- Full standard: no adjustment
- Half-standard: commensurate reduction in amplitude (usually 50%)
- Mixed: reduction in amplitude of precordial leads
- Right Atrial Abnormality (P pulmonale)
- Peaked P-wave in II (>3mm from 0-6mo or >2.5mm >6mo)
- Causes: right atrial volume overload, ASD, Ebstein, Fontan
- Left Atrial Abnormality (P mitrale)
- Wide, notched P-wave in II or biphasic in V1
- Causes: MS, MR
- Anatomical dominance of right ventricle until approximately 6mo
- RAD normal
- eRAD suggests AV canal defect
- 1st week of life: Upright
- Adolescent: Inverted
- Adult: Upright
- Right Ventricular Hypertrophy
- R-wave height >98% for age in lead V1
- S-wave depth >98% for age in lead V6
- T-wave abnormality (ex. upright in childhood)
- Causes: pHTN, PS, ToF
- Left Ventricular Hypertrophy
- R-wave height >98% for age in lead V6
- S-wave depth >98% for age in lead V1
- Adult-pattern R-wave progression in newborn (no large R-waves and small S-waves in right precordial leads)
- Left-axis deviation
- Causes: AS, coarctation, VSD, PDA
Normal Neonatal ECG
- 2mo old
- Inverted T-waves (normal)
- Tall R-waves in V1-V3
Extreme Axis Deviation
- Neonate with Down syndrome
- Isoelectric in I, Negative in aVF negative in II mean QRS vector -87°
- Extreme RAD suggestive of AV canal defect
- Unrepaired Coarctation
- Deep S-wave in V1 (>98%)
- Tall R-wave in V6 (>98%)
- 10 year-old boy with pulmonary Hypertension
- RAD after expected age for normal RAD
- Tall R-waves in V1 (>98%)
- Deep S-wave in V6 (>98%)
- ALCAPA (anomalous origin of the left coronary artery from the pulmonary artery): coronary artery arises anomalously from the pulmonary artery; as pulmonary arterial pressure falls during the first 6 months of infancy, prograde flow through the left coronary artery ceases and may even reverse.
- HLHS (hypoplastic left heart syndrome): coronary arteries are perfused from a hypoplastic, narrow aorta that is susceptible to flow disruption
- Orthotopic heart transplant with allograft vasculopathy
- Kawasaki: coronary artery aneurysm with subsequent thrombosis
Benign early repolarization
- 14 year-old male
- Concave ST-segment elevation
Left Atrial Abnormality:
- 9mo female with mitral insufficiency
- Broad biphasic P-wave in V1
- Tall, notched P-wave in II
Prolonged QT interval
- 18-year-old female
- Familial long QT syndrome and a history of cardiac arrest
- Delta wave, shortened PR interval
- O’Connor M, McDaniel N, Brady WJ. The pediatric electrocardiogram. Part I: Age-related interpretation. Am J Emerg Med. 2008;26(2):221-228. doi:10.1016/j.ajem.2007.08.003.
- Goodacre S, McLeod K. ABC of clinical electrocardiography: Paediatric electrocardiography. BMJ. 2002;324(7350):1382-1385.
- O’Connor M, McDaniel N, Brady WJ. The pediatric electrocardiogram Part II: Dysrhythmias. Am J Emerg Med. 2008;26(3):348-358. doi:10.1016/j.ajem.2007.07.034.
- O’Connor M, McDaniel N, Brady WJ. The pediatric electrocardiogram Part III: Congenital heart disease and other cardiac syndromes. Am J Emerg Med. 2008;26(4):497-503. doi:10.1016/j.ajem.2007.08.004.
- Schwartz P. Guidelines for the interpretation of the neonatal electrocardiogram. Eur Heart J. 2002;23(17):1329-1344. doi:10.1053/euhj.2002.3274.
XR Chest: Circular radioopaque foreign body likely in the antrum of the stomach.
A healthy 5 year-old boy is brought to the pediatric emergency department after he informed his parents that he accidentally swallowed a coin just prior to presentation. He has no complaints and on evaluation appears to be breathing comfortably and is tolerating secretions normally. A plain radiograph was obtained and is shown below.
The patient remained well-appearing and was discharged with primary care follow-up.
Indications for Emergent Endoscopy
- Esophageal button battery
- Severe symptoms
- Sharp foreign body in esophagus
- Multiple magnets in esophagus or stomach
Esophageal foreign bodies typically orient coronally. For example, a coin will appear as a circle on an anteroposterior projection.
Tracheal foreign bodies typically orient sagitally. For example a coin will appear as a line on an anteroposterior projection.
Algorithm for the Evaluation and Management of Pediatric Foreign Body Aspiration
- Sahn, B, et al. Foreign Body Ingestion Clinical Pathway. 1 Aug. 2016, www.chop.edu/clinical-pathway/foreign-body-ingestion-clinical-pathway. Accessed 26 Aug. 2017.
- Wyllie R. Foreign bodies in the gastrointestinal tract. Current Opinion in Pediatrics. 2006;18 N2 -(5).
- Uyemura MC. Foreign body ingestion in children. Am Fam Physician. 2005;72(2):287-291.
- Chung S, Forte V, Campisi P. A Review of Pediatric Foreign Body Ingestion and Management. Vol 11. 2010:225-230.
- Louie MC, Bradin S. Foreign Body Ingestion and Aspiration. Pediatrics in Review. 2009;30(8):295-301. doi:10.1542/pir.30-8-295.
- Green SS. Ingested and Aspirated Foreign Bodies. Pediatrics in Review. 2015;36(10):430-437. doi:10.1542/pir.36-10-430.
The following resource for neonatal resuscitation and neonatal critical care was developed with the guidance of Dr. Agrawal (Neonatology) while on rotation at the White Memorial Medical Center Neonatal Intensive Care Unit.
Endotracheal Tube Size1-3
- Simplified Formula
- Estimated gestational age in weeks ÷ 10 = round to nearest half-size uncuffed tube
|Gestation age (weeks)
||ETT Size (ID, mm)
||Depth (cm from lip)
Laryngoscope Blade Size
Umbilical Vein Catheter Placement4
- ED Indications
- Unstable neonate
- Necrotizing enterocolitis
- 4-5cm or until blood return (for emergent placement)
Umbilical artery/vein catheter position on plain radiograph.
Umbilical catheter size
Umbilical catheter positioning on plain radiographs
Umbilical venous catheter position can be verified with a plain radiograph. Positioning within the umbilical vein can be confirmed by tracing a cephalad trajectory from the insertion point at the umbilicus. An umbilical artery catheter will first pass caudally into the internal iliac artery before travelling cephalad into a common iliac artery and the abdominal aorta.
||0.1mL/kg (1:10,000) IV, 0.01mg/kg
||10mL/kg (normal saline, blood)
||5-20mcg/kg/min IV infusion
Neonatal Physiology and Transition to Extrauterine Life6
An important principle in neonatal resuscitation is supporting the appropriate transition from intra- to extra-uterine life which is dependent on several key anatomic and physiologic changes occurring in an optimal environment.
In the fetal circulatory system, oxygenated blood is delivered via the umbilical vein, entering the inferior vena cava via the ductus venosus. The majority of this oxygenated blood passes through the right atrium and into the left atrium through the foramen ovale to enter the systemic circulation.
Meanwhile, high pulmonary pulmonary vascular resistance (due to hypoxic vasoconstriction in fluid-filled alveoli) means that most of the deoxygenated right ventricular output is routed through the ductus arteriosus and enters into the systemic circulation – mixing with oxygenated blood distal to the highest priority end-organs (brain and heart), to be reoxygenated at the placenta.
The transition to extra-uterine life involves several key steps detailed below and is supported by appropriate ventilation, oxygenation and temperature regulation.
Alveolar Fluid Clearance
Catecholamine and hormone changes (predominantly corticosteroids) during the process of labor induce changes in enzymatic expression that result in the resorption of alveolar fluid into the interstitial space. At the time of delivery, negative intra-thoracic pressure from inspiration further promotes the resorption of alveolar fluid. Mechanical thoracic compression from delivery may also contribute.
Respiration and Breathing
Disconnection from the placenta ceases the transfer of placenta-derived factors including prostaglandins. The withdrawal of tonic inhibition of central respiratory drive from prostaglandins with cord clamping stimulates rhythmic breathing. The infant’s initial breaths and resultant lung expansion promotes alveolar expansion and stimulates surfactant production – this decreases alveolar surface tension, increases lung compliance and further facilitates breathing.
At delivery, clamping the umbilical cord removes a large bed of low-resistance circulation, increasing systemic vascular resistance and systemic blood pressure. At the same time, lung expansion and alveolar aeration decreases pulmonary vascular resistance and pulmonary arterial pressures. At the ductus arteriosus, increased systemic vascular resistance combined with decreased pulmonary vascular resistance decreases shunting and contributes to closure. Similarly, as left atrial pressure approaches and exceeds right atrial pressure, right-to-left flow across the foramen ovale ceases. Collectively, these changes serve to effectively separate the left- and right-sided circulations.
NRP Resuscitation Algorithm5,8
- Luten R, Kahn N, Wears R, Kissoon N. Predicting Endotracheal Tube Size by Length in Newborns. J Emerg Med. 2007;32(4):343-347. doi:10.1016/j.jemermed.2007.02.035.
- Peterson J, Johnson N, Deakins K, Wilson-Costello D, Jelovsek JE, Chatburn R. Accuracy of the 7-8-9 Rule for endotracheal tube placement in the neonate. J Perinatol. 2006;26(6):333-336. doi:10.1038/sj.jp.7211503.
- Kempley ST, Moreiras JW, Petrone FL. Endotracheal tube length for neonatal intubation. Resuscitation. 2008;77(3):369-373. doi:10.1016/j.resuscitation.2008.02.002.
- Anderson J, Leonard D, Braner DAV, Lai S, Tegtmeyer K. Videos in Clinical Medicine. Umbilical Vascular Catheterization. Vol 359. 2008:e18. doi:10.1056/NEJMvcm0800666.
- Association AAOPAAH. Textbook of Neonatal Resuscitation. 2016.
- Caraciolo J Fernandes MD. Physiologic transition from intrauterine to extrauterine life. UpToDate.
- Sadler TW. Langman’s Medical Embryology. Lippincott Williams & Wilkins; 2011.
- Perlman JM, Wyllie J, Kattwinkel J, et al. Part 7: Neonatal Resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. In: Vol 132. American Heart Association, Inc.; 2015:S204-S241. doi:10.1161/CIR.0000000000000276.
An 8-month old male is brought to the emergency department with fever. He has had four days of fever (temperature ranging from 37-40°C), rash on trunk and extremities, white-colored tongue discoloration, and irritability with decreased oral intake. Temperature on presentation was 39.4°C, examination revealed an erythematous maculopapular rash on the extremities and trunk including soles of the feet. Mucous membrane involvement was noted with oropharyngeal erythema and bilateral conjunctival injection. Neck examination demonstrated right-sided cervical adenopathy.
- WBC: 23.4 (N: 59%, B: 21%)
- ESR: 100mm/hr
- CRP: 7.59mg/dL
- Albumin: 3.3g/dL
- AST/ALT: 78U/L, 65U/L
- UA: 7WBC, no bacteria
The patient was admitted with a diagnosis of Kawasaki Disease and was treated with IVIG and high-dose aspirin. The patient demonstrated marked improvement with treatment and had a normal echocardiogram. He was discharged on hospital day three.
- Age: 6 months to 5 years
- Northeast Asian
- Possible heritable component
- Seasonal (winter/spring)
- Acute febrile (T > 39°C refractory to anti-pyretics)
- Subacute (coronary vasculitis)
- Fever >5d
- Criteria (4/5)
- Conjunctivitis (bilateral, non-exudative)
- Oropharynx changes (strawberry tongue, erythema, perioral)
- Cervical lymphadenopathy (unilateral, >1.5cm)
- Extremity changes (erythema, edema, palm/sole involvement)
- Incomplete (2-3 criteria)
- CBC: Elevated WBC (neutrophil predominant)
- Urinalysis: Sterile pyuria
- Acute phase reactants: Elevated ESR (>40-60mm/hr), CRP (>3.0-3.5mg/dL)
- CMP: Hyponatremia, hypoalbuminemia, hypoproteinemia, elevated transaminases
- ECG: AV block, ischemia/infarction (aneurysm/thrombosis)
- Echocardiography: Decreased LVEF, MR, pericardial effusion
- Hospital admission
- IVIG (2g/kg)
- Aspirin (80mg/kg/day)
Algorithm for the Evaluation of Kawasaki and Incomplete Kawasaki Disease3,4
- Shiari R. Kawasaki Disease; A Review Article. Arch Pediatr Infect Dis. 2014;2(1 SP 154-159).
- Yu JJ. Diagnosis of incomplete Kawasaki disease. Korean J Pediatr. 2012;55(3):83-87. doi:10.3345/kjp.2012.55.3.83.
- Newburger JW, Takahashi M, Gerber MA, et al. Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Pediatrics. 2004;114(6):1708-1733. doi:10.1542/peds.2004-2182.
- Yellen ES, Gauvreau K, Takahashi M, et al. Performance of 2004 American Heart Association recommendations for treatment of Kawasaki disease. Pediatrics. 2010;125(2):e234-e241. doi:10.1542/peds.2009-0606.
A young child, otherwise healthy, is brought to the pediatric emergency department after a fall. The parents report a fall from approximately 2 feet after which the patient cried immediately and without apparent loss of consciousness. Over the course of the day, the patient developed an enlarging area of swelling over the left head. The parents were concerned about a progressive decrease in activity and interest in oral intake by the child, and they were brought to the emergency department for evaluation. Examination demonstrated a well-appearing and interactive child – appropriate for age. Head examination was notable for a 5x5cm hematoma over the left temporoparietal skull with an underlying palpable skull irregularity not present on the contralateral side. Non-contrast head computed tomography was obtained.
Fracture of the left temporal and parietal bone with overlying scalp hematoma.
Algorithm for the Evaluation of Pediatric Head Trauma (PECARN)1,2,3
- Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170. doi:10.1016/S0140-6736(09)61558-0.
- Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiation-induced fatal cancer from pediatric CT. American Journal of Roentgenology. 2001;176(2):289-296. doi:10.2214/ajr.176.2.1760289.
- Schonfeld D, Bressan S, Da Dalt L, Henien MN, Winnett JA, Nigrovic LE. Pediatric Emergency Care Applied Research Network head injury clinical prediction rules are reliable in practice. Archives of Disease in Childhood. 2014;99(5):427-431. doi:10.1136/archdischild-2013-305004.
This post presents a tool for the rapid assessment of the cardiopulmonary status and cerebral/metabolic function of critically ill pediatric patients. The purpose is not to establish a diagnosis, rather to identify the particular physiological derangements to prioritize initial interventions. The tool was initially designed as a “triangle” – it has been adapted here (with permission) as a Venn diagram.1
Pediatric Assessment Diagram
Assessment of Appearance
- Tone: Moves spontaneously, resists examination
- Interactivity: Interacts with environment, reaches for items
- Consolability: Comforted by caregiver
- Gaze: Makes eye contact
Assessment of Work of Breathing
- Airway Sounds: Stridor, grunting, wheezing
- Position: Tripod
Assessment of Circulation
- Position of comfort
- Oxygen, suction
- Therapy as appropriate (albuterol, epinephrine, etc)
- Labs/radiographs as indicated
- Head/airway positioning
- 100% oxygen
- Ventilation support (BVM)
- Advanced airway
|Shock (compensated and decompensated)
- Fluid resuscitation
- Specific therapy (antibiotics, surgery)
- Labs/radiographs as indicated
- Pulse oximetry
- Rapid glucose
- Labs/radiographs as indicated
- Head/airway positioning
- 100% oxygen
- Ventilation support (BVM)
- Chest compressions as needed
- Specific therapy (defibrillation, epinephrine, amiodarone)
- Labs/radiographs as indicated
- The pediatric assessment triangle: a novel approach for the rapid evaluation of children. Pediatr Emerg Care. 2010;26(4):312-315. doi:10.1097/PEC.0b013e3181d6db37.
Below is a rapid reference for essential information related to the care of pediatric patients including sizing estimates for endotracheal tubes and weight-based dosing for critical/common medications (rapid sequence intubation, pediatric advanced life support, seizure management), compiled by Dr. Kelly Young1.
- 4 + Age/4 = uncuffed
- Subtract 0.5 for cuffed
- Gestational age (weeks) / 10 if premature
- Depth = ETTx3
- Newborn: 0
- <2yo: 1
- 2-8yo: 2
- >8yo: 3
- Other Tubes
- NGT = ETT x 2
- Chest tube = ETT x 4
||70 + (Age x2)
||1mg/kg (x2 infant, x3 neonate)
||2, 4, 10J/kg
||0.01mg/kg (0.1mL/kg of 1:10,000)
||0.02mg/kg (minimum dose 0.1mg, maximum 0.5mg)
||0.1mg/kg (max 6mg), 0.2 mg/kg (max 12mg)
|Calcium gluconate (10%)
|Calcium chloride (10%)
|Normal saline (0.9%)
||4cc/kg (first 10kg), 2cc/kg (second 10kg), 1cc/kg thereafter
||0.2mg/kg (max 10mg)
||90mg/kg divided BID
||10mg/kg day 1, 5mg/kg days 2-5
- Young, K. D. (2016, April 18). Pediatric Doses and Sizes. Lecture presented at Harbor-UCLA Medical Center in CA, Torrance.
5mo female with a history of multiple food allergies, GERD and FTT admitted from clinic for persistent failure to gain weight.
The patient’s mother states that the current diet is 3oz of Neocate 20cal/oz q3h, and that the baby sleeps through the night. The child has a history of reflux, but no emesis in the past few weeks since starting Reglan. There was a history of bloody diarrhea, however none since age 2mo after a change of formula. Mother reports known allergies to milk, soy, protein, and egg. No recent fevers/chills, emesis, diarrhea, fussiness.
The patient was born at 27wks via emergency Cesarean for non-reassuring fetal heart tracings, was intubated in the DR and remained in the NICU for one week.
- VS: 98/65mmHg, 114bpm, 98.1°, 33/min, 100% RA
- Gen: Small for age, smiling and interactive
- HEENT: PERRL, MMM, no lesions
- CV: RRR, no M/R/G, Lungs: CTAB
- Abdomen: +BS, soft, NT/ND, no masses, no hepatosplenomegaly
- Ext: Normal capillary refill
Assessment & Plan:
5mo female, ex-27wks with a history of multiple food allergies, GERD, FTT. Persistent failure to gain weight, admitted for evaluation of feeding habits and observed weight gain. The patient was determined to not be receiving adequate intake and was advanced to a high-calorie formula and parental education was provided. After two days of observed (and appropriate) weight gain, the patient was discharged with follow-up at multiple specialty clinics including GI, FTT, and A&I.
Differential Diagnosis for Failure to Thrive:
17 year-old female presenting to the pediatric ED with sore throat for 2 days.
The patient reports steadily worsening sore throat over the past 2 days, associated with a sensation of swelling. The pain is described as sharp, 4/10 in severity, located on the left side of her throat, and worsened with swallowing. She denies inability to swallow or difficulty breathing, she also denies fever, cough, new skin rashes or genital lesions.
She has no PMH/PSH, takes no medications, denies t/e/d use and is not currently sexually active.
- VS: 111/65mmHg, 80bpm, 97.8°, 16/min, 100% RA
- Gen: Well-appearing, NAD
- HEENT: PERRL, no conjunctival injection, TM clear b/l, minimal pharyngeal erythema on left with 6mm white circular lesion on left tonsil, no tonsillar enlargement, no uvular deviation, no cervical LAD, neck supple no masses, normal neck ROM
- CV: RRR, no M/R/G, Lungs: CTAB
- Abdomen: +BS, soft, NT/ND
- Ext: Warm, well-perfused, normal peripheral pulses
Assessment & Plan:
17yo female with no significant PMH with acute pharyngitis for 2 days. The most likely cause of the patient’s symptoms is viral pharyngitis, potentially herpangina (given the appearance of the tonsillar lesion). A more serious viral/bacterial pharyngitis is less likely given the absence of fever or significant erythema/exudate. There was no uvular deviation to suggest peritonsillar abscess and no evidence of airway obstruction to suggest other acute processes (epiglottitis, retropharyngeal abscess). The plan is to recommend supportive care and ibuprofen for symptomatic relief. The patient will be discharged home in good condition with precautions to return if symptoms worsen or she begins to have difficulty swallowing/breathing.
Differential Diagnosis of Acute Pharyngitis:
- Respiratory distress: epiglottitis, retropharyngeal abscess, peritonsillar abscess, EBV (obstruction in or near pharynx)
- Fatigue: infectious mononucleuosis
- Abrupt onset: epiglottitis
Evaluation (physical examination):
- Vesicles anterior: herpetic stomatitis, SJS, Behcet
- Vesicles posterior: herpangina (± involvement of extremities)
- Asymmetry: peritonsillar abscess
- Stridor, drooling, respiratory distress: airway obstruction
- Generalized inflammation: Kawasaki
5yo girl brought to the pediatric emergency department by her mother due to 3 days of fever.
The patient’s fever was first noted 3 days ago, measured at home to 103°F. It is associated with a moist cough, vomiting, and decreased PO intake. Her mother reports that she appears lethargic and has been urinating less frequently. The patient denies headache, changes in vision, burning with urination, or ear pain. No known sick contacts, attends day care.
PMH (Birth History):
No significant medical/surgical history. Ex-term born NSVD with no complications.
- VS: 95/65mmHg, 100bpm, 102.6°, 22/min
- General: Well-appearing, mildly irritated but consolable
- HEENT: NC/AT, PERRL, oropharynx without erythema, no cervical LAD
- CV: RRR, no M/G/R
- Lungs: No evidence of respiratory distress (retractions, flaring), faint crackles over right inferior lung fields
- Abd: +BS, soft, non-distended, TTP RLQ > LLQ, no rebound/guarding
- Back: No CVAT
- CXR PA/Lateral: RML/RLL infiltrate
5yo with 3 days persistent high fever and cough. These symptoms along with examination findings of crackles warranted further imaging (CXR) which revealed infiltrate in the right inferior lung field. The patient appeared clinically stable and was tolerating PO intake in the ED and was discharged home with azithromycin 5mg/kg/dose (with loading dose), clinic follow-up and strict return precautions.
Evaluation and Management of Pediatric Fever
A System for Pediatric Fever:
- <3mo: 38.0°C, 100.4°F
- 3-36mo: 39.0°C, 102.2°F
- Rectal > oral > axillary
Differential Diagnosis of Pediatric Fever:
Serious Bacterial Illness (SBI):
1) UTI and pyelonephritis
- Most common cause of SBI
- Accounts for 3-8% of uncharacterized fevers
- Female > male, uncircumcised > circumcised
- Consider BCx, CSF evaluation as 5-10% bacteremic at presentation
- Urinalysis: LE 75% specificity, Nitrites 97% specificity
2) Pneumonia and sinusitis
- Sinusitis uncommon <3yo (sinuses unformed)
- PNA diagnosed with CXR, obtain if findings of respiratory distress (grunting, tachypnea, hypoxemia) or rales on exam
- Diagnose with LP
- Meningitis suggested if:
- ANC > 1,000
- Protein > 80
- Seizure (particularly complex febrile seizure)
Diagnosis by Age Group:
- Physical exam findings:
- Tachypnea, hypoxemia → LRT infection
- Irritability, inconsolability, bulging anterior fontanelle → meningitis
- Vomiting/diarrhea → non-specific, GE, AOM, UTI, meningitis
- Recent immunization: increased risk of SBI (usually UTI) 24-72h after immunization
- Confirmed bronchiolitis (viral): enterovirus/parainfluenza associated with SBI
- Physical exam findings:
- Viral (URTI, GE) → vomiting, diarrhea, rhinorrhea, cough, rash; still playful and responsive
- UTI → fever, foul-smelling urine, crying when urinating
- Meningitis → irritability with handling, vomiting, bulging anterior fontanelle, complex febrile seizures
- Physical exam findings: presentation more adult-like
- Watch for:
- Group A Streptococcal pharyngitis
- Infectious mononulceosis
- Kawasaki: high fever (>5d), strawberry tongue, conjunctivitis, desquamating rash on palms/soles