Pediatric Emergencies in Emergency Medicine

Learning Objectives

• Apply the Pediatric Assessment Triangle (PAT) to rapidly categorize a sick child in under 60 seconds.
• Explain why children decompensate suddenly and how their physiology differs from adults in resuscitation.
• Work up a febrile infant using age-based risk criteria (0-28 days, 29-90 days, >90 days).
• Recognize and manage pediatric respiratory distress, seizures, and shock.
• Calculate weight-based drug and fluid doses using the Broselow tape approach.
• Identify red flags that distinguish a well-appearing child from one needing immediate resuscitation.

Quick Answer

Pediatric emergencies demand a different approach than adult emergencies because children compensate for illness longer, then crash faster and harder. The Pediatric Assessment Triangle (appearance, work of breathing, circulation to skin) lets you form a general impression in seconds, before you ever touch the child. The most important physiologic difference to remember: children maintain blood pressure through tachycardia and vasoconstriction until they are critically hypovolemic, so a normal blood pressure does not rule out shock — hypotension is a late, ominous sign. Fever workups, seizure management, and resuscitation dosing are all weight- and age-adjusted, which is why tools like the Broselow tape exist: to prevent dosing errors when every child is a different size.

Overview

A sick child is not a small adult. Children have higher metabolic rates, smaller physiologic reserves, and airway/cardiovascular anatomy that changes with age — all of which shape how emergencies present and how you must respond. In emergency medicine, pediatric cases are high-stakes for two reasons: first, children can look deceptively well right up until they suddenly deteriorate, because compensatory mechanisms (tachycardia, tachypnea, vasoconstriction) mask early shock or respiratory failure. Second, every dose, tube size, and fluid bolus must be individualized to weight and age, which introduces room for error under pressure.

This page focuses on three pillars that show up repeatedly on exams and in real practice: the Pediatric Assessment Triangle as your first 60-second read of any child, the age-stratified febrile infant workup (because "fever in a baby" is one of the highest-yield undifferentiated presentations in pediatrics), and the key ways pediatric resuscitation departs from the adult ACLS algorithm.

Common Pediatric Emergencies

1. Respiratory Distress

Respiratory distress is one of the most frequent presentations in pediatric emergency departments. It can manifest as:

• Tachypnea (rapid breathing rate)
• Grunting sounds
• Nasal flaring
• Retractions (chest or abdominal, sometimes with head-bobbing in infants)

Assessment:

• Measure oxygen saturation
• Assess respiratory rate and pattern (a falling respiratory rate in a tiring child is a danger sign, not improvement)
• Perform chest examination for wheeze, stridor, or asymmetric breath sounds

Interventions:

• Position the child properly (e.g., caregiver's lap, sniffing position for infants)
• Administer supplemental oxygen or high-flow nasal cannula if needed
• Consider nebulized bronchodilators or nebulized epinephrine (for croup) depending on the cause

Example: A 3-year-old presents with rapid breathing and wheezing after several days of a cold. Diagnosis: acute bronchiolitis, most commonly due to respiratory syncytial virus (RSV) in infants under 12 months.

2. Seizures

Seizures in children can be alarming and potentially life-threatening. They may present as:

• Convulsions
• Loss of consciousness
• Altered mental status

Assessment:

• Duration and frequency of the seizure
• Postictal state (confusion, sleepiness after the event)
• Neurological examination, plus a fever check — most childhood seizures are febrile seizures

Interventions:

• Maintain airway, breathing, and circulation (ABCs) first
• Administer benzodiazepines (e.g., lorazepam or midazolam) if the seizure lasts beyond 5 minutes
• Obtain imaging (e.g., CT) only if there are focal deficits, prolonged post-ictal state, or trauma — a simple febrile seizure in a well-appearing toddler does not need a head CT

Example: A 5-year-old has a generalized tonic-clonic seizure lasting 2 minutes during a fever of 39.5°C. Diagnosis: simple febrile seizure.

The Pediatric Assessment Triangle (PAT)

Before you touch a stethoscope, before you get vitals, you should already have a general impression of "sick" versus "not sick." That is exactly what the PAT is for — a 30-60 second, hands-off visual and auditory assessment done from across the room.

The genius of the PAT is that it doesn't require touching the child (useful in a frightened toddler who screams the moment you approach) and it tells you which system is failing before your formal exam even starts. A child who looks limp and disinterested (abnormal appearance) with normal breathing and color is very different from one who is alert but tachypneic with retractions (abnormal work of breathing) — they need different immediate priorities even though both are "sick."

Febrile Infant Workup

Fever in a young infant is treated very differently than fever in an older child, because young infants cannot reliably mount or localize signs of serious bacterial infection (SBI) — meningitis or bacteremia can hide behind a baby who "just seems fussy."

Age group	Approach
0-28 days	Full sepsis workup for any fever ≥38°C (100.4°F): blood culture, urine culture (catheterized), CSF studies via lumbar puncture, CBC. Empiric IV antibiotics and admission — no exceptions, even if the baby looks well.
29-60/90 days	Risk-stratify using validated criteria (e.g., Step-by-Step, PECARN, or Rochester criteria): blood and urine studies always; lumbar puncture and antibiotics reserved for infants who are ill-appearing, have abnormal labs (elevated procalcitonin/CRP, abnormal urinalysis), or fail low-risk criteria.
>90 days (3-36 months)	Focus shifts to identifying a source (otitis media, UTI, pneumonia, viral illness). Well-appearing, fully immunized children with an identified viral source generally do not need blood work.

The unifying exam principle: the younger the infant, the lower your threshold for invasive testing, because clinical appearance is the least reliable in neonates.

Pediatric Resuscitation: How It Differs From Adults

Several structural and physiologic differences change the resuscitation approach in children:

• Cause of arrest: Adult cardiac arrest is usually a primary cardiac event (arrhythmia); pediatric arrest is usually a hypoxic/respiratory event that progresses to bradycardia and then asystole. This is why pediatric BLS emphasizes airway and breathing (5 rescue breaths before compressions in the newborn/infant algorithm) rather than "compressions first" reflexively.
• Compression ratio and rate: Single rescuer uses 30:2 (compressions:breaths), same as adults, but two-rescuer pediatric CPR uses 15:2. Compression depth is about one-third of chest depth, not a fixed number of inches.
• Airway: The tongue is proportionally larger, the larynx is more anterior and cephalad, and the airway narrows at the cricoid ring (not the vocal cords as in adults) — uncuffed or appropriately sized cuffed tubes are chosen by age/weight formulas, not "one size."
• Drug dosing: Everything is weight-based (mg/kg), which is why a Broselow tape (color-coded by length, which correlates with weight) exists — to avoid dangerous calculation errors in a code.
• Epinephrine dose: 0.01 mg/kg IV/IO of the 1:10,000 concentration, repeated every 3-5 minutes — a tenfold dosing error here is one of the most dangerous and common pediatric medication errors.
• Blood pressure is a late sign: Children compensate with tachycardia and vasoconstriction; hypotension only appears once compensatory mechanisms fail, meaning a "normal" BP can coexist with significant shock.

Example: A newborn boy collapses immediately after birth with no spontaneous breathing, no detectable heart rate, and blue-gray skin. Management: clear the airway, provide positive-pressure ventilation first (not immediate compressions), begin chest compressions in a 3:1 ratio with ventilation per the Neonatal Resuscitation Program if the heart rate remains under 60/min despite adequate ventilation, and give epinephrine 0.01 mg/kg IV if there is no response.

Case Study: Diabetic Ketoacidosis (DKA)

A 12-year-old girl presents with polyuria, polydipsia, and lethargy. Initial vitals: T 38.9°C, HR 120 bpm, BP 90/60 mmHg.

Assessment:

• Hyperglycemia (blood glucose 300 mg/dL)
• Metabolic acidosis (pH 7.15, HCO3- 10 mEq/L)
• Ketonuria positive

Interventions:

• Cautious IV fluid resuscitation (pediatric DKA carries a real risk of cerebral edema from overly rapid fluid shifts — boluses are more conservative than in adult DKA)
• Insulin infusion (0.05-0.1 units/kg/hour), started only after initial fluid resuscitation, without an insulin bolus
• Electrolyte replacement (potassium, magnesium, phosphate) once potassium and urine output are confirmed adequate
• Frequent neurologic checks to catch early signs of cerebral edema (headache, altered mental status, bradycardia with hypertension)

Key Terms

Term	Definition
Pediatric Assessment Triangle (PAT)	A 30-60 second, hands-off assessment of appearance, work of breathing, and circulation to skin used to form a general impression of illness severity.
Broselow tape	A length-based color-coded tape used to estimate a child's weight and pre-calculate resuscitation drug doses and equipment sizes.
Serious bacterial infection (SBI)	A category encompassing meningitis, bacteremia, and UTI in infants — the primary concern driving aggressive febrile infant workups.
Compensated shock	A shock state in which blood pressure remains normal because tachycardia and vasoconstriction maintain perfusion; common in children before they decompensate.
Decompensated shock	Shock with hypotension, indicating that compensatory mechanisms have failed — a late and dangerous sign in pediatrics.
Febrile seizure	A generalized seizure triggered by fever in a child, typically age 6 months to 5 years, with a benign prognosis if simple (brief, generalized, no recurrence within 24 hours).
Cerebral edema (in DKA)	A dreaded, potentially fatal complication of pediatric DKA treatment linked to overly rapid fluid or osmotic shifts.
Retractions	Visible pulling-in of chest wall muscles (subcostal, intercostal, suprasternal) during breathing, indicating increased work of breathing.

Common Mistakes

Misconception 1: "A child with a normal blood pressure is not in shock."

• Why it's wrong: Children compensate extremely well through tachycardia and peripheral vasoconstriction, so blood pressure stays normal until shock is severe.
• Correct explanation: Look for early signs — tachycardia, delayed capillary refill, cool mottled extremities, and altered mental status — because by the time BP drops, the child is in decompensated shock and needs immediate resuscitation.

Misconception 2: "Every febrile infant needs the same workup regardless of age."

• Why it's wrong: Risk of serious bacterial infection and the reliability of clinical appearance both change dramatically with age.
• Correct explanation: Neonates (0-28 days) always get a full sepsis workup regardless of how well they look; older infants can be risk-stratified using validated clinical criteria and selective testing.

Misconception 3: "Chest compressions should always start immediately in a pulseless child, just like in adults."

• Why it's wrong: Most pediatric arrests are respiratory in origin, not primary cardiac events, so airway and ventilation take priority.
• Correct explanation: In infant/child BLS and neonatal resuscitation, rescue breaths are given first (and are the priority intervention), because restoring oxygenation often reverses the bradycardia before it progresses to full arrest.

Comparison and Connections

Feature	Adult Emergency Approach	Pediatric Emergency Approach
Cause of cardiac arrest	Primarily cardiac (arrhythmia)	Primarily respiratory, progressing to bradycardia/asystole
First resuscitation priority	Compressions (C-A-B)	Airway/breathing emphasized, especially in neonates
Blood pressure in shock	Drops relatively early	Maintained until late (decompensated shock is a late sign)
Drug dosing	Standard/fixed doses	Weight-based (mg/kg), often via Broselow tape
Fever significance	Rarely triggers invasive workup alone	Fever in a neonate mandates full sepsis workup
Airway anatomy	Narrowest at vocal cords	Narrowest at the cricoid ring

Practice Questions

Recall

1. What are the three components of the Pediatric Assessment Triangle? Answer guidance: Appearance, work of breathing, and circulation to skin.
2. What is the epinephrine dose used in pediatric cardiac arrest? Answer guidance: 0.01 mg/kg IV/IO of 1:10,000 concentration, repeated every 3-5 minutes.

Understanding 3. Why is hypotension considered a "late" finding in pediatric shock rather than an early warning sign? Answer guidance: Children have strong compensatory mechanisms (tachycardia, vasoconstriction) that maintain blood pressure until the child is severely hypovolemic/shocked; once BP falls, compensation has failed. 4. Why does pediatric BLS prioritize ventilation before compressions, unlike adult BLS? Answer guidance: Because most pediatric arrests result from respiratory failure/hypoxia rather than primary arrhythmia, restoring oxygenation can reverse the process before full arrest occurs.

Application 5. A 3-week-old infant presents with a temperature of 38.2°C but is feeding well and looks alert. What is the appropriate next step? Answer guidance: Perform a full sepsis workup (blood culture, urine culture via catheterization, lumbar puncture, CBC) and admit for empiric IV antibiotics — appearance is unreliable in neonates, so age alone triggers the full workup. 6. A 4-year-old has a 3-minute generalized seizure during a fever of 39.3°C, is back to baseline within 20 minutes, and has a normal neuro exam. What is the most likely diagnosis and next step? Answer guidance: Simple febrile seizure; no head CT or lumbar puncture needed in a well-appearing child with a benign exam — focus on identifying and treating the fever source.

Analysis 7. Compare why a Broselow tape is preferred over asking a caregiver for the child's estimated weight in an emergency. Answer guidance: Caregiver-estimated weight is often inaccurate under stress; length-based tapes correlate reliably with weight across most children and allow rapid, standardized drug/equipment selection without a scale. 8. A 10-year-old in DKA is treated with a large, rapid IV fluid bolus and becomes confused with a new headache. What complication should you suspect and why does pediatric DKA management differ from adult DKA management? Answer guidance: Suspect cerebral edema, a pediatric-specific DKA complication linked to rapid fluid/osmotic shifts; this is why pediatric DKA protocols use more cautious, gradual fluid replacement and frequent neuro checks compared to adult protocols.

FAQ

Why do children "crash" so suddenly compared to adults? Because their compensatory mechanisms (tachycardia, vasoconstriction, increased respiratory rate) are efficient right up until they're exhausted — then decompensation happens fast, with little warning between "compensating" and "critical."

Is a lumbar puncture really necessary for every feverish newborn? Yes, for infants 0-28 days old with fever ≥38°C, because clinical appearance cannot reliably exclude meningitis at that age, and missing it can be fatal or cause permanent neurologic damage.

Do all febrile seizures need an EEG or neuroimaging? No. A simple febrile seizure (brief, generalized, in a well-appearing child with a normal exam) needs no EEG or imaging. Complex features (focal, prolonged, or recurrent within 24 hours) warrant further workup.

Why is the epinephrine dose so easy to get wrong in pediatric codes? Because it's weight-based and concentration-dependent (1:10,000 for IV/IO vs. 1:1,000 for other routes), and under code stress, decimal-point and concentration errors are the most common medication errors in pediatric resuscitation.

Why is fluid management more cautious in pediatric DKA than adult DKA? Because children are uniquely susceptible to cerebral edema during DKA treatment, likely related to rapid shifts in osmolality; slower, more conservative fluid replacement reduces this risk.

Quick Revision

• PAT = Appearance + Work of Breathing + Circulation to skin; assess in under 60 seconds, hands-off.
• Normal BP does not rule out shock in children — hypotension is a late sign of decompensation.
• Neonates (0-28 days) with fever ≥38°C always get a full sepsis workup and IV antibiotics, regardless of appearance.
• Older infants (29-90 days) can be risk-stratified with validated criteria before invasive testing.
• Most pediatric cardiac arrests start as respiratory failure, not primary arrhythmia — ventilation is prioritized early.
• Epinephrine dose in pediatric arrest: 0.01 mg/kg IV/IO, 1:10,000 concentration, every 3-5 minutes.
• Broselow tape estimates weight by length to guide drug doses and equipment sizing.
• Simple febrile seizures (brief, generalized, well-appearing child) need no imaging or LP.
• Airway narrowing in children occurs at the cricoid ring, not the vocal cords as in adults.
• Pediatric DKA fluid resuscitation is more conservative than adult DKA due to cerebral edema risk.
• RSV bronchiolitis is the classic cause of wheeze and respiratory distress in infants under 12 months.
• Two-rescuer pediatric CPR uses a 15:2 compression:ventilation ratio; single-rescuer uses 30:2.

Related Topics

Prerequisites

• Basic Life Support (BLS) and CPR fundamentals
• Normal pediatric vital sign ranges by age
• Fluid and electrolyte physiology basics

Related Topics

• Neonatal resuscitation and the Neonatal Resuscitation Program (NRP)
• Pediatric Advanced Life Support (PALS)
• Common pediatric infectious disease presentations

Next Topics

• Toxicologic Emergencies (pediatric ingestions and poisoning)
• Trauma in Emergency Medicine (pediatric trauma considerations)
• Shock and Resuscitation (general emergency medicine principles)