What are the immediate steps for managing pediatric emergency cases, including respiratory distress, cardiac emergencies, anaphylaxis, and seizures in children?

Managing Pediatric Emergency Cases

In pediatric emergencies, immediately verify scene safety, assess responsiveness, activate emergency services, and simultaneously check for breathing and pulse within 10 seconds—then proceed with condition-specific interventions prioritizing airway, breathing, and circulation in that order. 1

Initial Assessment (First 10 Seconds)

• Verify scene safety before approaching to avoid becoming a second victim 1, 2
• Check responsiveness by shouting and tapping the child 1, 2
• Activate emergency response system immediately (or send someone if multiple rescuers present) 1
• Simultaneously assess breathing and pulse within 10 seconds—look for no breathing or only gasping while checking for a pulse 1

Cardiac Emergencies and CPR

When to Start CPR

Start CPR immediately if the child has no pulse, no breathing (or only gasping), OR if heart rate is <60/min with signs of poor perfusion. 3 This heart rate threshold is critical because bradycardia at this level compromises cardiac output and tissue perfusion. 3

CPR Technique

Compression depth: At least one-third of the anterior-posterior diameter of the chest (approximately 1.5 inches/4 cm in infants, 2 inches/5 cm in children) 1, 3

Compression rate: 100-120 compressions per minute with complete chest recoil after each compression 1, 3

Compression-to-ventilation ratio: 1, 3

• Single rescuer: 30 compressions to 2 breaths
• Two or more rescuers: 15 compressions to 2 breaths

Critical pitfall: Allow complete chest recoil between compressions—incomplete recoil prevents cardiac refilling and is a critical error. 2 Do not lean on the chest between compressions. 2

Defibrillation

• Use AED as soon as available—do not delay CPR to retrieve it, but apply immediately once present 1, 2
• Check rhythm every 2 minutes during CPR 2
• If shockable rhythm (VF/pulseless VT): give 1 shock, then immediately resume CPR for 2 minutes before rechecking rhythm 1, 2
• If non-shockable rhythm: continue CPR 1

Medications During Cardiac Arrest

Epinephrine: 0.01 mg/kg IV/IO (0.1 mL/kg of 0.1 mg/mL concentration), maximum 1 mg per dose, repeat every 3-5 minutes 1, 2

Amiodarone: 5 mg/kg IV/IO bolus for refractory VF/pulseless VT, may repeat up to 3 total doses 1, 2

Lidocaine: Initial 1 mg/kg IV/IO loading dose (use only if amiodarone unavailable) 1, 2

Critical pitfall: Do not delay CPR for medication administration—continuous compressions are essential for survival. 2

Respiratory Distress

Recognition of Severe Asthma in Children

Life-threatening features: 1

• PEF <33% predicted or best
• Poor respiratory effort
• Cyanosis, silent chest, fatigue or exhaustion
• Agitation or reduced level of consciousness

Acute severe asthma indicators: 1

• Too breathless to talk or feed
• Respirations >50 breaths/min
• Pulse >140 beats/min
• PEF <50% predicted

Immediate Treatment for Severe Asthma

First-line interventions (administer simultaneously): 1

• High-flow oxygen via face mask (maintain SaO2 >92%)
• Salbutamol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer (half doses in very young children)
• Intravenous hydrocortisone immediately
• Add ipratropium 100 mcg nebulized every 6 hours

If life-threatening features present: Give IV aminophylline 5 mg/kg over 20 minutes followed by 1 mg/kg/h maintenance infusion (omit loading dose if already receiving oral theophyllines) 1

Subsequent Management

If improving after 15-30 minutes: 1

• Continue high-flow oxygen
• Prednisolone 1-2 mg/kg daily (maximum 40 mg)
• Nebulized β-agonist every 4 hours

If NOT improving after 15-30 minutes: 1

• Continue oxygen and steroids
• Give nebulized β-agonist more frequently (up to every 30 minutes)
• Add ipratropium to nebulizer, repeat every 6 hours until improvement

Transfer to ICU Criteria

Transfer accompanied by physician prepared to intubate if: 1

• Deteriorating PEF or worsening exhaustion
• Feeble respirations, persistent hypoxia or hypercapnia
• Coma, respiratory arrest, confusion, or drowsiness

Seizures

Initial Management

Immediate actions during active seizure: 4

• Verify scene safety and assess responsiveness 4
• Activate emergency response system 4
• Check airway, breathing, and circulation 4

If not breathing normally but has pulse: Provide rescue breathing at 1 breath every 2-3 seconds (20-30 breaths/min) 4

If heart rate <60/min with poor perfusion: Initiate CPR immediately 4

If breathing normally with pulse: Monitor until emergency team arrives 4

Pharmacological Treatment

Benzodiazepines are first-line treatment for seizure crisis, though specific dosing details should follow local protocols. 4 Midazolam IV requires careful titration with continuous monitoring for respiratory depression. 5

Critical warnings for midazolam use: 5

• Ensure immediate availability of oxygen, resuscitative drugs, age-appropriate bag/valve/mask equipment, and skilled personnel for airway management
• Continuously monitor for hypoventilation, airway obstruction, or apnea
• Have flumazenil (reversal agent) immediately available
• Titrate slowly over at least 2 minutes, allowing 2+ minutes to evaluate sedative effect
• Risk of respiratory depression increases with concomitant opioids or CNS depressants

Anaphylaxis

Epinephrine is recommended in all anaphylaxis protocols and should be administered immediately. 6 While specific dosing wasn't detailed in the provided guidelines, epinephrine remains the cornerstone of anaphylaxis management with high agreement across protocols. 6

Steroids: 56% of state protocols recommend steroid use in anaphylaxis, though route and specific agent vary. 6

Special Considerations

Trauma

ABCDE sequence for primary survey: 7

• A: Establish patent airway with cervical spine immobilization
• B: Evaluate breathing, ventilation, oxygenation; treat tension pneumothorax, open pneumothorax, massive hemothorax immediately
• C: Evaluate and treat circulatory compromise and shock
• D: Assess for increased intracranial pressure and impending cerebral herniation
• E: Expose while preventing hypothermia

Post-Resuscitation Care

Induced hypothermia (32-34°C for 12-24 hours) may be considered if the child remains comatose after resuscitation. 8

Continue monitoring: Vital signs, oxygen saturation, and neurologic status throughout recovery period. 5

Common Pitfalls to Avoid

• Do not delay CPR for any reason when heart rate <60/min with poor perfusion—delays worsen outcomes 3
• Do not perform prolonged pulse checks—if uncertain after 10 seconds, start CPR 2
• Do not provide inadequate compression depth or rate—compressions must be hard and fast to be effective 2
• Do not use sedatives in severe asthma to exclude pneumothorax 1
• Do not give high-dose epinephrine routinely in cardiac arrest 8