Paediatric Emergencies: A Paramedic's Guide

Why Paediatric Emergencies Are Different

Paediatric emergencies are among the most challenging calls a paramedic will face. Children are not simply small adults — their anatomy, physiology, and response to illness differ significantly across age groups. For UK student paramedics, building confidence in assessing and managing unwell children is essential before entering clinical placement and independent practice.

This guide covers the key principles, common presentations, and JRCALC-aligned approaches you need to know when responding to paediatric emergencies in the pre-hospital setting.

The Paediatric Assessment Triangle (PAT)

Before you even lay a hand on a child, you can gather enormous clinical information using the Paediatric Assessment Triangle. This rapid, hands-off tool helps you form an immediate general impression within the first 30 to 60 seconds of patient contact.

The PAT has three components:

• Appearance: Tone, interactivity, consolability, look/gaze, and speech or cry. A child who is alert, engaged, and responsive is reassuring; one who is floppy, vacant, or inconsolable is a red flag.
• Work of Breathing: Look for accessory muscle use, nasal flaring, tracheal tug, grunting, or abnormal positioning such as tripoding. You do not need your stethoscope for this part.
• Circulation to Skin: Pallor, mottling, cyanosis, or prolonged capillary refill time all suggest poor perfusion and demand urgent action.

An abnormality in any one component should prompt a systematic ABCDE assessment and early escalation.

Key Physiological Differences to Remember

Understanding normal paediatric parameters is fundamental. Children compensate for shock and respiratory failure far more effectively than adults — but they decompensate rapidly and with little warning. By the time a child's blood pressure drops, they are in severe shock.

Normal ranges vary by age. As a guide for common parameters:

• Respiratory rate: Newborn 40–60 breaths/min; 1–5 years 25–30; 6–12 years 20–25; over 12 years approaches adult norms.
• Heart rate: Infant up to 160 bpm; 1–5 years up to 140; 6–12 years up to 120; adolescent up to 100.
• Systolic BP: A rough formula — 80 + (2 × age in years) — gives a lower acceptable limit for children over one year.

Weight estimation is equally important for drug calculations. In the absence of a known weight, use the APLS formula: Weight (kg) = (Age + 4) × 2 for children aged 1–10, or use a Broselow tape if available.

Common Paediatric Emergencies

Febrile Convulsions

Febrile convulsions are the most common cause of seizures in children aged six months to five years. They are typically associated with a rapidly rising temperature and are usually benign and self-limiting. Most resolve within five minutes without intervention.

Your priorities are airway management, safe positioning, and temperature management. If the seizure continues beyond five minutes, JRCALC guidance supports the administration of buccal midazolam (0.3 mg/kg) in the pre-hospital setting. Always consider alternative causes such as meningitis, encephalitis, or hypoglycaemia, and transport all children who have had a first febrile seizure to hospital for assessment.

Croup and Epiglottitis

Croup (laryngotracheobronchitis) presents with a characteristic barking cough, inspiratory stridor, and mild to moderate respiratory distress, typically in children aged six months to three years. It is usually viral in origin. Nebulised adrenaline and oral dexamethasone may be indicated in moderate to severe cases per JRCALC guidance.

Epiglottitis, now rare due to the Hib vaccine, is a life-threatening emergency. The child will appear toxic, sit still in a tripod position, drool, and have no cough. Do not examine the throat or agitate the child. Call for immediate backup and transport urgently — do not attempt airway intervention unless complete obstruction occurs.

Bronchiolitis and Asthma

Bronchiolitis predominantly affects infants under 12 months and presents with wheeze, crackles, increased work of breathing, and poor feeding. Management is largely supportive — oxygen therapy and positioning. Salbutamol is not routinely recommended in bronchiolitis.

Acute asthma in children over 12 months is managed similarly to adults, though drug doses must be weight-adjusted. Salbutamol via a spacer device is first-line. Severe or life-threatening features — silent chest, cyanosis, poor respiratory effort, SpO₂ below 92% — require nebulised salbutamol, ipratropium, and urgent transport.

Anaphylaxis

Anaphylaxis in children requires prompt recognition and treatment. Intramuscular adrenaline remains the cornerstone of treatment, dosed at 0.01 mg/kg of 1:1000 adrenaline up to a maximum of 0.5 mg. Use the outer mid-thigh as the injection site. Many children will have an auto-injector — administer this first if already available. Lay the child flat with legs raised unless respiratory distress is present, and call for HEMS or further backup for severe cases.

Safeguarding Considerations

In any paediatric emergency, safeguarding must always be part of your clinical thinking. Be alert to inconsistencies between the history given and the injuries or presentation observed. Consider whether the mechanism of injury is consistent with the child's developmental stage. Paramedics have a duty to refer safeguarding concerns to the receiving hospital team and, where appropriate, to follow local Trust safeguarding protocols.

Communication With Children and Families

Effective communication is a clinical skill. With young children, get down to their level, use simple language, and explain what you are doing before you do it. Involving a calm parent or carer is usually beneficial. Acknowledge parental anxiety — a frightened parent can inadvertently escalate a child's distress. Remain calm, clear, and confident in your approach.

Documentation and Handover

Accurate documentation of observations, interventions, and timelines is especially important in paediatric cases. Use a structured SBAR or ATMIST handover to the receiving team, and ensure your patient report form includes all weight estimates, drug doses given, and any safeguarding concerns noted.