pediatric emergencies

• Early/compensated shock: Tachycardia, cool extremities, delayed cap refill, weak peripheral pulses

• Late/decompensated shock:

• _Hypotension

• _{→ altered mental status}

• _{→ bradycardia/cardiac arrest}

late ominous sign of circulatory failure in peds

Severe distress: nasal flaring, head bobbing, inability to speak/cry, cyanosis.

signs of airway distress

perform CPR for 2 min, get AED

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_{⭐ PALS board rule: If HR <60/min + poor perfusion despite adequate oxygenation/ventilation → START CPR (chest compressions).}

_{Think: Pediatric bradycardia = usually hypoxia → pre-arrest sign.}

pulse less than 60 in child inn distress indcates

• UNSTABLE: atrial fibrillation/flutter

• UNSTABLE: supra ventricular tachycardia (SVT)

• ventricular tachycardia with a pulse (w/o pulse = defib)

synchronized cardioversion is the electrical management of choice for

Supraventricular tachycardia

-most common tachyarrhythmia

-may be stable or unstable

-abrupt onset, no rate variability

-no P waves, short QRS

->220 bpm in infants, >180 in older children

clinical signs of SVT

ventricular tachycardia

A rapid heart rhythm in which the electrical impulse begins in the ventricle (instead of the atrium), which may result in inadequate blood flow and eventually deteriorate into cardiac arrest.

-IV access (±adenosine)

-synchronized cardioversion

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• _{🟢 Stable SVT → adenosine after vagal maneuvers.}

• _{🔴 Unstable SVT → synchronized cardioversion FIRST (0.5–1 J/kg, then 2 J/kg).}

• _{In unstable SVT, adenosine can be considered if IV/IO access is already available, especially for regular narrow-complex SVT, but do not delay cardioversion.}

management of unstable SVT

perform synchronized cardioversion if pulse is present

defib if no pulse!

management of unstable ventricular tachy

vagal maneuvers----> consider adenosine IV

management of stable SVT

adenosine if the rhythm is regular and uniform QRS

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_{PER PALS:}

Situation	Management
Stable VT, pulse present	Antiarrhythmic + expert consultation
Medication options	Amiodarone OR procainamide
Becomes unstable	⚡ Synchronized cardioversion
Becomes pulseless VT	⚡ Defibrillation + CPR

_{PALS doses:}

• _{Amiodarone: 5 mg/kg IV/IO over 20–60 min}

• _{Procainamide: 15 mg/kg IV/IO over 30–60 min}

• _{⚠ Do NOT routinely give amiodarone and procainamide together → risk of hypotension/QT prolongation.}

_{⭐ Boards:
Stable VT + pulse → amiodarone/procainamide
Unstable VT + pulse → synchronized cardioversion
Pulseless VT → defibrillation + CPR}

management of stable ventricular tachycarddia

_{(stable = pulse+ & no cardiopulm compromised)}

1 rescuer → 30:2 compressions:breaths

2 rescuers → 15:2

ratio for CPR in pediatrics if no pulse of HR

Shock phenotype	What you see	Preferred vasoactive agent
🥶 Cold shock	Low cardiac output, ↑ SVR → cool extremities, delayed cap refill, weak pulses	Epinephrine
🔥 Warm shock	↓ SVR → warm/flushed extremities, bounding pulses, wide pulse pressure	Norepinephrine

Epinephrine → β₁ → ↑ contractility + cardiac output → helps cold/low-output shock

Norepinephrine → α₁ → ↑ vasoconstriction/SVR → helps warm/vasodilatory shock

adrenergic treatment for cold vs warm shock

1st dose: 2 J/kg

→ 2nd dose: 4 J/kg

→ ≥4 J/kg for subsequent (max 10 J/kg or adult dose).

dose of defribilllators

croup, diptheria

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	Croup	Diphtheria
Cause	Parainfluenza virus most commonly	Corynebacterium diphtheriae
Classic age	6 months–3 years	Usually unvaccinated/under-vaccinated children
Cough	⭐ Barking “seal” cough	Not typically barking
Stridor	Inspiratory stridor	Can occur if severe obstruction
Voice	Hoarse	Hoarse/muffled
Throat	No pseudomembrane	⭐ Gray, adherent pseudomembrane that bleeds if scraped
Neck	Usually normal	⭐ “Bull neck” cervical LAD/edema
X-ray	⭐ Steeple sign	Upper-airway narrowing may occur
Treatment	Dexamethasone ± nebulized epinephrine	Antitoxin + erythromycin/penicillin + isolation
Prevention	No routine parainfluenza vaccine	DTaP/Tdap

Important: Diphtheria toxin inhibits EF-2 → stops protein synthesis and can cause myocarditis and neuropathy.

Ddx for pt with barking cough, hoarse voice

IM Epinephrine (0.01 mg/kg, max 0.3-0.5 mg) into lateral thigh immediately.

Airway support + O₂.

IV fluids for hypotension.

Adjuncts: antihistamines, corticosteroids, inhaled bronchodilators.

Observe for biphasic reaction (≥4-6 hr).

management of anaphylaxis

Severe asthma unresponsive to initial bronchodilator.

Tachypnea, prolonged expiratory phase, wheezing → silent chest (ominous).

Hypoxemia, accessory muscle use.

presentation of status asthmaticus

Supportive: Nasal suction, O₂ if sats

management of bronchiolitis

Complete obstruction:

Infants <1 yr: back blows + chest thrusts.

Children >1 yr: abdominal thrusts (Heimlich).

Partial obstruction: Allow spontaneous coughing, avoid blind sweeps.

Rigid bronchoscopy = definitive removal.

management of foreign body aspiration

Mild: Humidified air, oral dexamethasone.

Moderate-severe (stridor at rest): Dexamethasone + nebulized racemic epinephrine.

Intubation if severe obstruction unresponsive to treatment.

management of croup

diabetic ketoacidosis

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_{Kussmaul breathing = deep, rapid, labored breathing caused by severe metabolic acidosis.}

_{The body is trying to blow off CO₂ → ↓ CO₂ → helps raise the pH.}

_{Example presentation:
Diabetic patient + hyperglycemia + dehydration + fruity/acetone breath + deep rapid breathing → DKA with Kussmaul respirations}

_{DKA → ketoacids ↑ → HCO₃⁻ ↓ → pH ↓ → Kussmaul breathing → CO₂ ↓.}

Polyuria, polydipsia, weight loss, abdominal pain, vomiting.

Kussmaul respirations, dehydration, altered mental status.

Labs: hyperglycemia, metabolic acidosis (low bicarb, low pH), ketonemia/ketonuria

Airway, IV access.

Fluids: 10-20 mL/kg isotonic saline bolus → careful correction to avoid cerebral edema.

Insulin infusion: 0.1 units/kg/hr (after fluids).

Electrolyte monitoring: Replace K⁺ once urine output confirmed (even if serum normal/low)

management of DKA

If symptomatic: IV dextrose bolus (0.5-1 g/kg)

• (D10 for infants, D25-50 for children).

• glucagon if unable to get iv access

If mild and alert: oral glucose if able to swallow.

Investigate underlying cause (endocrine, metabolic, insulin excess).

management of hypoglycemia

• Elevate head of bed, maintain normoxia and normocapnia.

• 3% HYPERtonic saline or mannitol if acute decompensation.

• Neurosurgery consult for shunt/hematoma evacuation.

Avoid hypotension, hypoxemia, and excessive fluids.

management of increased intracranial pressure

tachycardia

earliest sign shock

Benzodiazepines

tx for stimulant induced seizures

irritability, tremors, yawning, diarrhea, poor feeding

signs of opioid withdrawal

tremors, seizures, agitation.

signs of alcohol/benzo withdrawal

BRUE = Brief Resolved Unexplained Event 👶

Sudden, brief, now resolved episode in an infant <1 yr, characterized by ≥1 of:

• Cyanosis/pallor

• Absent, decreased, or irregular breathing

• Marked change in tone (hyper- or hypotonia)

• Altered responsiveness

By definition, infant returns to baseline after event

(dx of exclusion)

term, >60 days, first event, short duration, no CPR, no concerning hx/exam

-manage with reassurance

criteria of a low risk BRUE

premature, recurrent, abnormal exam, family history of sudden death

-admit these pts for monintoring, address underlying cause

criteria of a high risk BRUE

GER (physiologic): Spit-ups in infants, no distress, normal growth.

GERD (pathologic): Poor weight gain, irritability, feeding refusal, respiratory symptoms (apnea, wheeze, aspiration).

differentiate GER and GERD

bronchiolitis, pneumonia

examples of LRTI

seizure >5min or recurrent without recovery

define status epilepticus

1st line: IV/IM/PR benzodiazepine (lorazepam, diazepam, midazolam).

2nd line: IV fosphenytoin, valproate, levetiracetam.

3rd line: Intubation + anesthetic agents (midazolam, pentobarbital).

medical management of status epilepticus

Sudden, severe intermittent colicky abdominal pain (knees to chest).

"Currant jelly stool" (blood + mucus).

Palpable "sausage-shaped" abdominal mass.

Vomiting (may be bilious).

clinical presentation of intussusception

Immediate stabilization (IV fluids, NG decompression if needed).

1st image: U/S —> target/donught sign

Diagnostic + therapeutic air/contrast enema (if stable, no perforation).

Surgery if enema fails, signs of perforation, or peritonitis.

treatment of intussusception

Painless rectal bleeding (melena or bright red blood).

Sometimes presents with obstruction, diverticulitis, or mimics appendicitis.

Cause: Failure of the vitelline (omphalomesenteric) duct to completely obliterate during embryologic development.

• _{Normally: Vitelline duct disappears → if proximal portion persists → Meckel diverticulum.}

Occurs due to ectopic gastric mucosa secreting acid —> adjacent ileal ulceration —> bleeding

presentation of meckel's diverticulum

Meckel's scan (technetium-99m pertechnetate).

diagnostic modality of meckel's diverticulum

Intermittent painless rectal bleeding.

Often benign juvenile polyps (age 2-10).

Rarely, multiple polyps → polyposis syndromes with malignancy risk.

presentation of juvenile polyps

Protrusion of rectal mucosa through anus, esp. during straining.

Associated with constipation, cystic fibrosis, chronic diarrhea, malnutrition

presentation of rectal prolapse

Acute episode: Manual reduction (lubrication, gentle pressure).

Recurrent/prolonged: Surgical repair.

management of rectal prolapse

infection (esp. Pasteurella, anaerobes), rabies, tetanus.

main infectious risks from animal bites

	Face 🙂	Extremity 🖐🦵
Irrigation	✅ Copious irrigation	✅ Copious irrigation
Debridement	As needed	As needed
Primary closure	✅ Usually close for cosmetic benefit	⚠ Usually leave open if infection risk is significant
Infection risk	Lower due to excellent blood supply	Higher, especially hand bites
Antibiotic prophylaxis	Often indicated for moderate/severe facial bites	Especially indicated for hand, deep/puncture, high-risk wounds
First-line antibiotic	Amoxicillin-clavulanate	Amoxicillin-clavulanate

face vs extremity wound care from animal bite

History of head trauma with:

Headache, confusion, dizziness, amnesia, nausea/vomiting, photophobia.

• _{NO focal neuro deficits, seizure, or prolonged loss of consciousness.}

typical presentation of concussion

prolonged LOC, worsening headache, repeated vomiting, seizure, focal deficit →

^^^ if present → CT scan.

red flags of concussion

Physical & cognitive rest for 24-48 hrs.

Gradual return to school & sports once symptom-free, under medical supervision. STEP-WISE APPROACH

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Step	Management
1. Rule out emergency	Assess ABCs, neuro exam, GCS; look for signs of intracranial injury
2. Imaging?	CT is NOT routine; use clinical decision rules (e.g., PECARN) when indicated
3. First 24–48 hr	Relative physical + cognitive rest; avoid activities that significantly worsen symptoms
4. Symptoms	Acetaminophen can be used for headache; maintain hydration and normal sleep
5. Return to school	Gradual return within ~1–2 days as tolerated; accommodations if symptomatic
6. Return to sports	No same-day return to play. Gradual stepwise return only after return to regular activities/school and symptoms have resolved
7. Follow-up	Monitor symptoms and recovery; reassess if prolonged/worsening

management of concussion

MI, left ventricular wall rupture, acute VSD, CHF, massive PE, over dose on beta blockers

causes of cardiogenic shock

neurogenic shock

occurs when there is damage to the brain or spinal cord that inhibits transmission of neural stimuli to arteries and arterioles, which reduces vasomotor tone

spinal cord injury, ANS toxins, spinal anesthesia, GBS

causes of neurogenic shock

IV fluids

O2 therapy

vasopressors and inotropes

tx of cardiogenic shock

hypotension, tachycardia, shallow respirations, oliguria, confusion, cool, clammy skin

signs of cardiogenic shocck

IV fluid therapy

O2 therapy

blood transfffusion

tx of hypovolemic shock

hypotension, tachycardia, shallow respirations, oliguria, oligguria restlessness, cool./clammy skin

siggns of hypovolemic shock

hypotension, tachycardia, increased respirations, oliguria, fever

flushed and warm skin

signs of septic shock

hypotension, tachycardia, bronchoconstriction, oliguria, LOC, hives localized edema

signs of anaphylactic shock

IV fluid therapy, O2 therapy, inotropic agennts

-atropine if severe bradycardia

tx of neurogenic shock

hypotension, bradycardia, no bladder control, LOC

dry, warm skin

signs of neurogenic shock

neurogenic, anaphylactic, septic

types of shock associated with warm skin

obstructive shock

Shock that occurs when there is a block to blood flow in the heart or great vessels, causing an insufficient blood supply to the body's tissues.

Pulmonary embolism, tension pneumo, pericardial tamponade, restrictive cardiomyopathy

causes of obstructive shock

distributive shock

shock due to severe peripheral vasodilation

-peripheries are warm

septic shock, anaphylaxis, neurogenic

causes of distributive shock

cardiogenic shock

Tachycardia, hypotension

Poor perfusion (cool extremities, delayed cap refill)

Signs of fluid overload: hepatomegaly, pulmonary rales, gallop rhythm

Common causes: myocarditis, congenital heart disease, arrhythmia

Exam: muffled heart sounds, distended neck veins (tamponade); unilateral decreased breath sounds, tracheal deviation (pneumothorax).

exam findings associated with obstructive shock

dissociative shock

*Type of shock*

Perfusion problems occur because the *blood has a decreased ability to carry oxygen* to the tissues.

Causes: CO poisoning , Anemia , Cyanide poisoning

toddlers 1-3 y/o

age of peak risk for accidental ingestion

dosing errors

risk of poisoning in inffants is usually due to

Blind as a bat (Mydriasis)

Mad as a hatter (Altered mental status)

Red as a beet (vasodilation, flushed)

Hot as a hare (febrile)

Dry as a bone (no secretions/diaphoresis)

Bowel and bladder lose their tone

Heart runs alone (tachycardia)

signs of anticholinergic syndrome

Atropine, antihistamines, scopalamine, antipsychotics

agents of anticholinergic syndrome

SLUDGE(salivation, lacrimation, urination, deification, GI distress, emesis).

Presents with pin point pupils, sweating, vomiting, frothing of mouth, bradycardia, urination, diarrhea

presentation of cholinergic toxidrome

insecticides

agents of cholinergic toxidrome

miosis, sedation, respiratory depression

signs of opioid toxidrome

miosis

constricted pupils

glucagon

-monitor potassium

tx of CCB and beta blocker overdose

sodium bicarb

tx of TCA overdose

Acetylcholinesterase inhibitors

Promote the accumulation of acetylcholine, resulting in prolonged cholinergic effects

DUMBBELSS: Diarrhea, Urination, Miosis, Bronchospasm, Bradycardia, Excitation (CNS), Lacrimation, Sweating, Salivation

cholinergic effefcts

-Atropine & pralidoxime

tx for organophosphate poisoning

Hot, dry skin; flushed; dilated pupils; urinary retention; delirium, hallucinations; tachycardia

signs of anticholinergic toxidrome

Supportive, benzodiazepines for agitation, physostigmine in severe cases (avoid if TCA overdose)

mgmt of anticholinergic toxidrome

CNS depression, pinpoint pupils, respiratory depression, hypotension, bradycardia

signs of opioid toxidrome

Agitation, hypertension, tachycardia, dilated pupils, sweating, hyperthermia

signs of sympathomimetic toxidrome

Cocaine, amphetamines, ADHD meds

causes of sympathomimetic toxidrome

Supportive, benzodiazepines, avoid beta-blockers

mgmt of sympathomimetic toxidrome

Benzodiazepines, barbiturates, ethanol

causes of sedative toxidrome

Supportive, flumazenil rarely (risk of seizures), airway support

tx of sedative toxiddrome

Agitation, clonus, hyperreflexia, hyperthermia, diaphoresis

signs of serotonin synddrome

SSRIs, MAOIs, MDMA, drug interactions

agents of serotonin syndrome

Stop agents, supportive, cyproheptadine for severe cases

mgmt of serotonin syndrome

Lead pipe rigidity, fever, altered mental status, autonomic instability

signs of neuroleptic malignant syndrome

antipsychotics

cause of neuroleptic malignant syndrome

Stop antipsychotics, supportive, dantrolene or bromocriptine

tx of neuroleptic malignant syndrome

Tinnitus, hyperventilation (resp alkalosis → metabolic acidosis), vomiting, confusion.

signs of salicylate poisoning

Serum acetaminophen level at 4 hrs post ingestion

→ Rumack-Matthew nomogram.

best tool to evaluate acetaminophen poisonin

Activated charcoal (early),

alkalinize urine with IV sodium bicarb, fluids,

hemodialysis if severe.

tx of salicylate poisoning

GI phase (vomiting, diarrhea, hematemesis),

latent phase, shock, metabolic acidosis, hepatotoxicity.

presentation of iron overdose

Deferoxamine chelation, supportive, GI decontamination if early.

mgmt of iron overdose

hydrocarbon (gasoline, lamp oil) poisoning

Presentation: Coughing, choking, vomiting, respiratory distress → risk of aspiration pneumonitis.

Management: Supportive only (O₂, ventilation PRN). No gastric lavage/charcoal (risk of aspiration).

Remove exposure; chelation (succimer if moderate, EDTA if severe)

tx of lead poisoning