Respiratory Emergencies
Respiratory emergencies are the most common critical pediatric presentations. Candidates must distinguish upper from lower airway disease and recognize the classic patterns: croup (barking cough, stridor, steeple sign), epiglottitis (drooling, tripod positioning, muffled voice), bronchiolitis (wheezing, viral prodrome, age under two), asthma (diffuse wheeze, prolonged expiration), and foreign body aspiration (sudden onset, unilateral findings).
Understand severity assessment using work of breathing, air entry, mental status, and oxygen saturation. Know first-line therapies: nebulized epinephrine and corticosteroids for croup, bronchodilators and corticosteroids for asthma, supportive care for bronchiolitis, and avoidance of airway agitation in suspected epiglottitis. Recognize that pulse oximetry can be falsely reassuring and that clinical trajectory matters.
Traps: agitating a child with suspected epiglottitis by examining the throat; giving antibiotics routinely for bronchiolitis; and failing to recognize silent chest as impending failure in asthma. Another trap is attributing stridor to croup when the history suggests a foreign body or anaphylaxis.
Worked example: a child with asthma and a silent chest, exhaustion, and rising carbon dioxide is in impending respiratory failure and needs immediate escalation, not just another bronchodilator. Rule of thumb: worsening mental status and decreasing air entry are more ominous than the wheeze itself.