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]
How this fits into exams: This is a bread-and-butter GC topic. Past papers have directly asked about physical examination parameters for assessing a critically ill child (2016 SAQ Q10), dehydration assessment in young children (2023 Minicase), and acute surgical abdomen in paediatrics. MCQs test recognition of physiological differences (e.g. why bradycardia is ominous) and management algorithms (e.g. status epilepticus drug ladder). Expect SAQ/minicase stems that give you a sick child and ask you to systematically assess and manage.
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] |
| Obligate nose breathing until ~6 months of age | Nasal obstruction (secretions, choanal atresia) = airway obstruction in young infants. Always suction the nose. [1] |
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.
| 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 dependent on heart rate due to low stroke volume | The immature myocardium is stiff with fewer contractile elements. Stroke volume is relatively fixed. The ONLY way to increase CO is to increase HR. [1] |
| Bradycardia is ominous | Since CO = HR × SV and SV is fixed, bradycardia = falling CO = pre-arrest. In adults, bradycardia may be benign (vagal). In children, bradycardia usually means profound hypoxia or acidosis and imminent cardiac arrest. [1][2] |
| CVP less accurate (short neck) | JVP assessment unreliable in infants. Response to fluid bolus becomes similar to adults after ~8 weeks. [1] |
| 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.
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 — depressed anterior fontanelle is a sign of severe dehydration [1]
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 repetitive non-purposeful movements, consider seizure.
PEWS scoring parameters and action: [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: Children compensate well until they suddenly decompensate. PEWS provides an objective trigger for escalation before catastrophic deterioration.
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]
This is the fundamental difference from adults. In adults, cardiac arrest is usually primary (VF/VT from coronary disease). In children, cardiac arrest is usually secondary to respiratory failure or shock → hypoxia → bradycardia → PEA/asystole. This means:
- 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): [1]
- Improves chance of response to cardiac arrest
- Long-term prognosis still needs more review; increased risk of CNS complications
- Should consider for readily reversible cases, e.g. witnessed cardiac arrest, post-op cardiac
| Phase | Goal | Components |
|---|---|---|
| Phase 1: Basic CPR | Maintain oxygenation and circulation | Airway → Breathing → Circulation (traditional) or C → A → B (current emphasis) |
| 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]
Simplify BLS by recommending Compression Only for untrained lay rescuers. Option for trained rescuers also. [1]
UK guidelines still support rescue breaths [1]
2024 update: Respiratory Rate in infant < 1 year should be at least 30/min; ≥ 1 year should be 25/min [1]
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? Opening the airway and delivering rescue breaths is technically difficult for lay rescuers. Chest compressions can be started immediately, maintain some coronary and cerebral perfusion, and the 20-second delay in ventilation is acceptable given that most paediatric cardiac arrests have preceding hypoxia (some oxygen still in the lungs). For healthcare providers, ventilation remains critical because of the predominantly respiratory aetiology.
Priority Statement from Lecture
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]
Delayed cord clamping for > 30 seconds is reasonable for both term and preterm infants who do not require resuscitation at birth [1]
Why no routine MSL suctioning? Previous practice was to intubate and suction below the cords for non-vigorous babies born through meconium. Evidence shows this delays ventilation without improving outcomes. The priority is to start effective ventilation within the golden minute.
5. Airway Management in Children
Airway smaller and shorter than adult [1] Adult larynx: cylindrical, narrowest at vocal cords [1] Child larynx: funnel shape, narrowest at cricoid cartilage [1] More superior and anterior [1] Tongue and epiglottis relatively large [1]
These anatomical differences explain:
- Why uncuffed ETT was traditionally preferred (the cricoid ring acts as a natural "cuff")
- 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.
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: After giving fluid boluses (typically 20 mL/kg isotonic crystalloid, may repeat to 40–60 mL/kg total), if there's no improvement, you MUST think beyond hypovolaemia. A neonate presenting in shock may have undiagnosed ductal-dependent congenital heart disease (e.g. coarctation) where prostaglandin E1 is life-saving, not more fluids. [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 (parainfluenza) | Haemophilus influenzae type B |
| 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
NO throat examination — can precipitate complete obstruction [1]
NO X-ray neck — Very Dangerous with Medical Legal Consequence [1]
Do not place patient in horizontal position [1]
Transport patient sitting, with experienced doctor ready for intubation [1]
These are absolute rules. An examiner who sees you suggest "take a lateral neck X-ray" for suspected epiglottitis will mark you down. The classic "thumb sign" on lateral neck X-ray is an incidental finding, NOT something you should go looking for in a sick child.
7A. Management of Acute Epiglottitis — Full Protocol
Emergency stabilisation: [1]
- Monitor vital signs
- Oxygen supplement even if patient is NOT cyanotic
- NO throat examination
- Do NOT place patient in horizontal position
- X-ray neck is DANGEROUS and NOT necessary for confirmation of diagnosis
- Transport patient sitting with experienced doctor ready for intubation
Airway equipment to have ready: [1]
- Bag and mask
- Laryngoscope
- ET tubes just 1 size smaller than recommended (expect subglottic oedema)
- Percutaneous tracheostomy set
Supportive care: [1]
- Fluid and hydration
- Treatment of post-obstructive pulmonary oedema
- Sedation and avoid accidental extubation
- Care of ET tube
- Adequate humidification
Extubation criteria: [1]
- General condition improving
- Fever subsiding
- Presence of air leak (around the ETT — indicates reduced swelling)
- Usually done at 18–24 hours
Why the epiglottitis protocol is so strict: The inflamed, cherry-red epiglottis is teetering on the edge of complete airway obstruction. Any distress (crying from throat examination, lying flat, being moved to radiology) increases oxygen demand and respiratory effort, potentially tipping the child into total obstruction. The safest management is to keep the child calm and upright until definitive airway control (intubation in OR with anaesthetist present) can be achieved.
Post-Hib Vaccine Era
Acute epiglottitis has become rare in countries with universal Hib vaccination. However, it still occurs (non-type B strains, other organisms). Hib vaccine is NOT included in the Hong Kong Childhood Immunisation Programme as Hib infection has relatively lower occurrence in HK. [4] The concept remains highly examinable.
8. Status Epilepticus (SE)
Status Epilepticus: 3 seizures without awakening OR continuous motor seizure activity for > 30 minutes [1]
Treatment should be given for prolonged seizures of > 5 minutes [1]
Why treat at 5 minutes (not 30)?
- Spontaneous cessation unlikely if duration > 5–10 minutes
- Prolonged seizure more likely to progress to status
- The longer a seizure continues, the more resistant it becomes to treatment (self-sustaining through NMDA receptor activation and GABA receptor internalisation)
| Stage | Duration | Key Points |
|---|---|---|
| Prolonged seizure | > 5 min | Start treatment; prehospital/AED if available [1] |
| Initial/Early Convulsive SE | 20–30 min | Better response to first medications: > 80% respond within 30 min, 75% within 60 min, 65% within 90 min [1] |
| Established Convulsive SE | 30–60 min | Additional AEDs; close monitoring; investigate for underlying causes and complications [1] |
| Refractory SE | Unresponsive to 2 AEDs, duration > 60 min | High morbidity and mortality; requires ICU admission and aggressive control, ventilatory/haemodynamic support [1] |
Pre-hospital / 0–5 minutes: [1]
- Supportive: semi-prone position, O2 supplement
- Prepare anti-epileptic medications
- Pre-hospital treatment: single rectal diazepam 0.4 mg/kg (reduce to 0.25 mg/kg if already on regular anticonvulsants)
First-line (6–30 minutes): Benzodiazepines [1]
| Drug | Route | Notes |
|---|---|---|
| Diazepam | Rectal: convenient and effective; IM: NOT effective; IV: painful | Most commonly available. Repeat bolus after 5–10 min if needed. |
| Lorazepam | IV | Slightly more effective than diazepam |
| Midazolam | Buccal / intranasal: as effective as rectal diazepam | Very practical for prehospital/school settings |
Second-line (20–60 minutes): If NOT responsive [1]
- Intravascular access necessary
| Drug | Dosing | Side Effects |
|---|---|---|
| Phenytoin (first choice) | Loading 15–20 mg/kg IV, infusion rate < 1 mg/kg/min; then 5–8 mg/kg/day | Strong alkaline, hypotension, arrhythmia |
| Phenobarbital | Loading 15–20 mg/kg IV; then 3–5 mg/kg/day | Respiratory suppression, hypotension |
| Levetiracetam (Keppra) | Getting more popular | Little side effect, less CNS depression and haemodynamic disturbance |
Refractory SE ( > 60 minutes): [1]
- Midazolam continuous infusion: Loading 0.2 mg/kg slow IV bolus → infusion up to 30 mcg/kg/min
- Thiopentone or pentobarbitone infusion
- Propofol / other anaesthetic agents
- Sodium valproate
- ICU admission mandatory
Levetiracetam is getting more popular due to little side effect, less CNS depression and haemodynamic disturbance [1]
Exam Trap — IM Diazepam
IM diazepam is NOT effective [1] — It is poorly and erratically absorbed from muscle. Always use rectal, IV, or switch to buccal/intranasal midazolam. This is a favourite MCQ distractor.
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 flagged as important paediatric emergencies. While not covered in full detail in this particular lecture, they are covered in other GC lectures. Key points:
- Status asthmaticus: Nebulised salbutamol + ipratropium, IV MgSO₄, IV aminophylline, IV hydrocortisone. Monitor for silent chest (no air entry = near-death). [5]
- Anaphylaxis: IM adrenaline 0.01 mg/kg (use 1:1000 solution), repeated every 5 min. Weight-based dosing essential in children.
- Acute poisoning/drug overdose: Stabilise ABCs, identify substance, specific antidotes where available, activated charcoal if within 1 hour and airway protected.
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
- Pattern injuries (belt marks, cigarette burns, bilateral black eyes)
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:
- PPE adherence is critical before approaching any resuscitation
- COVID-19 pandemic highlighted challenges of aerosol-generating procedures (intubation, BVM, CPR) — appropriate PPE (N95, face shield, gown, gloves) must be donned
- Delta variant and Omicron related issues — COVID prognosis in children generally better than SARS but widespread [1]
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]
Likely Exam Questions
Q1 (modelled on 2016 SAQ Q10): A 6-month-old infant is brought to A&E in a drowsy state. List the parameters on physical examination that indicate the general well-being (or severity of illness) of this child. (10 marks)
Markscheme: Skin perfusion (colour, warmth, CRT < 2s), hydration (anterior fontanelle, mucous membranes, skin turgor), responsiveness (AVPU, alertness, irritability), respiratory (rate, grunting, flaring, recession, apnoea), cardiovascular (HR, BP, CRT), temperature (fever/hypothermia), seizure activity (subtle signs), urine output. 1 mark each.
Q2: Compare and contrast croup and acute epiglottitis. (8 marks)
Markscheme: Table with age, onset, aetiology, site of swelling, cough/voice, fever, appearance, recurrence. Award marks for each correct differentiating feature.
Q3: Outline the stepwise management of status epilepticus in a 3-year-old child. (10 marks)
Markscheme: ABCs + O₂ → first-line benzodiazepine (rectal diazepam 0.4 mg/kg or buccal midazolam; repeat once after 5–10 min) → second-line phenytoin 15–20 mg/kg IV over 20 min → if refractory, midazolam infusion or thiopentone in ICU. Include: check glucose, investigate cause, monitor for respiratory depression.
Q4: A 2-year-old child is found collapsed at home. Describe your approach to basic life support. How does paediatric BLS differ from adult BLS?
Markscheme: Check safety → assess responsiveness → call for help → C-A-B approach → 30 compressions : 2 breaths (single rescuer) or 15:2 (two healthcare rescuers) → AED when available. Differences: respiratory arrest predominates, ventilation more important, bradycardia is ominous, smaller compressions (1/3 AP diameter), higher respiratory rate (≥30/min for < 1yr, ≥25/min for ≥1yr [2024 update]).
Q5: In a neonate, which of the following is the MOST ominous sign? A. Tachycardia B. Bradycardia C. Mild tachypnoea D. Fever Answer: B — Bradycardia in a neonate = falling cardiac output (CO dependent on HR).
Q6: Which of the following routes should NOT be used for diazepam in status epilepticus? A. Rectal B. Intravenous C. Intramuscular D. Buccal (as midazolam) Answer: C — IM diazepam is NOT effective due to poor absorption.
Q7: In suspected acute epiglottitis, which of the following should be AVOIDED? A. Oxygen supplementation B. Lateral neck X-ray C. Sitting position D. IV antibiotics Answer: B — X-ray neck is dangerous and medico-legally indefensible; it delays airway management.
High Yield Summary
-
Children are NOT miniature adults — anatomical and physiological differences (cartilaginous thorax, diaphragmatic breathing, high airway resistance, CO dependent on HR, biphasic neonatal hypoxic response, greater insensible losses, hypoglycaemia risk) dictate all management.
-
Bradycardia is ominous in children — it means imminent cardiac arrest.
-
Respiratory arrest is more common than cardiac arrest in paediatrics — prioritise oxygenation/ventilation.
-
PEWS: 0–4 stable; 5–6 needs more monitoring; > 7 is critical.
-
CPR: C-A-B emphasis; compression-only for lay rescuers; ventilation still critical for healthcare providers. 2024 RR: ≥30/min ( < 1yr), ≥25/min (≥1yr). Golden minute for neonatal resuscitation.
-
Croup vs Epiglottitis: Subglottic/viral/barking cough vs supraglottic/Hib/toxic/muffled voice. Epiglottitis = NO throat exam, NO X-ray, keep upright, prepare for intubation.
-
Status Epilepticus: Treat at > 5 min. First-line: benzodiazepines (rectal diazepam or buccal midazolam). Second-line: IV phenytoin (first choice) or phenobarbital. Refractory: ICU + midazolam/thiopentone infusion. IM diazepam is NOT effective.
-
IO access (anterior tibia) for emergency vascular access. Non-hypovolemic shock causes: pneumothorax, pericardial effusion, sepsis, adrenal insufficiency, pulmonary HT, congenital heart disease.
-
Always check glucose, monitor temperature (hypothermia = red flag in neonatal sepsis), support the family, and consider NAI.
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)