Pediatric acute emergencies

Pediatric acute stems compress time: a seizing febrile toddler, a quiet toxic ingestion, a drooling child who will not lie flat, or an infant with RSV who is too tired to feed. Adult respiratory crisis algorithms live in Acute respiratory emergencies. This chapter owns the child-specific airway infection map, foreign body, febrile seizure, poisoning, and dehydration cues. Airway always comes first.

Airway first

Children have smaller airways, larger tongues relative to the mouth, and less reserve. Work of breathing climbs fast, then they tire and look deceptively quiet. Your first questions are always: Is air moving? Can they keep their own position of comfort? Do I need an airway team before I poke anything in the mouth?

1. Allow the position of comfort (tripod, parent’s lap) unless that blocks emergency care.
2. Give oxygen in the least agitating way that still works.
3. Do not force throat exams, supine positioning, or IV sticks that trigger complete obstruction when epiglottitis is likely.
4. NPO when operative airway or scope is likely.

Croup versus epiglottitis

Both are upper-airway problems, but the exam expects opposite handling. Viral croup (laryngotracheobronchitis) swells below the glottis and produces the barky cough and inspiratory stridor after a cold. Bacterial epiglottitis inflames the epiglottis itself; the child looks toxic, drools because swallowing hurts, and sits forward to keep the airway open.

Why the blade ban exists in epiglottitis: gagging or supine forced exam can convert a partial airway into a complete one. Keep the child with the caregiver, allow preferred position, give oxygen gently if tolerated, and move toward controlled airway management with a team ready. For croup, stridor at rest and marked retractions raise urgency; racemic epinephrine buys time while steroids reduce swelling, and the child still needs observation for return of distress.

RSV / bronchiolitis

Bronchiolitis in infants is usually viral (RSV is the classic name on stems). Inflammation and mucus plug the small airways. Wheeze, crackles, tachypnea, poor feeding, and nasal flaring appear. There is no routine “bronchodilator for every infant” rule on modern stems; care is supportive: oxygen for hypoxia, gentle nasal suction before feeds, hydration, and cardiorespiratory monitoring when ordered.

Isolation and contact/droplet practices follow facility RSV rules when the stem asks. Palivizumab appears only for specific high-risk prevention stems, not as treatment for every wheezy infant. The same trap as adult asthma applies: quieter breath sounds with fatigue mean the child is failing, not recovering.

Foreign-body airway obstruction

Foreign-body aspiration is sudden in a previously well toddler: cough, choke, asymmetric breath sounds, or silent complete obstruction after a grape, coin, or toy. Use age-appropriate BLS maneuvers. Never blind finger sweeps that push the object deeper.

1. If the child can cough forcefully and make sounds: allow coughing; monitor; do not blind sweep.
2. Infant with severe FBAO: back blows and chest thrusts per current BLS.
3. Child with severe FBAO: abdominal thrusts per current BLS (after infancy).
4. Unresponsive: start CPR sequence and look for the object only when you can see it.

Partial obstruction that persists needs urgent evaluation; a “quiet” child after choking may have a lodged object, not a cured scare. Prevention teaching (cut grapes, no loose coins, age-appropriate toys) shows up on discharge stems. Once the infant is unresponsive, the compression map is in Paediatric fluid and newborn.

Febrile seizures

A febrile seizure is a convulsion driven by a rapid temperature rise in a predisposed young child, usually lasting minutes. Your job during the event is mechanical safety: clear hard objects, ease to the side when able so saliva drains, time the seizure, give oxygen if ordered, and never force a tongue blade or pin the limbs. Afterward, assess breathing and color, then treat the fever and find the infection source as ordered.

1. Protect and time. Do not restrain or pry the mouth open.
2. After the seizure: recovery position, antipyretic as ordered, evaluate the cause.
3. Prolonged or repeated seizures: escalate as status pathway.

Parent teaching is reassurance plus honesty: most simple febrile seizures do not mean epilepsy, but any first seizure and any atypical or prolonged event needs medical evaluation. Avoid aspirin in viral illness patterns (Reye risk). That teaching also sits in Paediatric neurology. Ice-water immersion of a seizing or post-ictal child is a distractor that looks decisive and causes harm.

Poisoning and overdose

Children explore with their mouths. The first nursing moves are remove ongoing exposure, support ABCs, and get expert dosing advice (poison control or the ordered toxicology pathway) rather than inventing home remedies. Inducing vomiting is almost never the blind default on modern stems; corrosives and hydrocarbons can worsen injury if vomited.

Bring the container or a photo when possible. Activated charcoal and antidotes appear only when the stem and orders support them within the time window. Decontamination of skin/eyes with copious water for topical exposures is fair game when the stem describes splash injury.

Dehydration cues (when the stem stacks them)

Respiratory illness and gastroenteritis both drive dehydration in infants who cannot say they are thirsty. Deeper rehydration math lives in Paediatric fluid and newborn; here you need recognition and the airway-safe priority order.

Oral rehydration solution in small frequent amounts works when the child can protect the airway and is not in shock. IV fluids are for severe dehydration, shock, or when vomiting blocks oral intake. Do not force large bottles into a dyspneic RSV infant; airway and work of breathing still come first.

Priority map