Paediatric Emergency Medicine

1.1 Approach to the Paediatric Patient

• <50% normal fluid intake
• Prolonged lethargy
• No urine output for >6 hours
• Inconsolable crying
• Parental concern out of proportion

• Non-blanching rash → sepsis / meningococcaemia
• Bilious vomiting → obstruction until proven otherwise
• Grunting → respiratory distress

1.2 Common Chronic Conditions

2.2 PBLS and 2.3 PALS

• 2-rescuer CPR: 15:2 in infants and children; newborn 3:1
• Compression depth: one-third of the AP chest diameter
• Compression rate: 100–120/min
• Defibrillation: 4 J/kg for shockable rhythms
• IO access: use if IV access not secured within 60–90 seconds

Shock and Sepsis

• Initial fluid bolus: 10–20 mL/kg crystalloid, reassess after each bolus
• Give antibiotics within 1 hour
• Lactate >4 mmol/L suggests severe sepsis
• After 40 mL/kg fluid, start adrenaline or noradrenaline if needed

3.1–3.2 Pain Control and Sedation

• Sucrose for neonates during minor procedures
• Topical anaesthetics such as EMLA or amethocaine
• Intranasal fentanyl for moderate to severe pain
• Ketamine provides dissociative sedation and preserves airway reflexes
• Propofol gives deep sedation but no analgesia and can cause apnoea

4.4 Acute Neonatal Emergencies

• Duct-dependent lesions: PGE1 0.05–0.1 mcg/kg/min
• Neonatal seizures may be subtle; first-line is phenobarbitone 20 mg/kg
• Pathological jaundice includes onset within 24 hours or conjugated rise
• Neonatal resuscitation prioritises effective ventilation

Murmurs, Syncope, Tet Spells, and SVT

• Innocent murmurs are systolic, short, soft, and localised
• Syncope red flags: exertional episode, no prodrome, family history of sudden death
• Tet spell management: knee-chest position, oxygen, morphine, fluid, propranolol
• SVT: vagal manoeuvres, then adenosine 100–300 mcg/kg
• Unstable SVT requires synchronised cardioversion 0.5–2 J/kg

Croup, Asthma, Pneumonia, Bronchiolitis

• Croup requires steroids in all cases: dexamethasone 0.15 mg/kg
• Severe croup with stridor at rest: nebulised adrenaline
• Asthma first line: salbutamol MDI + spacer and oral prednisolone
• Life-threatening asthma: continuous bronchodilator, ipratropium, IV magnesium
• Bronchiolitis treatment is supportive; avoid routine bronchodilators and steroids

Bilious Vomiting, Pyloric Stenosis, Gastroenteritis

• Pyloric stenosis: projectile non-bilious vomiting in a 2–8 week infant
• Button battery in the oesophagus needs urgent removal
• Multiple magnets carry high perforation risk
• Gastroenteritis: use ORS first; ondansetron can reduce vomiting

Status Epilepticus and Raised ICP

• Stepwise treatment: benzodiazepine → levetiracetam or phenytoin → intubation
• Raised ICP signs: Cushing triad, bulging fontanelle, altered consciousness
• Emergency measures: head up 30°, hypertonic saline, avoid hypoxia and hypotension
• Complex febrile seizure is focal, prolonged, or recurrent within 24 hours

Febrile Child, Meningitis, MIS-C, DKA

• UTI is the most common serious bacterial infection in young children
• Meningitis: LP unless contraindicated; start cefotaxime or ceftriaxone promptly
• MIS-C presents with persistent fever, shock, and multi-organ involvement
• DKA insulin infusion: 0.05–0.1 units/kg/hr after rehydration begins
• Adrenal crisis: hydrocortisone IV, dextrose, and fluid resuscitation

Febrile Neutropenia, Sickle Cell, HUS, Nephrotic Syndrome

• Febrile neutropenia requires IV broad-spectrum antibiotics within 60 minutes
• Sickle cell acute chest syndrome: antibiotics, spirometry, exchange transfusion if severe
• HUS is mainly supportive care; avoid antibiotics in STEC-associated disease
• Nephrotic syndrome treatment: prednisolone 60 mg/m²/day

Primary Survey and Burns

• Catastrophic haemorrhage first; use a tourniquet when indicated
• Tension pneumothorax: needle thoracostomy followed by chest drain
• Massive transfusion protocol: 1:1:1 ratio plus TXA 15 mg/kg
• Burns first aid: cool running water for 20 minutes within 3 hours
• Modified Parkland: 3 mL/kg/%TBSA

Poisoning Principles and Antidotes

• Activated charcoal only for selected high-risk ingestions within 1 hour
• Paracetamol overdose uses the nomogram and NAC
• One-pill-kill agents include calcium channel blockers, sulfonylureas, tricyclics, and chloroquine
• Organophosphate poisoning: atropine plus pralidoxime
• Snakebite: pressure immobilisation and antivenom for systemic envenoming

Airway, IO Access, Chest Drain, LP

• RSI commonly uses ketamine with rocuronium or suxamethonium
• Cuffed ETT size formula: age/4 + 3.5
• Waveform capnography is the gold standard for tube confirmation
• Chest drain site: 4th–5th intercostal space, anterior axillary line
• Do not delay antibiotics for lumbar puncture in a critically ill child