Key Facts

Paediatric emergencies require specific knowledge of age-related normal values, weight-based dosing, and the recognition that children's physiology differs significantly from adults. The APLS (Advanced Paediatric Life Support) framework provides a structured approach.

Epidemiology

Children account for approximately 25% of all ED attendances. The most common presentations are respiratory illness, febrile illness, trauma, and gastroenteritis. Paediatric cardiac arrest is uncommon (~0.5-2 per 100,000 children/year) and is usually due to respiratory failure or shock (not primary cardiac causes).

Aetiology

• Respiratory: Bronchiolitis, croup, asthma, pneumonia, foreign body inhalation
• Infection/sepsis: Meningitis, UTI, septicaemia, gastroenteritis
• Trauma: Falls, RTCs, non-accidental injury
• Metabolic: DKA, hypoglycaemia, inborn errors of metabolism
• Neurological: Febrile seizures, epilepsy, meningitis/encephalitis

Pathophysiology

Children have higher metabolic rates, smaller functional residual capacity, and greater oxygen consumption relative to adults. They maintain cardiac output primarily through heart rate (limited stroke volume reserve). Decompensation is therefore rapid and catastrophic when compensatory mechanisms fail. The paediatric airway is smaller, more anterior, and the epiglottis is larger — increasing the risk of obstruction.

Paediatric Assessment Triangle

• Appearance: Tone, interactiveness, consolability, look/gaze, speech/cry (TICLS)
• Work of breathing: Nasal flaring, grunting, intercostal/subcostal recession, head bobbing, tracheal tug
• Circulation to skin: Pallor, mottling, cyanosis

Age-Specific Normal Values

Red Flags

• Non-blanching rash — meningococcal sepsis until proven otherwise
• Altered consciousness/activity level — serious infection, raised ICP, metabolic
• Persistent tachycardia despite antipyretics/fluids — significant illness
• Hypotension in a child — PRE-ARREST; this is a LATE sign
• Bulging fontanelle in infant — raised ICP
• Bile-stained vomiting in infant — malrotation/volvulus (surgical emergency)

Bedside

• Weight: Essential for all drug/fluid calculations
• Blood glucose: Capillary — hypoglycaemia common in sick children
• Temperature: Tympanic or axillary
• SpO2: Continuous in acutely unwell child
• Urine dipstick/MC&S: Febrile children — UTI screening

Bloods

• FBC, CRP, blood culture: If sepsis suspected
• U&Es, glucose: Dehydration, DKA
• Blood gas (capillary/venous): pH, lactate, bicarbonate
• Group and save: If significant haemorrhage or surgery anticipated

Imaging

• CXR: Respiratory distress, fever
• AXR: Suspected obstruction, ingested foreign body
• CT head: Significant head injury, reduced consciousness, seizures with focal features
• USS abdomen: Intussusception, pyloric stenosis, appendicitis

Special Tests

• LP: If meningitis suspected (after CT if raised ICP signs)
• Toxicology screen: If poisoning suspected

Non-pharmacological

• Paediatric assessment triangle: Rapid 'across the room' assessment
• ABCDE approach: Age-appropriate equipment (Broselow tape for sizing)
• Keep warm: Children lose heat rapidly (high BSA:weight ratio)
• Family presence: Evidence supports allowing parents at bedside during resuscitation

Pharmacological

• Fluid bolus: 20mL/kg 0.9% NaCl; reassess; up to 60mL/kg then consider inotropes
• Adrenaline (cardiac arrest): 10mcg/kg IV (0.1mL/kg of 1:10,000)
• Ceftriaxone 80mg/kg IV: Suspected meningitis/sepsis
• Dexamethasone 0.15mg/kg PO: Croup
• Nebulised adrenaline 5mL 1:1000: Severe croup
• Paracetamol 15mg/kg PO/PR + Ibuprofen 10mg/kg PO: Antipyretic/analgesic
• Buccal midazolam 0.5mg/kg (max 10mg): Seizure lasting >5 min
• IV lorazepam 0.1mg/kg: If midazolam fails

Surgical/Interventional

• IO access: If IV access fails within 60 seconds in arrest/peri-arrest
• Needle decompression: Tension pneumothorax (2nd ICS MCL)
• Emergency intubation: Use uncuffed ETT <8yr (or cuffed if available); ETT size = (age/4) + 4

Referral Criteria

• Sepsis with red-flag features — paediatric resuscitation area/PICU
• Meningitis — paediatric team, PICU
• NAI concerns — safeguarding team, social services, senior paediatrician
• Surgical emergencies (intussusception, volvulus, testicular torsion) — paediatric surgery

• Paediatric cardiac arrest survival: ~10-20% (better than adult OHCA due to often reversible cause)
• Meningococcal sepsis mortality: ~5-10% with treatment; ~50% without
• Febrile seizures: Benign in 95%; risk of epilepsy ~2-4% (vs 1% general population)
• Most paediatric ED presentations: Self-limiting viral illness with excellent prognosis
• NAI: Carries significant mortality and long-term morbidity; highest risk in infants

NICE Traffic Light System for Febrile Children (NG143)

APLS Drug Doses (Key)