child 5 cm). AED for >1 year.
2
Anaphylaxis management – IM adrenaline 0.01 mg/kg (max 0.5 mg) anterolateral thigh. High-flow oxygen, supine/legs elevated, repeat adrenaline every 5‑15 min. Adjuncts: IV fluid, nebulized salbutamol, chlorphenamine, hydrocortisone.
3
Diabetic ketoacidosis (DKA) protocol – Correct dehydration: 0.9% NaCl 10 mL/kg over 60 min (initial), then maintenance + deficit over 48h. Insulin infusion 0.05 U/kg/h (0.1 in older). Monitor K+, glucose, bicarbonate, ECG. Cerebral edema: mannitol 0.5 g/kg or hypertonic saline.
4
Trauma – primary survey (ATLS principles) – C‑spine immobilization, A (airway – cricoid pressure if needed), B (chest decompression for tension pneumothorax), C (control hemorrhage, pelvic binder, blood products), D (disability GCS), E (exposure, log roll).
5
Supraglottic airway/RSI in impending respiratory failure – Prepare for intubation: etomidate (0.3 mg/kg) + rocuronium (1 mg/kg). Post‑intubation sedation, confirm tube placement by capnography.
⚡ Key reminder: Weight-based drug doses (Broselow tape). Use intraosseous access if intravenous fails (especially <6 years). Do not delay adrenaline in anaphylaxis for IV access.

🧠 Quick reflex prompts – emergency care

🫀 First drug for status epilepticus?
Benzodiazepine: IV lorazepam 0.1 mg/kg, or buccal midazolam 0.2‑0.3 mg/kg.
💉 Dose of IM adrenaline in anaphylaxis (child)
0.01 mg/kg (1:1000) up to 0.3‑0.5 mg. Repeat every 5‑15 min.
📏 Initial fluid bolus for septic shock
20 mL/kg isotonic crystalloid (0.9% NaCl or Ringer's lactate). Reassess.
🧪 Most life‑threatening complication of DKA during treatment?
Cerebral edema – peak incidence 4‑12h after starting therapy. Prevent by slow fluid correction, avoid rapid glucose drop.
🦷 Choking infant (<1 year) – manoeuvre?
5 back blows (between scapulae) then 5 chest thrusts (two fingers, sternum).
⚡ In tension pneumothorax – immediate action?
Needle decompression (2nd intercostal space midclavicular line) or lateral 4th‑5th intercostal space (anterior axillary line).