PE24.1-23 | Pediatric Emergencies — Graded Quiz

For SINGLE-rescuer paediatric CPR (child or infant), the ratio is 30:2 at 100–120/min. The 15:2 ratio is for two-rescuer paediatric CPR only. A 2-year-old is a child, so depth is ≥1/3 AP diameter (~5 cm) not infant depth (4 cm). Two-thumb encircling is preferred for two-rescuer infant CPR.

Rescue ratios: single-rescuer (any age) = 30:2; two-rescuer paeds = 15:2. Rate 100–120/min for all. Depth: adult 5–6 cm; child ≥1/3 AP (~5 cm); infant ≥1/3 AP (~4 cm).

Key distinction: single-rescuer paeds CPR = 30:2 (same as adult); two-rescuer paeds = 15:2. Rate 100–120/min applies to both. Depth ≥1/3 AP diameter for both infant and child; in children ~5 cm.

Absent air entry + tracheal deviation away from the affected side = tension pneumothorax. This is a clinical diagnosis and a life-threatening emergency requiring immediate needle decompression at the second intercostal space, mid-clavicular line on the affected side (right), without waiting for a chest X-ray.

Tension pneumothorax: absent breath sounds + tracheal deviation away = clinical emergency. Needle decompression FIRST (2nd ICS MCL), then formal chest drain. Do not delay for imaging if clinical diagnosis is clear.

A nasopharyngeal airway addresses upper airway obstruction, not tension pneumothorax. Intubation in tension pneumothorax without decompression worsens the condition by raising airway pressure. Nebulised bronchodilators are for wheeze/bronchospasm.

In paediatric DKA, aggressive fluid boluses (20 mL/kg) are associated with increased risk of cerebral oedema, a major cause of DKA mortality. Guidelines recommend restricting resuscitation boluses to 10 mL/kg in DKA and reassessing, only escalating if there is haemodynamic compromise (shock with circulatory failure).

DKA fluid caution: max 10 mL/kg bolus (not 20 mL/kg); restrict fluids over 48 hours to reduce cerebral oedema risk. Monitor neurological status closely. Bolus only for haemodynamic compromise with circulatory failure, not just biochemical dehydration.

Standard 20 mL/kg is appropriate for septic/hypovolaemic shock but modified in DKA to 10 mL/kg due to cerebral oedema risk. 40 mL/kg worsens this risk. Oral rehydration is contraindicated in severe DKA.

Phenytoin 18–20 mg/kg IV is the preferred second-line drug for status epilepticus. CRITICAL precaution: must be diluted in 0.9% normal saline — NEVER in dextrose-containing solutions (causes crystalline precipitation). Infuse at no more than 1 mg/kg/min with cardiac monitoring for bradycardia/hypotension.

Status epilepticus ladder: 1st line — lorazepam IV or rectal diazepam; 2nd line — phenytoin 18–20 mg/kg IV in NORMAL SALINE (NEVER dextrose); 3rd line — phenobarbitone or sodium valproate IV. ALERT: phenytoin + dextrose = crystalline precipitation = blocked line + no drug delivery.

Phenytoin in dextrose precipitates in the infusion line — a potentially fatal error. Additional benzodiazepines after two doses increase respiratory depression risk without better seizure control. Phenobarbitone IV (not IM) is an alternative second-line agent.

AVPU score 'P' (responds to Pain) = severely depressed consciousness (equivalent to GCS ~8). The first airway step for any unconscious child is manual airway opening — head-tilt chin-lift (no trauma) or jaw thrust (trauma). Assess breathing AFTER opening the airway. Positioning precedes all other interventions.

AVPU: A=Alert, V=Voice, P=Pain (severe impairment), U=Unresponsive (critical). Unconscious child airway: (1) position — head-tilt chin-lift or jaw thrust; (2) assess breathing; (3) suction if secretions; (4) bag-mask ventilation if apnoeic or ineffective breathing. Recovery position for breathing unconscious child without suspected trauma.

Suctioning is a secondary step once airway is opened. Nasopharyngeal airway insertion without prior positioning does not guarantee airway patency. Bag-mask ventilation without a patent airway is ineffective.

Venturi masks are fixed-performance devices — they entrain a precise amount of air based on the Venturi aperture size, delivering a defined FiO₂ regardless of flow variations. Available settings: 24%, 28%, 31%, 35%, 40%, 60%. This is the only device guaranteeing a specified precise FiO₂.

Venturi mask = only FIXED-PERFORMANCE oxygen delivery device. Apertures: 24, 28, 31, 35, 40, 60% FiO₂. Use when precise FiO₂ is clinically required (COPD with hypercapnia, monitoring PaO₂/FiO₂ ratio). All other masks are variable-performance.

Nasal cannulas and simple masks are variable-performance — the actual FiO₂ depends on the patient's inspiratory flow and breathing pattern. Non-rebreather masks deliver high but imprecise FiO₂ (60–90%).

Hepatomegaly and a gallop rhythm (S3 or summation gallop) are clinical signs of cardiogenic shock with cardiac failure. Aggressive fluid resuscitation (20 mL/kg) in cardiogenic shock worsens pulmonary oedema — the initial bolus should be 5–10 mL/kg with careful reassessment. All other options listed are common to all shock types.

Shock fluid bolus modifications: standard 20 mL/kg for septic/hypovolaemic; 10 mL/kg for DKA; 5–10 mL/kg with caution for cardiogenic (watch for worsening signs of cardiac failure — hepatomegaly, pulmonary oedema, gallop). Always reassess after each bolus.

CRT >3s, tachycardia, and altered consciousness occur in all shock types. Only signs of cardiac dysfunction (gallop, hepatomegaly, pulmonary oedema) distinguish cardiogenic from septic/hypovolaemic shock and mandate fluid restriction.

WHO Plan C severe dehydration for CHILDREN (>12 months): Ringer's lactate 100 mL/kg total — give 30 mL/kg FAST over 30 minutes, then 70 mL/kg over 2.5 hours. The slower schedule (1h + 5h) applies to INFANTS <12 months.

WHO Plan C severe dehydration: Ringer's lactate 100 mL/kg. Children >12 months: 30 mL/kg in 30 min, then 70 mL/kg in 2.5 h. Infants <12 months: 30 mL/kg in 1 h, then 70 mL/kg in 5 h. Reassess after initial bolus — if improved, continue; if worsening, repeat.

The 1h + 5h schedule is for infants <12 months. Children >12 months receive faster rehydration: 30 min + 2.5 hours. ORS is contraindicated in a lethargic child unable to drink.

Normal core temperature in infants is 36.5–37.5°C; below 36.5°C is hypothermia. At 35°C this infant is hypothermic. Immediate management: skin-to-skin with caregiver, warm environment (≥25°C), feed immediately (breastmilk prevents hypoglycaemia), monitor blood glucose. Ice-cold IV fluids are contraindicated and worsen hypothermia.

Neonatal/infant thermal regulation: normal 36.5–37.5°C. Hypothermia <36.5°C → warm skin-to-skin, hat, warm room, early feed, blood glucose check. Hypothermia increases risk of hypoglycaemia, sepsis, respiratory distress, and coagulopathy. NEVER cold sponge a hypothermic baby.

35°C is below the normal lower limit of 36.5°C — this is hypothermia, not fever. Cold sponging worsens hypothermia. IV ice-cold fluids are harmful. The primary interventions are warmth and feeding.

Informed consent for minors requires parental/guardian consent. In a life-threatening emergency where parents cannot be reached, the emergency exception (best interests standard) allows the procedure with full documentation. The child's assent should still be sought as part of best practice, even if not legally sufficient. Deferring a life-threatening procedure is inappropriate.

Informed consent for paediatric procedures: require parental/guardian written consent. Emergency exception: when parents unavailable and life threatened, proceed with best interests documentation + full explanation to parents as soon as available. Child assent is ethically important (recognises autonomy) but legally insufficient in India for minors.

Proceeding without documentation is ethically wrong. A 10-year-old's assent, while important, is not legally sufficient for parental consent. Deferring a life-threatening procedure is dangerous.