Pediatric Emergencies
What the board tests
Rapid paediatric assessment, weight-based dosing, the febrile infant pathway, and the common respiratory and metabolic emergencies, where dose errors and over-investigation are the usual failure points.
Assessment and the febrile infant
- Pediatric Assessment Triangle: appearance, work of breathing, circulation to skin. It determines immediate action before vital signs.
- Estimate weight as (age in years + 4) x 2, or use a length-based tape, and dose everything by weight.
- Febrile infant aged 28 days or less: full sepsis evaluation including lumbar puncture, IV antibiotics and admission, regardless of appearance.
- Age 29-90 days: use a validated risk stratification pathway to decide on LP, antibiotics and admission.
Respiratory and neurological
- Bronchiolitis is supportive: oxygen or high-flow nasal cannula, hydration, suction. Do not routinely give salbutamol, steroids or antibiotics.
- Croup: dexamethasone 0.15-0.6 mg/kg; nebulised adrenaline 0.5 mL/kg of 1:1000 (maximum 5 mL) for moderate to severe stridor, with observation for rebound after 2-4 h. Suspected epiglottitis: do not inspect the throat; take to theatre with anaesthesia.
- Status epilepticus: midazolam 0.2 mg/kg buccal or IM, or lorazepam 0.1 mg/kg IV, then a second-line agent.
- Anaphylaxis: IM adrenaline 0.01 mg/kg (maximum 0.5 mg) into the anterolateral thigh.
Fluids and DKA
- Dehydration: isotonic crystalloid 20 mL/kg bolus for shock; avoid hypotonic maintenance fluids.
- DKA: give 10 mL/kg only if shocked, then rehydrate over 48 h, start insulin at 0.05-0.1 unit/kg/h, and watch for headache, bradycardia and hypertension as signs of cerebral oedema, treated with mannitol 0.5-1 g/kg or 3% saline.
Worked example
A 3-year-old with a 2-day history of vomiting and polyuria is drowsy, glucose 28 mmol/L, pH 7.10, ketones 5 mmol/L. Give 10 mL/kg isotonic saline because of drowsiness, then start insulin 0.05 unit/kg/h with rehydration over 48 h, monitor neurology hourly, and add potassium once urine output is established. Reasoning: the child is not in circulatory shock, so a large bolus would increase cerebral oedema risk.
Traps
Routine bronchodilators in bronchiolitis; inspecting the throat in suspected epiglottitis; adrenaline dose errors in children; large or repeated boluses in paediatric DKA; missing non-accidental injury patterns.