Paediatric emergencies essentials

What an adult ICU resident needs when a sick child arrives: paediatric resuscitation and weight-based doses, sepsis and fluids, airway sizes and ventilation, bronchiolitis and croup, DKA, and safe transfer to a PICU — with worked doses for 10–20 kg children and Indian context.

6 topics

01
PALS and weight-based doses
Paediatric cardiac arrest (AHA/AAP 2025), bradycardia and SVT, weight estimation and the core resuscitation doses — with worked examples for a 10 kg and 20 kg child.
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02
Paediatric sepsis and fluids
Phoenix sepsis criteria, the first-hour bundle from the Surviving Sepsis Campaign paediatric guideline, how much fluid to give (and when not to), vasoactive choice, maintenance fluids, and Indian special cases.
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03
Paediatric airway: sizes, RSI and first ventilator settings
Endotracheal tube size and depth, laryngoscope blades and supraglottic airways by age/weight, a safe paediatric rapid sequence intubation, and lung-protective initial ventilation per PALICC-2.
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04
Bronchiolitis and croup
Two common respiratory emergencies of infancy: bronchiolitis (supportive care, oxygen thresholds, HFNC/CPAP, what not to give) and croup (steroids for all, nebulised adrenaline for stridor at rest, and the dangerous mimics including diphtheria).
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05
Paediatric diabetic ketoacidosis
ISPAD 2022-based management of DKA in children and adolescents: severity, cautious fluid deficit replacement over 24–48 h, insulin 0.05–0.1 unit/kg/h without bolus, potassium rules, the two-bag dextrose approach and recognising and treating cerebral oedema.
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06
Safe transfer of a sick child to PICU
Stabilise-then-transfer: deciding when and how to move a critically ill child within or between hospitals, communication with the receiving PICU, team, equipment and oxygen planning, in-transit monitoring and handover — adapted to Indian ambulance realities.
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Drugs in this module

Doses written for this module's context. The same drug may read differently in another module.

Adrenaline (epinephrine) — paediatric

Catecholamine (alpha + beta agonist)

Indications: Cardiac arrest; anaphylaxis; fluid-refractory (cold) septic shock; moderate–severe croup (nebulised); symptomatic bradycardia
Adult dose: Paediatric doses: arrest 0.01 mg/kg IV/IO (= 0.1 mL/kg of 0.1 mg/mL), max 1 mg, every 3–5 min. Anaphylaxis 0.01 mg/kg IM of 1 mg/mL (max 0.5 mg). Infusion 0.05–1 mcg/kg/min. Croup: nebulised 0.5 mL/kg of 1 mg/mL (max 5 mL).
Preparation (India): 1 mg/mL (1:1000) 1 mL ampoules. Make 0.1 mg/mL by diluting 1 mL in 9 mL NS. Infusion e.g. 0.3 mg/kg in 50 mL: 1 mL/h = 0.1 mcg/kg/min.
Cautions: Confusing 1 mg/mL with 0.1 mg/mL causes 10-fold errors — label syringes. Extravasation risk if given peripherally undiluted.
Monitoring: ECG, BP, perfusion, lactate, glucose.

Amiodarone — paediatric

Class III antiarrhythmic

Indications: Shock-refractory VF/pulseless VT; perfusing wide-complex or refractory SVT (with expert advice)
Adult dose: Arrest: 5 mg/kg IV/IO bolus (max 300 mg), may repeat up to a total of 15 mg/kg. Perfusing tachycardia: 5 mg/kg over 20–60 min.
Preparation (India): 150 mg/3 mL ampoule; dilute in D5W.
Cautions: Hypotension, bradycardia, QT prolongation; avoid combining with other QT-prolonging drugs without expert input.
Monitoring: ECG, BP.

Lidocaine (lignocaine) — paediatric

Class Ib antiarrhythmic

Indications: Shock-refractory VF/pVT (alternative to amiodarone)
Adult dose: 1 mg/kg IV/IO bolus; infusion 20–50 mcg/kg/min.
Preparation (India): 2% (20 mg/mL) preservative-free for IV use.
Cautions: Seizures and myocardial depression with toxicity.
Monitoring: ECG, neurological status.

Adenosine — paediatric

Purinergic AV-nodal blocker

Indications: SVT with a pulse after vagal manoeuvres
Adult dose: 0.1 mg/kg rapid IV push (max 6 mg) with immediate saline flush; second dose 0.2 mg/kg (max 12 mg).
Preparation (India): 3 mg/mL, 2 mL vials.
Cautions: Give through a large proximal vein with a two-syringe/three-way-tap flush; transient asystole; bronchospasm in asthma.
Monitoring: Continuous ECG recording during the dose.

Atropine — paediatric

Antimuscarinic

Indications: Bradycardia from increased vagal tone or primary AV block; selected intubations at risk of bradycardia
Adult dose: 0.02 mg/kg IV/IO (max single dose 0.5 mg); may repeat once.
Preparation (India): 0.6 mg/mL ampoules.
Cautions: Not a substitute for oxygenation/ventilation in hypoxic bradycardia (commonest cause in children).

Dextrose 10% — paediatric

Carbohydrate

Indications: Hypoglycaemia in children (check glucose in every sick child)
Adult dose: 2–5 mL/kg of 10% dextrose IV/IO (0.2–0.5 g/kg); recheck glucose in 15–30 min; then maintenance dextrose.
Preparation (India): 10% dextrose bags; to make from 25%: 2 parts 25% + 3 parts water/NS (approx. 10%).
Cautions: Avoid 25–50% dextrose peripherally in small children (vein injury); avoid hyperglycaemia.

Calcium chloride / calcium gluconate — paediatric

Electrolyte

Indications: Documented hypocalcaemia, hyperkalaemia, calcium-channel blocker toxicity (not routine in arrest)
Adult dose: Calcium chloride 10%: 20 mg/kg (0.2 mL/kg) IV/IO slowly (max 1 g). Calcium gluconate 10%: 60 mg/kg (0.6 mL/kg) IV/IO slowly (max 3 g).
Preparation (India): Calcium gluconate 10% 10 mL ampoules are the usual Indian presentation; calcium chloride less widely stocked.
Cautions: Severe tissue injury if extravasated (especially chloride); not routine in cardiac arrest (2025 PALS).

Sodium bicarbonate — paediatric

Alkalinising agent

Indications: Hyperkalaemia, sodium-channel blocker (TCA) toxicity; not routine in arrest
Adult dose: 1 mEq/kg slow IV/IO (8.4% = 1 mEq/mL; dilute 1:1 in infants).
Cautions: Not recommended routinely in paediatric arrest; flush line before catecholamines (inactivation).

Balanced crystalloid / 0.9% saline bolus — paediatric

IV fluid

Indications: Septic shock and hypovolaemia
Adult dose: 10–20 mL/kg over 5–20 min, reassess after each bolus; up to 40–60 mL/kg in the first hour where intensive care is available, stopping at signs of fluid overload (crackles, hepatomegaly, rising work of breathing). Balanced crystalloid (Ringer's lactate) suggested over 0.9% saline.
Preparation (India): Ringer's lactate and 0.9% saline widely available; use 50 mL syringes 'push-pull' for small children.
Cautions: Without intensive care and without hypotension, SSC suggests no bolus (maintenance fluids instead). Severe acute malnutrition: use smaller, slower volumes (WHO).
Monitoring: HR, capillary refill, BP, liver span, crackles, urine output, lactate.

Noradrenaline (norepinephrine) — paediatric

Alpha-1 > beta-1 agonist

Indications: Warm (vasodilated) septic shock after fluids
Adult dose: 0.05–1 mcg/kg/min IV infusion, titrated to perfusion and age-appropriate MAP.
Preparation (India): Common paediatric 'rule of 0.3': 0.3 mg/kg in 50 mL; 1 mL/h = 0.1 mcg/kg/min.
Cautions: May start through a good peripheral line in dilute form while central access is obtained (SSC).

Ceftriaxone — paediatric

Third-generation cephalosporin

Indications: Empirical antibiotic for community-acquired sepsis/meningitis beyond the neonatal period
Adult dose: Sepsis: 50–80 mg/kg IV once daily (max 2 g). Meningitis: 100 mg/kg/day IV in 1–2 doses (max 4 g/day). Give within 1 h of recognising septic shock.
Preparation (India): 250 mg, 500 mg, 1 g vials.
Cautions: Avoid in neonates with hyperbilirubinaemia and with calcium-containing IV fluids in neonates.

Hydrocortisone — paediatric

Glucocorticoid

Indications: Catecholamine-resistant septic shock with suspected adrenal insufficiency; known adrenal insufficiency/chronic steroid use
Adult dose: Commonly 2 mg/kg IV bolus (max 100 mg), then 1 mg/kg 6-hourly (max 50 mg/dose) or 50–100 mg/m²/day.
Preparation (India): 100 mg vials.
Cautions: SSC suggests against routine use when fluids and vasopressors restore stability.

Ketamine — paediatric

NMDA antagonist (dissociative anaesthetic)

Indications: Induction for intubation in shocked or asthmatic children; procedural sedation
Adult dose: Induction 1–2 mg/kg IV (reduce to 0.5–1 mg/kg in profound shock); IM 4–5 mg/kg if no access.
Preparation (India): 50 mg/mL vials (10 mL); dilute to 10 mg/mL for children.
Cautions: Laryngospasm and hypersalivation (rare); may still drop BP in catecholamine-depleted shock.

Rocuronium — paediatric

Non-depolarising neuromuscular blocker

Indications: Rapid sequence intubation
Adult dose: 1–1.2 mg/kg IV.
Preparation (India): 10 mg/mL (5 mL vials); refrigerate.
Cautions: Only after airway plan and failed-airway backup are ready; sugammadex availability varies.

Fentanyl — paediatric

Opioid analgesic

Indications: Analgesia/blunting response at intubation; post-intubation analgesia
Adult dose: 1–2 mcg/kg IV slowly; infusion 1–4 mcg/kg/h.
Preparation (India): 50 mcg/mL ampoules.
Cautions: Chest wall rigidity with rapid large doses (infants); hypotension; apnoea.

Dexamethasone (croup)

Glucocorticoid

Indications: Croup (all severities)
Adult dose: 0.15–0.6 mg/kg PO (or IM/IV) single dose; 0.15 mg/kg is effective for mild–moderate croup; 0.6 mg/kg (max about 10–16 mg) often used for severe croup.
Preparation (India): 0.5 mg tablets; 4 mg/mL injection can be given orally mixed in syrup.
Cautions: Single dose is usually enough.

Budesonide (nebulised)

Inhaled glucocorticoid

Indications: Croup when oral route is not tolerated
Adult dose: 2 mg nebulised single dose.
Preparation (India): 0.5 mg/2 mL respules (use 4 respules = 2 mg).

Regular (soluble) insulin — paediatric DKA

Insulin

Indications: Paediatric DKA
Adult dose: 0.05–0.1 unit/kg/h IV infusion, started at least 1 h after starting fluid replacement; NO bolus.
Preparation (India): 100 units/mL vials; 50 units in 50 mL NS = 1 unit/mL (prime the line).
Cautions: Hypokalaemia and hypoglycaemia; start only once K⁺ ≥3.5 mmol/L (ISPAD) or with K⁺ replacement running.
Monitoring: Hourly glucose, 2–4-hourly electrolytes/blood gas, hourly neuro observations.

Potassium chloride (in IV fluids) — paediatric DKA

Electrolyte

Indications: Potassium replacement in DKA
Adult dose: Usually 40 mmol/L in rehydration fluid (20 mmol/L if fluid rate >10 mL/kg/h); start with initial volume expansion if hypokalaemic, with insulin if normokalaemic, and after urine output if hyperkalaemic. Keep within 0.5 mmol/kg/h.
Preparation (India): 15% KCl = 2 mmol/mL (10 mL ampoule = 20 mmol); premixed bags preferred to avoid errors.
Cautions: Never give KCl as an IV bolus; mix bags thoroughly.

Mannitol — paediatric

Osmotic diuretic

Indications: Cerebral oedema in DKA (or raised ICP)
Adult dose: 0.5–1 g/kg IV over 10–15 min; may repeat after 30 min if no response.
Preparation (India): 20% mannitol (200 mg/mL): 0.5–1 g/kg = 2.5–5 mL/kg.
Cautions: Diuresis and hypovolaemia; crystallises if cold.

Hypertonic saline 3% — paediatric

Osmotic agent

Indications: Cerebral oedema in DKA (alternative to mannitol)
Adult dose: 2.5–5 mL/kg of 3% NaCl IV over 10–15 min.
Preparation (India): 3% NaCl bags available in most Indian hospitals; can be prepared from 0.9% saline + 15% or 23.4% NaCl per pharmacy protocol.
Cautions: Hypernatraemia, hyperchloraemic acidosis.

6 topics

PALS and weight-based doses

Paediatric sepsis and fluids

Paediatric airway: sizes, RSI and first ventilator settings

Bronchiolitis and croup

Paediatric diabetic ketoacidosis

Safe transfer of a sick child to PICU

Drugs in this module

Module references (19)