Pediatrics
Little patients, big anxiety — weight-based everything.
High-yield before the exam
- Kids compensate until they crash: tachycardia is early shock, hypotension is LATE and ominous.
- Use a length-based tape (Broselow) — weight-based dosing beats memory under stress.
- Pediatric bradycardia is usually hypoxia: oxygenate and ventilate BEFORE reaching for atropine or epi.
- Airway differences: occiput padding under shoulders, smaller tongue-to-mouth ratio, no cricoid pressure debates on the exam.
- Fluid bolus 20 mL/kg for perfusion problems; reassess lung sounds after every bolus.
Drug cards6
Dose: Arrest: 1 mg (1:10,000) IV/IO q3–5 min. Anaphylaxis: 0.3–0.5 mg (1:1,000) IM. Push-dose: 5–20 mcg q1–5 min.
Indications
- Cardiac arrest (all rhythms)
- Anaphylaxis
- Symptomatic bradycardia infusion
- Post-ROSC hypotension
Cautions
- Increases myocardial O₂ demand
- Never 1:1,000 IV push in arrest
- Extravasation causes tissue necrosis
EPI
- E — Every 3–5 minutes
- P — Push 1 mg of the dilute (1:10,000)
- I — IM 1:1,000 for anaphylaxis
Pearl: First drug in every arrest rhythm, but it never replaces compressions — CPR is the drug.
Dose: Arrest (VF/pVT): 300 mg IV/IO, then 150 mg. Stable VT: 150 mg over 10 min.
Indications
- Shock-refractory VF/pulseless VT
- Stable wide-complex tachycardia
- Rate control in some AF
Cautions
- Hypotension with fast push
- Bradycardia and QT prolongation
- Avoid with other QT-prolonging drugs
3-1-5
- 300 mg first arrest dose
- 150 mg second dose
- Given after the 3rd shock
Pearl: In arrest it is a rapid push; with a pulse it goes slow, or the pressure drops out from under you.
Dose: 6 mg rapid IV push + 20 mL flush, then 12 mg; may repeat 12 mg.
Indications
- Stable narrow-complex SVT
- Diagnostic unmasking of flutter
Cautions
- Never for irregular/wide (possible WPW AF)
- Asthma — can trigger bronchospasm
- Warn the patient: chest pressure and doom feeling
FAST
- F — Flush hard, 20 mL
- A — Arm up, closest port
- S — Six then twelve
- T — Tell them it feels awful
Pearl: Half-life under 10 seconds. If it did not work, the push was too slow, not the dose too small.
Dose: 1 mg IV q3–5 min, max 3 mg.
Indications
- Symptomatic bradycardia
- Organophosphate poisoning (large doses)
Cautions
- Ineffective in Mobitz II and 3rd-degree block
- Do not delay pacing for it
- Anticholinergic: dry, hot, blind, mad
1-3-3
- 1 mg per dose
- Every 3–5 minutes
- 3 mg total max
Pearl: Symptomatic means hypotension, altered mentation, ischemia or shock — not just a number on the monitor.
Dose: 0.05–0.5 mcg/kg/min titrated to MAP ≥ 65.
Indications
- Septic and cardiogenic shock
- Post-ROSC hypotension
Cautions
- Central line preferred; watch peripheral site
- Reflex bradycardia
- Ischemia in end vessels
Levo = Leave the pressure up
- First-line for most shock
- Titrate to MAP, not systolic
- Fix volume alongside it
Pearl: MAP ≥ 65 is the target because that is the pressure the kidneys and brain actually perfuse at.
Dose: Seizures: 5 mg IM/IN or 2.5–5 mg IV. Sedation: 1–2.5 mg IV titrated.
Indications
- Status epilepticus
- Sedation for cardioversion
- Cocaine/stimulant chest pain and agitation
Cautions
- Respiratory depression — bag and ETCO₂ ready
- Synergistic crash with opioids
- Paradoxical agitation in some patients
VERSED
- Versed = very effective sedation
- E — Expect amnesia
- R — Respirations need watching
- S — Seizures stop
- E — ETCO₂ on
- D — Dose small, repeat
Pearl: First-line benzo for stimulant toxicity — it treats the catecholamine storm, not just the behavior.
Rhythms to know4
Sinus Bradycardia · < 60
- Normal P waves
- Regular
- Slow
Action: Symptomatic → atropine 1 mg, then pacing / dopamine / epi drip.
Sinus Tachycardia · 100–150
- P before every QRS
- Regular
- Gradual onset
Action: Find and fix the why: pain, fever, hypovolemia, hypoxia.
SVT · 150–250
- Narrow, very fast, regular
- P waves buried in T
- Abrupt onset
Action: Vagal → adenosine 6/12/12 → sync cardioversion if unstable.
Ventricular Tachycardia · 100–250
- Wide, bizarre QRS
- Regular
- No P waves
Action: Pulse + stable → amiodarone. Pulse + unstable → sync. No pulse → defibrillate.
Field cases1
Warm, flushed toddler on the mat, sleepy but arousable. Two days of ear pain and fever. Seizure lasted about 90 seconds per staff.
Vitals: Temp 39.4 C · HR 158 · RR 30 · SpO₂ 97% · glucose 96
Monitor: Sinus tachycardia, appropriate for fever and age.
Skills to drill21
BVM ventilation
Mastery: One-person seal with visible chest rise, 10–12 breaths/min, ETCO₂ 30–35 — no bag-squeezing marathons.
Drill: Bag a manikin for 5 minutes solo with a capno line. If ETCO₂ leaves 30–35, slow down.
OPA / NPA placement
Mastery: Sizes and seats an adjunct in under 10 seconds, knows gag = no OPA.
Drill: Blindfold size-and-place drill: measure ear-to-mouth, insert, ventilate, confirm rise.
Supraglottic airway (i-gel/King)
Mastery: Inserts, seals, and confirms with capnography on the first attempt during compressions.
Drill: Time yourself: CPR pause under 10 seconds, waveform present, no gastric sounds.
Endotracheal intubation
Mastery: First-pass success with bougie backup, continuous capno, and a plan B already open.
Drill: Three passes on the manikin weekly; call out your backup plan before every attempt.
Airway suctioning
Mastery: Clears vomit/blood in under 15 seconds per pass, pre-oxygenates, never blinds a tube.
Drill: Simulated emesis scenario: suction, re-bag, reassess — beat the 15-second clock.
IV access
Mastery: Hits an AC or forearm vein in two sticks or fewer, clean securement, first-try above 70%.
Drill: Ten sticks a week on the trainer arm; verbalize vein selection out loud each time.
IO access (EZ-IO)
Mastery: Proximal humerus or tibial IO in under 60 seconds during an arrest, flush under pressure.
Drill: Arrest sim: drill, secure, pressure-bag flush, and run epi through it inside 2 minutes.
High-performance CPR
Mastery: 100–120/min, 2-inch depth, full recoil, compressor swap under 5 seconds, 60%+ fraction.
Drill: Metronome drill: 2 minutes on, swap mid-count, zero lean on the feedback device.
Defibrillation & cardioversion
Mastery: Pads on and first shock inside 90 seconds of arrival; syncs for unstable tachy without being asked.
Drill: Verbalize the charge-clear-shock sequence while compressions continue to last second.
Transcutaneous pacing
Mastery: Pads, rate 60–80, milliamps up until mechanical capture — confirmed by pulse, not just spikes.
Drill: On the trainer: find capture threshold, then palpate a femoral pulse to prove capture.
12-lead acquisition
Mastery: Clean, artifact-free 12-lead in under 5 minutes — V4R and posterior leads when the story calls for them.
Drill: Do V4R on every inferior STEMI practice strip until it is muscle memory.
Rhythm & 12-lead interpretation
Mastery: Calls the rhythm in 10 seconds, spots STEMI, Wellens, de Winter, and Sgarbossa in paced rhythms.
Drill: Ten strips a day. Say rate, rhythm, intervals, and axis out loud before looking at the answer.
Medication math
Mastery: Computes drips, weight-based doses, and push-dose pressors without a calculator under pressure.
Drill: Five drip problems before every shift: dopamine, epi, amiodarone, lidocaine, weight-based peds.
Assessment & vitals
Mastery: Full head-to-toe with lung sounds, pupils, and skin in under 3 minutes, trending not snapshotting.
Drill: Practice a 90-second rapid trauma and a 3-minute medical assessment until narrated smooth.
History taking (OPQRST/SAMPLE)
Mastery: Pulls a complete history from a scared patient in plain language, and hears what is not said.
Drill: Role-play with a partner who answers evasively — get the whole SAMPLE anyway.
Scene safety & size-up
Mastery: Reads the scene before the patient: hazards, mechanism, number of patients, resources needed.
Drill: On every arrival, say your size-up out loud before touching anyone. Every time.
Lifting & moving
Mastery: Power lifts, stair chair, and draw-sheet moves with zero back strain — for a 30-year career.
Drill: Practice the stair chair with a partner monthly; legs lift, back stays locked.
Radio report / handoff
Mastery: A 60-second report that paints the patient: age, chief, vitals, findings, treatment, ETA — no filler.
Drill: Record yourself giving mock reports; cut every wasted word until it is under a minute.
Documentation (PCR)
Mastery: Chart written like a lawyer reads it: times, findings, refusals with capacity, narrative that matches the monitor.
Drill: After every call, write the refusal or AMA paragraph from memory and compare to the real one.
Protocol fluency
Mastery: Runs every cardiac algorithm from memory and knows exactly which drugs need online medical control.
Drill: Blank-page test: write the ACS, brady, and arrest algorithms from scratch, then grade yourself.
Ultrasound / capnography use
Mastery: Reads ETCO₂ trends as a vital sign — CPR quality, tube confirmation, ROSC spike, sepsis clue.
Drill: Narrate the capno waveform on every call: number, shape, trend, and what you will do about it.
Board-style exam questions22
1. Pediatric patient with stridor at rest and drooling. Priority action?
2. Pediatric arrest is most commonly caused by:
3. Newborn is limp with a heart rate of 50 after 30 seconds of effective ventilation. Next?
4. Pediatric patient with a fever, petechial rash and hypotension. Suspect:
5. Pediatric ventilation rate with an advanced airway in place during CPR?
6. Newborn APGAR components include:
7. A 2-year-old child has a barking cough and inspiratory stridor that improves with cool night air. Best prehospital management?
8. An infant with severe bronchiolitis has a respiratory rate of 80 that suddenly drops to 20 with head bobbing. This means:
9. Correct bag-mask technique for a pediatric patient?
10. A newborn is not breathing after drying and stimulation. First intervention?
11. Best indicator of adequate ventilation in a child you are bagging?
12. A 6-year-old child in cardiac arrest. Compression depth and rate?
13. Two-rescuer CPR compression-to-ventilation ratio for a child with no advanced airway?
14. First defibrillation energy for pediatric VF?
15. Symptomatic bradycardia in a child at a heart rate of 48 with poor perfusion despite oxygen and ventilation. Next step?
16. A child struck by a car has a normal blood pressure, a heart rate of 160 and delayed capillary refill. This represents:
17. Waddell triad in a child struck by a vehicle involves injuries to:
18. Suspected child abuse is suggested by:
19. A 3-year-old child has a brief generalized seizure with a temperature of 39.4 C and is now sleepy but arousable. Best management?
20. Pediatric fluid bolus for compensated shock?
21. A child with known peanut allergy has hives, vomiting and stridor. First drug?
22. An infant is limp with a glucose of 32. Correct dextrose therapy?
Keep going
Educational review only — always follow your local protocols and medical direction. Not affiliated with or endorsed by the NREMT.