What are the management strategies for common pediatric emergencies, including respiratory distress, cardiac arrest, severe injuries, seizures, anaphylaxis, and severe infections, in children?

Management of Common Pediatric Emergencies

Pediatric emergencies require immediate recognition and aggressive treatment of respiratory or cardiac insufficiency to prevent progression to cardiac arrest, which is the key to improving survival without neurological deficit. 1

Initial Assessment and Stabilization

Airway and Breathing Management

• Begin with face mask oxygen or high-flow nasal cannula oxygen for respiratory distress and hypoxemia, escalating to nasopharyngeal CPAP if needed before considering mechanical ventilation. 1
• Establish peripheral intravenous or intraosseous access for fluid resuscitation and medication administration when central access is unavailable. 1
• Perform cardiovascular resuscitation before intubation to minimize cardiovascular instability during the procedure. 1
• Never perform blind finger sweeps of the pharynx, as these can impact a foreign body in the larynx. 1, 2

Circulation Assessment

Target these specific resuscitation endpoints: 1

• Capillary refill ≤2 seconds
• Normal blood pressure for age
• Equal peripheral and central pulses
• Warm extremities
• Urine output ≥1 mL/kg/hour
• Normal mental status
• ScvO2 ≥70% with cardiac index 3.3-6.0 L/min/m²

Respiratory Emergencies

Foreign Body Aspiration/Choking

For witnessed choking with visible obstruction, deliver 5 back blows followed by 5 chest thrusts in infants, checking the mouth between cycles. 1

• Hold infants prone along your forearm with head lower than chest for back blows. 1
• Use chest thrusts (not abdominal thrusts) in infants under 1 year to avoid visceral rupture. 1
• In children over 1 year, substitute abdominal thrusts for chest thrusts after the second round of back blows. 1
• If foreign body aspiration is suspected based on witnessed choking, proceed directly to imaging and possible bronchoscopy regardless of current symptoms, as normal chest X-ray does NOT exclude aspiration. 2

Severe Asthma/Respiratory Distress

• Initiate oxygen therapy immediately via face mask or high-flow nasal cannula. 1
• Respiratory failure is the most common cause of cardiopulmonary arrest in pediatric patients, making prompt recognition critical. 3

Cardiac Arrest Management

Follow ACCM-PALS guidelines with chest compressions at 100/minute and 5:1 compression-to-ventilation ratio regardless of number of rescuers. 1

Key Differences from Adult Resuscitation

• Pediatric cardiac arrest is primarily respiratory in origin (hypoxia causing bradycardia/asystole), not primary cardiac events. 1, 4
• Cardiac arrest is defined as absence of central pulse or signs of circulation, OR heart rate <60/min in an unresponsive child with poor perfusion. 4
• Compression depth should be one-third of chest diameter. 1

Defibrillation

• Start with 0.5-1 J/kg for cardioversion; if unsuccessful, increase to 2 J/kg. 1

Refractory Shock

Evaluate for and reverse pneumothorax, pericardial tamponade, or endocrine emergencies (hypoadrenalism, hypothyroidism) in patients with shock unresponsive to initial resuscitation. 1

Septic Shock

Fluid Resuscitation

Administer isotonic crystalloids or albumin in 20 mL/kg boluses over 5-10 minutes, titrated to reverse hypotension and restore perfusion without inducing hepatomegaly or rales. 1

• If hepatomegaly or rales develop, initiate inotropic support rather than additional fluids. 1
• In non-hypotensive children with severe hemolytic anemia (malaria, sickle cell), blood transfusion is superior to crystalloid bolusing. 1

Antibiotics and Source Control

Administer empiric antibiotics within 1 hour of identifying severe sepsis, obtaining blood cultures first when possible but never delaying antibiotics. 1

• Add clindamycin and anti-toxin therapies for toxic shock syndromes with refractory hypotension. 1
• Pursue early and aggressive source control. 1
• Avoid etomidate in pediatric patients with septic shock despite its minimal hemodynamic effects. 1

Inotropic Support

Begin peripheral inotropic support immediately in children unresponsive to fluid resuscitation while establishing central venous access. 1

Seizures

• Assess for tonic eye deviation, nystagmus, tonic-clonic movements, or infantile spasms during the event. 2
• Obtain family history of sudden unexplained death before age 35 to evaluate for cardiac arrhythmia/Long QT syndrome. 2

Anaphylaxis

• Immediate recognition and treatment are critical for survival. 5
• Follow standard anaphylaxis protocols with epinephrine as first-line therapy. 5

Trauma Management

Do not routinely hyperventilate even in head injury cases. 1

• Insert orogastric (not nasogastric) tubes in patients with maxillofacial trauma or suspected basilar skull fracture. 1
• Maintain high suspicion for child abuse in trauma cases, using screening protocols for early detection. 1
• Consider resuscitative thoracotomy only in highly select circumstances of penetrating trauma with short transport times. 1

Common Pitfalls to Avoid

• Do not be falsely reassured by normal vital signs or radiographs when clinical history suggests serious pathology (e.g., foreign body aspiration). 2
• Do not delay antibiotics to obtain cultures in septic shock. 1
• Avoid blind finger sweeps in choking patients. 1, 2
• Do not use abdominal thrusts in infants under 1 year. 1
• Never hyperventilate trauma patients routinely. 1

Mental Health Emergencies

Pediatric mental health emergencies require a multidisciplinary team approach with specialized screening tools and pediatric-trained mental health consultants. 1

• Maintain confidentiality for adolescents seeking mental health care unless they pose harm risk to self or others. 1
• Address emotional trauma promptly with culturally appropriate, pediatric-specific stress intervention in the initial hours after trauma. 1