managing-pediatric-emergencies

# Managing Pediatric Emergencies

Adapts emergency protocols for pediatric patients using weight-based dosing, age-adjusted vital sign norms, and the Broselow tape methodology for equipment sizing and medication dosing.

## Why This Skill Exists

Children are not small adults — their physiology, anatomy, pharmacokinetics, and disease presentations differ fundamentally from adults. Medication errors in pediatric emergency care occur at 3 times the rate of adult care, with dosing errors being the most common type. A 10-fold dosing error — the most dangerous medication error in pediatrics — occurs in approximately 1 in 1,000 pediatric ED visits and can be lethal with medications like epinephrine, insulin, and opioids.

The Broselow-Luten system provides length-based weight estimation and pre-calculated equipment sizes and drug doses. PALS (Pediatric Advanced Life Support) protocols from the AHA define resuscitation algorithms, and the Emergency Medical Services for Children (EMSC) program sets national standards for pediatric emergency readiness. Only 18% of US emergency departments meet all pediatric readiness standards, making systematic protocol adherence essential for safe pediatric emergency care.

---

## Checkpoint A: Pre-Draft Intake (Mandatory)

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

| Age | Heart Rate | Respiratory Rate | SBP (mmHg) | Weight (kg) |
|-----|-----------|-----------------|-------------|-------------|
| Newborn | 120-160 | 30-60 | 60-80 | 3-4 |
| 1-12 months | 100-160 | 25-40 | 70-100 | 4-10 |
| 1-3 years | 90-150 | 20-30 | 80-110 | 10-15 |
| 4-5 years | 80-140 | 20-25 | 85-110 | 16-20 |
| 6-12 years | 70-120 | 15-20 | 90-120 | 20-40 |
| 13-18 years | 60-100 | 12-20 | 100-130 | 40-70 |

**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

| PAT Result | Interpretation | Urgency |
|------------|---------------|---------|
| All normal | Stable | Continue systematic evaluation |
| Abnormal appearance only | CNS dysfunction or systemic illness | High priority |
| Abnormal breathing only | Respiratory distress | Immediate respiratory support |
| Abnormal appearance + breathing | Respiratory failure | Immediate intervention |
| Abnormal appearance + circulation | Compensated shock → decompensating | Immediate fluid resuscitation |
| All abnormal | Cardiopulmonary failure | Resuscitation team activation |

---

## Step 2: Weight-Based Medication Dosing

### Critical Emergency Medications (weight-based)

| Medication | Dose | Route | Max Single Dose | Notes |
|------------|------|-------|-----------------|-------|
| Epinephrine (cardiac arrest) | 0.01 mg/kg (0.1 mL/kg of 1:10,000) | IV/IO | 1 mg | NEVER use 1:1,000 concentration IV |
| Epinephrine (anaphylaxis) | 0.01 mg/kg (0.01 mL/kg of 1:1,000) | IM | 0.3 mg (<30 kg), 0.5 mg (≥30 kg) | Anterolateral thigh |
| Atropine | 0.02 mg/kg | IV/IO | 0.5 mg | Minimum dose 0.1 mg (below this may cause paradoxical bradycardia) |
| Amiodarone | 5 mg/kg | IV/IO | 300 mg | For VF/pulseless VT |
| Adenosine | 0.1 mg/kg (1st), 0.2 mg/kg (2nd) | Rapid IV push | 6 mg (1st), 12 mg (2nd) | Must be rapid push with flush |
| Dextrose | D10W: 5 mL/kg; D25W: 2 mL/kg | IV | — | D50 is NOT used in children <8 years |
| Diazepam (status epilepticus) | 0.2 mg/kg | IV; 0.5 mg/kg rectal | 10 mg IV; 20 mg rectal | Second-line after midazolam |
| Midazolam (status epilepticus) | 0.1 mg/kg IV; 0.2 mg/kg IM/IN | IV/IM/IN | 10 mg | First-line for active seizures |
| Ceftriaxone (meningitis) | 50 mg/kg | IV | 2 g | Do not delay for LP |

### 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)
- **H**ypovolemia, **H**ypoxia, **H**ydrogen ion (acidosis), **H**ypo/hyperkalemia, **H**ypothermia, **H**ypoglycemia
- **T**ension pneumothorax, **T**amponade, **T**oxins, **T**hrombosis (PE/coronary)

### Equipment Sizing by Broselow Color Zone

| Color | Weight (kg) | ETT (uncuffed) | ETT (cuffed) | Laryngoscope | NG Tube |
|-------|------------|----------------|--------------|--------------|---------|
| Grey | 3-5 | 3.5 | 3.0 | Miller 1 | 8 Fr |
| Pink | 6-7 | 3.5-4.0 | 3.0-3.5 | Miller 1 | 8 Fr |
| Red | 8-9 | 4.0 | 3.5 | Miller 1-2 | 10 Fr |
| Purple | 10-11 | 4.5 | 4.0 | Miller 2 | 10 Fr |
| Yellow | 12-14 | 5.0 | 4.5 | Mac 2 | 12 Fr |
| White | 15-18 | 5.5 | 5.0 | Mac 2 | 12 Fr |
| Blue | 19-23 | 6.0 | 5.5 | Mac 2 | 14 Fr |
| Orange | 24-29 | 6.5 | 6.0 | Mac 3 | 14 Fr |
| Green | 30-36 | 7.0 | 6.5 | Mac 3 | 16 Fr |

---

## Step 4: Common Pediatric Emergency Presentations

### Fever Without Source (Age-Based Approach)

| Age | Approach | Key Concern |
|-----|----------|------------|
| 0-28 days | Full sepsis workup: CBC, blood culture, UA + culture, LP, CXR; admit + empiric antibiotics (ampicillin + gentamicin or cefotaxime) | Late-onset GBS, E. coli, HSV; HSV PCR if risk factors |
| 29-60 days | Risk stratify using Rochester/Philadelphia/Step-by-Step criteria; low-risk may be managed outpatient with close follow-up | Serious bacterial infection rate 7-10% |
| 61-90 days | UA + culture; blood culture if ill-appearing; LP if <2 months or ill-appearing | UTI is the most common source |
| 3-36 months | Evaluate for UTI (especially uncircumcised males <6 months, females <2 years); CXR if respiratory symptoms | Pneumonia, UTI, occult bacteremia (now rare post-PCV13) |

### 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.