GC145 A Critically Ill Child Childhood Medical Emergencies
Childhood medical emergencies are acute, life-threatening clinical situations in pediatric patients requiring immediate recognition and intervention to prevent cardiopulmonary arrest, organ failure, or death.
Management of the Critically Ill Child — Childhood Medical Emergencies
The big idea: Children are NOT miniature adults. Their unique anatomy, physiology, and developmental stage create a fundamentally different clinical landscape for recognising and managing critical illness. This lecture (GC 145, Dr. N.S. Tsoi, QMH Paediatrics) covers the physiological/anatomical differences, paediatric assessment, CPR (basic + advanced), specific emergencies (airway, status epilepticus, shock), and the mindset of early recognition and escalation. [1]
Learning objectives (from the slide deck):
- Understand the physiological, anatomical, and pathological differences which influence evaluation and treatment [1]
- Basic principles of paediatric resuscitation [1]
- Important emergency conditions and management principles [1]
Age range covered: Neonate to 18 years; 500g to 100kg [1]
1. Physiological & Anatomical Differences — Why Children Are NOT Miniature Adults
This is the conceptual foundation for everything else. Every management decision in paediatric emergencies flows from understanding these differences.
"Less respiratory reserve, higher need for oxygen supplement" [1]
| Feature | Why It Matters |
|---|---|
| Cartilaginous thorax, more horizontal ribs → diaphragmatic breathing important | The rib cage doesn't generate the negative intrathoracic pressure as efficiently as in adults. Children rely heavily on the diaphragm. Any process that impairs diaphragmatic excursion (abdominal distension, gastric dilatation during BVM) rapidly leads to respiratory failure. [1][2] |
| High airway resistance, especially during upper airway obstruction → more common in small children | Poiseuille's law: resistance ∝ 1/r⁴. A small amount of mucosal oedema (e.g. 1mm) in a neonatal airway dramatically increases resistance. This is why croup/epiglottitis can be life-threatening in children but rarely in adults. [1] |
| Biphasic response to hypoxia in neonates: initial increase in respiratory effort, then APNOEA | Unlike adults who progressively increase respiratory drive with worsening hypoxia, neonates may paradoxically become apnoeic. This means a neonate who was working hard to breathe and then "settles down" may actually be deteriorating, not improving. [1] |
| Young infants preferentially breathe through the nose | Nasal obstruction can cause important distress, but “obligate until 6 months” is an oversimplification. Clear visible obstruction gently when needed; routine deep suction can cause trauma, bradycardia or delay ventilation. |
High Yield — Exam Trap
A neonate who was previously tachypnoeic and is now "quiet" may have progressed to apnoea from the biphasic hypoxic response — this is DETERIORATION, not improvement. Students commonly interpret the cessation of respiratory distress as improvement.
Reading the airway-radius diagram (slide 6): the teaching model compares a 4-mm infant lumen with an 8-mm adult lumen after 1 mm of circumferential oedema. The smaller airway loses a much larger fraction of cross-sectional area (shown as 75% vs 44%) and the slide estimates a much larger resistance increase (16-fold vs threefold). The exact numbers idealise a rigid tube and laminar flow, but the clinical message is sound: small reductions in paediatric airway radius can sharply increase work of breathing.
| Feature | Why It Matters |
|---|---|
| Small absolute blood volume | A neonate has ~80 mL/kg → ~180 mL total for a 2.25 kg baby. Losing even 20 mL is a significant proportion. [1][2] |
| Cardiac output is strongly heart-rate dependent | Infants have limited ability to augment stroke volume, so marked bradycardia can rapidly reduce output; heart rate is not literally the only determinant. [1] |
| Bradycardia with compromise is ominous | Correct hypoxia and other reversible causes urgently. If HR remains < 60/min with cardiopulmonary compromise despite effective ventilation with oxygen, start CPR; a heart-rate value without the clinical context is not enough. [8] |
| Bedside filling-pressure estimates are limited | Neck anatomy and distress make JVP/CVP assessment difficult. Use perfusion, blood pressure, urine output, examination, dynamic response and point-of-care imaging where available; do not infer a fixed “adult-like” fluid response after 8 weeks. |
| Reactive pulmonary vasculature in neonates → prone to pulmonary hypertension (PPHN) | The neonatal pulmonary vessels retain their fetal reactivity. Hypoxia, acidosis, hypothermia can trigger pulmonary vasoconstriction → PPHN → right-to-left shunting → profound cyanosis. [1] |
| Variable catecholamine response, need titration | Immature sympathetic innervation and receptor density mean responses to inotropes are less predictable. Titrate carefully. [1] |
"Bradycardia is ominous" — this is one of the most commonly tested facts in paediatric emergencies. [1]
| Feature | Why It Matters |
|---|---|
| Greater insensible water loss | Higher body surface area to volume ratio → proportionally more evaporative loss through skin. [1][2] |
| Greater heat loss | Same SA:volume principle. Hypothermia develops rapidly, especially in neonates. Hypothermia → acidosis → coagulopathy (lethal triad). [1] |
| Hypoglycaemia more common; need higher glucose infusion | Limited glycogen stores, higher metabolic rate. Always check glucose in a sick child. [1] |
| Appropriate urine output: neonate 2 mL/kg/hr; child 1 mL/kg/hr | These are different from adults (0.5 mL/kg/hr). Use age-appropriate targets when assessing adequacy of resuscitation. [1] |
| Hypo- and hypernatraemia; Hypocalcaemia in newborns | Immature renal concentrating ability and hormonal regulation → electrolyte disturbances common. Neonatal hypocalcaemia occurs due to immaturity of parathyroid function and interrupted transplacental calcium supply. [1] |
High Yield — Temperature in Paediatric Emergencies
"Apart from persistent high fever, hypothermia can occur in severe sepsis especially in neonate and small child." [1] — Hypothermia in a neonate/infant with suspected infection is a RED FLAG for severe sepsis. Do not be reassured by the absence of fever.
The large head and relatively small legs explain why infants lose heat and water rapidly and why paediatric burn charts differ from the adult rule of nines. The lecture image labels:
| Region | Approximate proportion shown |
|---|---|
| Head and neck | 21% |
| Each arm | 10% |
| Anterior trunk | 13% |
| Posterior trunk | 13% |
| Buttocks/genital region | 6% |
| Each leg | 13.5% |
These are the proportions printed on this teaching image; use an age-adjusted Lund–Browder chart for an actual burn calculation.
2. General Examination of the Critically Ill Child
This section directly maps to the 2016 SAQ Q10: "What parameters obtained during physical examination could be used as an indicator of the general well-being of a child?" [3]
The PAT can be completed in less than 30 seconds. [1]
| Component | What to Look For | Why |
|---|---|---|
| Appearance | Abnormal tone, decreased interaction, inconsolable, abnormal look/gaze, abnormal speech/cry | Reflects adequacy of cerebral perfusion, oxygenation, and CNS function |
| Work of Breathing | Abnormal sounds (stridor, grunting, wheezing), abnormal positioning (tripod, sniffing), retractions, nasal flaring, apnoea/gasping | Reflects respiratory effort and reserve. Grunting = auto-PEEP to prevent alveolar collapse. |
| Circulation to Skin | Pallor, mottling, dusky appearance, cyanosis | Reflects perfusion. Mottling = cutaneous vasoconstriction = compensated shock. |
Skin perfusion — colour, warmth, capillary refill (normal < 2 seconds) [1]
Hydration state — the slide associates a depressed anterior fontanelle with severe dehydration. [1] Fontanelle appearance is only one clue and is affected by position and other conditions; grade dehydration from the full clinical picture.
Responsiveness — irritability, alertness, response to stimuli, depressed conscious state [1]
Respiratory — tachypnoea, bradypnoea, grunting, nasal flaring, obligate nose breathing till 6 months of age [1]
Seizure recognition:
Seizures may not always be tonic/clonic — may present as impaired alertness, abnormal vital signs (e.g. fixed & unreactive pupils), abnormal movement (e.g. cycling or chewing activity) [1]
This is important because subtle seizures in neonates and infants are easily missed. If a child has unexplained altered consciousness with autonomic changes or stereotyped repetitive movements, consider seizure and obtain EEG when appropriate. Fixed unreactive pupils are a critical neurologic sign but are not specific for seizure.
The lecture's local-era PEWS scoring parameters and actions: [1]
- 0–4 (stable): continue 4-hourly assessment
- 5–6: more frequent assessment, doctor notification needed
- > 7: Critical — frequent assessment q30min, immediate doctor notification
Based on: Behaviour, cardiovascular parameters, respiratory parameters [2]
Why PEWS matters: PEWS supports trend recognition and escalation, but it does not replace clinical concern or ABCDE assessment. Escalate a seriously unwell child even when the numerical score is below a trigger.
The PEWS Grid Shown in the Slide
| Domain | 0 | 1 | 2 | 3 |
|---|---|---|---|---|
| Behaviour | Playing/appropriate | Sleeping | Irritable | Lethargic/confused or reduced response to pain |
| Cardiovascular | Pink; CRT 1–2 s | Pale or CRT 3 s | Grey or CRT 4 s; HR 20 above normal | Grey/mottled or CRT ≥5 s; HR 30 above normal or bradycardia |
| Respiratory | Normal; no recession/tracheal tug | RR > 10 above normal, accessory muscles; FiO₂ ≥30% or O₂ ≥4 L/min | RR > 20 above normal, recession/tracheal tug; FiO₂ ≥40% or O₂ ≥6 L/min | RR 5 below normal with recession/tug/grunting; FiO₂ ≥50% or O₂ ≥8 L/min |
Add 2 points for quarter-hourly nebulisers or persistent postoperative vomiting in the specific historical chart shown. The score bands, oxygen rows and response rules are not portable between institutions; use the current local chart at the bedside and never delay urgent review to finish scoring.
4. Paediatric Cardiac Arrest & CPR
"Sudden unexpected cessation of functional ventilation and circulation in a person otherwise not expected to die" [1]
"Respiratory arrest more common than cardiac arrest" [1]
Respiratory illness remains a major cause of paediatric arrest. A common pathway is respiratory failure or shock → hypoxia/acidosis → bradycardia → PEA/asystole, although primary cardiac and shockable rhythms still occur. This means: [8][9]
- Prevention of respiratory arrest prevents most paediatric cardiac arrests
- Ventilation/oxygenation is even more critical than in adult CPR
- Shockable rhythms (VF/VT) are uncommon in children
In addition to Post-Cardiac Arrest Care, highlighted Recovery support [1]
Option of eCPR (extracorporeal CPR): the slide presents it as a bridge for a potentially reversible arrest. [1]
The two visual chains differ mainly at the start:
| In-hospital cardiac arrest | Out-of-hospital cardiac arrest |
|---|---|
| Early recognition and prevention | Prevention |
| Activate the in-hospital emergency response | Activate emergency medical services |
| High-quality CPR | High-quality CPR |
| Advanced resuscitation | Advanced resuscitation |
| Post-arrest care | Post-arrest care |
| Recovery support for child and family | Recovery support for child and family |
The eCPR diagram shows venous blood leaving the patient, passing through a pump and oxygenator, then returning through an arterial limb. It is a bridge that maintains perfusion while a reversible cause is treated—not routine CPR for every arrest. Current evidence is most supportive in selected cardiac/surgical in-hospital arrests when an established ECPR system can deploy rapidly; evidence remains insufficient for a general OHCA or non-cardiac recommendation. Do not translate the image into a promise of better outcome for every child. [8]
| Phase | Goal | Components |
|---|---|---|
| Phase 1: Basic CPR | Maintain oxygenation and circulation | In cardiac arrest, begin high-quality compressions and add ventilation; in a seriously ill child with a pulse, assess and support airway/breathing first [9] |
| Phase 2: Advanced Life Support | Restore spontaneous circulation | Drugs, ECG, Fibrillation (defibrillation) |
| Phase 3: Prolonged Life Support | Post-resuscitation care | G = Gauging (cause of arrest, assess condition), H = Human Mentation (cerebral resuscitation), I = Intensive Care Support |
Emphasis on Circulation is MOST important — RATE, depth of compression, minimum interruption [1]
Time difference: first ventilation after 30 compressions (delay of ~20 seconds) [1]
The slide's compression-only language needs qualification. For paediatric OHCA, compressions plus breaths improve survival, so rescuers are encouraged to give breaths if able and willing. Compression-only CPR is preferable to doing nothing when a rescuer cannot provide breaths. [9]
The slide's “≥30/min in infants and ≥25/min in older children” line and the older embedded 10/min table come from different guideline eras. The 2025 AHA/AAP recommendation is 20–30 breaths/min for infants and children receiving CPR with an advanced airway, or rescue breaths when a pulse is present. Avoid excessive ventilation. [9]
Gift of life: organ donation should be considered in those who do not have ROSC, brain death, or withdrawal of care [1]
Why C-A-B in arrest? It minimises delay to perfusion once cardiac arrest is recognised. It does not make oxygenation unimportant in children: provide breaths promptly, and in a child with a pulse and inadequate breathing, support ventilation rather than starting arrest compressions. [9]
Priority Statement from Lecture
The six-person diagram separates tasks so compressions and ventilation are not interrupted:
| Role | Core job in the visual |
|---|---|
| Team leader | Assign roles, integrate information, monitor performance and maintain closed-loop communication |
| Compressor | Deliver high-quality compressions and switch about every 2 minutes |
| Airway | Open/maintain the airway and provide ventilation |
| Monitor/defibrillator | Identify rhythm, coordinate rhythm checks and deliver shocks |
| IV/IO/medications | Obtain access, prepare/administer drugs and announce each dose |
| Timer/recorder | Record cycles, shocks and drugs; announce the next rhythm check/medication time |
The visual adds a CPR coach beside the monitor/defibrillator role to watch compression rate, depth, recoil and pauses while the leader manages the whole resuscitation.
| Component | Child (1 year to puberty) | Infant (< 1 year, excluding newborn) |
|---|---|---|
| Recognition | Unresponsive; no normal breathing/only gasping; no definite pulse within 10 s | Same |
| One rescuer, no advanced airway | 30:2 | 30:2 |
| Two or more rescuers, no advanced airway | 15:2 | 15:2 |
| Compression rate | 100–120/min | 100–120/min |
| Depth | At least one-third AP diameter, about 5 cm | At least one-third AP diameter, about 4 cm |
| Hand position | One or two hands on lower half of sternum | 2025 update: one-hand or two-thumb–encircling hands; the two-finger technique has been removed because it often fails to achieve adequate depth [9] |
| Quality | Full recoil; minimise pauses to < 10 s | Same |
The slide combines obsolete and interim ventilation rates. For clinical use, follow the current local PALS algorithm; the 2025 AHA/AAP range is 20–30/min with an advanced airway or when giving rescue breaths to a child with a pulse. [9]
For a comatose child aged 24 hours to 18 years after in- or out-of-hospital arrest, the slide offers two reasonable pathways with continuous core-temperature monitoring:
- 32–34°C for days 1–2, then 36–37.5°C for days 3–5, or
- 36–37.5°C throughout days 1–5.
The practical invariant is active temperature control and fever prevention; the choice requires the local post-arrest protocol and intensive-care team.
Golden Minute (60-second mark) for completing initial steps, re-evaluating, and beginning ventilation if required [1]
Apart from SpO2 monitor, additional ECG monitoring is recommended [1]
Suctioning non-vigorous infants with MSL (meconium-stained liquor) approach NOT recommended — avoiding unnecessary delay in initiation of ventilation [1]
The slide states delayed cord clamping for > 30 seconds in infants not requiring resuscitation. [1] The 2025 AHA/AAP update recommends deferring clamping for at least 60 seconds in most term and preterm newborns who do not need immediate resuscitation. [10]
Why no routine MSL suctioning? Previous practice was to intubate and suction below the cords for non-vigorous babies born through meconium. Routine oral, nasal or endotracheal suction is now not recommended, whether fluid is clear or meconium-stained. Suction only when obstruction is evident; endotracheal suction may help when ventilation remains ineffective despite corrective steps and tracheal obstruction is suspected. Effective ventilation, judged by a rising heart rate, is the priority. [10]
5. Airway Management in Children
Airway smaller and shorter than adult [1] Adult larynx: cylindrical, narrowest at vocal cords [1] The slide depicts the traditional “funnel-shaped, narrowest at cricoid” model. [1] More superior and anterior [1] Tongue and epiglottis relatively large [1]
Modern imaging shows paediatric airway shape is more complex than this simplified diagram; the functionally limiting level varies and is not a reason to force an oversized tube. The practical lessons remain:
- Why uncuffed ETTs were traditionally preferred, while correctly sized cuffed tubes are now acceptable
- Why intubation is technically more difficult (more anterior larynx, bigger tongue obscuring view)
- Why a straight blade (Miller) is often preferred in neonates (to lift the large epiglottis)
NON-cuffed endotracheal tube commonly used in the past but with better designed cuffed ETT, getting popular [1]
Cuffed ETTs can be used in infants and children provided correct tube size and cuff inflation pressure are used [1]
Exhaled CO2 detection is recommended for confirmation of endotracheal tube placement [1]
Quick reference tool [1] — length-based colour-coded tape that estimates weight from length, allowing rapid drug dose and equipment size selection. Essential in paediatric emergencies where weighing the child is impractical.
The following slide is a legacy local drug/equipment table. Use a current, institution-approved resuscitation aid and verify concentrations; do not transcribe doses from the screenshot, because formulations and guideline algorithms change.
6. Fluid Administration During Resuscitation
For volume bolus and effective delivery of medication [1] Method: same as bone marrow puncture; disposable needle available [1] Site: usually anterior tibia because more convenient [1]
Why IO? In critically ill children, peripheral venous access can be extremely difficult due to small veins, vasoconstriction, and oedema. IO provides rapid, reliable vascular access. Any drug or fluid that can be given IV can be given IO. The medullary cavity of long bones acts as a non-collapsible vein.
Possible aetiologies: [1]
- Pneumothorax
- Pericardial effusion, myocardial dysfunction
- Intestinal ischaemia, sepsis
- Adrenal insufficiency
- Pulmonary arterial hypertension
- Congenital heart disease, e.g. coarctation of aorta
Why this list matters: Give resuscitation fluid in weight-based aliquots according to the local paediatric shock protocol and reassess after every aliquot. If there is little improvement—or hepatomegaly, crackles or another sign of overload appears—think beyond hypovolaemia rather than repeatedly giving fluid. A shocked neonate may have duct-dependent congenital heart disease (e.g. critical coarctation), where urgent specialist care and prostaglandin E1 may be life-saving. [1][2]
This is an extremely high-yield comparison table that appears directly on the slides:
| Feature | Croup | Acute Epiglottitis |
|---|---|---|
| Age | 6 months – 3 years | 2–6 years |
| Onset | Gradual | Acute |
| Aetiology | Viral (often parainfluenza) | Hib is classic; other bacteria and non-infectious supraglottitis also occur |
| Swelling | Subglottic | Supraglottic |
| Cough/voice | Hoarse, barking cough | Muffled voice ("hot potato voice") |
| Fever | Absent to high | High |
| Appearance | Not acutely ill | Anxious, toxic |
| Larynx | Non-tender | Tender |
| Recurrence | May recur | Rare |
| Seasonal | Winter | None |
CRITICAL — Epiglottitis Management Rules
Do not provoke the airway with routine throat examination, venepuncture or imaging before it is safe [1][11]
Keep the child calm, with the carer, in the position of comfort; do not force them supine [11]
Do not place patient in horizontal position [1]
Transport patient sitting, with experienced doctor ready for intubation [1]
The principle is airway safety before diagnostic completeness. In moderate/severe obstruction, defer unnecessary examination, blood-taking and imaging until an advanced-airway team is present or the airway is secured. A stable child may undergo specialist-directed investigation in a controlled setting; the slide's medicolegal phrasing should not be read as a ban on all imaging in every presentation. [11]
7A. Management of Acute Epiglottitis — Full Protocol
Reading the clinical images
The photographs are recognition aids, not a severity score: look for an anxious child who cannot settle, open-mouth breathing, drooling, neck extension/tripod positioning and later exhaustion or reduced interaction. The lateral neck image demonstrates the classic enlarged “thumb” epiglottis, while the endoscopic photograph shows a swollen erythematous epiglottis. Neither image justifies moving an unstable child to radiology or attempting bedside laryngoscopy solely to prove the diagnosis.
Emergency stabilisation: [1]
- Monitor vital signs
- Offer oxygen without upsetting the child; hypoxia is a late sign
- Defer routine throat examination, venepuncture and imaging until the airway is safe
- Do not force the child supine; allow the position of comfort
- Keep the position of comfort and obtain immediate senior anaesthesia/PICU/ENT support; plan controlled airway management
Airway equipment to have ready: [1]
- Bag and mask
- Laryngoscope
- ET tubes just 1 size smaller than recommended (expect subglottic oedema)
- Age-appropriate rescue-airway and surgical-airway equipment with ENT expertise; a blind percutaneous tracheostomy is not a generic paediatric rescue step
Supportive care: [1]
- Fluid and hydration
- Treatment of post-obstructive pulmonary oedema
- Sedation and avoid accidental extubation
- Care of ET tube
- Adequate humidification
The slide's extubation cues: [1]
- General condition improving
- Fever subsiding
- Presence of air leak (around the ETT — indicates reduced swelling)
- “Usually 18–24 hours” is a lecture-era estimate, not a deadline; extubate only after clinical improvement and a multidisciplinary airway-readiness assessment
Why the protocol is so strict: The image shows a swollen, cherry-red epiglottis that can critically narrow the inlet. Distress, sedation or forced repositioning can precipitate complete obstruction. Keep the child calm while a coordinated anaesthesia/ENT/PICU plan is made; once airway safety permits, obtain cultures and give appropriate IV antibiotics according to local guidance. [11]
Post-Hib Vaccine Era
Acute epiglottitis has become rare where Hib vaccination is routine, but it still occurs from Hib in under-immunised children, other organisms and non-infectious causes. As of the current Hong Kong government schedule, Hib vaccine is available privately but is not included in the universal HK Childhood Immunisation Programme; ask about the child's actual vaccines rather than assuming protection. [12]
8. Status Epilepticus (SE)
The slide's “three seizures or continuous motor seizure > 30 minutes” definition is obsolete. For convulsive status epilepticus, use the ILAE operational time points: t1 = 5 minutes, when emergency treatment should begin, and t2 = 30 minutes, when the risk of long-term consequences rises. Recurrent seizures without recovery of consciousness also constitute status. [13][14]
The 20/30/60-minute stage labels and response percentages are historical teaching. Treatment is response-driven and time-critical: do not wait for the next labelled interval. Refractory status means ongoing seizure despite an appropriately dosed benzodiazepine and an appropriate second-line antiseizure medicine; it is not defined by waiting > 60 minutes. Persistent motor quiescence after paralytic/intubation does not exclude electrographic status—obtain EEG in the intensive-care pathway.
- Immediate resuscitation: note start time, protect from injury, ABC, monitor, check bedside glucose and correct a reversible metabolic cause. Give oxygen/ventilatory support when indicated and call for help. [14]
- First line at 5 minutes: follow an available individual emergency plan. Otherwise give an adequately dosed benzodiazepine—buccal midazolam or rectal diazepam in the community, or IV lorazepam when IV access and resuscitation facilities are immediately available. [14]
- If ongoing 5–10 minutes later: give one second benzodiazepine dose and obtain emergency expert help. Count prehospital doses to avoid unrecognised benzodiazepine stacking and respiratory depression. [14]
- If still ongoing after two benzodiazepine doses: give one current protocol-selected IV second-line medicine: levetiracetam, phenytoin or sodium valproate. NICE notes levetiracetam may be quicker to administer and have fewer adverse effects; selection depends on contraindications and the child's context. The slide's “phenytoin first choice at 20 minutes” hierarchy is outdated. [14]
- Refractory status: immediate PICU/neurology/anaesthesia management, airway and haemodynamic support, continuous EEG and protocol-directed anaesthetic therapy. If the first second-line option fails, specialist advice may guide another second-line option or phenobarbital/general anaesthesia. [14]
Medication Safety
Use a current local paediatric status-epilepticus chart for exact weight-based doses, concentrations and maximums. The fixed dose ladder in slides 41–44 is legacy content and should not be used at the bedside.
Investigations for underlying causes, e.g. brain malformation, infections, poisoning, overdose, etc. [1]
Underlying causes to consider: meningitis/encephalitis (LP when stable), hypoglycaemia, hyponatraemia, hypocalcaemia, inborn errors of metabolism (neonates), structural brain lesion, poisoning/drug overdose, febrile seizure (if < 5 years, but status from febrile seizure still needs treatment).
Status asthmaticus, acute poisoning, drug overdose, cardiovascular emergency, anaphylaxis [1]
These are signposts, not management algorithms in this deck. Use the dedicated current pathway rather than extrapolating a drug list:
- Status asthmaticus: assess severity repeatedly; a quiet/silent chest, exhaustion, altered consciousness or poor respiratory effort signals life-threatening disease. Bronchodilator, steroid, magnesium and ventilatory decisions are severity- and protocol-dependent; aminophylline is not a routine first-line addition.
- Anaphylaxis: first-line treatment is IM adrenaline 1 mg/mL (1:1000), 0.01 mg/kg to the age/protocol maximum, into the anterolateral thigh, repeated according to response and the emergency protocol. Check concentration carefully. [15]
- Acute poisoning/drug overdose: stabilise ABCs, contact poison-control/toxicology support and use substance-specific decontamination/antidote guidance. Activated charcoal is selective, time- and airway-dependent—not a default intervention.
Cause of sudden deterioration: [1]
- Head trauma
- Surgical abdomen, e.g. internal haemorrhage, intussusception, malrotation of gut
Non-accidental injuries [1]
Why this matters: Always think surgical causes when a child suddenly deteriorates. Intussusception classically presents with intermittent colicky abdominal pain, vomiting, and redcurrant-jelly stools in a 6-month to 2-year-old (directly tested in 2023 Minicase). [6] Malrotation with midgut volvulus is a surgical emergency presenting with bilious vomiting in a neonate — delay in diagnosis → bowel necrosis.
Non-accidental injury (NAI): Always consider in any child presenting with unexplained injuries, especially if:
- Injuries inconsistent with developmental stage
- Delay in seeking medical attention
- Inconsistent or changing history from caregivers
- Patterned or sentinel injuries, multiple injuries of different apparent mechanisms, or an injury unexplained by the history. No single bruise pattern proves abuse; follow the local safeguarding pathway.
Hospitalisation especially ICU admission is stressful not just to patient but also immediate family members [1]
Support should extend to parents and family members [1]
In an exam answer (SAQ/OSCE), always include a line about family support, parent communication, and psychological care. This shows holistic, patient-centred thinking.
Universal Precaution [1]
SARS / COVID-19 [1]
Key points:
- Apply standard precautions and do not delay an immediately life-saving response when a safe response is possible
- Select respiratory protection, eye protection, gown/gloves and room controls by suspected pathogen, transmission route and procedure under the current local infection-control policy
- Delta variant and Omicron related issues — COVID prognosis in children generally better than SARS but widespread [1]
The isolation visual specifies an airborne infection isolation room with negative pressure, en-suite toilet and at least 12 air changes/hour, plus airborne, droplet and contact precautions in addition to standard precautions. The pictured PPE includes an N95 respirator, eye/face protection, gown and gloves. These are COVID-era lecture instructions; match PPE and room requirements to the organism, procedure and current infection-control policy.
From the supporting Block C "Spotting the Sick Child" material: [7]
The 3-minute toolkit is a systematic rapid assessment:
- A — Airway: secretions, stridor, foreign body
- B — Breathing: rate, effort, recession, SpO₂
- C — Circulation: HR, CRT, skin colour, BP
- D — Disability: AVPU/GCS, pupils, posture, glucose
- E — Exposure: rash (petechiae/purpura = meningococcal disease), temperature, signs of abuse
"Children who are starting to decompensate can look deceptively well, but the clues will be there if you make a thorough examination" [7]
Close monitoring and better understanding the physiological difference between adult and children is important in early detection of acute deterioration [1]
Master the technique of paediatric CPR and know when to seek help [1]
Understand the basic management principles on paediatric emergencies [1]
Variations in maturation of organ systems and physiologic responses [1]
Child is NOT a miniature adult [1]
Physiological condition similar to adult by 8 to 12 years, but not mentally [1]
Small "margin for error" [1]
Early consultation [1]
High Yield Summary
- Children are not miniature adults: airway size, diaphragmatic breathing, heart-rate-dependent cardiac output, neonatal hypoxic response, heat/water loss and glucose reserve all change assessment and treatment.
- Bradycardia is ominous; paediatric arrest is commonly the end result of respiratory failure or shock.
- Use the PAT for the first impression, then structured ABCDE assessment and the institution's PEWS/escalation chart.
- Deliver high-quality, age-appropriate CPR with explicit team roles, minimal pauses and recovery/post-arrest care.
- In suspected epiglottitis, keep the child calm and upright and secure the airway with an experienced team; do not provoke the airway for a routine throat examination or radiograph.
- Treat a convulsive seizure at 5 minutes; escalate promptly if first-line treatment fails and investigate the cause.
- Use IO access when urgent vascular access cannot be obtained; reassess shock physiology rather than assuming every non-responder needs more fluid.
- Always check glucose and temperature, support the family and consider a surgical cause or non-accidental injury when the story does not fit.
Active Recall - Critically Ill Child
[1] Lecture slides: GC 145. A critically ill child childhood medical emergencies.pdf (all pages/slides) [2] Senior notes: Adrian Lui Pediatrics Notes.pdf (p487, Section 14.3 Pediatric Emergencies) [3] Past papers: 2016 Fourth Summative SAQ.pdf (Q10) [4] Senior notes: MBBS Final MB (Pediatrics) (Felix PY Lai).pdf (p171, Hib vaccine section) [5] Senior notes: Ryan Ho Critical Care.pdf (p13, Management of Lower Airway Emergencies) [6] Past papers: 2023 Fourth Summative Minicase.pdf (Case Two — intussusception) [7] Paediatrics slides: Block C - Spotting the Sick Child.pdf (p2, p4) [8] American Heart Association/American Academy of Pediatrics. Part 8: Pediatric Advanced Life Support—2025 Guidelines. 2025. [9] American Heart Association/American Academy of Pediatrics. Part 6: Pediatric Basic Life Support—2025 Guidelines. 2025. [10] American Heart Association/American Academy of Pediatrics. Part 5: Neonatal Resuscitation—2025 Guidelines. 2025. [11] Royal Children's Hospital Melbourne. Acute upper airway obstruction clinical guideline. [12] Hong Kong Department of Health, Family Health Service. Schedule of Hong Kong Childhood Immunisation Programme. [13] International League Against Epilepsy. Definition and classification of status epilepticus. [14] NICE. Treating status epilepticus, repeated or cluster seizures, and prolonged seizures (NG217). Updated 2025. [15] World Health Organization. Brief overview of anaphylaxis as an adverse event following immunization.
GC144 A Child With Recurrent Infections Primary Immunodeficiencies
Primary immunodeficiencies are a group of inherited disorders characterized by defects in one or more components of the immune system, leading to increased susceptibility to recurrent, severe, or unusual infections in childhood.
GC146 A Jaundiced Child
A jaundiced child presents with yellow discoloration of the skin and sclera due to elevated bilirubin, requiring systematic evaluation to distinguish physiological, hemolytic, hepatocellular, or obstructive causes across different age groups.