Paediatric Emergencies, Intensive Care and Anaesthesiology
This domain tests structured resuscitation of the child, weight-based drug and fluid calculations, and recognition of shock and raised intracranial pressure. The recurring theme is that children compensate well and then decompensate abruptly, so early signs must not be dismissed.
Assessment
Use the paediatric assessment triangle (appearance, work of breathing, circulation) followed by ABCDE. Estimate weight with the APLS formula (age + 4) x 2 kg, or a length-based tape. Normal ranges differ by age: heart rate about 120-160 in infants, 90-140 in toddlers, 70-110 in school age; respiratory rate 30-40 in infants falling to 12-20 in adolescence; systolic pressure roughly 70 + (2 x age).
Shock and resuscitation
- Fluid bolus 10-20 mL/kg crystalloid, reassess, repeat; septic shock needs antibiotics within one hour and early vasoactive support if fluid-refractory.
- Compressions at 100-120/min with a compression to ventilation ratio of 15:2 for two rescuers; adrenaline 10 micrograms/kg; defibrillation 2 J/kg then 4 J/kg.
- Check glucose in any collapsed child; hypoglycaemia is a readily missed cause.
- Raised intracranial pressure: headache, vomiting, hypertension with bradycardia, unequal pupils; nurse at 30 degrees, avoid hypoxia and hypercapnia, use hypertonic saline or mannitol.
Specific emergencies
Croup versus epiglottitis versus inhaled foreign body: do not examine the throat if epiglottitis is suspected. Burns: Parkland formula for crystalloid, and remember airway involvement. Paracetamol overdose: N-acetylcysteine; check the timed concentration. Drowning and trauma: cervical spine protection and early haemorrhage control.
Anaesthesia
Standard fasting is 2 hours for clear fluids, 4 hours for breast milk and 6 hours for solids. Premedication and consent follow the same legal rules as any procedure; for elective surgery the child must be fit and the parents fully informed.
Worked example
A 15 kg 3-year-old with fever, mottled skin, capillary refill 4 seconds and a blood pressure of 70/40. This is septic shock. Give 20 mL/kg (300 mL) crystalloid rapidly, reassess, repeat once, take cultures if not delaying antibiotics, give broad-spectrum antibiotics within the hour, and start adrenaline if the child remains hypotensive after 40-60 mL/kg.
Traps
Using adult bolus volumes; delaying antibiotics for cultures; forgetting glucose; attempting to visualise the throat in suspected epiglottitis; applying adult defibrillation energies.