Managing Pediatric Emergencies

1. What is the child's age and weight? (Default: if weight unknown, use Broselow tape or age-based estimation: weight in kg = (age × 2) + 8 for ages 1-10)
2. What are the presenting symptoms and duration? (Default: document with caregiver as historian)
3. What are the vital signs? (Default: compare against age-adjusted normal ranges)
4. What is the child's immunization status? (Default: query and document)
5. What is the child's medication and allergy history? (Default: query caregiver and document)
6. Who is the legal guardian present and is consent available? (Default: document legal guardian identity)
7. Are there any chronic medical conditions or special healthcare needs? (Default: query for technology dependence — tracheostomy, VP shunt, G-tube, home ventilator)
8. What is the child's birth history if <1 year? (Default: gestational age, birth weight, NICU course)

Documents to Request

• Growth chart and prior weight measurements
• Immunization records
• Medication list and known allergies
• Prior ED visit records
• Subspecialist notes for children with complex medical conditions
• School health plan or emergency care plan if applicable

Step 1: Age-Adjusted Vital Sign Assessment

Normal Pediatric Vital Sign Ranges

Minimum acceptable SBP by age: SBP = 70 + (age in years × 2) for ages 1-10. SBP <90 for age >10.

Pediatric Assessment Triangle (PAT)

Rapid across-the-room assessment before touching the child:

• Appearance: Tone, interactiveness, consolability, look/gaze, speech/cry (TICLS mnemonic)
• Work of Breathing: Nasal flaring, retractions, tripoding, head bobbing, audible sounds
• Circulation to Skin: Pallor, mottling, cyanosis

Step 2: Weight-Based Medication Dosing

Critical Emergency Medications (weight-based)

Fluid Resuscitation

• Initial bolus: 20 mL/kg isotonic crystalloid (NS or LR) over 5-20 minutes
• Reassess after each bolus: heart rate, capillary refill, mental status, blood pressure
• Repeat up to 60 mL/kg in the first hour for septic shock
• If no improvement after 40-60 mL/kg: initiate vasopressor support (epinephrine or norepinephrine)

Step 3: Pediatric Resuscitation (PALS Framework)

Cardiac Arrest Algorithm

Shockable rhythms (VF / pulseless VT):

1. CPR 2 min → rhythm check
2. Defibrillation: 2 J/kg (1st), 4 J/kg (2nd and subsequent)
3. Epinephrine 0.01 mg/kg IV/IO every 3-5 min
4. Amiodarone 5 mg/kg IV/IO (after 3rd shock)
5. Continue CPR cycles; address reversible causes (Hs and Ts)

Non-shockable rhythms (asystole / PEA):

1. CPR 2 min → rhythm check
2. Epinephrine 0.01 mg/kg IV/IO every 3-5 min
3. Address reversible causes (Hs and Ts)

Hs and Ts (Reversible Causes)

• Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/hyperkalemia, Hypothermia, Hypoglycemia
• Tension pneumothorax, Tamponade, Toxins, Thrombosis (PE/coronary)

Equipment Sizing by Broselow Color Zone

Step 4: Common Pediatric Emergency Presentations

Fever Without Source (Age-Based Approach)

Pediatric Status Epilepticus Protocol

1. 0-5 min: Stabilize (ABCs, glucose, oxygen); benzodiazepine first-line
2. 5 min: Midazolam 0.2 mg/kg IM/IN or lorazepam 0.1 mg/kg IV (max 4 mg)
3. 10 min: Repeat benzodiazepine once if still seizing
4. 15-20 min: Second-line: fosphenytoin 20 mg PE/kg IV or levetiracetam 40-60 mg/kg IV or valproate 20-40 mg/kg IV
5. >30 min: Refractory status epilepticus — consider continuous infusion (midazolam, pentobarbital) and ICU admission

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Was the child's weight accurately determined (measured, Broselow, or age-based estimate) and documented?
2. Were all medication doses calculated per kilogram with maximum doses verified?
3. Were vital signs compared against age-adjusted normal ranges?
4. Were age-specific protocols applied (neonatal fever workup, Broselow equipment sizing)?
5. Was the legal guardian identified and informed consent documented?

Quality Audit

• Weight documented in kilograms (measured or estimated with method stated)
• Vital signs compared to age-adjusted normal ranges
• PAT (Pediatric Assessment Triangle) assessed and documented
• All medication doses calculated per kg with max dose cap verified
• Epinephrine concentration specified (1:10,000 IV vs. 1:1,000 IM)
• Fluid resuscitation documented as mL/kg with reassessment after each bolus
• Equipment sizes appropriate for weight/Broselow zone
• Age-specific protocols applied (neonatal fever workup, pediatric sepsis, status epilepticus)
• Immunization status documented
• Caregiver/guardian identified and consent documented
• Child abuse screening performed per institutional protocol (bruising in non-mobile children, patterned injuries, inconsistent history)
• Pain assessment using age-appropriate tool (FLACC <3 years, Wong-Baker 3-7, NRS >7)
• Disposition includes specific pediatric follow-up instructions and return precautions

Guidelines

1. Always weigh children in kilograms — never estimate when a scale is available. Kilogram-only scales prevent the lb/kg conversion errors that account for the majority of 10-fold dosing mistakes.
2. Use the Broselow tape for all children where actual weight is unknown — tape-based weight estimation is accurate within 10-20% for the majority of children and is far safer than ad hoc guessing.
3. Never administer D50W (50% dextrose) to children under 8 years — use D10W (5 mL/kg) for neonates and infants, D25W (2 mL/kg) for children 1-8 years.
4. All febrile neonates (≤28 days) require full sepsis workup including lumbar puncture and empiric antibiotics — do not discharge pending cultures regardless of appearance.
5. Verify the concentration of epinephrine before every administration — 1:10,000 (0.1 mg/mL) for IV cardiac arrest, 1:1,000 (1 mg/mL) for IM anaphylaxis. Concentration confusion is one of the most lethal medication errors in pediatrics.
6. Apply the Pediatric Assessment Triangle before touching the child — this 30-second across-the-room assessment provides more prognostic information than vital signs alone.
7. Screen for child abuse in all pediatric injury presentations — bruising in non-mobile infants (pre-cruising age), patterned injuries, and history inconsistent with developmental stage require mandatory reporting.
8. Involve parents/caregivers in resuscitation decisions and allow family presence during resuscitation when supported by institutional policy — family presence is endorsed by AHA and AAP.