Pediatric Emergencies¶
Category: Special Populations Sources: UCLA EMT Ultimate Study Guide (2026); raw/protocols/nm-sop-guidelines-treatment-2022.pdf Last updated: 2026-05-06
Overview¶
Pediatric patients are not small adults. Anatomical differences affect airway management, normal vital sign ranges differ dramatically by age, and compensation patterns mean children can maintain normal blood pressure much longer than adults in shock — then crash suddenly. Assessment requires age-appropriate communication, a 30-second doorway evaluation (PAT), and age-specific normal values to recognize when something is wrong.
Key Points¶
- PAT (Pediatric Assessment Triangle) — 30-second from-the-doorway visual assessment before touching the patient; any two sides abnormal = immediate intervention
- Children compensate longer than adults — normal BP does not rule out shock; tachycardia + skin signs come first
- Tachycardia is the FIRST sign of shock in children; hypotension is a late, ominous sign
- Anatomical differences affect airway management — larger occiput, larger tongue, obligate nose breathing in infants
- Grunting = respiratory failure, not distress — the child is trying to maintain alveolar pressure
- Minimum BP formula: 70 + (2 × age in years) = minimum acceptable systolic BP
- Fever in infants <3 months = medical emergency requiring immediate transport regardless of apparent stability
Pediatric Vital Signs by Age¶
| Age Group | Age Range | RR (breaths/min) | HR (bpm) | Systolic BP (mmHg) | Assessment Tip |
|---|---|---|---|---|---|
| Newborn | 0–1 month | 30–60 | 85–205 | 70–95 | Obligate nose breather; capillary refill over BP |
| Infant | 1–12 months | 30–60 | 100–190 | 70–105 | Brachial pulse; hold with parent; assess at end |
| Toddler | 1–3 years | 24–40 | 100–190 | 85–115 | Separation anxiety; bring comfort object |
| Preschool | 3–6 years | 22–34 | 60–140 | 85–115 | Explain literally; use imagination; FBAO risk |
| School Age | 6–12 years | 18–30 | 60–140 | 85–115 | Involve child in assessment; maintain modesty |
| Adolescent | 12–18 years | 12–16 | 60–100 | 110–130 | Physical adult, emotional child; private questions away from family |
KEY DIFFERENTIATOR — Pediatric Shock: Children compensate for shock more effectively and for longer than adults. A child in significant hemorrhagic shock may maintain a normal blood pressure until near cardiovascular collapse. Do not be falsely reassured by a normal BP in a child with tachycardia, mottled skin, or altered mental status. When the BP finally falls in a child — it falls fast. Tachycardia is the first sign; hypotension is the last.
Minimum acceptable systolic BP = 70 + (2 × age in years) - 2-year-old: 70 + 4 = 74 mmHg - 6-year-old: 70 + 12 = 82 mmHg - 10-year-old: 70 + 20 = 90 mmHg
Pediatric Assessment Triangle (PAT)¶
The PAT is completed before touching the patient — a 30-second doorway assessment using visual and auditory information only. It gives an immediate sense of severity before any hands-on examination.
Three sides of the triangle:
| Side | Components | Abnormal Findings | What They Mean |
|---|---|---|---|
| Appearance | TICLS: Tone, Interactiveness, Consolability, Look/Gaze, Speech/Cry | Limp tone, no eye contact, inconsolable, weak/no cry, unresponsive to parent | Neurological compromise, hypoxia, shock, severe illness |
| Work of Breathing | Abnormal sounds (stridor, grunting, wheezing) | Retractions | Nasal flaring | Head bobbing | Seesaw respirations | Any of these findings | Upper/lower airway obstruction; respiratory distress or failure |
| Circulation to Skin | Pallor | Mottling | Cyanosis | Capillary refill >2 seconds | Any of these findings | Circulatory failure; shock; dehydration |
KEY DIFFERENTIATOR — PAT Interpretation: Any TWO sides of the PAT abnormal = immediate life-threatening emergency. Grunting = auto-PEEP — the child is expiring against a partially closed glottis to keep alveoli open = respiratory failure (not just distress). Mottling = circulatory failure. Abnormal appearance alone = sick child regardless of other findings.
TICLS mnemonic (Appearance): Tone · Interactiveness · Consolability · Look/Gaze · Speech/Cry
Pediatric Anatomical Differences — Clinical Impact¶
| Difference | Impact on Assessment / Management |
|---|---|
| Larger occiput | Causes neck flexion when supine — place pad under shoulders (not head) to maintain neutral airway in children <8 years |
| Larger tongue relative to airway | Most common cause of airway obstruction; tongue falls back easily in unconscious child |
| Obligate nose breathing (infants) | Nasal congestion alone can cause respiratory distress in infants |
| Cartilaginous ribs | Internal organ injury WITHOUT rib fracture — a child can have pulmonary contusion with no broken ribs |
| Growth plates (epiphyseal plates) | Weaker than ligaments — suspect fracture before sprain in pediatric extremity injury; growth plate fractures may not be obvious on X-ray |
| Fontanelles | Present until ~18 months — bulging = increased ICP; sunken = dehydration |
| Smaller airway diameter | Even minor swelling causes significant resistance (resistance ∝ 1/r⁴); croup/epiglottitis more dangerous |
| Higher metabolic rate | Decompensate faster; hypoxia develops more rapidly than in adults |
Pediatric Airway Management¶
OPA sizing: measure from center of mouth to earlobe OR from corner of mouth to earlobe. Insert with direct visualization using a tongue depressor — do NOT rotate as in adults (may damage soft palate and push tongue back).
NPA sizing: measure from nostril to earlobe. Contraindicated in suspected skull fracture (CSF from nose, periorbital ecchymosis). Use lubricated, bevel toward septum.
BVM for pediatrics: - Use appropriately sized pediatric mask — create tight seal - Ventilation rate: infant/child 20 breaths/min (1 breath every 3 seconds) - Volume: visible chest rise only — do not over-inflate; children's lungs are small - Two-provider BVM preferred: one to maintain seal, one to squeeze
Suction: Use bulb syringe for neonates and young infants. Rigid tip (Yankauer) for children >1 year.
Pediatric Shock — Recognition and Management¶
Signs of shock in children (in order of appearance): 1. Tachycardia (earliest, most sensitive sign) 2. Pale, mottled, or ashen skin color 3. Capillary refill >2 seconds 4. Cool extremities 5. Decreased urine output 6. Altered mental status (late) 7. Hypotension (VERY LATE — near-cardiovascular collapse)
EMT-B management: - High-flow O₂ immediately - Control external hemorrhage - Supine position; keep warm - Rapid transport — minimize scene time - IV/IO access en route (ALS scope); 20 mL/kg isotonic fluid bolus
Common Pediatric Medical Emergencies¶
Croup vs. Epiglottitis¶
| Croup | Epiglottitis | |
|---|---|---|
| Onset | Gradual (over days) | Sudden (hours) |
| Age | 6 months – 3 years | Any (historically 2–6 years pre-vaccine; now older/adults) |
| Fever | Low-grade | High (>101°F) |
| Cough | Barky, seal-like | Absent or muffled |
| Drooling | No | Yes — hallmark |
| Position | Any | Tripod (sitting forward, drooling) |
| Voice | Hoarse | Muffled/"hot potato" voice |
| EMT action | Humidified O₂, calm, transport | Do NOT examine throat; do NOT agitate; O₂; rapid transport; call ahead |
KEY DIFFERENTIATOR — Epiglottitis: DROOLING + HIGH FEVER + SUDDEN ONSET + TRIPOD POSITION = epiglottitis until proven otherwise. Do NOT examine the throat — this can cause complete laryngospasm and airway obstruction. Do not force the child to lie down. Keep child in position of comfort with caregiver. Rapid transport.
Febrile Seizures¶
- Most common seizure type in children ages 6 months – 5 years
- Caused by rapid rise in temperature, not the absolute temperature
- Typically brief (<15 min), generalized, single episode
- Not inherently dangerous but requires evaluation — cannot distinguish from more serious causes prehospital
- Management: airway, recovery position, O₂, monitor temperature, transport
- Prolonged (>5 min) or focal febrile seizure = priority transport
Foreign Body Airway Obstruction (FBAO)¶
- Infant (<1 year): 5 back blows alternating with 5 chest thrusts (not abdominal thrusts — risk of liver injury)
- Child (>1 year): Heimlich abdominal thrusts
- Unconscious (any age): Begin CPR; each time you open airway for breaths, look for the object and remove if visible — do NOT perform blind finger sweeps
Fever in Infants <3 Months¶
- Any rectal temperature >100.4°F (38°C) in infant <3 months = medical emergency
- Neonates cannot mount inflammatory response like older children — sepsis can be present without high fever
- Transport immediately; do not wait for fever workup prehospital
Age-Appropriate Communication¶
| Age | Approach |
|---|---|
| Infant | Speak to caregiver; examine with parent holding; approach slowly; avoid separating from parent |
| Toddler | Allow security object; simple words; demonstrate on parent or toy first; exam from least invasive to most invasive (toe to head) |
| Preschool | Explain simply and literally; avoid words like "cut" or "shot"; fear of pain and body damage is prominent |
| School age | Involve in assessment; explain what you're doing and why; maintain modesty; address the child directly |
| Adolescent | Speak to patient, not just parents; ask parents to step back for sensitive questions; confidentiality concerns; treat as adult |
NREMT Relevance¶
- Minimum BP = 70 + (2 × age) — know the formula
- Tachycardia is FIRST sign of shock in children; hypotension is LATE and ominous
- PAT: complete before touching; two sides abnormal = immediate intervention
- Grunting = respiratory failure (auto-PEEP), not distress — BVM may be needed
- Pad under shoulders (not head) to maintain neutral airway in children <8 years
- TICLS mnemonic for PAT Appearance side
- Epiglottitis: do NOT examine throat; drooling + high fever + tripod = epiglottitis
- FBAO infant: back blows + chest thrusts (NOT abdominal thrusts)
- Cartilaginous ribs: internal organ injury with NO rib fractures is possible
- Fontanelle bulging = increased ICP; sunken = dehydration
Related¶
- neonatal-resuscitation — neonatal resuscitation; APGAR; newborn-specific management
- respiratory-distress — Croup vs. Epiglottitis; pediatric respiratory emergencies
- shock — shock recognition; pediatric compensation pattern
- seizure — febrile seizures; status epilepticus criteria; pediatric considerations
- vital-signs — full vital signs table including pediatric ranges
- nremt-master-differentiator — Croup vs. Epiglottitis comparison; pediatric vital signs table
Sources¶
- UCLA EMT Ultimate Study Guide (2026) — Ch 26: Pediatric Vital Signs & Assessment
raw/protocols/nm-sop-guidelines-treatment-2022.pdf— Pediatric Emergencies protocols