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Of the approximately 140 million annual emergency department (ED) visits in the United States, over 30 million (20%) are children 18 years and younger. Respiratory disorders are the leading cause of all pediatric ED visits (32%), with injuries and poisonings (27%) also accounting for a significant percentage. Though the vast majority (97%) of children presenting for ED evaluation are discharged home, nearly 1 million each year require hospital admission from the ED and, sadly, nearly 3000 children die every year in US EDs.

This chapter begins with the initial approach to the acutely ill pediatric patient, discusses the differentiation and initial management of shock, presents the general approach to the evaluation of pediatric trauma patients, summarizes commonly used emergency drugs, and concludes with the management of a number of common clinical scenarios in pediatric emergency medicine.



  • Most causes of pediatric cardiac arrest are due to hypoxia from respiratory failure.

  • Hypotension is a late finding in pediatric shock; early signs may include tachycardia, capillary refill > 2 seconds, skin mottling, and decreased mental status.

A pediatric patient in serious distress may present with a known diagnosis or in cardiorespiratory failure of unknown cause. The initial approach must be simple and consistent in order to rapidly identify physiologic derangements and injuries, prioritize management, and reverse life-threatening conditions immediately. Once stabilized following interventions, the provider must then carefully consider the underlying cause, focusing on those that are treatable or reversible. Specific diagnoses can then be made, and targeted therapy initiated.

Pediatric cardiac arrest most commonly results from progressive respiratory deterioration or shock as opposed to a primary cardiac etiology. Unrecognized deterioration may lead to bradycardia, agonal breathing, hypotension, and ultimately asystole. Resulting hypoxic and ischemic insult to the brain and other vital organs make neurologic recovery extremely unlikely, even in the doubtful event that the child survives the arrest. When cardiopulmonary arrest does occur, survival is rare and most often associated with significant neurological impairment. Current data reflect a 6% survival rate for out-of-hospital cardiac arrest, 8% for those who receive prehospital intervention, and 27% survival rate for in-hospital arrest. Children who respond to rapid intervention with ventilation and oxygenation alone or to less than 5 minutes of advanced life support are much more likely to survive neurologically intact. In fact, more than 70% of children with respiratory arrest who receive rapid and effective bystander resuscitation survive with good neurologic outcomes. Therefore, it is essential to recognize the child who is at risk for progressing to cardiopulmonary arrest and to provide aggressive intervention before asystole occurs.

Please see the selected references at the end of this section for more information on the specifics of the American Heart Association’s Pediatric Advanced Life Support (PALS) guidelines, most ...

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