Pediatric Respiratory/SOB

No patient weight set. Open Pediatric Weight, Age, Height, or Length Tape to enable dose calculations.
A · Airway (Pediatric)

Patency, position, anticipate failure

Assessment
  • Position of comfort (caregiver's lap); avoid agitation in stridor / suspected epiglottitis / FB.
  • Look for: stridor, drooling, tripoding, retractions, head-bobbing, grunting, nasal flaring.
  • Large occiput → place towel under shoulders for sniffing position (infants).
  • Predict failure: GCS ≤ 8, fatigue, silent chest, paradoxical breathing, falling SpO₂ on max O₂.
Interventions
  • Suction, jaw-thrust, age-appropriate OPA / NPA (NPA size = nare-to-tragus).
  • BVM with appropriate mask + PEEP valve; 2-person seal preferred. Apneic O₂ via NC.
  • ETT size (cuffed): age/4 + 3.5 · uncuffed: age/4 + 4. Depth: ETT size × 3 (cm at lip).
  • Most experienced operator; video laryngoscopy preferred if available; difficult-airway cart.
  • Stridor / angioedema / suspected epiglottitis: keep child calm, OR-ready intubation with anesthesia + ENT.
Quickcards · Pediatric RSI doses (weight-based)
(induction)
IV
2 mg/kg
1.5–2 mg/kg; preferred in shock / asthma
(induction)
IV
0.3 mg/kg
0.3 mg/kg; hemodynamically neutral
(paralytic)
IV
1.2 mg/kg
⚠ Max: Onset 45–60 s · DOA 45–60 min
(paralytic)
IV
2 mg/kg
Avoid: ↑K, burns >24 h, NM dz; <10 kg use 3 mg/kg
(pretreatment)
IV
2 mcg/kg
1–3 mcg/kg slow push
(pre-RSI in <1 yr)
IV
0.02 mg/kg
Min 0.1 mg · max 0.5 mg; consider <1 yr or repeat sux
Croup-specific airway pearls
  • Single dose 0.6 mg/kg PO/IM/IV (max 16 mg) for ALL croup severities.
  • Stridor at rest → nebulized racemic epi 0.5 mL of 2.25% in 3 mL NS (or L-epi 5 mL of 1 mg/mL); observe ≥3 h post for rebound.
  • If intubation needed: ETT 0.5–1 mm SMALLER than predicted (subglottic narrowing).
B · Breathing (Pediatric)

Oxygenation, ventilation, work of breathing

Assessment
  • Age-based RR norms: infant 30–60 · toddler 24–40 · child 20–30 · adolescent 12–20.
  • Work of breathing: retractions (subcostal/intercostal/suprasternal), grunting, nasal flaring, head bobbing.
  • Pattern: wheeze (asthma/bronchiolitis/FB) · crackles (pneumonia/CHF) · stridor (croup/FB) · absent breath sounds (PTX/effusion).
  • Watch for fatigue / silent chest / rising CO₂ — early signs of impending failure in children.
Interventions
  • O₂ ladder: NC 1–4 L → simple mask 6–10 L → NRB 10–15 L → HFNC 1–2 L/kg/min → NIV → intubation.
  • Bronchiolitis: supportive (suction, hydration, HFNC); avoid routine bronchodilators / steroids / abx.
  • Asthma: SABA + ipratropium ×3 + early systemic steroid; mag for severe; epi IM for peri-arrest.
  • Tension PTX: needle decompression — 2nd ICS midclavicular line (preferred in young children); chest tube to follow.
  • Pneumothorax in neonate: 18–20 G angiocath, anterior 2nd ICS MCL.
Quickcards · Pediatric breathing doses
neb
Neb
2.5 mg (<20 kg) / 5 mg (≥20 kg) q20 × 3
Continuous 0.5 mg/kg/h (max 15 mg/h) for severe
Ipratropium neb
Neb
0.25 mg (<20 kg) / 0.5 mg (≥20 kg) q20 × 3
First 3 doses only
IV
2 mg/kg
2 mg/kg load, then 0.5–1 mg/kg q6h
(asthma/croup)
PO/IV
0.6 mg/kg
0.6 mg/kg single dose
IV
40 mg/kg
25–50 mg/kg over 20 min for severe asthma
IM (anaphylaxis / peri-arrest)
IM
0.01 mg/kg (1 mg/mL)
⚠ Max: Max 0.3 mg child / 0.5 mg adolescent; q5–15 min
Racemic neb (croup)
Neb
0.5 mL of 2.25% in 3 mL NS
Observe ≥3 h post for rebound
Terbutaline (refractory asthma)
SQ/IV
0.01 mg/kg SQ; IV gtt 0.4 mcg/kg/min
Cardiac monitor; max 0.4 mg SQ
(CAP)
IV
50 mg/kg
50–75 mg/kg/day; ± azithro 10 mg/kg
Ampicillin (CAP <5 yr)
IV
50 mg/kg
50 mg/kg q6h
Wheezing infant · Bronchiolitis vs asthma
  • Bronchiolitis (typically < 2 yr): first wheezing episode + URI prodrome; supportive care, suction, hydration, HFNC. Bronchodilator/steroid trial NOT routine.
  • Asthma (typically ≥ 2 yr): recurrent wheeze, atopy, bronchodilator-responsive; full SABA + steroid pathway.
  • Foreign body: sudden onset, focal wheeze/decreased breath sounds, age 6 mo–4 yr → rigid bronchoscopy regardless of stability.
Pediatric pneumothorax · recognize → decompress → drain
Time-critical
Recognition
  • Sudden respiratory distress, asymmetric chest rise, ↓ breath sounds; in neonates suspect after PPV/birth trauma.
  • Tension: hypotension, bradycardia (kids), tracheal deviation, severe hypoxia — clinical dx, do NOT wait for CXR.
  • POCUS (absent sliding ± lung point) faster than CXR.
Management
  1. High-flow O₂; continuous SpO₂.
  2. Tension PTX → needle decompression: 18–20 G angiocath (neonate/infant) or 14–16 G (older child), 2nd ICS MCL (preferred in pediatrics — thinner anterior wall).
  3. Chest tube: size by weight — neonate 8–10 Fr · infant 10–12 Fr · child 12–20 Fr · adolescent 20–28 Fr. Pigtail acceptable for spontaneous PTX.
  4. Insertion site: 4th–5th ICS anterior axillary line (safe triangle).
  5. Any PTX on PPV needs a chest tube.
C · Circulation (Pediatric)

Perfusion, preload, rate/rhythm

Assessment
  • Children compensate with tachycardia — hypotension is a LATE sign. Watch HR, cap refill (≥3 s = poor), mottling, mental status, urine output.
  • Hypotensive SBP threshold: <60 (neonate) · <70 (1 mo–1 yr) · <70 + (2×age in yr) (1–10 yr) · <90 (≥10 yr).
  • Bradycardia in a child = HYPOXIA until proven otherwise — fix airway/breathing first.
Interventions
  • IV ×2 (largest tolerated); IO if no access in 90 s in decompensated shock.
  • Crystalloid bolus 10–20 mL/kg balanced (LR/PlasmaLyte); reassess after each. Up to 60 mL/kg in first hour for septic shock.
  • PRBC 10–15 mL/kg for ongoing massive bleeding; pediatric MTP (1:1:1 at 10–15 mL/kg) if unstable.
  • Start vasoactives early in fluid-refractory shock — peripheral epi/NE acceptable as bridge.
  • Treat rhythm: synchronized cardioversion if unstable (0.5–1 J/kg → 2 J/kg); defib 2 → 4 J/kg.
Quickcards · Pediatric circulatory doses
Crystalloid bolus
IV/IO
20 mL/kg (max 1 L)
Reassess after each bolus; up to 60 mL/kg/h in septic shock
PRBC
IV/IO
10–15 mL/kg
Active bleed or Hgb <7 (or <8 cardiac)
(cardiac arrest)
IV/IO
0.01 mg/kg (0.1 mL/kg of 0.1 mg/mL)
⚠ Max: q3–5 min · max 1 mg
drip
IV gtt
0.05–1 mcg/kg/min
First-line peds shock; titrate to perfusion
drip
IV gtt
0.05–2 mcg/kg/min
Warm shock / vasoplegia
Push-dose
IV/IO
1 mcg/kg q2–5 min
⚠ Max: Bridge to drip only
(bradycardia)
IV/IO
0.02 mg/kg
⚠ Max: Min 0.1 mg · max 0.5 mg child / 1 mg adolescent
(SVT)
IV
0.1 mg/kg → 0.2 mg/kg
⚠ Max: Max 6 mg → 12 mg
(VT/VF)
IV/IO
5 mg/kg
⚠ Max: Max 300 mg per dose; cumulative 15 mg/kg/day
IV
60 mg/kg (0.6 mL/kg)
Hyperkalemia, CCB tox; max 3 g
(trauma/hemoptysis)
IV
15 mg/kg
10–15 mg/kg over 10 min, then 10 mg/kg q8h
IV
1 mEq/kg
Wide-QRS TCA tox / severe acidosis