Pediatric Emergencies

Framework for Pediatric Emergency Assessment

Pediatric emergencies require immediate recognition, rapid assessment, and age-specific interventions. Children differ from adults in anatomy, physiology, pharmacodynamics, and psychological response to illness or injury. Family nurse practitioners (FNPs) must differentiate between life-threatening conditions and benign presentations, often with limited history and nonverbal patients.

This section covers the high-yield emergencies most frequently tested on FNP board exams, including respiratory distress, shock, seizures, anaphylaxis, and traumatic injury. Mastery of these concepts is essential for safe clinical practice and certification success.^[1][2]

Essential Pediatric Emergency Terminology

• Pediatric Assessment Triangle (PAT) — A rapid, hands-off visual assessment used to identify the physiologic stability of a child. Components: appearance, work of breathing, and circulation to the skin.^[3]
• Cardiopulmonary arrest in children — Most often results from progressive respiratory failure or shock, not primary cardiac causes (as in adults).^[1]
• Respiratory distress vs. respiratory failure — Distress is compensated (tachypnea, retractions, nasal flaring). Failure is decompensated (bradypnea, altered mental status, cyanosis, impending arrest).^[2]
• Compensated vs. decompensated shock — Compensated: tachycardia, cool extremities, delayed capillary refill, normal blood pressure. Decompensated: hypotension, bradycardia (late sign), altered consciousness.^[1]
• Weight-based dosing — All pediatric emergency medications are dosed per kilogram (mg/kg). Use the Broselow tape or a length-based system when weight is unknown.^[4]

Structured Emergency Evaluation Protocols

The Pediatric Assessment Triangle (PAT)

1. Appearance — Assess tone, interactiveness, consolability, gaze, and cry (TICLS mnemonic). Abnormal appearance suggests neurologic or metabolic compromise.
2. Work of breathing — Observe for retractions (suprasternal, intercostal, subcostal), nasal flaring, head bobbing, grunting, and abnormal breath sounds.
3. Circulation to the skin — Evaluate pallor, mottling, cyanosis, and capillary refill time (>2 seconds is abnormal).^[3]

Primary and Secondary Survey (APLS Approach)

1. A — Airway — Open with head-tilt/chin-lift (no cervical spine injury) or jaw-thrust (if trauma suspected). Clear obstruction if present.
2. B — Breathing — Assess rate, effort, breath sounds, and oxygen saturation. Provide supplemental oxygen or bag-valve-mask ventilation as needed.
3. C — Circulation — Assess heart rate, pulse quality, capillary refill, blood pressure, and skin temperature. Establish IV/IO access.
4. D — Disability — Rapid neurologic exam: AVPU (Alert, Voice, Pain, Unresponsive), pupil reactivity, and Glasgow Coma Scale.
5. E — Exposure — Fully undress the child to identify hidden injuries, rashes, or signs of abuse, while preventing hypothermia.^[1][2]

Weight-Based Resuscitation

• Use the Broselow tape or a standardized length-based system to estimate weight in children <12 years old.
• Alternative formula (if length-based tool unavailable): Weight (kg) = (Age in years × 2) + 8 for children aged 1–10 years.^[4]
• All emergency medications (epinephrine, adenosine, atropine, amiodarone, etc.) must be calculated in mg/kg and drawn up accurately prior to administration.

Presentation Patterns in Pediatric Emergencies

Respiratory Distress and Failure

• Early signs (compensated): Tachypnea, intercostal/subcostal retractions, nasal flaring, grunting, accessory muscle use, tachycardia.
• Late signs (decompensated/failure): Bradypnea, irregular breathing, head bobbing, seesaw respirations, cyanosis, altered mental status, bradycardia.^[2]

Shock (Hypovolemic, Distributive, Cardiogenic)

Critical exam point: Hypotension is a late and ominous finding in pediatric shock. Do not rely on normal blood pressure to rule out shock.^[1][5]

Seizures (Status Epilepticus)

• Continuous seizure activity lasting >5 minutes, or two or more seizures without full return to baseline.
• Assess airway, breathing, circulation immediately. Check blood glucose rapidly.
• Common causes: febrile seizure (most common in ages 6 months–5 years), epilepsy, infection (meningitis/encephalitis), electrolyte imbalance, toxin exposure, head trauma.^[6]

Anaphylaxis

• Rapid onset of urticaria, angioedema, stridor, wheezing, hypotension, and/or gastrointestinal symptoms (vomiting, diarrhea).
• Cutaneous symptoms may be absent in up to 20% of pediatric anaphylaxis cases.^[7]

Diagnostic Workup and Clinical Reasoning

• Respiratory distress: Obtain pulse oximetry, arterial blood gas (if severe), and chest radiograph. Assess for foreign body aspiration (sudden onset, unilateral wheeze), croup (barking cough, stridor), bronchiolitis (wheezing, nasal congestion in infants), and asthma (expiratory wheeze, prolonged expiration).^[2]
• Shock: Evaluate heart rate, blood pressure (use appropriate cuff size), capillary refill, and mental status. Obtain bedside glucose, lactate, blood cultures (if septic), and consider point-of-care ultrasound (FOCUS) to assess cardiac function and IVC collapsibility.^[5]
• Seizures: Immediate bedside glucose check. Obtain electrolytes, calcium, magnesium, and anticonvulsant levels if applicable. Consider CT head or lumbar puncture if intracranial pathology or meningitis suspected.^[6]
• Anaphylaxis: Clinical diagnosis — no lab test is required. Serum tryptase may support the diagnosis but should not delay treatment.^[7]
• Trauma: Perform primary and secondary survey per ATLS/APLS guidelines. Immobilize cervical spine. Obtain focused imaging (FAST exam, CT as indicated). Assess for non-accidental trauma if injury pattern is inconsistent with history.^[1]

Acute Management Strategies for Pediatric Emergencies

Respiratory Failure

• Administer high-flow oxygen via non-rebreather mask or bag-valve-mask if breathing is inadequate.
• Consider continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) in awake, spontaneously breathing children with respiratory distress.
• Rapid sequence intubation (RSI) is indicated if respiratory failure persists or consciousness deteriorates.^[2]
• For foreign body aspiration: perform back blows and chest thrusts (<1 year old) or abdominal thrusts (>1 year old). Use Magill forceps only if object is visualized during laryngoscopy.^[1]

Shock Resuscitation

• Hypovolemic shock: Administer 20 mL/kg isotonic crystalloid (normal saline or lactated Ringer's) IV/IO bolus. Reassess and repeat up to 60 mL/kg. Consider blood products if hemorrhagic shock.^[5]
• Distributive shock (septic): Fluid resuscitation plus broad-spectrum antibiotics within 1 hour of recognition. Vasopressors (norepinephrine, epinephrine) if fluid-refractory. Obtain blood cultures prior to antibiotics if possible without delay.^[5]
• Cardiogenic shock: Administer fluid cautiously (5–10 mL/kg slow push). Avoid excessive volume. Consider inotropes (milrinone, dobutamine) and consult cardiology urgently.^[1]

Status Epilepticus Management Sequence

1. First-line (0–5 minutes): Stabilize airway, breathing, circulation. Check glucose. Administer benzodiazepine — rectal diazepam (0.5 mg/kg), intranasal/intramuscular midazolam (0.2 mg/kg), or IV lorazepam (0.1 mg/kg).^[6]
2. Second-line (5–20 minutes): If seizure continues, administer fosphenytoin (20 mg PE/kg IV/IO) or levetiracetam (40–60 mg/kg IV).
3. Third-line (>20 minutes): Continuous EEG monitoring. Administer midazolam infusion, pentobarbital, or propofol with ICU support. Consider pyridoxine for refractory seizures in infants.^[6]

Anaphylaxis

• Epinephrine IM (0.01 mg/kg, max 0.3–0.5 mg) in the anterolateral thigh — first-line treatment. Do not delay for antihistamines or steroids. Repeat every 5–15 minutes as needed.^[7]
• Place the patient supine with legs elevated if hypotensive. Administer oxygen. Start IV fluids (20 mL/kg bolus).
• Diphenhydramine 1 mg/kg IV/IM/PO (max 50 mg) and methylprednisolone 1–2 mg/kg IV (max 125 mg) are adjuncts, not replacements for epinephrine.
• Albuterol nebulization for bronchospasm. Observe for biphasic reaction (up to 20% of cases) — monitor for at least 4–6 hours post-resolution.^[7]

Risk Mitigation and Complication Avoidance

• Hypothermia prevention: Children lose body heat rapidly due to high body surface area-to-weight ratio. Use warm fluids, warming blankets, and overhead warmers during resuscitation. Hypothermia worsens coagulopathy and metabolic acidosis.^[1]
• Medication dosing errors: Pediatric medication errors occur most frequently during emergencies. Use weight-based dosing tools (Broselow tape, code sheets) and double-check calculations with a second clinician. Avoid decimal errors (e.g., 0.1 mg vs. 1 mg).^[4]
• Cervical spine immobilization: Presume spinal injury in any child with multisystem trauma, altered mental status, or injury above the clavicles. Use a properly sized cervical collar and manual stabilization during airway management.^[1]
• Non-accidental trauma (child abuse): Consider in cases of unexplained injury, inconsistent history, delayed presentation, or patterned bruising (e.g., handprint, belt mark). Report to child protective services per state law. Document injuries with photographs and body diagrams.^[1]
• Biphasic anaphylaxis: Symptoms may recur 1–8 hours after initial resolution. Families should be prescribed an epinephrine auto-injector and taught proper use. Provide an allergy action plan.^[7]

Board-Focused Clinical Pearls

• Know the Pediatric Assessment Triangle (PAT) — It is heavily tested on FNP board exams as the first step in any pediatric emergency assessment.
• Normal vital signs change with age. Memorize age-appropriate ranges: heart rate decreases from 120–160 (neonate) to 70–100 (adolescent); respiratory rate decreases from 30–60 (neonate) to 12–20 (adolescent).^[1]
• Blood pressure is NOT a reliable indicator of early shock. Children compensate with tachycardia and increased systemic vascular resistance. Hypotension is a pre-arrest sign.
• Epinephrine IM is the ONLY first-line treatment for anaphylaxis. Antihistamines and steroids are adjunctive. Test questions often try to trick you into giving diphenhydramine first — do not fall for it.^[7]
• In status epilepticus, give a benzodiazepine first. If the seizure continues beyond 5 minutes, proceed to fosphenytoin or levetiracetam. Always check glucose immediately.^[6]
• Fluid boluses: 20 mL/kg IV/IO, reassess, repeat. This is the standard approach for hypovolemic and septic shock. Do not give dextrose-containing fluids for boluses unless treating hypoglycemia.^[5]
• Age-specific airway anatomy: children have a larger occiput, smaller nares, relatively larger tongue, higher and more anterior glottis, and narrower cricoid ring (the narrowest part of the pediatric airway, unlike adults where the glottis is narrowest).
• Use length-based systems (Broselow tape) for weight estimation and drug dosing — this is the recommended standard by the AAP and AHA.^[4]

References and Sources

1. American Academy of Pediatrics, American College of Emergency Physicians. APLS: The Pediatric Emergency Medicine Resource. 5th ed. Jones & Bartlett Learning; 2020. https://www.amazon.com/APLS-Pediatric-Emergency-Medicine-Resource/dp/1449695965
2. Mick NW, Wright JL, DeBerry L. Pediatric Respiratory Emergencies: An Evidence-Based Approach. Emerg Med Clin North Am. 2018;36(2):345-363. https://www.sciencedirect.com/science/article/abs/pii/S0733862717301402
3. Dieckmann RA, Brownstein D, Gausche-Hill M. The pediatric assessment triangle: a novel approach for the rapid evaluation of children. Pediatr Emerg Care. 2010;26(4):312-315. https://nwhrn.org/wp-content/uploads/2018/08/Dieckmann-et-al-the-PAT.pdf
4. American Heart Association. Pediatric Advanced Life Support (PALS) Provider Manual. AHA; 2020. https://shopcpr.heart.org/pals-provider-manual
5. Davis AL, Carcillo JA, Aneja RK, et al. The American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock. Crit Care Med. 2017;45(6):1061-1093. https://doi.org/10.1097/CCM.0000000000002425
6. Glauser T, Shinnar S, Gloss D, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the Guideline Committee of the American Epilepsy Society. Epilepsy Currents. 2016;16(1):48-61. https://doi.org/10.5698/1535-7597-16.1.48
7. Shaker MS, Wallace DV, Golden DBK, et al. Anaphylaxis—a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis. J Allergy Clin Immunol. 2020;145(4):1082-1123. https://doi.org/10.1016/j.jaci.2020.01.017