Emergency and Critical Care
This domain tests the systematic assessment of the acutely ill child, resuscitation, shock, and time-critical antidotes.
Assessment and resuscitation
- The paediatric assessment triangle evaluates appearance, work of breathing and circulation at the bedside before any equipment.
- Estimated weight in children aged 1-10 years: (age + 4) x 2 kg.
- High-quality CPR: rate 100-120/min, depth one third of the anteroposterior chest diameter, compression-to-ventilation ratio 30:2 for one rescuer and 15:2 for two.
- Epinephrine 0.01 mg/kg of 1:10,000 intravenously or intraosseously; defibrillation at 2 J/kg, escalating to 4 J/kg.
Shock
- Compensated shock maintains blood pressure with tachycardia and prolonged capillary refill; decompensated shock brings hypotension.
- Give 20 mL/kg isotonic crystalloid boluses (10 mL/kg in neonates and cardiac disease) and reassess; septic shock requires antibiotics within the first hour.
Fluids and electrolytes
- Maintenance with the 4-2-1 rule. Use isotonic fluid with dextrose rather than hypotonic fluid, which causes hospital-acquired hyponatraemia.
Toxicology and environmental emergencies
- Activated charcoal is useful within 1 hour of ingestion in a protected airway.
- Naloxone reverses opioids; N-acetylcysteine treats acetaminophen overdose, guided by the Rumack-Matthew nomogram at 4 hours.
- Burns: Parkland formula of 4 mL/kg per percent total body surface area of lactated Ringer solution in 24 hours, half in the first 8 hours.
Worked example
A 2-year-old arrives convulsing for 5 minutes. Reasoning: check glucose, secure intravenous access, give lorazepam 0.1 mg/kg, repeat once after 5 minutes if seizures persist, then load levetiracetam.
Traps
Using hypotonic maintenance fluid; delaying epinephrine in anaphylaxis; under-resuscitating septic shock; and forgetting the glucose check in any altered conscious state.