Recognition and Management of Respiratory and Circulatory Emergencies
Pediatric deterioration is predictable: respiratory distress progresses to respiratory failure and then arrest, and compensated shock progresses to hypotensive shock and then cardiac arrest. Bradycardia in a child should be treated as hypoxia until proven otherwise, so oxygenation and ventilation come before any drug.
Begin with the pediatric assessment triangle - appearance, work of breathing, and circulation to skin - which takes seconds and needs no equipment. A limp, unresponsive child with a weak cry is abnormal on appearance alone even with a normal respiratory rate. Then perform the ABCDE assessment and compare vital signs with age-specific norms.
Distinguish distress from failure. Distress means tachypnea with retractions, nasal flaring, grunting, head bobbing, stridor or wheeze, but preserved mental status and saturation. Failure adds altered mental status, poor respiratory effort, cyanosis, and bradycardia; that child needs bag-mask ventilation now, not a nebulizer trial.
Shock is inadequate oxygen delivery. Compensated shock shows tachycardia, cool mottled extremities, capillary refill over 2 seconds, weak pulses, and narrow pulse pressure while blood pressure remains normal. Hypotension is a late sign; approximate systolic thresholds are under 60 mmHg in a term neonate, under 70 in an infant 1–12 months, under 70 + (2 × age in years) for ages 1–10, and under 90 over age 10. Treat with oxygen, IV/IO access, and 20 mL/kg isotonic crystalloid boluses, reassessing for hepatomegaly, rales, or worsening work of breathing after each.
Trap: choosing an answer that waits for hypotension before treating shock, or giving epinephrine before ventilation in a hypoxic bradycardic child.
Worked example: an 8-month-old with HR 200, capillary refill 4 seconds, mottling, and BP 78/50 is in compensated shock despite the normal pressure - give 20 mL/kg and reassess.