Pediatric Emergency Medicine Reference Guide

1. Background & Epidemiology

Children account for approximately 20% of all ED visits in the United States. In 2015, 30 million children under 18 were evaluated in U.S. EDs. About 5% present with severe illness requiring rapid recognition and intervention.

Trauma remains the leading cause of pediatric ED visits and death in children ages 1–19. Over 50% of childhood deaths in 2017 were trauma-related, most commonly from motor vehicle collisions, homicide, suicide, drowning, burns, and nonaccidental trauma.

2. Pediatric Differences

Preverbal children cannot localize pain; systematic exams are essential.
Fear and anxiety may alter mental status and vital signs.
Multisystem trauma is more common due to smaller body mass.
Hypotension is a late sign of shock.
Higher surface area → increased heat and fluid loss.

3. Principles of Critical Illness

Critical illness in children centers on threats to oxygen delivery. Clinical manifestations include:

CNS: irritability, confusion, seizures, unresponsiveness
Cardiovascular: tachycardia, bradycardia, hypotension
Skin: pallor, cyanosis, mottling, delayed cap refill

4. Pediatric Triage & High-Risk Conditions

Most pediatric EDs use the 5-level Emergency Severity Index (ESI). ESI 1 requires immediate intervention; ESI 2 requires evaluation within 30 minutes.

        Pediatric High-Risk Conditions
        Hematology/oncology patient with fever
Shunt patient with headache, vomiting, or fever
Diabetic with altered mental status
Bleeding disorder with trauma
Ocular exposure or severe eye pain
Post-tonsillectomy hemorrhage
Suicidal ideation or attempt
G-tube/GJ-tube dislodgement
Smoke inhalation or CO exposure
Open fracture or neurovascular compromise
Abdominal pain with peritoneal signs
Sickle cell patient with fever or pain
Cardiac patient with increased O₂ needs
Infants ≤60 days with fever or hypothermia
Scrotal pain
ALTE/BRUE with cyanosis
Ingestions (non–foreign body)
C-spine immobilized on backboard
Abdominal trauma with significant pain
Permanent tooth available for reimplantation

      

5. Trauma Scoring Systems

GCS, Trauma Score, and Pediatric Trauma Score (PTS) help identify children at risk for major morbidity or mortality. PTS < 8 indicates need for pediatric trauma center transfer.

Category	Older Children (Standard GCS)	Infants (Pediatric GCS)	Score
Eye Opening (E)
Eye Opening	Spontaneous	Spontaneous	4
	To voice	To voice	3
	To pain	To pain	2
	None	None	1
Verbal Response (V)
Verbal	Oriented	Coos, babbles	5
	Confused	Irritable cry, consolable	4
	Inappropriate words	Cries to pain	3
	Incomprehensible sounds	Moans to pain	2
	None	None	1
Motor Response (M)
Motor	Obeys commands	Normal spontaneous movements	6
	Localizes pain	Withdraws to touch	5
	Withdraws to pain	Withdraws to pain	4
	Flexion (decorticate)	Flexion	3
	Extension (decerebrate)	Extension	2
	None	None	1

6. Vital Signs

Vital signs vary significantly by age. Trends are more important than isolated values.

Age	Tachycardia	RR	Systolic Hypotension
1 mo–1 yr	>180	>34	<75
1–5 yrs	>140	>22	<74
5–12 yrs	>130	>18	<83
12–18 yrs	>120	>14	<90

7. Resuscitation Team Composition

Team leader (physician)
Bedside nurses/techs
Respiratory therapist
Documenting nurse
Pharmacist (weight-based dosing)
Child Life Specialist
Social worker/family support

8. Primary Survey (ABCDE)

A: Airway + C-spine
B: Breathing
C: Circulation
D: Disability
E: Exposure/Environment

Primary Survey Component	Assessment	Immediate Actions	Expanded Clinical Guidance
A — Airway + Cervical Spine
Airway	Determine patency Identify obstruction (partial/complete) Assess for stridor, gurgling, secretions Evaluate need for C‑spine immobilization	Reposition (sniffing position) Suction airway OPA/NPA placement Provide CPAP/PEEP as needed Prepare for intubation Maintain C‑spine precautions	Use chin‑lift or jaw‑thrust to open airway while minimizing C‑spine movement. Anticipate a difficult airway early; involve the most experienced clinician. For extrathoracic obstruction, reposition and suction first. For intrathoracic disease, provide supplemental oxygen and PEEP. Intubate when clinically indicated; consider LMA or BVM if intubation is delayed. All major trauma patients should receive supplemental oxygen.
B — Breathing
Breathing	Assess respiratory effort Observe chest rise, retractions Auscultate breath sounds Monitor SpO₂ and ETCO₂	Apply continuous monitoring (SpO₂, ETCO₂) Administer oxygen Assist ventilation with BVM Prepare for ETT or LMA Needle decompression or chest tube if indicated	ETCO₂ helps differentiate V/Q mismatch (normal/low ETCO₂) from hypoventilation (high ETCO₂). In trauma, respiratory compromise often results from depressed mental status rather than lung pathology. Decompress stomach to improve ventilation. Continuous monitoring is essential for both intubated and non‑intubated patients.
C — Circulation
Circulation	Assess HR, BP, rhythm Evaluate pulses, cap refill Inspect skin color (pallor, cyanosis) Look for external hemorrhage	Control bleeding with direct pressure Establish IV/IO access Begin fluid resuscitation Monitor perfusion continuously	Shock signs vary: cold shock (tachycardia, poor perfusion) vs warm shock (bounding pulses, flushed skin). Hypotension is a late and ominous sign in children—requires ~50% volume loss. External hemorrhage must be controlled immediately. Cardiogenic shock may present with normal HR. Assess perfusion using pulses, cap refill, mental status, and skin findings.
D — Disability (Neurologic)
Disability	Assess mental status (AVPU, GCS) Evaluate pupils Check motor activity and symmetry Identify focal deficits	Treat hypoglycemia Manage seizures Initiate ICP management if needed Consider cardioversion/defibrillation if indicated	CNS failure may result from primary disease (mass, hemorrhage, status epilepticus) or secondary hypoxia/hypoperfusion. Elevated ICP requires hypertonic therapy, controlled ventilation, and maintenance of MAP. Avoid hyperthermia; treat fever aggressively. Consider antimicrobials or surgical decompression depending on etiology.
E — Exposure & Environment
Exposure	Fully expose patient Log roll to inspect back Check temperature Look for trauma, burns, rashes	Prevent hypothermia Use warm blankets, warmed fluids Increase ambient temperature	Children lose heat rapidly due to large surface area. Hypothermia worsens coagulopathy, hemodynamics, and metabolic demand. Examine axillae, perineum, and back for hidden injuries. Treat hyperthermia aggressively when present.
IV Access
IV Access	Attempt peripheral IVs Assess for difficult access Prepare for IO if needed	Place two large‑bore IVs Use IO for severe illness or failed IV attempts Follow IV escalation pathway	IO access is fast and reliable in critically ill children. Increasing numbers of children have difficult IV access due to chronic illness. Escalation may include ultrasound‑guided IV, EJ access, or central line placement. Rapid access is essential for fluids, medications, and resuscitation.

9. IV Access & Fluid Resuscitation

Two large-bore IVs when possible
IO access for critically ill or difficult access
20 mL/kg isotonic boluses up to 60 mL/kg
Early blood transfusion for trauma non-responders

Time Window	Access Procedure	Expanded Clinical Guidance
0–5 Minutes
0–5 minutes	• First peripheral IV (largest gauge possible) • Consider IO immediately in severely ill patients	• Establish two large‑bore IVs within the first 15 minutes whenever possible. • Severely ill children (shock, arrest, severe trauma) should not wait for multiple IV attempts — IO is appropriate immediately. • Early vascular access is essential for rapid fluid resuscitation, medications, and labs. • Begin isotonic fluid boluses (NS or LR) as soon as access is obtained.
5–10 Minutes
5–10 minutes	• Second peripheral IV attempt • Consider ultrasound‑guided peripheral IV • Consider external jugular (EJ) access (US‑guided) • Notify vascular access specialist (IV team)	• Ill patients require a second access site, ideally peripheral. • Ultrasound guidance improves success in difficult‑access children. • EJ access is a rapid alternative when peripheral attempts fail. • Early involvement of an IV team improves success and reduces delays. • Continue fluid resuscitation using 20 mL/kg aliquots, reassessing VS, MS, and perfusion after each bolus.
10–15 Minutes
10–15 minutes	• If still no access: — EZ‑IO — EJ (US‑guided) — Central line (US‑guided) — Call intensivist or surgeon for assistance	• IO access is reliable and fast for critically ill children; do not delay beyond 2 failed IV attempts. • Central venous access may be required for vasopressors, transfusion, or severe shock. • Early escalation prevents delays in resuscitation. • If fluid boluses (up to 60 mL/kg) fail to improve perfusion, consider: — Vasopressors or inotropes — Treatment of hypoxemia, acidosis, electrolyte abnormalities • For trauma patients who fail to respond to crystalloid boluses, initiate early blood transfusion (cross‑matched or type O‑negative). • Use warmed blood and fluids to prevent hypothermia. • Avoid albumin or synthetic colloids — no proven benefit in pediatric septic shock or trauma. • Avoid dextrose‑containing fluids initially (risk of hyperglycemia and neurologic injury). • Treat hypoglycemia with 10% dextrose, then start maintenance dextrose infusion if needed. • Massive transfusion protocols vary by institution; follow local guidelines.

10. Secondary Survey

Body Region	Exam Findings	Potential Disease Implications	Potential Complications
Head
Head	Hematomas, lacerations	Occult traumatic brain injury	Intracranial hemorrhage, seizures, herniation
Head	Step-offs	Skull fracture	Epidural hematoma, CSF leak, meningitis
Head	VP shunt	Shunt malfunction, ↑ ICP	Herniation, hydrocephalus, infection
Head	Bulging fontanel	Increased ICP	Brain herniation, seizures
Head	Sunken fontanel	Dehydration	Shock, electrolyte derangements
Head	Battle sign	Basilar skull fracture	CSF leak, meningitis, cranial nerve injury
Eyes
Eyes	Pupil abnormalities	Toxidromes, ↑ ICP, ruptured globe	Vision loss, herniation
Eyes	EOM palsies	↑ ICP, orbital cellulitis	Orbital abscess, cavernous sinus thrombosis
Eyes	Proptosis	Orbital cellulitis, retrobulbar bleed	Vision loss, intracranial spread
Eyes	Scleral icterus	Hemolysis, liver disease	Acute liver failure, anemia complications
Eyes	Papilledema	Increased ICP	Vision loss, herniation
Eyes	Raccoon eyes	Skull fracture	Intracranial bleeding, meningitis
Ears
Ears	Mastoid tenderness	Mastoiditis	Intracranial abscess, venous sinus thrombosis
Ears	TM abnormalities	AOM, TM rupture, basilar skull fracture	Hearing loss, meningitis
Nose
Nose	Nasal flaring	Respiratory distress	Respiratory failure
Nose	Septal hematoma	Septal injury	Septal necrosis, deformity
Throat
Throat	Dry mucous membranes	Dehydration	Shock, electrolyte imbalance
Throat	Exudative pharyngitis	Strep, mono	Airway obstruction, splenic rupture (mono)
Throat	Tonsillar deviation, trismus	Peritonsillar abscess	Airway compromise, sepsis
Throat	Vesicles, Koplik spots	HSV, coxsackie, measles	Encephalitis, dehydration
Throat	Drooling	RPA, epiglottitis, bacterial tracheitis	Complete airway obstruction
Neck
Neck	Meningismus	Meningitis	Sepsis, seizures, shock
Neck	Pain with rotation	Retropharyngeal abscess	Airway compromise, mediastinitis
Neck	C-spine tenderness	C-spine fracture	Paralysis, spinal cord injury
Chest
Chest	Retractions	Respiratory distress	Respiratory failure
Chest	Flail chest	Rib fractures, contusion	Pneumothorax, respiratory failure
Lungs
Lungs	Decreased air entry	Asthma, pneumothorax	Respiratory arrest
Lungs	Wheezing	Asthma	Status asthmaticus
Lungs	Rales	Pneumonia, CHF	Respiratory failure, sepsis
Lungs	Inspiratory stridor	Croup, foreign body	Complete airway obstruction
Heart
Heart	Murmurs	CHD, valvular disease	Heart failure, endocarditis
Heart	Rubs	Pericarditis	Cardiac tamponade
Heart	Gallops	CHF, cardiomyopathy	Cardiogenic shock
Heart	Tachycardia	SVT, shock	Cardiac arrest
Heart	Muffled heart sounds	Tamponade	Cardiac arrest
Abdomen
Abdomen	Distension	Obstruction, volvulus	Bowel ischemia, perforation
Abdomen	Hepatomegaly	CHF, malignancy	Liver failure, shock
Abdomen	Splenomegaly	Sequestration, malignancy	Splenic rupture, shock
Abdomen	Tenderness	Appendicitis, pancreatitis, torsion	Perforation, sepsis
Abdomen	Peritoneal signs	Peritonitis	Sepsis, shock
Abdomen	Seatbelt sign	Intra-abdominal injury	Solid organ injury, bowel perforation
Genitourinary
GU	External vaginal exam	Lacerations, imperforate hymen	Hemorrhage, infection
GU	Testicular exam	Torsion	Testicular necrosis, infertility
GU	Pelvic exam	PID, ectopic pregnancy	Sepsis, hemorrhage
Extremities
Extremities	Joint swelling	Septic arthritis, fracture	Joint destruction, osteomyelitis
Extremities	Edema	CHF, renal disease	Pulmonary edema, renal failure
Extremities	Poor perfusion	Shock, dehydration	Limb ischemia, organ failure
Skin
Skin	Petechiae/purpura	ITP, HSP, meningococcemia	DIC, shock
Skin	Urticaria	Anaphylaxis	Airway compromise, shock
Skin	Characteristic rashes	Viral exanthems, Lyme, SJS	Sepsis, dehydration, airway involvement (SJS)
Skin	Erythema, fluctuance	Abscess, cellulitis	Necrotizing fasciitis, sepsis
Neurologic
Neuro	Cranial nerve palsies	↑ ICP, masses, meningitis	Permanent neurologic deficits
Neuro	Altered mental status	ICH, meningitis, toxins	Seizures, herniation, arrest
Neuro	Weakness	CVA, GBS	Respiratory failure (GBS), paralysis
Neuro	Sensory deficits	CVA, myelitis	Permanent deficits
Neuro	Ataxia	Mass, cerebellitis	Falls, aspiration
Neuro	Loss of sphincter tone	Spinal cord injury	Permanent paralysis
Neuro	Areflexia	GBS, spinal injury	Respiratory failure
Psychiatric
Psych	Flat affect	Depression	Self-harm risk
Psych	Suicidal ideation	Ingestion, attempt	Self-harm, death
Psych	Hallucinations	Psychosis, drug effects	Violence, self-harm

SAMPLE History (Rapid Pediatric History Tool)

Component	Description
Signs & Symptoms	What symptoms occurred prior to presentation?
Allergies	Any drug or food allergies?
Medications	Current meds? Any given before arrival?
Past Medical History	Chronic illnesses, surgeries, baseline conditions
Last Meal	Time of last oral intake
Events Leading to Presentation	What happened immediately before ED arrival?