Ch10: Paediatric Emergencies & Resuscitation

Preparatory Mindset

Paediatric emergencies and resuscitation is the most OSCE-heavy chapter — examiners run simulation stations on ABCDE assessment, choking, CPR, status epilepticus, sepsis/shock, anaphylaxis, and febrile seizure. The mindset:

• ABCDE (Airway, Breathing, Circulation, Disability, Exposure) — the universal rapid assessment (<1 min) that every paediatric emergency OSCE tests. Airway is the priority (the "P" airway score warns when to maintain it).
• Paediatric CPR: 15 compressions : 2 breaths (single rescuer), 100-120/min, depth ~1/3 of chest, compression-to-breath ratio and rates adjusted by age; no pulse/HR <60 → compressions.
• Choking: back blows + abdominal thrusts (Heimlich — child), conscious vs unconscious algorithms; do NOT do blind finger sweeps.
• Status epilepticus (≥5 min convulsion): ABC → benzodiazepine (lorazepam/midazolam) → second-line (phenytoin/levetiracam) → ICU (thiopental/propofol) — and treat hypoglycaemia, check temperature, consider meningitis.
• Septic shock in children: recognition (cold extremities, prolonged cap refill, tachycardia, ↓BP late) → IV fluid bolus (20 mL/kg) → early antibiotics → inotropes — the "Golden Hour".
• Anaphylaxis: IM adrenaline (0.01 mg/kg = 0.1 mL/kg of 1:1000, max 0.5 mL) immediately → ABC, fluid, antihistamines/steroids adjuncts.

The common theme: early recognition + structured ABCDE + timely definitive interventions save paediatric lives.

Core Concepts

1. The ABCDE assessment (the universal tool)

Assessment should take <1 min — treat life threats as they are found, not sequentially.

2. Paediatric basic life support (BLS/CPR)

Sequence: check response → open airway → check breathing (≤10 s) → 5 rescue breaths (child) → start compressions → 15:2 → call for help/AED as soon as possible → AED: 4 J/kg (defibrillation) for shockable rhythms (VF/pulseless VT — rare in children, mostly post-cardiac surgery/hypothermia); most paediatric cardiac arrests are respiratory/hypoxic in origin — ventilation is critical.

Reversible causes (the 4 Hs and 4 Ts): Hypoxia, Hypovolaemia, Hypo/hyperkalaemia + metabolic, Hypothermia; Tension pneumothorax, Tamponade, Toxins, Thromboembolism.

3. Choking (foreign body airway obstruction)

Conscious child:

• Infant (<1 yr): 5 back blows (between shoulder blades) → 5 chest thrusts (alternating; NOT abdominal thrusts in infants).
• Child: 5 back blows → 5 abdominal thrusts (Heimlich) (fist above umbilicus, below xiphoid).
• Call for help after each cycle if not clearing; do NOT do blind finger sweeps (push object further).

Unconscious child: start CPR (15:2) — the compressions may dislodge the object; look in mouth only if visible; remove visible object.

4. Status epilepticus (SE) — the convulsing child

Definition: convulsion lasting ≥5 minutes (or recurrent without recovery) — an emergency; febrile convulsion (simple — 6 mo-5 yr, generalised, <15 min, once in 24 h) is common and benign, but prolonged/focal/recurrent = investigate (meningitis, epilepsy, metabolic).

SE management ladder:

1. ABC + oxygen; check glucose (bedside) + temperature.
2. First-line: IV lorazepam 0.1 mg/kg (or IV/IM/IN midazolam 0.1-0.2 mg/kg) — up to 2 doses.
3. Second-line (if still seizing ~10 min): IV phenytoin 20 mg/kg (or fosphenytoin / levetiracetam 40-60 mg/kg) — with cardiac monitoring (phenytoin arrhythmia).
4. Third-line (refractory — ICU): IV thiopental/propofol/midazolam infusion (anaesthesia) — intubation + EEG monitoring.
5. Treat cause: hypoglycaemia (10% dextrose 2 mL/kg), hyponatraemia, hypocalcaemia, meningitis (empiric antibiotics if suspected), fever (paracetamol).

5. Septic shock in children (recognition + Golden Hour)

Recognition — the "cold shock" pattern (children): cold/mottled extremities, prolonged capillary refill (>2 s), weak pulses, tachycardia, lethargy, ↓urine output, hypotension (LATE sign in children — compensated shock maintains BP!); warm shock (early/infection) — flash cap refill, bounding pulses; febrile + non-blanching rash = meningococcaemia.

Management (within the first hour):

1. ABC + high-flow O₂.
2. IV/IO access × 2; bloods (FBC, cultures, glucose, lactate, gas).
3. Fluid resuscitation — 20 mL/kg crystalloid bolus (repeat as needed; watch for pulmonary oedema/hepatomegaly); inotropes (adrenaline/noradrenaline) early if not improving.
4. Empiric IV antibiotics immediately (ceftriaxone ± vancomycin; ± acyclovir in infants).
5. Treat hypoglycaemia, hypocalcaemia, acidosis; temperature control.
6. Urgent PICU transfer; notify senior.

6. Anaphylaxis (the allergic emergency)

Diagnosis: acute onset (minutes — 2 hours) after allergen (food, drugs, insect sting) with skin/mucosal changes + respiratory (wheeze, stridor, hypoxia) and/or cardiovascular (hypotension, collapse) involvement; two or more systems involved.

Management:

1. IM adrenaline 0.01 mg/kg (0.1 mL/kg of 1:1000) — max 0.5 mL — into the anterolateral thigh — repeat every 5 min as needed (THE first-line, life-saving drug).
2. ABC + high-flow O₂, lie flat with legs raised, IV access.
3. IV fluid bolus (20 mL/kg) if hypotensive.
4. Adjuncts (never replace adrenaline): chlorphenamine (antihistamine), hydrocortisone (steroid), salbutamol neb (bronchospasm).
5. Observe ≥6-12 hours (biphasic reaction risk); prescribe adrenaline auto-injector + allergy referral + avoidance plan.

High-Yield Points

Topic Summary

Paediatric emergencies run on ABCDE (airway first; treat as found), paediatric CPR (15:2, 100-120/min, 1/3 chest depth — most arrests are respiratory), choking (back blows → chest/abdominal thrusts — no blind sweeps), status epilepticus (benzodiazepine → phenytoin/levetiracetam → ICU anaesthesia; treat hypoglycaemia), septic shock (recognise compensated shock — BP drops late; 20 mL/kg fluid + antibiotics in the hour), and anaphylaxis (IM adrenaline first — repeat q5 min; observe for biphasic reaction). The OSCE gold: structured ABCDE + early recognition + definitive interventions in the right order.