Pediatric Calls: High Risk, High Impact
Pediatric emergencies demand a unique blend of speed, precision, and emotional control from paramedics. While these cases represent a small percentage of total calls, they carry outsized risk. Pediatric patients deteriorate quickly, and subtle missteps in airway management, medication dosing, or shock treatment can have irreversible consequences. Unlike adult calls, where protocols feel second nature, pediatric ALS cases often push paramedics out of routine and into high-cognitive-load territory.
Emotional intensity adds another layer of complexity. Seeing critically ill children can trigger anxiety, tunnel vision, and hesitation—especially when family members are present and distressed. Despite the challenge, field providers must act decisively. The margin for error is slim, and the expectations from caregivers, receiving facilities, and medical oversight are high. Paramedic training must account for this complexity and provide more than just algorithm memorization.
If you’re in the process of applying for paramedic training, make sure to review our step-by-step guide to getting started. Preparing for these advanced responsibilities starts with proper program entry and clinical readiness.
Rapid Pediatric Assessment: Spotting Trouble Early
Pediatric Assessment Triangle (PAT) for Initial Impressions
The Pediatric Assessment Triangle (PAT) offers a fast, structured approach to initial field evaluation. It centers on three observable elements: appearance, work of breathing, and circulation to skin. Unlike a full physical exam, the PAT can be conducted in seconds from across a room. An abnormal finding in any one category requires escalation. If two or more areas raise concern, ALS interventions must begin immediately.
Vital Sign Red Flags by Age Group
Vital signs vary dramatically with age, making accurate interpretation critical. Newborns may have resting heart rates above 140 bpm, while a six-year-old with the same value indicates distress. Paramedics must memorize or reference pediatric norms for heart rate, respiratory rate, and blood pressure by age bracket. Bradycardia often signals hypoxia rather than a primary cardiac issue. Tachypnea may signal fever, pain, or early shock.
Weight-Based Estimation: Handtevy, Broselow, and Mental Math
Weight estimation tools like Broselow tapes and Handtevy apps allow for fast dose calculations, but their accuracy depends on visual age estimation and tool familiarity. The Handtevy system maps age to weight and then to drug doses and equipment sizes, while Broselow color zones are based on length. In chaotic scenes, paramedics should also practice quick mental calculations using formulas like (age × 2) + 10 to approximate weight.
Pediatric Respiratory Distress and Failure: ALS Protocols
Differentiating Upper vs Lower Airway Obstruction
Stridor and hoarseness point to upper airway involvement—think croup or foreign body aspiration. Wheezing suggests lower airway issues like bronchiolitis or asthma. Clear recognition matters because treatments differ. Racemic epinephrine may help in croup, while albuterol and ipratropium benefit lower airway constriction. Misapplying therapies can delay relief and worsen outcomes.
Bronchodilators, Epi, and Nebulizer Techniques in Kids
Nebulized albuterol, often combined with ipratropium, is the mainstay for asthma in children. Intramuscular epinephrine may be indicated for severe cases unresponsive to nebulized therapy. Delivering medications via mask or blow-by requires adapting to patient age and cooperation. Secure the mask gently and explain the process to the child or caregiver to reduce anxiety and improve compliance.
Suctioning, Positioning, and Oxygen Setup Tips
Simple interventions often save lives. Proper positioning—such as elevating the head in respiratory distress—improves air exchange. Gentle suctioning of the oropharynx clears secretions, especially in infants with bronchiolitis. Oxygen should be administered using age-appropriate masks or nasal cannula, with careful attention to flow rates to avoid cold stress or agitation.
Indications for Assisted Ventilation or Intubation
When respiratory effort fails or oxygenation remains inadequate, paramedics may need to provide assisted ventilations. Bag-valve-mask (BVM) technique must be flawless to avoid gastric insufflation. Intubation in pediatrics remains controversial due to risks and alternative airway options like supraglottic devices. Field systems may prioritize effective BVM and SGA over endotracheal intubation unless absolutely necessary.
Prehospital Seizure Management and Status Epilepticus
Common Triggers: Fever, Epilepsy, Trauma
Febrile seizures in toddlers are common and often self-limiting. More concerning are prolonged seizures or those triggered by known epilepsy, head injury, or toxin exposure. Identifying seizure etiology on scene may be impossible, so treatment should prioritize seizure cessation and airway protection.
First-Line Medications and Preferred Routes (IV, IM, IN)
Benzodiazepines are the gold standard. Midazolam is often used for its rapid onset and multiple route options. Intranasal (IN) and intramuscular (IM) administration offer advantages when IV access is delayed. The goal is to stop the seizure quickly while minimizing respiratory compromise. Dosage must be carefully calculated based on weight.
When to Escalate and What to Document
Status epilepticus—defined as seizures lasting longer than five minutes—requires aggressive intervention. If two benzodiazepine doses fail, paramedics must consider advanced airway management and transport to a facility equipped for escalation. Document onset time, interventions, patient response, and any recurrence during transit.
Transport Tips Post-Seizure
After seizure resolution, closely monitor for respiratory depression. Keep the child in a recovery position if unresponsive. Reassess blood glucose, as hypoglycemia can mimic or precipitate seizures. Communicate clearly with caregivers about what happened and what will occur next at the receiving facility.
Pediatric Hypoperfusion: Field Management of Shock
Types of Shock in Pediatric Patients
Children most often present with hypovolemic or distributive shock. Blood loss, vomiting, diarrhea, or sepsis are typical causes. Obstructive and cardiogenic shock occur less frequently but must be recognized. Early shock signs include delayed cap refill, mottled skin, and altered mental status—often appearing before hypotension.
Cap Refill, Skin Signs, and Mental Status
Capillary refill over two seconds in a child is concerning. Cool extremities, pallor, or cyanosis suggest circulatory compromise. A sudden change in behavior—lethargy, irritability, or confusion—often signals hypoperfusion before vital signs change. These indicators must prompt immediate fluid resuscitation and transport.
Fluid Bolus Guidelines and Dosing Tools
Paramedics typically begin with a 20 mL/kg bolus of isotonic crystalloid, repeated as needed. Weight-based dosing charts or digital apps ensure accurate calculations. Monitor for improved perfusion signs after each bolus and reassess lung sounds to detect fluid overload.
Starting an IO in Pediatric Patients
When IV access fails or time is critical, intraosseous (IO) insertion offers a fast, reliable route. Proximal tibia is the preferred site in young children. Providers must stabilize the limb, confirm placement, and flush adequately before administering medications or fluids. Ongoing monitoring is essential to prevent complications like extravasation.
Caregiver Communication and Scene Management
Building Trust Fast with Family Under Stress
Caregivers often feel helpless and terrified during pediatric emergencies. A calm demeanor and clear explanations build rapport quickly. Use simple language and repeat critical points. Assure them that your focus is on stabilizing their child with advanced tools and training.
Explaining ALS Procedures in Plain Terms
Informed cooperation from caregivers improves procedural success. Before intubation, IO insertion, or drug administration, give a brief, digestible explanation. Phrases like “We’re giving medicine to stop the seizure” or “This helps her breathe easier” can reduce panic and gain consent.
Managing Crowded Scenes and Reactions
Pediatric calls often attract large, emotional crowds. Assign one provider to speak with the family while others perform care. Consider requesting law enforcement to manage bystanders if safety becomes a concern. Maintain focus and use your team’s roles efficiently.
What to Say When the Outcome is Uncertain
When prognosis is unclear, express empathy without making promises. Say, “We’re doing everything we can to help” and describe steps being taken. Document conversations clearly and prepare hospital staff with key family concerns or dynamics during handoff.
Transport Decision-Making for Pediatric Patients
Criteria for ALS Transport vs BLS or Refusal
Any child receiving ALS interventions—medications, oxygen, IV/IO fluids—must be transported via ALS unit. Minor complaints in stable children may qualify for BLS or refusal with caregiver agreement, but local protocols should guide decisions. Document clearly and involve medical control when uncertain.
Partnering with Flight or Specialty Teams for Critical Peds
Critical pediatric patients requiring ventilators or pressors may need transfer to pediatric ICUs. In rural or prolonged transport settings, air medical services can offer advanced capabilities. Stabilize the child before transfer and maintain clear communication with flight crews during handoff.
Pediatric-Safe Restraint Systems and Safety Checks
Use approved child restraint systems when available. Never transport infants or toddlers unrestrained or held by a caregiver. Verify proper strap placement and vehicle anchoring. Ensure that oxygen lines, monitors, and IV tubing allow for safe transport without tangling.
Documentation Tips for Complex Pediatric Transports
Capture timelines of all interventions, patient responses, and caregiver statements. Include estimated weight, drug doses, equipment sizes, and any challenges encountered. Note transport time, unit crew, and any radio consults performed during the call.
Key Equipment and Medication Considerations
Pediatric Drug Bags: What Every Paramedic Should Know
Drug bags should include weight-based pre-drawn medications or clearly labeled vials with pediatric concentrations. Recheck expiration dates often and restock after each use. Color-coded systems reduce error risk but require training to use effectively.
Monitor Leads, BP Cuffs, and Airway Gear for Smaller Patients
Stock multiple sizes of BP cuffs, SpO₂ sensors, and ECG electrodes. Mismatched equipment yields unreliable readings. Test airway devices (NPAs, OPAs, masks, tubes) regularly to ensure proper fit and seal for pediatric patients.
Avoiding Common Errors in Sizing and Setup
One common error is using adult-sized BVMs or ET tubes in smaller children. Always verify size and depth with current weight references. Pre-measure suction catheter length and confirm ventilator settings are pediatric-safe.
Cross-Checking Doses with Protocols Under Pressure
In high-stress pediatric scenes, always cross-check medications with a second provider or validated dosing app. Avoid verbal-only verification. Pause briefly to ensure that route, dose, and concentration match protocol expectations.
Clinical Readiness Starts in Training
Why Sim Lab Pediatric Scenarios Are Not Optional
Low call frequency makes pediatric scenarios essential during training. Sim labs allow paramedics to practice rare but high-impact skills—like infant IO access or respiratory failure management—without real-time pressure.
Crosswalk to PALS and National Registry Expectations
Paramedic students should know how pediatric protocols align with PALS algorithms and National Registry scenarios. These frameworks provide consistent benchmarks for airway, rhythm, and shock management. Practicing within these structures enhances test performance and field confidence.
Partner Drills and Case Study Learning
Review real pediatric cases in team settings. Assign roles and walk through timeline critiques. Identify missed cues or documentation gaps and use peer feedback to improve future readiness.
Review of Common Missed ALS Steps in Pediatric Calls
Frequent errors include delayed glucose checks, over-ventilation during BVM, and underdosing of medications. Use after-action reviews to catch and address these trends. Include pediatric-specific metrics in your department’s QA/QI process.
What Comes Next in Pediatric EMS Research
Pediatric Protocol Variability and Push for National Standards
Protocols for pediatric ALS vary across states and agencies. This lack of standardization increases error risk. National initiatives now aim to unify pediatric protocols for better training and safer care delivery.
Integration of Real-Time Weight-Based Decision Aids
Emerging tools include electronic apps that integrate real-time patient age and weight with dosing, equipment sizes, and drug sequences. These reduce calculation errors and speed up decision-making during pediatric resuscitations.
Ongoing Pediatric Data Collection and Its Impact on ALS Training
Data from pediatric EMS registries help identify gaps in care and drive updates to field protocols. Case audits also inform curriculum improvements and preceptor focus areas during paramedic clinicals.
How Simulation Tech is Improving Pediatric ALS Competency
High-fidelity manikins now replicate pediatric vital signs, seizure activity, airway resistance, and even emotional cues. Simulation centers use these tools to sharpen ALS skills, improve crew communication, and reduce scene-time delays.
Making Every Call Count: Final Perspective
The Weight of Pediatric Calls on Paramedics
Each pediatric emergency challenges your technical skill, emotional control, and clinical judgment. These cases leave lasting impressions. Whether the outcome is positive or tragic, your preparation makes a difference.
Review and CQI: Learning from the Hardest Runs
Use every pediatric run to improve. Document meticulously, debrief with your team, and seek out CQI feedback. These habits turn anxiety into mastery.
Mentorship and Mental Health for ALS Providers
Pediatric cases can weigh heavily on providers. Don’t carry that burden alone. Peer support, structured debriefs, and mentorship programs offer space to reflect and grow.
Commitment to Excellence in Pediatric Prehospital Care
Mastery in pediatric ALS comes from repetition, education, and humility. Each call is an opportunity to refine your craft and advocate for the most vulnerable patients in the EMS system.
Frequently Asked Questions
What’s the best way to estimate pediatric weight in emergencies?
Most agencies use the Broselow tape or Handtevy app, which estimate weight based on height or age. These tools help quickly determine equipment sizes and drug dosages when scales aren’t available. Mental formulas like (age × 2) + 10 offer fast, backup approximations.
Can intranasal meds replace IVs for seizures in kids?
Yes, intranasal benzodiazepines like midazolam are often used when IV access is delayed or difficult. They provide fast absorption and are effective in terminating seizures. This route is especially helpful in younger, combative patients where IVs are not feasible.
When is an IO preferred over an IV in pediatric shock?
IO access is preferred when IV attempts fail or time is critical, especially in unstable patients. It’s fast, reliable, and allows for the delivery of fluids and medications. EMS protocols often recommend IO placement after two failed IV attempts or if perfusion is rapidly declining.
Do all pediatric seizures need transport if they resolve quickly?
Not all resolved seizures require ALS transport, but most systems recommend hospital evaluation. Febrile seizures in known patterns may qualify for BLS transport or even refusal with medical control input. Still, documentation and caregiver education are essential.
What safety checks should be done when transporting children?
Verify that restraints are age-appropriate and securely fastened. Ensure oxygen lines, monitors, and IV lines are safely positioned and free from entanglement. Double-check medication administration, vital signs, and transport destination readiness before departure.