PEDS and neonate
Introduction and Definitions
Care for a newborn or neonate must be tailored specifically to meet the unique physiological needs of this population, while also supporting the needs of the parents or caregivers.
● Newborn: Defined as an infant within the first few hours after birth.
● Neonate: Defined as an infant within the first month (1 month) after birth.
General Pathophysiology and Statistical Assessment
● Cardiopulmonary Interventions: Approximately 1% of all deliveries require skilled care interventions to optimize cardiopulmonary function.
● Low Birth Weight Statistics: Approximately 8% of newborns delivered each year weigh less than 5.5 lb (2,500 g).
Transition from Fetus to Newborn
Fetal Circulation and Shunts
In utero, fetal circulation relies on three major blood flow deviations or shunts, which divert blood away from the lungs and liver:
● Ductus venosus
● Foramen ovale
● Ductus arteriosus
Under normal physiological conditions, these three shunts close off at birth.
Respiratory Activation and Vascular Changes
● Triggering First Breath: The newborn’s initial breath is triggered by mild hypoxia and hypercapnia experienced during delivery.
● Pulmonary Vascular Resistance: As the newborn takes its first breaths and the lungs fill with air, pulmonary vascular resistance drops drastically, allowing significantly more blood to flow through the pulmonary vasculature to the lungs.
● Complications of Delayed Transition: A delay in the decrease of pulmonary pressure results in a delayed transition, severe hypoxia, potential brain injury, or death.
Arrival and Immediate Care of the Newborn
Preparation and Minimum Equipment
Before delivery, obtain a detailed patient history and prepare the surrounding environment. The absolute minimum equipment required includes:
● Warm, dry blankets
● Sterile bulb syringe
● Two small umbilical clamps or ties
● Pair of clean scissors
In-Ambulance Delivery Sequence
1. Wrap or cover using warm blankets.
2. Rapidly confirm and assess ABCs: Airway, Breathing, Circulation.
3. Place the newborn directly on the mother’s chest.
4. Perform suctioning: clear the mouth first, then suction the nose.
5. Keep the newborn strictly at the level of the mother until the cord is clamped.
6. Clamp and cut the umbilical cord.
Primary Survey and Assessment
Perform a primary survey simultaneously with initial treatment interventions:
● Skin, Head, and Eyes: Inspect thoroughly for physical irregularities or birth trauma.
● Umbilical Cord: Inspect for structural abnormalities or bleeding.
● Abdomen: Inspect for abnormal findings, such as umbilical hernias.
Immediate Hypothermia Prevention
Newborns possess limited thermoregulatory capabilities and are at extreme risk for hypothermia:
● Place the infant immediately on prewarmed towels or under a radiant warmer.
● Thoroughly dry the head and body.
● Promptly remove all wet, soiled towels and replace them with a clean, dry towel.
● Cover the head with a warm cap.
Post-Birth Cyanosis and Thermoregulation
● Initial Presentation: All babies present with cyanosis immediately after birth.
● Vigorous Newborn Management: If the newborn remains vigorous and begins to turn pink within the first 5 minutes, maintain ongoing observation and continue thermoregulation via direct skin-to-skin contact on the mother’s chest.
Apgar Scoring
● Purpose: The Apgar score is a standardized tool used to evaluate and record the clinical condition of the newborn at birth.
● Reevaluation Protocol: If the Apgar score is less than 7, repeat the evaluation every 5 minutes until 20 minutes after birth.
Neonatal Resuscitation Algorithm
Follow established, current neonatal resuscitation guidelines:
● The Golden Minute: Within the first 60 seconds after birth, complete the initial assessment steps, reevaluation, and initiation of ventilation if required.
● Oxygenation: Administer supplemental oxygen if target preductal oxygen saturation values are not reached.
● Ventilation Threshold: If the newborn is apneic or has a heart rate less than 100 beats/min, immediately initiate positive-pressure ventilation (PPV).
● Chest Compression Threshold: Initiate chest compressions if the newborn’s pulse rate drops below 60 beats/min.
● Pharmacologic Step: If effective ventilation and chest compressions fail to improve severe bradycardia, administer epinephrine, preferably via an intravenous (IV) line.
Drying, Positioning, and Tactile Stimulation
● Airway and Positioning: After ensuring a patent airway, place the infant on their back or side with the neck maintained in a neutral “sniffing position.”
● Tactile Stimulation: Stimulate breathing by thoroughly drying the newborn and flicking the soles of the feet.
● Airway Clearance: Consider airway suctioning if PPV is required or if the airway appears physically obstructed.
Airway Management Techniques and Devices
Free-Flow (Blow-By) Oxygen
● Indication: Administer free-flow oxygen if the infant is cyanotic or pale, but PPV is not specifically indicated.
● Delivery Methods: Delivered via an oxygen mask held near the face or directly via oxygen tubing.
Oral Airways and Advanced Airway Alternatives
Oral airways or advanced airway interventions are indicated in specific anatomical or congenital obstructions:
● Bilateral choanal atresia
● Pierre Robin sequence
● Macroglossia
● Craniofacial defects
Special Consideration: In cases of Pierre Robin sequence, macroglossia, and craniofacial defects, an endotracheal (ET) tube is inserted down a nostril. In bilateral choanal atresia, nasal passage insertion is obstructed, necessitating an alternative approach.
Bag-Mask Ventilation (BMV)
Indications
● Apneic newborn
● Inadequate respiratory effort
● Heart rate less than 100 beats/min after clearing the airway, correct positioning, and tactile stimulation
Delivery Devices
● Self-inflating bag with an oxygen reservoir
● Flow-inflating bag
● T-piece resuscitator
Ventilation Rate: 40–60 breaths/min.
Causes of Ineffective BMV
● Inadequate mask seal against the face
● Incorrect head/neck positioning
● Copious secretions obstructing the airway
● Pneumothorax
● Equipment malfunction
Endotracheal Intubation
Indications
● Meconium-stained amniotic fluid in a nonvigorous newborn
● Congenital diaphragmatic hernia
● Requirement for prolonged PPV
● Craniofacial anomalies preventing adequate mask seal
Required Equipment
● Suction equipment
● Laryngoscope handle and blades
● Shoulder roll
● Adhesive tape
● ET tube
● Appropriate stylet
Gastric Decompression
Indications
● Prolonged bag-mask ventilation causing gastric distention
● Abdominal distention that impedes diaphragmatic movement and ventilation
● Suspected diaphragmatic hernia or gastrointestinal congenital anomaly
Circulatory Support and Vascular Access
Chest Compressions
Indication: Pulse remains less than 60 beats/min despite adequate resuscitation and ventilation efforts.
Personnel: Requires a minimum of two responders for coordinated compression and ventilation.
Techniques
● Thumb Technique: Two thumbs on the sternum with hands encircling the torso. Preferred technique.
● Two-Finger Technique: Index and middle finger on the lower half of the sternum.
Compression Depth: One-third of the anteroposterior diameter of the chest.
Ratio: 3 compressions to 1 ventilation.
Target:
● 90 compressions/min
● 30 breaths/min
● 120 total events/min
Do not deliver compressions simultaneously with ventilations.
Reassessment
● Reassess heart rate after 60 seconds of well-coordinated chest compressions and ventilations.
● If pulse rises above 60 beats/min, cease chest compressions and recheck pulse.
● If pulse rises above 100 beats/min, gradually slow the ventilation rate and decrease PPV pressure.
Vascular Access
● Umbilical Vein: The umbilical vein can be catheterized in specialized settings.
● Prehospital Access: Peripheral IV and intraosseous (IO) access are more commonly utilized in prehospital emergency care. Consult medical direction regarding local protocols for IO access in neonates.
Pharmacologic Interventions
● Medications are rarely required during neonatal resuscitation.
● All medication dosages in neonates are calculated strictly based on weight.
Family and Transport Considerations
● Transport to the nearest appropriate medical facility once the newborn is stabilized as much as possible.
● Maintain clear communication with the family.
● Continually monitor the newborn’s status.
High-Risk Newborn Transport Protocol
1. Referring hospital physician initiates transport request.
2. Mode of transportation is determined.
3. Specialized transport team is mobilized and equipment is assembled.
4. Upon arrival, the specialized transport team assumes care and continues stabilization.
Neonatal Apnea
Definition: A pause in breathing lasting 20 seconds or longer.
Pathophysiology: Can rapidly lead to severe hypoxemia and bradycardia. Frequently follows episodes of hypoxia or hypothermia.
Clinical Need: Requires immediate respiratory support to prevent permanent brain and organ damage.
Assessment and Management: Obtain a careful clinical history to identify etiologic risk factors, conduct a thorough physical examination, and differentiate between primary and secondary apnea.
Neonatal Bradycardia
Causes
Most frequently results from hypoxia and often responds directly to effective PPV.
Other causes include:
● Hypovolemia
● Pneumothorax
● Head injury
● Therapeutic procedures/interventions
Management Algorithm
● Heart rate less than 100 beats/min: Initiate PPV.
● Heart rate remains less than 60 beats/min: Initiate chest compressions.
● Heart rate remains less than 60 beats/min despite CPR: Administer epinephrine.
● Reassess pulse after 1 minute.
Acidosis in the Neonate
Clinical Suspicion: Suspect metabolic acidosis if severe bradycardia persists after adequate ventilation, high-quality chest compressions, and volume expansion.
Intervention: Consider administering a normal saline fluid bolus to improve tissue perfusion and clearance of metabolic acids.
Definitive Treatment: Identify and treat the underlying etiology.
Needle Decompression for Pneumothorax
Causes
● Inhalation of meconium
● Lung tissue weakness due to infection
● Overly aggressive PPV pressure
Clinical Presentation
Severe respiratory distress unresponsive to PPV accompanied by unilateral decreased breath sounds.
Procedure
1. Clean the insertion site thoroughly with alcohol.
2. Prepare needle decompression equipment.
3. Insert the needle directly above the upper edge of the second rib in the midclavicular line.
4. If there is a symptomatic, ongoing air leak, place a 22-gauge angiocatheter in a similar intercostal location.
5. Reassess continuously during transport for reaccumulation of air.
Meconium-Stained Amniotic Fluid
Risks and Morbidity
Inhalation of meconium-stained fluid can cause:
● Atelectasis
● Persistent pulmonary hypertension
● Severe hypoxemia
● Aspiration pneumonitis
● Pneumothorax
Reducing the Risk of Persistent Pulmonary Hypertension
● Maintain a clear airway.
● Keep the newborn warm.
● Minimize physical stimulation.
● Administer supplemental oxygen as indicated.
Assessment and Management
● If the infant is depressed or nonvigorous at birth, immediately initiate PPV.
● Endotracheal intubation and direct suctioning may be required to clear physical meconium obstruction.
● If the infant fails to improve following standard neonatal resuscitation, suspect airway occlusion or pneumothorax.
● Prevent hypothermia.
● Reassess continuously.
Low Blood Volume (Hypovolemia)
Causes
● Abruptio placentae
● Twin-to-twin transfusion
● Placenta previa
● Septic shock
Clinical Signs
● Marked pallor
● Persistently low pulse rate
● Weak peripheral pulses
● Absence of circulatory improvement following adequate ventilation and oxygenation
Management: Administer an IV/IO fluid bolus.
Congenital Diaphragmatic Hernia
Pathophysiology: An abnormal defect or opening in the diaphragm allows abdominal contents to migrate into the thoracic cavity.
Signs and Symptoms
● Marked respiratory distress
● Heart sounds displaced to the right side of the chest
● Bowel sounds within the thoracic cavity
Management
● Supplemental oxygen
● Continuously monitor heart rate
● Avoid bag-mask ventilation if possible to prevent air distention of intrathoracic bowel
● Prepare for definitive surgical correction
Respiratory Distress and Cyanosis
Most Common Cause: Prematurity.
Other causes include:
● Intrinsic respiratory conditions
● CNS depression
● Septic shock
● Severe metabolic acidosis
● Congenital cardiac anomalies
Assessment
● Verify airway patency.
● Evaluate breathing adequacy.
● Confirm pulse.
● Count respiratory rate.
● Determine whether symptoms increase during feeding.
Four Pillars of Management
1. Establish and maintain a patent airway.
2. Ensure adequate oxygen delivery.
3. Provide effective ventilation.
4. Support adequate systemic circulation.
Respiratory Depression Secondary to Maternal Opioid Use
Chronic Maternal Opioid Use / Opioid Use Disorder
Administering naloxone (Narcan) to a newborn of a mother with chronic opioid use disorder may precipitate severe neonatal withdrawal seizures.
Naloxone is no longer recommended as a first-line drug in neonatal resuscitation in these scenarios.
Management: Provide high-quality ventilatory support and immediate transport.
Acute Maternal Opioid Administration
If neonatal respiratory depression is caused by acute opioid administration to the mother during labor/delivery, naloxone may be administered to the newborn via IV or IM route.
Premature and Low-Birth-Weight Infants
Definitions
● Premature Infant: Delivered before 37 weeks of gestation.
● Low-Birth-Weight Infant: Weighs less than 5.5 lb (2,500 g).
Assessment
Determining prematurity in the field relies on:
● Physical features of the infant
● Family information regarding gestational age
● Maternal or fetal complications
Management
● Continuous cardiorespiratory support
● Maintain a strict thermoneutral environment
● When providing PPV, use only the minimum peak airway pressure necessary to produce visible chest rise
● Clear the airway as indicated
● Gentle tactile stimulation
● Supplemental oxygen as indicated
● PPV as indicated
● Chest compressions as indicated
● Aggressive warming
Neonatal Seizures
Neonatal seizures indicate an underlying neurological disorder or structural abnormality. Prolonged seizure activity can cause secondary brain injury.
Types
● Subtle
● Clonic
● Tonic
● Spasms
● Myoclonic
Assessment and Management
● Evaluate prenatal and birth history.
● Perform physical examination.
● Obtain vital signs and oxygen saturation.
● Administer supplemental oxygen as indicated.
● Provide assisted ventilation when necessary.
● Monitor blood pressure.
● Establish vascular access.
Hypoglycemia Threshold: If blood glucose is less than 40 mg/dL, administer an IV bolus of D10W.
● Monitor respiratory status.
● Maintain normal body temperature.
● Keep the family informed during transport.
Neonatal Hypoglycemia
Definition: Blood glucose less than 45 mg/dL.
Complications: Seizures and permanent brain damage.
Risk Factors: Conditions associated with decreased glycogen stores or significantly increased metabolic glucose utilization.
Management
● Measure blood glucose.
● Obtain vital signs.
● Address ABCs first.
● Correct oxygenation and ventilation problems.
● Treat hypoglycemia.
● Maintain a thermoneutral environment.
Vomiting in the Newborn
Occasional spitting up can be normal. Persistent or bilious, green-tinged vomiting is abnormal and may indicate upper digestive tract obstruction or increased intracranial pressure.
Aspiration can cause airway obstruction and pulmonary complications.
Causes
● Esophageal atresia
● Gastroesophageal reflux disease (GERD)
● Infantile hypertrophic pyloric stenosis (IHPS)
● Intestinal malrotation
● Congenital intestinal conditions
● Hirschsprung disease
Causes of Sudden, Forceful Vomiting
● Asphyxia
● Meningitis
● Hydrocephalus
● Neonatal withdrawal syndromes
Clinical Findings
● Abdominal distention
● Fever or history of ill contacts
● Temperature instability
● Apnea
● Bradycardia
● Abdominal tenderness/guarding
● Minimal or absent bowel sounds
Management
1. Address ABCs.
2. Consider gastric decompression.
3. Do not administer antiemetics.
4. Initiate fluid resuscitation if dehydrated.
5. Position the newborn on their side during transport to reduce aspiration risk.
Neonatal Diarrhea
Causes
● Poisoning
● Gastroenteritis
● Lactose intolerance
● Neonatal abstinence syndrome
Assessment
● Estimate the number and volume of loose stools.
● Monitor for decreased urine output.
● Assess the degree of dehydration.
Management: Begin with standard ABC management.
Neonatal Jaundice
Pathophysiology
Results from liver immaturity and inability to conjugate bilirubin during the first week of life.
Other causes include:
● Hemolysis
● Red blood cell disorders
● Polycythemia
● Excessive tissue bruising
Management
● Rapid transport
● IV fluids if significant clinical jaundice is present
● Contact medical control
● Definitive hospital treatment primarily consists of phototherapy
Thermoregulation, Fever, and Hypothermia
Normal Temperature
● Average: 37.5°C (99.5°F)
● Normal Neonatal Range: 36.6–37.2°C (97.9–99.0°F)
Neonatal Fever
Definition: Rectal temperature greater than 38°C (100.4°F).
A sick or infected newborn may not always develop a fever because of immature thermoregulation.
Noninfectious causes include:
● Environmental overheating
● Dehydration
Signs and Symptoms
● Irritability
● Somnolence
● Decreased feeding
● Skin warm to touch
Management
● Examine for skin rashes.
● Obtain a detailed history.
● Assess respiratory rate and work of breathing.
● Monitor vital signs.
● Ensure adequate oxygenation and ventilation.
● Perform CPR if indicated.
● Cool safely as indicated.
Neonatal Hypothermia
Definition: Core body temperature less than 35°C (95°F).
Newborns are particularly sensitive to environmental temperatures immediately after delivery. Always consider underlying infection in a hypothermic infant.
Signs and Symptoms
● Cool skin
● Pallor
● Acrocyanosis
● Central cyanosis
● Apnea
● Bradycardia
Prevention
● Warm your hands before touching the newborn.
● Dry thoroughly after birth.
● Place a prewarmed cap on the head.
● Maintain direct skin-to-skin contact with the mother.
Treatment
● Administer D10W if hypoglycemic.
● Once stabilized, cover with warm blankets on the mother’s chest.
● Increase ambulance cabin temperature.
● Chemical heat packs may be considered, but never place them directly against the newborn’s skin.
Common Birth Injuries
Most birth injuries are self-limiting and occur secondary to newborn size, macrosomia, or abnormal presentation during delivery.
Types of Trauma
● Forceps/vacuum injuries
● Excessive head molding
● Caput succedaneum
● Cephalohematoma
● Linear skull fractures
● Brachial plexus injuries
● Facial nerve palsy
● Diaphragmatic paralysis
● Laryngeal nerve injury
● Spinal cord injury
Bone Fractures
Clavicle Fracture
The clavicle is the most frequently fractured bone during birth.
Findings include:
● Crepitus
● Palpable bony irregularity
● Reduced or absent arm movement on the affected side
Long Bone Fractures
Usually present as decreased or absent spontaneous movement of the affected extremity.
Visceral and Systemic Trauma
● Intra-abdominal birth injuries are uncommon.
● Severe birth trauma can lead to systemic hypoxia and shock.
Congenital Heart Disease
Congenital heart disease is the most common structural birth defect and can cause varying degrees of cardiorespiratory compromise.
Rapid detection, immediate transport, and early medical control communication are important.
Noncyanotic Heart Disease
Left-to-Right Shunts
Oxygenated blood is shunted from the high-pressure left side of the heart toward the right side.
Atrial Septal Defect (ASD)
Abnormal opening in the interatrial septum separating the right and left atria.
Ventricular Septal Defect (VSD)
Abnormal opening in the interventricular septum separating the right and left ventricles.
Patent Ductus Arteriosus (PDA)
Failure of the fetal ductus arteriosus to close after birth. Excessive pulmonary blood flow can eventually lead to heart failure.
Coarctation of the Aorta (CoA)
Structural narrowing of the aorta. Frequently associated with other cardiac lesions and may remain asymptomatic until later in childhood.
Cyanotic Heart Disease
Right-to-Left Shunts
Deoxygenated blood from the right side of the heart bypasses the lungs and mixes into systemic circulation.
Pulmonary Stenosis
Structural defect involving the pulmonic valve.
Possible findings include:
● Jugular vein distention
● Cyanosis
● Right ventricular hypertrophy
Truncus Arteriosus
The pulmonary artery and aorta form a single common great vessel.
● Causes excessive pulmonary blood flow.
● Requires surgical intervention.
Hypoplastic Left Heart Syndrome (HLHS)
Severe underdevelopment of the left side of the heart.
Fatal without surgical intervention.
Tetralogy of Fallot (ToF)
Consists of four defects:
1. Ventricular septal defect (VSD)
2. Pulmonary stenosis
3. Right ventricular hypertrophy
4. Overriding aorta
Treatment: Requires surgical repair.
Transposition of the Great Arteries (TGA)
The pulmonary and systemic circulations run in parallel rather than in series.
● Deoxygenated blood returns from the body and is pumped back to the body.
● Oxygenated blood returns from the lungs and is pumped back toward the lungs.
Total Anomalous Pulmonary Venous Return (TAPVR)
All four pulmonary veins fail to connect normally to the left atrium and instead drain into the right-sided circulation.
This produces significant right-sided volume overload and abnormal pulmonary/systemic circulation.
Developmental Stages and Pediatric Assessment
Children differ significantly from adults in their anatomy, physiology, and emotional responses. An effective approach to pediatric patients must be tailored to the child’s specific age, developmental stage, and social context.
Age Classifications
Neonate: The first month of life.
Infant: The first 12 months of life.
Toddler: Ages 1 to 2 years.
Preschool-Age Child: Ages 3 to 5 years.
School-Age Child: Ages 6 to 12 years.
Adolescent: Ages 13 to 18 years.
Assessment and Interaction Strategies by Stage
Neonates and Infants
Keep the child warm during examination to prevent hypothermia.
Support a young infant’s head and neck at all times.
Older infants remain calmest when held in a parent’s arms.
If the infant is quiet, auscultate heart and lung sounds first before proceeding with more invasive exam components.
Toddlers
Utilize the Pediatric Assessment Triangle (PAT) for initial visual evaluation.
Perform examinations on the parent’s lap whenever possible.
Position yourself at the child’s eye level.
Enlist the assistance of a parent or caregiver.
Maintain flexibility in the examination sequence.
Preschool-Age Children
Children in this age group are increasingly verbal and active.
Respect modesty during the physical exam.
Allow the child to participate in their care where appropriate.
Establish firm, clear limits on behavior if the child acts out.
School-Age Children
Capable of abstract thought and comprehending cause-and-effect relationships.
By age 8, pediatric anatomy and physiology closely mirror adult characteristics.
Explain every assessment step in simple, understandable language.
Adolescents
Once secondary sexual characteristics have developed, evaluate and treat the patient as an adult.
Address and reassure the patient directly.
Offer as much control over medical decisions and care as clinically appropriate.
Pediatric Anatomy, Physiology, and Pathophysiology
The Head
Infants and young children possess heads that are disproportionately large relative to their overall body mass.
Keep the head covered to prevent significant heat loss.
The anterior and posterior fontanelles remain open during infancy, offering a window into fluid status and intracranial pressure.
The Neck and Airway
Characterized by a short neck and narrow airway passages.
The epiglottis is long, floppy, and U-shaped.
The nares must be kept clear of secretions using suctioning.
Avoid hyperextension of the neck, which can collapse the soft pediatric trachea.
Maintain a clean airway free of mucus, blood, and fluids.
The Respiratory System
Pediatric patients have smaller tidal volumes and a smaller functional residual capacity.
Metabolic demand for oxygen is double that of an adult, leading to faster baseline breathing rates.
Infants rely predominantly on the diaphragm during inspiration.
Intercostal and accessory muscles fatigue rapidly.
High susceptibility to hypoxia can trigger rapid cardiovascular collapse and cardiac arrest.
The Cardiovascular System
Cardiac output in infants and young children is rate-dependent.
Children rely on an increased pulse rate to maintain cardiac output and compensate for decreased oxygenation.
Cardiac reserves are limited but vigorous; injured children can maintain a normal blood pressure despite significant intravascular volume loss.
Hypotension is a late and ominous indicator of decompensated shock.
The Heart and Mediastinum
Electrocardiogram (ECG) readings normally demonstrate large right-sided forces in young infants.
The pediatric mediastinum is significantly more mobile than in adults.
The Nervous System
Neural tissues and vascular structures are fragile.
The brain and spinal cord have less structural protection from the cranium and vertebral column.
The pediatric brain receives nearly twice the blood flow of an adult brain, rendering minor head injuries clinically significant and increasing susceptibility to hypoxia.
The Spinal Column
The anatomic fulcrum of the pediatric cervical spine is located higher than in adults and gradually descends with growth.
Vertebral fractures and spinal cord injuries are uncommon in young children.
In any mechanism of injury (MOI) involving high energy, assume a cervical spine injury and maintain Spinal Motion Restriction (SMR).
The Abdomen and Pelvis
Abdominal organs are highly vulnerable to blunt trauma.
Solid organs (liver, spleen) are proportionally larger.
Children have minimal subcutaneous fat and less protective abdominal musculature.
The Musculoskeletal System
Skeletal growth plates remain open until late adolescence; bone growth is required to reach adult height.
Pediatric bones are weaker than surrounding ligaments and tendons, making fractures more common than sprains.
Slipped Capital Femoral Epiphysis (SCFE): Occurs in children and adolescents, most frequently in overweight individuals. Presentation includes difficulty walking, a noticeable limp, inability to bear weight on the affected limb, and painful, restricted hip flexion and rotation.
All suspected sprains, strains, and fractures require stabilization.
The Chest and Lungs
The pediatric chest wall is thin and the ribs are highly pliable.
Significant internal parenchymal lung injury can exist without overt thoracic cage fractures.
Increased risk of iatrogenic pneumothorax during bag-mask ventilation.
The Integumentary System
Skin is thinner and more elastic.
High body surface area (BSA)-to-weight ratio combined with less subcutaneous tissue increases vulnerability to hypothermia, physical tissue injury, and thermal burns.
Metabolic Differences
Limited stores of glycogen and glucose.
Vulnerable to rapid hypovolemia and severe electrolyte derangements.
Continuous active warming is required during transport.
Pediatric Patient Assessment and Primary Survey
General Approach and Caregiver Interactions
Pediatric assessment requires adapting skills to match developmental stages and utilizing size-appropriate equipment.
Establishing rapid rapport with caregivers is critical.
Approach the situation in a calm, professional manner.
Allow caregivers to accompany the child during transport whenever possible.
The pediatric patient remains the first clinical priority.
Scene Size-up
Review dispatch information while en route to anticipate size-specific equipment and assessment strategies.
Apply appropriate Standard Precautions.
Observe the child’s position prior to approach.
Analyze the scene for clues regarding the Mechanism of Injury (MOI) or Nature of Illness (NOI).
Inspect the environment for pill bottles, household chemicals, alcohol, or illicit drug paraphernalia.
Assess home cleanliness, safety, the physical appearance of siblings, presence of medical technology/devices, and evidence of substance abuse.
Pediatric Assessment Triangle (PAT)
Form an initial general impression from a distance without touching the patient by evaluating three components:
Appearance: Reflects central nervous system function, muscle tone, and interactiveness. Grossly abnormal appearance signals an immediate life threat requiring emergency intervention.
Work of Breathing: Reflects compensatory efforts to maintain gas exchange (e.g., retractions, grunting, head bobbing, nasal flaring).
Circulation to Skin: Indicates adequacy of core perfusion and cardiac output. Assess for:
Pallor: Pale skin or mucous membranes.
Mottling: Patchy skin discoloration from vasoconstriction.
Cyanosis: Blue discoloration of skin and mucous membranes.
Hands-on Primary Survey (ABCDEs)
If PAT demonstrates critical abnormalities, proceed immediately to the hands-on assessment, treat life threats, and initiate transport.
Weight Estimation: Determine weight using a pediatric length-based resuscitation tape measure.
Airway (A): Assess for patency and adequate chest expansion. Position the airway and suction secretions, blood, or vomit as needed.
Breathing (B): Calculate respiratory rate, auscultate breath sounds in all fields, and continuously monitor pulse oximetry (SpO2).
Circulation (C): Auscultate the heart or palpate a central pulse for 30 seconds and double the value. Evaluate skin Color, Temperature, and Condition (CTC).
Disability (D): Evaluate level of consciousness using the AVPU scale or Pediatric Glasgow Coma Scale (pGCS). Assess pupillary reactivity and motor activity.
Exposure (E): Perform a rapid body exam. Expose necessary areas while protecting against rapid hypothermia.
Pediatric Glasgow Coma Scale (pGCS)
Eye Opening
4: Spontaneous
3: To speech
2: To pain
1: None
Verbal Response
5: Smiles, oriented to sounds, follows objects, interacts (Infant) / Oriented, appropriate (Child)
4: Cries but consolable, inappropriate interactions (Infant) / Confused (Child)
3: Inconsolably persistent crying, screaming to pain (Infant) / Inappropriate words (Child)
2: Grunting, moaning to pain (Infant) / Incomprehensible sounds (Child)
1: None
Motor Response
6: Moves spontaneously, purposefully (Infant) / Obeys commands (Child)
5: Withdraws to touch (Infant) / Localizes pain (Child)
4: Withdraws to pain
3: Abnormal flexion to pain (decorticate posturing)
2: Abnormal extension to pain (decerebrate posturing)
1: None
Transport Decisions
Immediate transport is mandated for trauma patients presenting with:
High-risk or severe MOI.
Physiologic instability or vital sign abnormalities.
Significant anatomical structural damage.
Unsafe scene environment.
Vascular access should be attempted en route rather than delaying scene departure.
Secondary Assessment and Vital Signs
Blood Pressure Assessment
Measure blood pressure on the upper arm or thigh. The minimum acceptable systolic blood pressure for children aged 1 to 10 years is calculated as:
Minimal Systolic BP = 70 + (2 x age in years)
Pain Assessment and Management
Select age-appropriate pain scales incorporating pictorial representations (e.g., Wong-Baker FACES scale).
Discuss the child’s behavioral responses with caregivers.
Pharmacologic options include Acetaminophen, Opiates, Benzodiazepines, and Nitrous oxide.
Weigh therapeutic benefits against risks of respiratory depression, particularly in unstable patients.
Always consider potential non-accidental trauma/child abuse when evaluating pediatric injuries.
Reassessment
Continuously monitor the patient by re-evaluating:
Pediatric Assessment Triangle (PAT)
Transport priority
Vital signs
Efficacy of therapeutic interventions
Targeted examination of affected organ systems
Pathophysiology, Assessment, and Management of Respiratory Emergencies
Cardiopulmonary arrest in children is primarily secondary to progressive respiratory failure or shock. Rapid recognition and treatment of respiratory compromise are vital.
Stages of Respiratory Compromise
Respiratory Distress: Increased work of breathing required to maintain adequate pulmonary gas exchange.
Respiratory Failure: Compensatory mechanisms fail, resulting in inadequate gas exchange, hypoxia, and CO2 retention.
Respiratory Arrest: Complete cessation of spontaneous breathing.
Emergency Respiratory Management Protocols
Administer supplemental high-flow oxygen.
Initiate continuous ECG monitoring.
Establish IV access.
Manage airway patency.
Reserve supraglottic airways and endotracheal intubation for cases where bag-mask ventilation is ineffective.
Foreign Body Airway Obstruction (FBAO)
High incidence in infants and toddlers.
Clinical Presentation
Mild Obstruction: Patient conscious, stridor present, increased work of breathing, preserved skin color.
Severe Obstruction: Cyanosis, marked respiratory distress, progression to unconsciousness.
FBAO Management Procedures
Responsive Infant (< 1 year)
Deliver 5 back slaps between the scapulae.
Flip infant supine and deliver 5 chest thrusts over the lower sternum.
Repeat until object is expelled or infant becomes unresponsive.
Unresponsive Infant (< 1 year)
Initiate CPR with 30 chest compressions.
Inspect the oral cavity; remove foreign body only if clearly visible (no blind finger sweeps).
Attempt ventilation; continue compressions and ventilation cycles.
Reassess pulse.
Responsive Child (> 1 year)
Administer abdominal thrusts (Heimlich maneuver) until object is cleared or patient loses consciousness.
Unresponsive Child (> 1 year)
Place supine, perform 30 chest compressions.
Inspect mouth and clear visible objects.
Perform direct laryngoscopy and remove foreign body under direct visualization using Magill forceps.
Anaphylaxis
Rapid-onset, life-threatening systemic allergic response triggered by antigen exposure.
Mild: Isolated urticaria (hives) and wheezing.
Severe: Airway compromise, stridor, oral/lip edema, profound shock, and altered consciousness.
Treatment: Immediate Intramuscular Epinephrine, supplemental high-flow oxygen, IV fluid resuscitation, Diphenhydramine (Benadryl), inhaled bronchodilators, and systemic corticosteroids.
Upper Airway Infections
Croup (Laryngotracheobronchitis)
Viral infection causing upper airway inflammation.
History: Several days of upper respiratory cold symptoms and low-grade fever.
Signs: Characteristic barky “seal-like” cough, inspiratory stridor, respiratory distress.
Management: Position of comfort, minimize agitation, administer systemic Dexamethasone, nebulized racemic epinephrine, and assisted bag-mask ventilation if respiratory failure occurs.
Epiglottitis
Severe bacterial inflammation of the epiglottis and supraglottic structures.
Signs: High fever, toxic appearance, anxious, sitting in a “sniffing” or tripod position, drooling, inability to swallow, stridor, cyanosis. Symptoms progress rapidly.
Management: Do not agitate or examine throat. Assess immunization status. Transport immediately with preparations for emergency airway management (BMV and endotracheal intubation).
Bacterial Tracheitis
Bacterial infection of subglottic tracheal tissues.
Signs: High fever, severe croup-like cough, stridor, respiratory distress following a primary viral illness.
Management: Keep patient calm; provide oxygen and supportive airway management.
Lower Airway and Parenchymal Disorders
Asthma
Chronic inflammatory airway disorder involving bronchospasm, mucosal edema, and mucus hypersecretion.
Triggers: Viral upper respiratory infections, allergens, cold air, weather shifts, secondhand smoke.
Signs: Persistent cough, expiratory wheezing, extended expiratory phase, retractions.
Management: Position of comfort, high-flow oxygen, nebulized bronchodilators (Beta-2 agonists), IM Dexamethasone, and IM/SQ Epinephrine for severe, refractory distress.
Respiratory Syncytial Virus (RSV) and Bronchiolitis
Viral infection leading to inflammation and edema of the small bronchioles.
Highly contagious via direct droplet contact or contaminated surfaces/fomites.
Early Symptoms: Sneezing, rhinorrhea, nasal congestion, cough, low fever.
Progressive Signs: Tachypnea, intercostal/subcostal retractions, diffuse wheezing and rales (crackles), mild to severe hypoxia.
High-Risk Groups: Preterm infants, infants under 6 months, underlying congenital heart disease, chronic lung disease, immunocompromised.
Management: Supportive care, suctioning thick nasal secretions, oxygen administration. If refractory, administer nebulized racemic epinephrine. Maintain standard PPE (gloves, hand hygiene, equipment decontamination).
Pneumonia
Infection of the lung parenchyma.
Signs: Unusually rapid breathing (tachypnea), grunting, wheezing, localized rales, fever or hypothermia.
Management: Supportive oxygenation and transport.
Pertussis (Whooping Cough)
Highly contagious bacterial respiratory infection presenting initially with common cold symptoms, progressing to severe paroxysmal coughing fits.
Maintain airway patency and transport.
Cystic Fibrosis (CF)
Genetic exocrine gland disorder leading to abnormally thick mucus accumulation in respiratory and digestive tracts.
Signs: Chronic cough, tachypnea, chest pain, pulmonary crackles, recurrent infections.
Management: Administer oxygen and support ventilation.
Bronchopulmonary Dysplasia (BPD)
Chronic lung condition seen in premature infants exposed to long-term high-concentration oxygen therapy and mechanical ventilation.
Patients often require chronic home oxygen. Manage ABCs, consider bag-mask ventilation, positive airway pressure, or intubation during acute decompensation.
Pediatric Airway Management, Oxygenation, and Advanced Airway Interventions
Basic Airway Positioning and Adjuncts
Position airway using modified head tilt-chin lift or jaw-thrust maneuver without hyperextending the neck.
Oropharyngeal Airway (OPA)
Indication: Unresponsive patients without a gag reflex.
Function: Moves the tongue forward away from the posterior pharynx; facilitates suctioning.
Insertion: Insert using a tongue depressor to lift the tongue, sliding the airway directly over the tongue. Avoid rotating 180 degrees to prevent soft tissue damage to the hard and soft palates.
Nasopharyngeal Airway (NPA)
Indication: Conscious or semi-conscious patients with altered level of consciousness requiring airway support.
Contraindications: Severe facial trauma; rarely utilized in infants under 1 year of age.
Complications: Epistaxis, mucosal trauma, airway obstruction if sizing is incorrect.
Supplemental Oxygen Delivery
Blow-by Technique
Used when low oxygen concentrations are needed or when the child cannot tolerate a facial mask.
Nonrebreathing Mask
Preferred for pediatric patients in respiratory distress or failure.
Administers up to 95% inspired oxygen at flow rates of 10 to 15 L/min.
Bag-Mask Ventilation (BMV)
Indication: Apnea, severe respiratory failure, or inadequate respiratory rate/depth despite oxygenation.
Ventilation Rate: 20 to 30 breaths/min for infants and children.
Technique: Ensure proper mask seal using the “C-E” grip. Two-person ventilation is preferred to optimize seal and volume delivery.
Complications: Hyperventilation or excessive pressure causes gastric distention, elevated intrathoracic pressure, and decreased venous return (preload) to the heart.
Advanced Airway Management
Supraglottic Airways
Utilized for positive-pressure ventilation in apneic or unresponsive patients when advanced airway control is required and intubation is unfeasible.
Endotracheal Intubation (ETI)
Indications: Cardiopulmonary arrest, severe traumatic brain injury, inability to maintain airway patency, or requirement for prolonged mechanical ventilation when BMV is ineffective.
Complications: Hypoxia, unrecognized esophageal placement, induced emesis/aspiration, elevated intracranial pressure (ICP), bradycardia, and vocal cord or dental trauma.
Equipment Selection
Laryngoscope blade length extends from the corner of the mouth to the tragus of the ear.
Blade Sizes:
Premature newborn: Size 0 straight blade.
Full-term newborn to 1 year: Size 1 straight blade.
2 years to adolescent: Size 2 straight blade.
Adolescent+: Size 3 straight or curved blade.
Endotracheal Tube (ET) Sizing Formulas
Uncuffed ET Tube Sizing
Infants up to 1 year: 3.5 mm
Children 1 to 2 years: 4.0 mm
Children > 2 years:
Uncuffed Tube Size (mm) = 4 + (age in years / 4)
Cuffed ET Tube Sizing
Infants: 3.0 mm
Children 1 to 2 years: 3.5 mm
Children > 2 years:
Cuffed Tube Size (mm) = 3.5 + (age in years / 4)
Insertion Depth and Monitoring
Insert tube to a depth of 2 to 3 cm beyond the vocal cords.
Confirm and record depth mark at the corner of the lip.
Maintain continuous pulse oximetry and ECG monitoring.
Use the DOPE mnemonic to troubleshoot sudden deterioration in an intubated patient:
D: Displacement of tube (esophageal or right mainstem).
O: Obstruction (mucus plug, kink, blood).
P: Pneumothorax (tension pneumothorax).
E: Equipment failure (oxygen disconnect, bag failure, cuff leak).
Gastric Decompression
Indication: Placement of a Nasogastric (NG) or Orogastric (OG) tube to decompress the stomach, remove gastric contents via suction, and improve ventilatory capacity.
Contraindications: Unresponsive patients without a protected advanced airway (intubate prior to placement).
Procedure: Measure from nose/mouth to earlobe, then to xiphoid process; mark tube. Lubricate tip. OG: pass over tongue into hypopharynx and stomach. NG: pass through naris. If resistance met, try OG route.
Confirmation: Aspirate gastric contents and auscultate a rush of air over the epigastrium. Secure to nose/cheek. Remove immediately if choking, coughing, or voice alterations occur.
Pathophysiology, Assessment, and Management of Shock
Shock is defined as systemic hypoperfusion resulting in inadequate delivery of oxygen and nutrients to tissues to meet cellular metabolic demands.
Classifications of Shock
Hypovolemic Shock: Loss of intravascular fluid volume (most common type in children).
Distributive Shock: Abnormal vasodilation and fluid third-spacing.
Cardiogenic Shock: Primary myocardial pump failure.
Stages of Shock
Compensated Shock: Tachycardia, peripheral vasoconstriction, delayed capillary refill (> 2 seconds), cool extremities, and narrow pulse pressure. Normal systolic blood pressure maintained.
Decompensated Shock: Compensatory mechanisms fail. Profound tachycardia, weak/absent peripheral pulses, altered mental status, cold mottled skin, and hypotension (an ominous, late finding pre-cardiac arrest).
Hypovolemic Shock Management
Causes: Dehydration (vomiting/diarrhea), hemorrhage, burns.
Position of comfort, high-flow oxygen, keep patient warm, direct pressure for hemorrhage.
Obtain Intravenous (IV) or Intraosseous (IO) access.
Fluid Resuscitation: Administer isotonic crystalloids (Normal Saline or Lactated Ringer’s) as a rapid fluid bolus of 20 mL/kg. Reassess perfusion and repeat as indicated.
IO needles consist of a solid-bore stylet inside a sharpened hollow needle, inserted into the proximal tibia or distal femur if IV access fails.
Distributive Shock (Septic Shock) Management
Caused primarily by systemic sepsis.
Manifests as altered vascular tone, fluid leaking into interstitial spaces, vasodilation.
Administer repetitive isotonic crystalloid or colloid fluid boluses (20 mL/kg).
Treat fluid-refractory septic shock with continuous vasoactive infusions (Epinephrine or Norepinephrine).
Cardiogenic Shock Management
Underlying causes: Congenital heart disease, myocarditis, cardiomyopathy, severe dysrhythmias.
Signs: Respiratory distress, listlessness, pale/cyanotic/clammy skin, hepatomegaly (enlarged liver), sweating during feeding.
Management: Oxygen, position of comfort, rapid transport to a facility with pediatric critical care capabilities.
Fluid boluses must be administered with extreme caution (5 to 10 mL/kg). Stop fluids if work of breathing increases, SpO2 drops, or pulmonary crackles develop.
Pathophysiology, Assessment, and Management of Cardiovascular Emergencies
Pediatric cardiac arrest rarely stems from primary cardiac disease; it typically results from uncorrected hypoxemia or circulatory shock.
Pediatric Dysrhythmias
Bradydysrhythmias
Almost always secondary to tissue hypoxia.
Treatment: Airway clearance, high-flow oxygen, assisted ventilation. If heart rate remains < 60 beats/min with poor perfusion despite adequate ventilation and oxygenation, begin chest compressions and administer Epinephrine.
Sinus Bradycardia: HR below normal range for age.
Atrioventricular (AV) Blocks
First-degree AV Block: Prolonged PR interval; usually asymptomatic, requires no intervention.
Second-degree AV Block: Progressive PR prolongation with dropped QRS; may progress to Third-degree block and cause hemodynamic compromise.
Tachydysrhythmias
Elevated pulse rate classified by QRS complex duration:
Narrow-Complex Tachycardia: QRS duration ≤ 0.09 seconds.
Wide-Complex Tachycardia: QRS duration > 0.09 seconds.
Supraventricular Tachycardia (SVT)
Most common pediatric tachydysrhythmia requiring active intervention.
Characteristics: Unvarying heart rate > 220 beats/min in infants or > 180 beats/min in children; narrow QRS; absent P waves.
Management:
Adequate Perfusion: Attempt vagal maneuvers (e.g., ice to face); establish IV and administer Adenosine.
Poor Perfusion / Unstable: Immediate Synchronized Cardioversion (0.5 to 1 J/kg, escalating to 2 J/kg).
Wide-Complex Tachycardia / Ventricular Tachycardia (VT)
Stable with Pulses: Antidysrhythmic infusions (e.g., Amiodarone or Procainamide) under expert consultation.
Unstable with Pulses: Synchronized Cardioversion.
Pulseless VT / Ventricular Fibrillation (VF): Immediate CPR, Defibrillation (2 J/kg initial, subsequent 4 J/kg, max 10 J/kg), vascular access, Epinephrine, and Amiodarone/Lidocaine.
Non-Shockable Pulseless Arrest (Asystole / PEA)
High-quality CPR, vascular access, Epinephrine administration every 3-5 minutes, advanced airway placement, and correction of reversible causes.