At the Bedside
- First 5 seconds: decide if the child is sick. Use appearance, work of breathing, and circulation to skin; if abnormal, move immediately to resuscitation.
- Primary survey = ABCDE
- Airway: position, suction, jaw thrust; look for obstruction, stridor, vomiting, altered mental status.
- Breathing: oxygen, pulse ox, capnography if available; assess rate, effort, air movement, symmetry; support with BVM if ineffective.
- Circulation: check pulses, perfusion, cap refill, BP, mental status, urine output if available.
- Disability: AVPU/GCS, glucose immediately for altered child.
- Exposure: full exam, temperature, rash, trauma signs; keep warm.
- Airway/Breathing support
- High-flow O2 if hypoxemic or in distress; not all critically ill children need intubation.
- Bag-mask ventilation is often the most important lifesaving step. Use two-person BVM, good seal, appropriately sized mask, airway adjuncts.
- Consider NPA/OPA, suction, or advanced airway if failing BVM.
- If intubating: optimize preoxygenation, hemodynamics, and backup plan; avoid prolonged attempts.
- Circulation
- If shock suspected, start with 10–20 mL/kg isotonic crystalloid bolus; reassess after each bolus.
- In septic shock, give fluid in increments and move early to vasopressors if poor response or fluid overload risk.
- Blood is preferred for hemorrhagic shock; use balanced resuscitation.
- Establish IV quickly; if difficult, go IO early.
- Disability / causes
- Check point-of-care glucose in every altered child.
- Consider toxidromes, seizure, meningitis/encephalitis, trauma, metabolic disease, DKA, sepsis, congenital heart disease, adrenal crisis, anaphylaxis.
- Disposition
- Any child needing repeated boluses, vasopressors, noninvasive support, airway support, or frequent reassessment generally needs PICU.
- If unstable, do not wait for full diagnosis before initiating resuscitation and consulting critical care.
- Common trap: kids maintain BP until late; normal BP does not exclude shock.
A Classic Presentation
A 3-year-old boy is brought in by EMS for lethargy and labored breathing after 2 days of fever and poor intake. He’s tachycardic, tachypneic, mottled, with delayed cap refill and diminished mental status, but his blood pressure is still normal. You give oxygen, establish IO access after failed IV attempts, check a glucose of 48, start dextrose and a 20 mL/kg isotonic bolus, then reassess and escalate to broad-spectrum antibiotics and PICU consultation when perfusion remains poor.
Patient Presentation to Attending
How you’d present this patient on the floor
This is a 3-year-old previously healthy boy with 2 days of fever, poor intake, and progressive lethargy presenting with respiratory distress and poor perfusion. My main concern is compensated septic shock with evolving respiratory failure, because he’s tachycardic, tachypneic, mottled, and has delayed cap refill even though his blood pressure is still normal. On exam he’s somnolent but arousable, with cool extremities and increased work of breathing; his glucose was low at 48. I’m less worried this is just viral bronchiolitis or isolated dehydration because the perfusion abnormality and mental status change are out of proportion to a simple URI picture. We’ve started oxygen, obtained IO access after failed IVs, given dextrose and a 20 mL/kg fluid bolus, and I’m reassessing for need for vasopressors and broader sepsis management. He’s likely PICU-bound depending on his response over the next few minutes.
Study Directive
- Draw the pediatric ABCDE primary survey from memory and verbalize what you would do in the first 60 seconds.
- Drill weight-based shock dosing: 10–20 mL/kg bolus, D10 5 mL/kg, epi 0.01 mg/kg IM.
- Practice a pediatric sepsis oral presentation using appearance, work of breathing, and circulation to skin.
- Review when to choose IO access and list the indications for immediate PICU consultation.
- Rehearse a “crashing child” checklist: glucose, oxygen, BVM, IV/IO, fluids, antibiotics, pressors, warming.