Paediatric Emergencies: A Paramedic's Guide

Why Paediatric Emergencies Feel Different

For many student paramedics, the prospect of a paediatric emergency is one of the most anxiety-inducing scenarios they can face. Children are not simply small adults — their physiology, anatomy, and the way they compensate for illness differ significantly from grown-ups. Understanding these differences is not just academically important; it can be the difference between a good outcome and a preventable death.

This guide walks through the core principles of paediatric assessment and management in the pre-hospital setting, aligned with UK JRCALC guidelines and NHS practice. Whether you are preparing for your paramedic science degree or heading into your first clinical placements, this is essential knowledge to have firmly in your grasp.

Understanding Paediatric Anatomy and Physiology

Before you can manage a sick child effectively, you need to understand why they deteriorate differently from adults. Key physiological differences include:

• Higher respiratory rate: Children have faster baseline respiratory rates, which means fatigue sets in more quickly during respiratory distress.
• Greater physiological reserve: Children can maintain near-normal blood pressure even with significant volume loss, but when they decompensate, they do so rapidly and catastrophically.
• Larger head relative to body: This makes airway positioning crucial — a neutral rather than extended position is required in infants to maintain a patent airway.
• Smaller airways: Even minor swelling can cause disproportionate airway obstruction. The narrowest point in a child's airway is the cricoid ring, unlike adults where it is the glottis.
• Higher metabolic rate: Children consume oxygen more rapidly, meaning hypoxia develops faster than in adults.

The Paediatric Assessment Triangle (PAT)

The Paediatric Assessment Triangle is a rapid, visual assessment tool used before you even touch the child. It gives you an immediate impression of how unwell a child is and guides your initial approach. The three components are:

1. Appearance: Assess tone, interactiveness, consolability, gaze, and speech or cry. A child who is not interested in their environment, floppy, or inconsolable is a significant red flag.
2. Work of breathing: Look for abnormal sounds (stridor, grunting, wheeze), abnormal positioning, retractions (intercostal, subcostal, suprasternal), and nasal flaring.
3. Circulation to skin: Assess skin colour — pallor, mottling, or cyanosis all indicate poor peripheral perfusion.

The PAT takes seconds and directs whether you move immediately to life-saving intervention or proceed with a more structured assessment. It is a widely used tool taught across UK paramedic programmes and is worth practising until it becomes instinctive.

Normal Paediatric Vital Signs

Knowing what is normal for different age groups is fundamental. Abnormal vital signs in isolation are less useful than trends, but you must have a baseline. The following are approximate JRCALC reference values:

• Newborn (0–3 months): RR 40–60 /min, HR 110–160 /min, systolic BP ~70 mmHg
• Infant (3–12 months): RR 30–40 /min, HR 100–160 /min, systolic BP ~80 mmHg
• Toddler (1–2 years): RR 25–35 /min, HR 100–150 /min, systolic BP ~85 mmHg
• Preschool (3–5 years): RR 25–30 /min, HR 95–140 /min, systolic BP ~90 mmHg
• School age (6–12 years): RR 20–25 /min, HR 80–120 /min, systolic BP ~100 mmHg

A simple formula for estimating the lower limit of acceptable systolic BP in children over one year: 70 + (2 × age in years). Below this threshold, assume decompensated shock.

Common Paediatric Emergencies in Pre-Hospital Care

Febrile Convulsions

Febrile convulsions are the most common neurological emergency in children, typically occurring in those aged six months to five years. Most are simple (lasting under 15 minutes, generalised, and resolving spontaneously) and carry a benign prognosis. However, your role is to manage the airway, protect the child from injury, and administer Buccal Midazolam or PR Diazepam per JRCALC guidelines if the seizure is prolonged. Always consider serious underlying causes such as meningitis, especially if the child remains unwell post-ictally.

Bronchiolitis

Bronchiolitis predominantly affects infants under 12 months and is most commonly caused by Respiratory Syncytial Virus (RSV). It presents with coryzal symptoms followed by wheeze, tachypnoea, and increased work of breathing. Pre-hospital management is largely supportive — positioning, supplemental oxygen to maintain SpO2 above 92%, and early escalation for infants showing signs of respiratory failure. Avoid salbutamol unless there is a clear bronchospastic component, as evidence does not support its routine use in bronchiolitis.

Croup

Croup causes a characteristic barking cough and inspiratory stridor due to subglottic inflammation. It is most common in children aged one to three years. Pre-hospital management includes keeping the child calm (agitation worsens obstruction), administering nebulised Adrenaline (1:1000) in severe cases per local protocols, and considering oral or IM Dexamethasone where within your scope of practice and guidelines.

Anaphylaxis

Anaphylaxis in children follows the same ABCDE approach as in adults. Intramuscular Adrenaline remains the first-line treatment and should be given without delay. Weight-based dosing is critical — use a Broselow tape or your service's reference tool if you are uncertain of the child's weight. The dose for children under 12 years is 0.15 mg IM (0.15 mL of 1:1000); over 12 years or if the child appears adult-sized, use the adult dose of 0.5 mg IM.

Paediatric Cardiac Arrest

Paediatric cardiac arrest is most commonly caused by respiratory failure rather than a primary cardiac event, which is why maintaining oxygenation and ventilation is paramount. Use the 15:2 compression-to-ventilation ratio for two-rescuer CPR in children. Compression depth should be at least one-third of the chest diameter. Use a defibrillator with paediatric pads or an attenuator for children under eight years, with an energy dose of 4 J/kg for shockable rhythms.

Communication and Family-Centred Care

Managing a sick child means managing a frightened family too. Calm, clear communication with parents or carers is therapeutic in itself — a distressed carer escalates a distressed child. Whenever safe to do so, allow parents to remain close and involved. Use age-appropriate language with the child, and never underestimate what even a toddler can understand about tone and intent.

Key Takeaways for Student Paramedics

• Children are not small adults — their physiology demands a tailored assessment approach.
• The Paediatric Assessment Triangle gives you a rapid, structured first impression.
• Know your age-appropriate vital sign ranges and weight-based drug dosing before you need them.
• Respiratory compromise is the most common pathway to paediatric cardiac arrest — protect the airway and oxygenate early.
• Remain calm, communicate clearly, and involve carers — it improves outcomes for everyone.