What is the comprehensive initial assessment and management protocol for a pediatric emergency, covering airway, breathing, circulation, disability, exposure, and weight‑based treatments?

Pediatric Emergency Management Protocol

Initial Approach: Safety, Stimulation, and Help

Begin all pediatric emergencies with scene safety verification, gentle stimulation of the child (shaking or pinching), and immediately shouting for help—do not move the child unless in a dangerous location. 1

The ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure) provides the systematic framework for all pediatric emergencies, with airway assessment always occurring first. 1, 2

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A - Airway Assessment and Management

Opening the Airway

• Infants (<1 year): Use a neutral head position or place a rolled towel under the shoulders; avoid hyperextension as this can paradoxically obstruct the airway. 1
• Children (>1 year): Use head tilt-chin lift maneuver ("sniffing the morning air" position) or jaw thrust if trauma is suspected. 1
• All ages: Jaw thrust is often the most effective technique and should be used when cervical spine injury is possible. 1, 3

Airway Patency Assessment

Look, listen, and feel for airflow at the mouth/nose by: 1

• Looking for chest and abdominal movement
• Listening at the mouth and nose for breath sounds
• Feeling for expired air movement with your cheek

Foreign Body Obstruction (Choking)

If witnessed aspiration or strong suspicion of foreign body: 1

• Never perform blind finger sweeps of the pharynx—this can impact the foreign body into the larynx
• Back blows: Deliver 5 smart blows to the middle of the back with the child prone and head lower than chest (hold infant along forearm; older child across your thighs while kneeling)
• Chest thrusts: Follow with chest compressions in supine position if back blows unsuccessful

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B - Breathing Assessment and Support

Respiratory Distress Recognition

Critical signs requiring immediate intervention include: 1

• Respiratory rate >50 breaths/min in children
• Accessory muscle use, tracheal tug, intercostal/subcostal/sternal recession
• Grunting, stridor, or noisy breathing
• Inability to speak or feed due to breathlessness
• Cyanosis or oxygen saturation <92%

Rescue Breathing

If no spontaneous respiration detected: 1

• Deliver 5 initial breaths, each lasting 1-1.5 seconds
• Infants: Use mouth-to-mouth-and-nose technique 4
• Children: Use mouth-to-mouth technique only
• Maintain airway positioning throughout

Oxygen Therapy

• Deliver high-flow oxygen via face mask to all children with respiratory distress or emergency conditions 1
• Maintain oxygen saturation >92% using pulse oximetry 1

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C - Circulation Assessment and Support

Pulse Check (Within 10 Seconds)

• Infants: Check brachial pulse on inside of upper arm 1, 4
• Children: Check carotid or femoral pulse 3
• Critical threshold: Heart rate <60/min with poor perfusion requires CPR 3, 4

Chest Compressions Technique

Infants (<1 year): 1, 4

• Use 2-finger technique on lower third of sternum, one finger's breadth below nipple line
• Compress at least one-third of anterior-posterior chest diameter (~3 cm)
• Rate: 100-120 compressions/minute
• Single rescuer: 30:2 compression-to-ventilation ratio
• Two rescuers: 15:2 compression-to-ventilation ratio

Children (>1 year): 3

• Compress lower third of sternum
• Depth: at least one-third of anterior-posterior diameter (~5 cm)
• Rate: 100-120 compressions/minute
• Single rescuer: 30:2 ratio
• Two rescuers: 15:2 ratio

Critical CPR Principles

• Allow complete chest recoil between compressions 3, 4
• Minimize interruptions in compressions 3, 4
• Change compressor every 2 minutes or sooner if fatigued 3, 4
• Compression phase should occupy half the cycle and be smooth, not jerky 1

Defibrillation

• Apply AED as soon as available 3
• Shockable rhythms only: Ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) 3, 5
• Asystole is NOT shockable—resume CPR immediately without attempting shock 5
• If shockable rhythm: Deliver 1 shock, then immediately resume CPR for 2 minutes before rechecking rhythm 3

Medication Administration

Epinephrine (first-line for all cardiac arrest): 3, 4, 5

• Dose: 0.01 mg/kg IV/IO (0.1 mL/kg of 0.1 mg/mL concentration)
• Maximum single dose: 1 mg
• Repeat every 3-5 minutes
• Administer as soon as vascular access obtained

Refractory VF/Pulseless VT: 3

• Amiodarone: 5 mg/kg IV/IO bolus, OR
• Lidocaine: 1 mg/kg IV/IO loading dose

Do NOT use atropine in pediatric cardiac arrest—it is not evidence-based and delays appropriate epinephrine administration. 5

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D - Disability (Neurological Assessment)

Responsiveness Assessment

• Determine responsiveness by gentle shaking or pinching 1
• Assess level of consciousness: Alert, responsive to voice, responsive to pain, unresponsive 1
• Monitor for: Agitation, restlessness, confusion, drowsiness—these may indicate hypoxia or airway compromise 1

Life-Threatening Neurological Signs

• Reduced level of consciousness or coma 1
• Exhaustion or fatigue in context of respiratory distress 1
• Confusion or agitation (may indicate worsening hypoxia) 1

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E - Exposure and Environmental Control

• Fully expose the child to identify all injuries, bleeding, or rashes while maintaining body temperature 2
• Prevent hypothermia, especially in infants and during resuscitation 2

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Weight-Based Treatment Considerations

Emergency Medication Dosing

All emergency medications in pediatrics are weight-based (mg/kg), requiring accurate weight estimation if actual weight unknown: 3, 4, 5

• Use length-based tape (Broselow tape) for rapid weight estimation
• Have pre-calculated drug doses readily available
• Double-check all calculations before administration

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Activation of Emergency Services

After 1 minute of basic life support, activate emergency medical services: 1

• Carry infants/small children to telephone
• Provide child's approximate age to dispatcher
• Restart CPR immediately after calling and continue without interruption

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Condition-Specific Protocols

Acute Severe Asthma

Immediate treatment: 1

• High-flow oxygen via face mask
• Salbutamol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer (half doses in very young children)
• Add ipratropium 100 mcg nebulized every 6 hours
• Intravenous hydrocortisone or oral prednisolone 1-2 mg/kg daily (maximum 40 mg)

Life-threatening features requiring ICU transfer: 1

• Peak flow <33% predicted, poor respiratory effort
• Silent chest, cyanosis, fatigue/exhaustion
• Deteriorating despite treatment, persistent hypoxia/hypercapnia
• Confusion, drowsiness, coma, or respiratory arrest

If not improving after 15-30 minutes: 1

• Increase nebulized β-agonist frequency to every 30 minutes
• Consider IV aminophylline 5 mg/kg over 20 minutes, then 1 mg/kg/hour maintenance (omit loading dose if already on oral theophyllines)

Tracheostomy Emergencies

Initial "Safety, Stimulate, Shout" approach, then: 1

• Assess both native airway AND tracheostomy patency
• Attempt suction through tracheostomy tube
• If suction catheter does not pass or tube visibly displaced, proceed to emergency tube change
• Deliver high-flow oxygen to both face and tracheostomy site
• If bleeding present, address hemorrhage control while maintaining airway

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Critical Pitfalls to Avoid

• Never delay resuscitation waiting for equipment—begin immediately with available resources 1
• Never perform blind finger sweeps in suspected choking—this can worsen obstruction 1
• Never use atropine in pediatric cardiac arrest 5
• Never attempt defibrillation for asystole—this wastes time and delays effective CPR 5
• Never hyperextend infant necks—use neutral positioning 1
• Never allow inadequate compression depth—must be at least one-third of chest diameter 3, 4
• Never continue compressions beyond 2 minutes without rotating—fatigue compromises quality 3, 4