Pediatric Emergency, Critical Care and Toxicology
Emergency and critical care items test structured assessment, resuscitation numbers that must be automatic, shock and fluid strategy, and antidote pairing in poisoning. Toxicology questions are usually single-best-answer: identify the toxidrome, name the antidote, and state the window for decontamination.
Structured assessment
Use the Pediatric Assessment Triangle (appearance, work of breathing, circulation) to triage, then a full ABCDE approach. Reassess after every intervention.
Resuscitation numbers
- Compressions at 100-120 per minute to one-third of the anteroposterior chest depth, with a 15:2 compression-to-ventilation ratio when two rescuers are present.
- Epinephrine 0.01 mg/kg of 1:10,000 intravenously or intraosseously, repeated every 3-5 minutes.
- Defibrillation 2 J/kg, then 4 J/kg.
Shock
Give 20 mL/kg boluses of isotonic crystalloid and reassess after each; in septic shock consider inotropes after 40-60 mL/kg. Watch for hepatomegaly, crackles and worsening work of breathing that signal fluid overload. In trauma, control the bleeding rather than loading with fluid.
Toxicology
- Paracetamol: N-acetylcysteine; interpret levels on the Rumack-Matthew nomogram from four hours after ingestion.
- Organophosphate: atropine plus pralidoxime. Opioid: naloxone. Iron: desferrioxamine. Carbon monoxide: 100% oxygen. Salicylate: urinary alkalinisation with sodium bicarbonate.
- Activated charcoal within one hour only if the airway is protected and the substance is adsorbed.
- Beware flumazenil in mixed overdose because of seizure risk.
Other emergencies
Anaphylaxis: intramuscular adrenaline into the thigh. Burns: Parkland formula of 4 mL x weight in kg x percentage total body surface area, half in the first eight hours from the time of injury. Drowning: hypoxia is the target, so oxygenate and ventilate early.
Worked example
A 3-year-old is brought in an hour after swallowing an unknown number of iron tablets, with vomiting and bloody diarrhoea. This is early iron toxicity. Obtain a serum iron level and abdominal radiograph, give activated charcoal if the airway is protected and the ingestion was recent, and start desferrioxamine for systemic toxicity (metabolic acidosis, shock, serum iron above the treatment threshold). Monitor for hepatic failure over the next 48 hours.
Traps
Giving repeated fluid boluses without reassessing, using flumazenil in a mixed overdose, and forgetting that the Parkland clock starts at the time of the burn, not at arrival.