Paediatric Emergencies: A Paramedic's Guide

Why Paediatric Emergencies Feel Different

Ask any paramedic what makes them nervous, and paediatric emergencies are consistently near the top of the list. Children are not simply small adults — their anatomy, physiology, and the way they respond to illness and injury differ significantly from adults. For student paramedics in the UK, developing confidence in assessing and managing sick children is an essential part of your training and one that will stay with you throughout your career.

This guide walks through the key principles of paediatric pre-hospital care, grounded in JRCALC guidelines and NHS practice, to help you approach these calls with greater confidence and clinical clarity.

Understanding Paediatric Anatomy and Physiology

Before you can assess a child effectively, you need to understand what makes their physiology unique. Key differences include:

• Airway: Children have a proportionally larger head and occiput, a shorter neck, a more anterior and cephalad larynx, and a narrower trachea. Even small amounts of swelling can cause significant obstruction.
• Breathing: Infants are obligate nasal breathers. Respiratory rate is higher in children and decreases with age. Children rely heavily on diaphragmatic breathing, so abdominal distension can compromise ventilation.
• Circulation: Children have a higher heart rate and lower blood pressure than adults. Crucially, they compensate extremely well — hypotension is a late and serious sign of shock in children.
• Neurology: Children have a larger relative surface area and limited thermoregulatory reserve, making hypothermia a real risk. Glasgow Coma Scale modifications are needed for younger children.

Understanding these differences will directly shape your assessment approach and help you interpret vital signs accurately using age-appropriate reference ranges.

The Paediatric Assessment Triangle

The Paediatric Assessment Triangle (PAT) is a rapid, hands-off initial assessment tool used widely in pre-hospital and emergency paediatric care. It allows you to form an immediate impression of a child's condition before you even touch them. The three components are:

• Appearance: Is the child alert, responding to you, making eye contact? Are they consolable? Do they have normal tone and movement?
• Work of Breathing: Look for signs of increased effort — nasal flaring, tracheal tug, intercostal or subcostal recession, head bobbing, use of accessory muscles.
• Circulation to Skin: Assess skin colour — pallor, mottling, or cyanosis can all indicate compromised perfusion.

An abnormality in any one component should prompt a more detailed assessment. Abnormalities in all three indicate a critically unwell child requiring immediate intervention.

Common Paediatric Emergencies in Pre-Hospital Care

Febrile Convulsions

Febrile convulsions are the most common seizure type in children aged 6 months to 5 years, typically triggered by a rapid rise in temperature. Most are simple (lasting under 5 minutes, generalised, resolving spontaneously) and carry a good prognosis. Your priorities are airway management, safety, and parental reassurance. If the seizure continues beyond 5 minutes, treat as status epilepticus per JRCALC guidance — buccal midazolam or rectal diazepam are your first-line options in the pre-hospital setting.

Croup and Epiglottitis

Croup (laryngotracheobronchitis) is common and typically presents with a characteristic barking cough, stridor, and mild respiratory distress. Keep the child calm — agitation worsens stridor. Nebulised adrenaline and dexamethasone may be indicated for moderate to severe presentations per local protocols.

Epiglottitis is rarer but life-threatening. Suspect it in a child who is drooling, has a muffled voice, prefers to sit forward, and appears toxic. Do not attempt to examine the throat — this can precipitate total obstruction. Blue light transfer with pre-alert is essential.

Bronchiolitis and Asthma

Bronchiolitis predominantly affects infants under 12 months, caused most commonly by RSV. There is limited evidence for bronchodilators in bronchiolitis — supportive care, positioning, and monitoring are your mainstays. Asthma becomes more relevant in older children and should be managed with salbutamol via spacer and device, ipratropium bromide for moderate to severe attacks, and IV or IM magnesium sulphate in severe or life-threatening presentations as per JRCALC.

Anaphylaxis

Paediatric anaphylaxis is managed with IM adrenaline — weight-based dosing applies, and auto-injector devices (e.g., EpiPen Junior for children 15–30 kg) are commonly encountered. Ensure you know the correct doses, routes, and when to repeat. Fluid resuscitation with 10 ml/kg sodium chloride 0.9% boluses may be required.

Meningococcal Disease

A non-blanching petechial or purpuric rash in an unwell child must be treated as meningococcal septicaemia until proven otherwise. IM or IV benzylpenicillin should be administered pre-hospital unless there is a documented penicillin allergy with anaphylaxis — do not delay transport to obtain IV access.

Fluid Resuscitation in Children

The JRCALC guidance for paediatric fluid resuscitation recommends 10 ml/kg boluses of sodium chloride 0.9%, reassessing after each bolus. In trauma, a more restrictive approach is used — permissive hypotension principles apply, targeting a radial pulse presence rather than normal blood pressure, to avoid diluting clotting factors.

Accurate weight estimation matters. Use a length-based tape (such as the Broselow tape) or the formula (Age + 4) x 2 for children aged 1–10 years when weight is unknown.

Safeguarding Awareness

Every paediatric call carries a safeguarding dimension. Be alert to inconsistencies between reported mechanism and injuries observed, unexplained bruising in non-mobile infants, delayed presentations, and inappropriate carer affect. Document your findings accurately and objectively, follow your Trust's safeguarding referral pathway, and never feel that raising a concern is an overreaction.

Communication With Children and Parents

Get down to the child's level — literally. Use age-appropriate language, involve parents or carers, and avoid separating the child from their caregiver unless clinically necessary. A calm, reassuring manner will reduce the child's distress and make your assessment considerably easier.