This document provides an overview of pediatric emergencies for EMS providers. It begins with background on pediatrics in EMS, noting that while pediatric patients make up over 50% of ER visits, they only account for about 5% of EMS calls. This results in few opportunities for providers to treat pediatric patients. The document then reviews general pediatric assessment strategies and techniques. It discusses several common pediatric emergencies like respiratory emergencies such as foreign body airway obstruction, croup, asthma, and bronchiolitis. It also reviews seizures. For each emergency, it provides information on recognition signs and recommended treatment. The document aims to equip EMS providers with the essential knowledge to properly assess and treat ill or

1. Pediatrics CME
Nick Mark, EMT-C

2. Outline
• Background: Pediatrics in EMS
• General Pediatric Assessment Strategies
• Pediatric Emergencies
– Respiratory Emergencies
– Seizures
• Scenarios

3. Background: Pediatrics in EMS
• Pediatrics constitute over 50% of ER visits
but only about 5% of EMS calls are for
pediatric patients.
– Why is this?
• This has two consequences:
– EMS providers have few opportunities to
practice working with pediatric patients
– The few calls we do get for pediatric patients
tend to be more serious

4. Background: Pediatrics in EMS
• Some common pediatric emergencies
include:
– FBAO
– Fever
– Meningitis
– Respiratory distress
– Sepsis
– Seizures
– SIDS
– Trauma

5. Pediatric Age Groups
•
•
•
•
•
•
Newborn (first 6 hours)
Neonate (first 28 days)
Infant (first year)
Toddler (1 to 3 years)
Preschooler (3 to 5 years)
School age (6 to 12
years)
• Adolescent (12 to
adulthood)
How much does a child
weigh at each age?

6. Pediatric Assessment Techniques
• Initial Assessment (quick assessment that can
be done within seconds of arriving on scene)
– Appearance
• Mental status (alert, crying, obtunded, no response)
• Muscle tone (moving, not moving, limp)
– Breathing
• Respiratory rate (too fast, too slow, irregular)
• Respiratory effort (use of accessory muscles, nasal flaring,
retractions, grunting)
• Check breath sounds
– Circulation
• Skin color (pallor, peripheral cyanosis, central cyanosis)
• Capillary Refill (normal is within 2 seconds)
• Pulse (too fast, too slow, irregular, normal)

7. Pediatric Assessment Techniques
• Detailed assessment
– With adults this is typically done head to toe, with
pediatrics it is better to do the opposite
• Why?
– Take a SAMPLE history (use the parents for detailed
hx if possible)
– Determine
• Hx of fever or infection
• Hx of vomitting or fever and check hydration status (skin
turgor, check fontanalles in infants, look for xerosis)
• Frequency of urination
– Why are these important questions to ask?
– Take vitals and measure pulse oximetry
• How is pulse oximetry different in pediatrics than in adults?

8. Pediatric Assessment Techniques
• Detailed assessment (cont.)
– Try to invent a game you can play or begin a
conversation about something you can talk about for
at least several minutes (Batman, Sesame Street,
toys, school, etc.).
– Explain each step in your assessment (“now I’m going
to feel your tummy…”).
– With older patients explain why you are doing each
step (“I need to make sure your stomach is OK”).
– With younger patients, avoid separating them from
their parents if possible.
• Why?

9. Pediatric Assessment Techniques
• Detailed assessment (cont.)
– Explain things as simply as possible avoiding
technical terminology and jargon.
– Do NOT condescend.
– Do NOT lie or make promises you cannot be sure to
keep.
– Be alert for injuries that seem inconsistent with their
explanation – this is usually a sign of child abuse.
• Examples?
– If you suspect child abuse, you must report it by
calling 1-800-RICHILD.

10. Normal Vital Signs by Age
• In general remember as children age their
pulse and breathing rates get slower, and
their BP gets higher.
• By adolescence these values approach
those of adults.
• Two general rules (for children 1-10):
– Weight in kg = 2 x age (in years) + 8
– Lowest permissible systolic BP = 70 + 2 x age
(in years)

11. Normal Vital Signs by Age
Age
Breaths/Min Beats/Min Minimum Systolic BP
Neonate
30-50
120-160
60
Infant
20-30
80-140
70
Toddler
20-30
80-130
74-76
Preschool
20-30
80-120
76-80
School Age
12-30
60-100
80-84
Adolescent
10-20
60-100
84-90

12. Respiratory Emergencies

13. Respiratory Emergencies
• Respiratory distress is the leading cause
of ER visits and EMS calls for children
• Respiratory compromise is one of the
leading causes of death in children
– What is the leading cause of death in
children?
• Respiratory emergencies can effect
children of all ages
• EMS intervention can be life-saving

14. Respiratory Emergencies
• Many different etiologies
– Choking (FBAO)
– Epiglottitis
– Croup
– Asthma
– Bronchiolitis
– Which of these is most common? Which is
most serious?

15. The Pediatric Airway
• Several key differences
between adult and
pediatric airway
– Larger floppier
epiglottis
• Epiglottitis
• More difficult
intubations
– Smaller, funnel
shaped trachea
• FBAO is more likely
• No blind finger
sweeps
• Why?

16. Respiratory Emergencies - FBAO
• Foreign Body Airway Obstruction (FBAO)
– Usual causes are hard candy, nuts, small toys, coins, and
balloons
• Recognition
– Apnea, inspiratory stridor, rales, rhonchi, wheezing, inability to
speak, anxiety, decreased breath sounds, muffled voice
• Treatment
– If the patient is not breathing, open the airway and perform the
AHA approved maneuvers for clearing the obstruction
• Heimlich, backblows, abdominal or chest compressions.
• If properly trained you may use a laryngoscope with Magills forceps
to try and remove the obstruction.
– If patient is breathing, be as calming and supportive as possible.
Do not agitate the patient and transport sitting up as comfortably
as possible. Be alert for change in status.

17. Respiratory Emergencies - FBAO
• Treatment (cont.)
– If patient is not breathing ventilate using a
BVM.
– Administer oxygen at 15 LPM by NRB.
– If patient is wheezing
• Contact Medical Control for permission to
administer ALBUTEROL 2.5 mg (0.083%) by
nebulizer over 5-10 minutes.
– For infants younger than 6 months use half the dose.

18. Respiratory Emergencies –
Epiglottitis
• Inflammation of the
epiglottis and
surrounding
structures caused by
bacterial infection.
• This condition is a
true emergency with
mortality rates as high
as 10%.
• Typically occurs in
children 3-7 years old.

19. Respiratory Emergencies –
Epiglottitis
• Recognition
– Rapid onset (6-8 hours) of sore throat,
dysphagia, muffled voice, high fever,
drooling, inspiratory stridor or rattle
– Child is often found obtunded in tripod
position
– Signs of respiratory distress are often present

20. Respiratory Emergencies –
Epiglottitis
• Treatment
– It is absolutely essential that the patient be handled
as calmly as possible. Anxiety or aggravation can
cause increased swelling and precipitate respiratory
arrest.
• Defer all painful procedures.
• Transport patient sitting up in position of comfort.
• Do not try to visualize the swelling or look in the mouth.
– Administer high flow humidified O2 by NRB.
– Administer 5 ml of EPINEPHRINE 1:1,000 by
nebulizer. This can reduce upper airway swelling.
– Have airway equipment (BVM, ET equip) ready in
case patient’s condition deteriorates.
– Inform medical control early so preparations can be
made at hospital for treatment.

21. Respiratory Emergencies – Croup
• Inflammation of the
upper airways caused
by a viral infection.
• Very common (50 per
1000 children)
• Usually occurs in
children aged 6
months to 3 years.
(median age of onset
is 18 months).
Sites of inflammation in
pediatric airway infections

22. Respiratory Emergencies – Croup
• Recognition
– Low grade fever, barking cough,
hoarseness, inspiratory stridor, wheezing
– Signs of respiratory distress
– Often occurs at night
• Treatment
– Same as for epiglottitis.
– The patient is likely to respond well to cool
humidified O2.

23. Respiratory Emergencies –
Epiglottitis vs. Croup
•
•
•
•
•
•
Croup
6 months – 3 years
Slow onset
Barking cough
No drooling
Low grade fever (<104°F)
•
•
•
•
•
•
Epiglottitis
3 – 7 years
Rapid onset
No barking cough
Copious drooling
High fever (>104°F)
• Responds well to tx
• Moderately serious
• Very Serious

24. Respiratory Emergencies – Asthma
• In contrast to croup &
epiglottitis, asthma is
inflammation of the
lower airways.
• It is very common
(effects 50-100 out of
1000 children under
10 YO)

25. Respiratory Emergencies – Asthma
• Recognition
– Typically it is either exercise, allergy, or
infection induced
– S/Sx include wheezing, prolonged expiration,
tachypnea, dyspnea, and anxiety
– A silent chest is an especially bad sign.
• Why?

26. Respiratory Emergencies – Asthma
• Treatment
– Administer cool humidified oxygen.
– Provide ventilations if breathing is inadequate.
– Contact Medical Control for permission to administer
ALBUTEROL 2.5 mg (0.083%) by nebulizer over 5-10 minutes.
• For infants younger than 6 months use half the dose.
– If patient has severe respiratory distress, administer
EPINEPHRINE 1:1,000 0.01 mg/kg SQ.
• Maximum dose is
– 0.3 mg in pt. > 20 kg
– 0.2 mg in pt. < 20 kg
– 0.1 mg in pt. < 10 kg
• For patients with cardiac problems call medical control before
administering EPINEPHRINE.
• What are some potential problems that EPINEPHRINE and
ALBUTEROL can cause? What should you be alert for when giving
these drugs?

27. Respiratory Emergencies –
Bronchiolitis
• Bronchiolitis is a viral inflammation of the
lower airways.
• It usually effects children under 2 YO.
• Usually presents with symptoms similar to
those of asthma.
• Can be very serious in infants.
– Why do you think this is?
• More common in the winter months.

28. Respiratory Emergencies –
Bronchiolitis
• Recognition
– Wheezing and tachypnea are most common
symptoms. Also anxiety, shortness of breath,
and cyanosis.
• Treatment
– Same as asthma
– Patient is not as likely to respond well to βagonists (EPI, ALBUTEROL)

29. Respiratory Emergencies –
Asthma vs. Bronchiolitis
• Asthma
• Occurs in all ages, more
common in children > 2
YO
• Occurs throughout the
year
• Family hx of asthma
• Bronchiolitis
• Usually occurs in children
under 2 YO
• Responds well to βagonists (EPI and
ALBUTEROL)
• Does NOT respond well
to EPI/ALBUTEROL
• Most common in winter,
spring
• No family hx

30. Respiratory Emergencies
General Notes
• Treat respiratory emergencies
aggressively. Be prepared for patients to
decompensate.
• Do not hesitate to give neonates oxygen if
you suspect they need it.
• Remember to treat the parents too.

31. Seizures

32. Pediatric Seizures
• A seizure is caused by abnormal electrical activity in the
brain.
• Seizures can cause impaired consciousness and/or
abnormal behavior.
• There are many causes of seizures including:
– Epilepsy
– Infection
– Trauma
– Neoplasm
– Metabolic problems (electrolytes, uremia, hypoxia, acidosis, etc.)
– Hypoglycemia
– Poisoning
– Hyperthermia
Which of these causes do you think is most common in children?
Which do you think is usually most serious?

33. Pediatric Seizures
• Types of pediatric
seizures
– Grand mal (tonic
clonic)
– Petit mal (absence)
– Partial
– Status epilepticus
Which type is most
common is children?
• Stages of a grand-mal
– Aura
– Tonic-clonic
– Postictal

34. Pediatric Seizures - Febrile
• Febrile seizures are caused by fever resulting
from a viral infection.
• Very common (20-50 per 1000) in children under
7 YO.
• Most common in children aged 6 months to 5
years.
• There is usually a family history.
• They are usually benign.
– If they are longer than 20 minutes they are probably
not febrile and indicate something much more
serious.

35. Pediatric Seizures
• Recognition
– Seizure phase: unresponsiveness, involuntary
skeletal muscle contractions, dyspnea, apnea
– Postictal phase: confusion, altered LOC,
retrograde amnesia

36. Pediatric Seizures
• Treatment
– Protect the airway
• Place patient LLR
• Suction to clear vomit
• Use airway adjunct and ventilate if patient is
apneic
– Protect patient from injury

37. Pediatric Seizures
• Treatment (cont.)
– Take a thorough history of the parents to try and R/O
differentials
•
•
•
•
•
Hx of medical problems
Medication use
Possibility of head injury
Recent illness (fever, nucal rigidity, photophobia, phonophobia)
Possibility of poisoning
– Other important questions
•
•
•
•
•
Did patient vomit during the seizure?
Duration of seizure?
Description of seizure
Condition of child when found
Last meal
– Why are these important questions to ask?

38. Pediatric Seizures
• Treatment
– Manage the airway and provide oxygen
– If patient is febrile (temp > 102°F) administer
ACETAMINOPHEN 15 mg/kg rectally.
– Check blood glucose using glucometer
– If bG is < 60 mg/dl (or if you suspect hypoglycemia)
• If patient is awake with intact gag reflex who can swallow,
administer ORAL GLUCOSE 15 gm PO. (If pt. is younger
than one year, contact medical control.)
• For patients without an intact gag reflex, contact medical
control and administer GLUCAGON 0.1 mg/kg (max dose 1.0
mg) IM.

39. Pediatric Seizures
General Notes
• Never assume “it’s just a febrile seizure.”
• All patients who have a seizure should be
transported for evaluation.
• Always consider differential causes
especially trauma, hypoglycemia, and OD.
• Seizure activity ALWAYS extremely
serious in a neonate.
• Remember to treat the parents too.

40. Scenarios