Initial Management Steps for Common Pediatric Emergencies
The initial management of common pediatric emergencies should focus on respiratory distress, seizures, and psychiatric/behavioral emergencies, as these represent the most frequent life-threatening conditions requiring prompt intervention in ambulatory settings. 1
Respiratory Emergencies
Respiratory emergencies are the most common reason parents seek emergency care for children and represent the leading cause of cardiopulmonary arrest in pediatric patients 2. Initial management includes:
Respiratory Distress/Asthma Exacerbation:
- Immediate interventions:
- Position patient upright to optimize respiratory mechanics
- Administer supplemental oxygen to maintain SpO2 > 94%
- Give inhaled short-acting beta-agonists (albuterol) via nebulizer or metered-dose inhaler with spacer 2, 1
- Consider systemic corticosteroids for moderate to severe exacerbations
- Monitor vital signs continuously
Foreign Body Aspiration:
- For conscious child with partial obstruction:
- Allow child to maintain position of comfort
- Administer oxygen
- Transport immediately to emergency facility
- For complete obstruction:
- Perform age-appropriate airway clearance maneuvers (back blows/chest thrusts for infants, abdominal thrusts for children)
- Proceed to basic life support algorithm if patient becomes unresponsive
Seizure Management
Seizures represent one of the top three pediatric emergencies encountered in ambulatory settings 1:
- Initial steps:
- Position patient on side to prevent aspiration
- Clear area of hazardous objects
- Do not restrain or place objects in mouth
- Administer benzodiazepines if seizure persists beyond 5 minutes:
- Buccal midazolam (0.2-0.5 mg/kg)
- Rectal diazepam (0.2-0.5 mg/kg)
- IV/IO lorazepam (0.1 mg/kg) if vascular access available
- Monitor vital signs and oxygen saturation
- Prepare for potential respiratory depression after benzodiazepine administration
Psychiatric/Behavioral Emergencies
Psychiatric and behavioral emergencies are increasingly common in pediatric ambulatory settings 1, 3:
- For acute agitation/aggression:
- Ensure safety of patient and staff
- Use verbal de-escalation techniques
- Consider chemical restraint only if necessary for patient safety
- Rule out medical causes of altered mental status (hypoglycemia, toxidrome, head injury)
- Arrange appropriate psychiatric evaluation and disposition
General Approach to Pediatric Emergencies
Essential Equipment and Medications
Ambulatory practices should maintain:
- Oxygen delivery systems (nasal cannula, non-rebreather mask)
- Bag-valve-mask devices in appropriate sizes
- Airway adjuncts
- Intraosseous access devices (easier alternative to IV access in emergencies) 4
- Emergency medications (albuterol, epinephrine, anticonvulsants)
- Length-based resuscitation tape or precalculated drug-dosing charts 4
Weight Estimation
Use length-based tools (Broselow tape) or age-based formulas to estimate weight for medication dosing:
- Weight (kg) = (Age in years + 4) × 2
Common Pitfalls and Caveats
Medication dosing errors: Use precalculated drug-dosing charts and double-check all emergency medication doses 4
Delayed recognition of respiratory failure: Monitor for signs of impending respiratory failure (increased work of breathing, decreased mental status, inability to maintain adequate oxygenation) rather than waiting for desaturation
Inadequate preparation: Office practices are often underprepared for pediatric emergencies, with studies showing average preparedness scores of only 53.7 out of a possible 156 5
Failure to recognize psychiatric presentations of medical conditions: Always consider organic causes of altered mental status or behavioral changes before attributing to psychiatric causes 3
Parental presence management: Have a designated staff member support and inform parents during emergency management 4
Regular simulation training and implementation of standardized protocols are essential to improve outcomes in these rare but critical events 4.