⚡ Pediatric Emergency & Critical Care
Mnemonics · Diagnostics · Treatment

High-yield review for EM, CC, Anesthesia — based on Nelson Textbook of Pediatrics. Screening, diagnostic tools, and most accurate treatments + memorable mnemonics.

📚 Rapid recall | 🧠 Clinician‑friendly | 🚨 Resuscitation focus

🚨 Triage of Acutely Ill Child (Chapter 78)

🔍 Screening & Key clues

ESI (Emergency Severity Index) level 1-5.
Red flags: GCS ≤14, bulging fontanelle, petechiae, toxic appearance.
ABC primary survey.

🧪 Diagnostic tests

Bedside glucose, pulse ox, blood gas (if shock/resp failure), lactate, rapid viral testing. CXR for respiratory distress.
Capnography for intubated.

💊 Most accurate treatment

Prioritize airway (jaw thrust) → 100% O2 → vascular access → fluid bolus (20 mL/kg). Treat underlying cause.
Septic shock: antibiotics & fluids.

📌 Mnemonic: “ABCDE”
A: Airway + C-spine → B: Breathing (O2) → C: Circulation (IV/IO, fluids) → D: Disability (GCS, glucose) → E: Exposure (full exam, temp).
🧠 Recall: “PECARN” for head CT
Children <2y: no AMS, no scalp hematoma, normal behavior → very low risk.

🫀 Pediatric Cardiorespiratory Emergencies & Resuscitation (Ch 79)

🫁 Screening

Pulse oximetry, capnography, blood gas. Identify respiratory distress (stridor, wheezing, grunting).
Lactate, bedside US for shock.

🧪 Diagnostics

ECG (arrhythmia, ischemia), chest X‑ray, troponin (myocarditis).
Post‑arrest: EEG, head CT.

💊 Treatment (PALS 2020)

High‑quality CPR (100‑120/min, depth 1/3 AP), epinephrine 0.01 mg/kg IV/IO q3‑5min. Defibrillation 2 J/kg → 4 J/kg.
Post‑arrest: target normothermia (36‑37.5°C).

⚡ “LEAN” for post‑arrest
L: Lactate clearance, E: Euvolemia, A: Avoid hyperoxia (SpO2 94‑99%), N: Normothermia.
🧠 “Hs & Ts”
Hypovolemia, Hypoxia, H+ (acidosis), Hypo/hyperkalemia, Hypothermia; Tension pneumothorax, Tamponade, Toxins, Thrombosis.

🩻 Acute Care of Multiple Trauma (Ch 80)

🔎 Screening (Field triage)

GCS, SBP, RR, mechanism (ejection, rollover, pedestrian).
FAST exam for free fluid.

🧪 Diagnostics

Trauma pan‑scan (CT head, C‑spine, chest/abdomen/pelvis).
NEXUS criteria to clear C‑spine. FAST, eFAST for pneumothorax.

💊 Treatment (ATLS)

Primary survey ABCDE. Hemorrhagic shock: 20 mL/kg crystalloid, massive transfusion (1:1:1).
Needle decompression for tension pneumothorax.

📌 “NEXUS” C‑spine
No midline tenderness, No intoxication, Normal alertness, No focal deficit, No distracting injury → can clear collar.
🚨 “AMPLE” history
A: Allergies, M: Meds, P: Past medical, L: Last meal, E: Events.

🧬 Spinal Cord Injuries (Ch 81)

🦴 Screening

C‑spine immobilization in trauma. NEXUS criteria. Neurologic deficit → suspect SCIWORA.

🧪 Diagnostics

Plain radiographs + CT for bony injury. MRI for SCIWORA or ligamentous injury.

💊 Treatment

Maintain mean arterial pressure (MAP 85‑90 mmHg adolescent).
Spinal cord injury: avoid hypotension; methylprednisolone NOT routinely recommended.

🧠 “SCIWORA”
Spinal Cord Injury Without Radiographic Abnormality → MRI essential.
📌 Neurogenic shock = hypotension + bradycardia
Treat with fluids + norepinephrine.

🧠 Neurologic Emergencies & Stabilization (Ch 82)

🧠 Screening

GCS, pupils, Cushing triad (HTN + bradycardia + irregular breathing).
Vital signs, rapid glucose.

🧪 Diagnostics

Non‑contrast head CT (bleeding, mass effect), MRI for axonal injury, ICP monitor (EVD).

💊 Treatment (TBI tiers)

First‑tier: HOB 30°, sedation, hypertonic saline (3%) 2‑5 mL/kg. Second‑tier: pentobarbital, decompressive craniectomy.

💡 “CUSHING” (heralding herniation)
C: Cushings triad (HTN, brady, irregular resp).
U: urgent hyperventilation + hypertonic saline.
⚙️ CPP = MAP – ICP
Target CPP: 2‑6y ≥50, 7‑10y ≥55, 11‑16y ≥65 mmHg.

📄 Brain Death: Death by Neurologic Criteria (Ch 83)

📋 Screening

Irreversible coma, absent brainstem reflexes, apnea test prerequisite (normothermia, no drugs).

🧪 Diagnostics

Apnea test (PaCO2 ≥60 mmHg above baseline). Ancillary: EEG (electrocerebral silence), radionuclide CBF (no perfusion).

⚖️ Most accurate declaration

Two exams (separate physicians), inter‑exam interval: 12 h (>2y) / 24 h (infants).
Confirm with apnea test +/− ancillary.

🧠 “BRAN” – Brain death reflexes
Brainstem: pupils, Corneal, Oculocephalic, Gag/Cough, Apnea.
📌 No confounders: “WARM”
W: euvolemia, A: no anesthesia/sedation, R: normothermia (>36°C), M: Metabolic normal.

❤️ Syncope & Postural Tachycardia (Ch 84)

🩺 Screening

History (prodrome, triggers, exercise), family history of sudden death, orthostatic vitals.

🧪 Diagnostics

12‑lead ECG (must), echocardiogram (HCM, structural), tilt‑table test, Holter.

💊 Treatment

Vasovagal: fluids, salt, counterpressure maneuvers. POTS: exercise, fludrocortisone/midodrine.
Cardiac syncope (LQTS, HCM): beta‑blocker, ICD.

🚩 “RED FLAGS” cardiac syncope
R: during exercise, E: Ejection murmur, D: drowning family history, F: Family sudden death.
⚡ POTS = HR ↑>40 standing, no hypotension
Treatment: “FISH” – Fluids, Increase salt, Strength training (recumbent), Heat avoidance.

🩸 Shock & Septic Shock (Ch 85)

⚠️ Screening

Tachycardia, poor perfusion, delayed cap refill, altered mental status. Hypotension = late.

🧪 Diagnostics

Lactate (>2 mmol/L), blood gas, ScvO2, cultures. Phoenix Sepsis Score ≥2.

💊 Treatment (SSC 2020)

Fluid bolus 20 mL/kg (up to 60 mL/kg), 1‑hour bundle: antibiotics, lactate, fluids. Vasoactive: epinephrine (cold) / norepinephrine (warm).

💊 “COLD vs WARM” shock
Cold (cool ext, delayed cap refill) → Epinephrine.
Warm (flushed, bounding) → Norepinephrine.
📌 “HDIE” for CCB/BB overdose
High‑Dose Insulin Euglycemia: 1 unit/kg bolus, infusion 1‑10 u/kg/hr.

🌬️ Acute Respiratory Distress & Failure (Ch 86)

🫁 Screening

Stridor (upper airway), wheezing (lower), grunting (parenchymal), SpO2, work of breathing.

🧪 Diagnostics

ABG/VBG, CXR, capnography, P/F ratio. PARDS criteria.

💊 Treatment

Oxygen (HFNC, CPAP), bronchodilators (asthma), racemic epinephrine (croup). Intubation for failure. Lung‑protective (low Vt, PEEP).

🎯 “PEEP” – for ARDS
Prevent atelectrauma. Use PEEP ≥5, target plateau <30.
🧪 “LEARN” capnography
Low EtCO2 = hyperventilation, High = hypoventilation, sudden drop = dislodgement.

🏔️ Altitude Illness (Ch 87)

🧗 Screening

Headache, nausea, dizziness, Lake Louise Score. Ataxia = HACE.

🧪 Diagnostics

Clinical diagnosis. Pulse oximetry (hypoxia), CXR (HAPE: patchy edema).

💊 Treatment

Descent, oxygen. AMS: acetazolamide 2.5 mg/kg q12h; HACE: dexamethasone 0.15 mg/kg; HAPE: nifedipine/amlodipine.

🏔️ “HACE” & “HAPE”
HACE: Headache, Ataxia, Confusion → Dexamethasone + descent.
HAPE: Hypoxia, Crackles → Oxygen + descent + nifedipine.

💧 Drowning & Submersion (Ch 88)

🏊 Screening

Submersion duration, need for CPR, GCS, pupils, hypothermia.

🧪 Diagnostics

ABG, CXR (aspiration, ARDS), lactate, core temperature.

💊 Treatment

Bystander CPR (2 rescue breaths first). Advanced airway, oxygen, active rewarming if hypothermic. Target normothermia (36‑37.5°C).

🚨 “SOAP” – drowning resusc
S: start with 2 rescue breaths, O: oxygenate, A: avoid hyperoxia post‑ROSC, P: prevent fever.
❄️ Hypothermic arrest
Defib once <30°C, hold subsequent shocks until >30°C.

🔥 Burn Injuries & Lightning (Ch 89)

🔥 Screening

%TBSA (Lund‑Browder), depth, inhalation injury (facial burns, soot).

🧪 Diagnostics

COHb, cyanide level, electrolytes, CXR (inhalation).

💊 Treatment

Parkland formula (4 mL/kg/%TBSA), escharotomy, topical antibiotics. Lightning: reverse triage, cardiac arrest often reversible.

⚡ Parkland: “4-2-4”
4mL x kg x %TBSA (LR), half over first 8 hours from burn time.
⚡ Lightning “LICHT”
Lichtenberg figures, I: Immediate CPR, C: Cardiac arrest treat first, H: Hyperthermia, T: Tympanic rupture.

❄️ Cold Injuries (Ch 90)

🧊 Screening

Core temp (<35°C hypothermia), frostbite classification.

🧪 Diagnostics

ECG (Osborne J wave), coagulation, lactate.

💊 Treatment

Rewarming: active external (mild) / internal (severe). Frostbite: 37‑39°C water bath, ibuprofen, tPA in severe.

❄️ “J wave” hypothermia
Osborne wave (J point deflection).
CPR modifications: double epinephrine interval.
🩺 Chilblains (pernio)
Painful red toes after cold, damp exposure → self‑limited, topical steroids.

💉 Anesthesia & Procedural Sedation (Ch 91-92)

🩺 Screening

ASA status, NPO (2‑4‑6‑8), difficult airway predictors, MH history.

🧪 Monitoring

Pulse ox, capnography, ECG, NIBP, temperature.

💊 Sedation & Reversal

Propofol/ketamine for deep sedation. Reversal: naloxone (opioids), flumazenil (benzodiazepines), sugammadex (rocuronium).

⏱️ NPO “2‑4‑6‑8”
Clear liquids: 2h, breast milk: 4h, formula: 6h, solids: 8h.
🔥 MH: “DANTROLENE”
Dantrolene 2.5 mg/kg IV; avoid succinylcholine/volatiles.

🩺 Pediatric Pain Management (Ch 93)

📊 Assessment

FLACC (2m‑7y), FACES (3y+), NRS (7y+), revised FLACC for cognitive impairment.

💊 WHO Ladder

Step 1: acetaminophen/ibuprofen, step 2: weak opioid (avoid codeine), step 3: strong opioid.

🧠 Neuropathic pain

Gabapentin, pregabalin, amitriptyline, duloxetine (fibromyalgia). CRPS: aggressive PT + CBT.

📌 “FLACC”
Face, Legs, Activity, Cry, Consolability – score 0‑10.
⚠️ “NO CODEINE” <12y
Ultra‑rapid metabolizers → respiratory depression.

⚠️ Poisoning & Antidotes (Ch 94)

🧪 Screening

Anion gap, osmolar gap, ECG (QRS, QTc), acetaminophen level, salicylate level.

💊 Antidotes

Naloxone (opioids), NAC (APAP), fomepizole (methanol/EG), sodium bicarbonate (TCA, ASA), DigiFab (digoxin).

🩺 Toxidromes

Anticholinergic: hot/dry/dilated, Cholinergic: SLUDGE, Opioid: miosis + resp depression, Sympathomimetic: tachycardia + agitation.

🧪 MUDPILES (anion gap)
Methanol, Uremia, DKA, Paraldehyde, Iron/INH, Lactic acidosis, Ethylene glycol, Salicylates.
💊 TCA: “SODIUM BICARB”
1‑2 mEq/kg for wide QRS >100 ms.
Goal: QRS <100 ms, pH 7.45‑7.55.