PE24.1-23 | Pediatric Emergencies — Practice Quiz

In two-rescuer paediatric CPR the ratio is 15:2 (not 30:2 which is for adults/single-rescuer); compressions should be 100–120/min and depth should be at least one-third the anterior-posterior chest diameter.

PALS two-rescuer CPR: ratio 15:2, rate 100–120/min, depth ≥1/3 AP diameter. Use two thumbs encircling technique for infants. Do not interrupt compressions for more than 10 seconds.

For two-rescuer paediatric CPR (PALS): ratio is 15:2 and rate is 100–120/min. The 30:2 ratio is for adults or single-rescuer. A rate of 80/min is too slow.

The recommended paediatric defibrillation energy is 2–4 J/kg for the initial shock in shockable rhythms (VF or pulseless VT). Defibrillation is ONLY indicated for shockable rhythms; asystole and PEA are not shockable.

Paediatric defibrillation: 2–4 J/kg for VF/pulseless VT (shockable rhythms only). Asystole and PEA are NOT shockable — continue CPR. Use smallest paddle/pad that does not touch each other on the chest.

Defibrillation in children starts at 2–4 J/kg. 1 J/kg is insufficient; 5–7 J/kg and 10 J/kg are excessive and can cause myocardial injury.

A non-rebreather mask at 10–15 L/min delivers the highest FiO₂ (~60–90%) among non-invasive devices. This child has critical hypoxaemia (SpO₂ 72%) and needs maximal oxygen therapy immediately.

Oxygen devices and approximate FiO₂: nasal cannula 24–44%, simple mask 40–60%, non-rebreather 60–90%, Venturi = FIXED FiO₂. For critical hypoxaemia: non-rebreather mask first; escalate to bag-mask ventilation or intubation if SpO₂ remains inadequate.

Nasal cannula and simple masks provide inadequate FiO₂ for critical hypoxaemia. Venturi at 24% is designed for controlled low-dose oxygen (e.g., COPD) and is inappropriate here.

For non-cardiogenic, non-DKA paediatric shock, the standard initial fluid bolus is 20 mL/kg of normal saline or Ringer's lactate administered rapidly over 5–10 minutes. For a 20 kg child, this is 400 mL. Reassess after each bolus.

Paediatric shock resuscitation: 20 mL/kg isotonic crystalloid bolus over 5–10 min for septic/hypovolaemic shock. EXCEPTION — use 10 mL/kg in DKA, cardiogenic shock, or neonates. Reassess pulse, CRT, BP, urine output after each bolus.

5 mL/kg is sub-therapeutic. 10 mL/kg may be used in DKA, neonates, or suspected cardiogenic shock. 40 mL/kg without reassessment risks fluid overload.

Status epilepticus is defined as a seizure lasting ≥5 minutes. With IV access, lorazepam 0.1 mg/kg IV is the first-line benzodiazepine (preferred over diazepam IV due to longer duration of action and less respiratory depression per kg dose). Phenytoin is second-line, never diluted in dextrose (causes precipitation).

Status epilepticus: seizure ≥5 minutes. With IV access — lorazepam 0.1 mg/kg IV (first-line). Without IV — diazepam per rectum 0.5 mg/kg or midazolam buccal/intranasal. Second-line: phenytoin 18–20 mg/kg IV in NORMAL SALINE (NEVER in dextrose — precipitates). Third-line: phenobarbital or sodium valproate.

Diazepam IV is an acceptable alternative but lorazepam 0.1 mg/kg is preferred as first-line. Phenytoin is second-line and must NEVER be mixed in dextrose. Sodium valproate is a second/third-line agent.

For hypoglycaemia in a drowsy/unconscious child, give 10% dextrose 2 mL/kg IV (= 24 mL for 12 kg). Dextrose 50% is never used in children due to risk of hyperosmolar damage, phlebitis, and rebound hypoglycaemia.

Hypoglycaemia in children: use 10% dextrose 2 mL/kg IV — NEVER 50% dextrose in paediatrics. Recheck blood glucose 15–30 minutes after treatment and maintain on dextrose infusion. Assess AVPU/GCS to monitor consciousness: A=Alert, V=Voice, P=Pain, U=Unresponsive.

Normal saline does not treat hypoglycaemia. Dextrose 50% is contraindicated in children — use 10% dextrose 2 mL/kg. Oral glucose is unsafe in an unconscious child (aspiration risk).

Skin pinch returning slowly (>2 seconds but ≤3 seconds), sunken eyes, irritability, poor drinking — these are features of SOME dehydration (Plan B: ORS 75 mL/kg over 4 hours in supervised setting). Severe dehydration requires lethargic/unable-to-drink AND skin pinch very slowly (≥3 seconds) → Plan C with IV Ringer's lactate.

IMNCI dehydration classification — SOME dehydration: ≥2 of sunken eyes, skin pinch slowly, irritable, drinks eagerly → Plan B: ORS 75 mL/kg over 4 hours supervised. SEVERE: lethargic/unconscious + skin pinch very slowly → Plan C: Ringer's lactate (infant <12 months: 30 mL/kg in 1 hour then 70 mL/kg in 5 hours; child: 30 mL/kg in 30 min then 70 mL/kg in 2.5 hours).

SOME dehydration (Plan B) is identified by 2 or more of: sunken eyes, skin pinch slowly, irritable, drinks eagerly/poor. Severe needs lethargy/unconscious + skin pinch very slowly. No dehydration = none of these signs.

Skin-to-skin contact (kangaroo mother care) is the most effective and immediately available method to warm a hypothermic neonate in a facility with or without a radiant warmer. It uses the mother's body heat, promotes breastfeeding, and reduces mortality.

Neonatal hypothermia (<36.5°C) management: DRY immediately, skin-to-skin contact (KMC), warm room (≥25°C), hat on head. The ABCDE of thermal care — keep warm, dry, skin-to-skin, feed early (breastfeed), delay bath. Hypothermia increases the risk of hypoglycaemia, respiratory distress, and coagulopathy.

While a radiant warmer is useful if available, skin-to-skin contact is immediately available, free, evidence-based, and equally or more effective for hypothermia management. Wet wrapping increases evaporative heat loss. IV fluids do not significantly rewarm.

For infant CPR with two rescuers: two-thumb encircling technique (both thumbs on the lower third of the sternum, fingers encircle the chest), depth ≥1/3 anterior-posterior diameter (approximately 4 cm in infants). This provides superior perfusion pressure compared to two-finger technique.

Infant CPR landmarks — just below the nipple line (lower third of sternum). Preferred two-rescuer technique: two-thumb encircling. Acceptable single-rescuer: two-finger. Depth ≥1/3 AP diameter (~4 cm infant, ~5 cm child). Full chest recoil between compressions without lifting hands entirely. Rate: 100–120/min.

Heel of hand and one-hand techniques are for children/adults. Two-finger technique on the lower third is acceptable for single-rescuer infant CPR but two-thumb encircling is preferred with two rescuers. Upper third is incorrect — always lower third (just below nipple line).

Without IV access, rectal diazepam 0.5 mg/kg is the immediately available route for active seizure. Do not delay by attempting IV access when the rectal route is available and the seizure is active. Phenytoin is NOT given IM. Dextrose is only indicated if hypoglycaemia is confirmed.

Seizure without IV access: diazepam per rectum 0.5 mg/kg (max 10 mg) — act immediately, do not wait for IV. Alternative: midazolam intranasal 0.2 mg/kg or buccal 0.3 mg/kg. Remember the unconscious child positioning — lateral (recovery) position except if trauma suspected.

Waiting for IV access prolongs the seizure and risks hypoxic brain injury. Phenytoin IM causes tissue necrosis and is contraindicated. 50% dextrose is not given in paediatric emergencies (use 10% dextrose only if hypoglycaemia confirmed).