Pregnancy creates two patients and dramatically changes maternal physiology. Blood volume +40–50%, HR +10–20 bpm, mild respiratory alkalosis is normal. Understand these changes to avoid critical errors.
Cardiovascular Changes
| PARAMETER | CHANGE | CLINICAL IMPACT |
|---|---|---|
| Blood volume | +40–50% by term | Can lose significant blood before showing shock signs |
| Cardiac output | +30–50% | Higher baseline demands throughout pregnancy |
| Heart rate | +10–20 bpm above baseline | Mild tachycardia is normal — do not dismiss it |
| Blood pressure | Decreases slightly 2nd trimester; returns 3rd | BP ≥140/90 after 20 weeks = hypertensive disorder |
| Aortocaval compression | Uterus compresses IVC when supine after ~20 wks | Left lateral tilt or manual uterine displacement mandatory |
| Coagulation | Hypercoagulable state | Higher PE risk; protective against PPH |
Respiratory Changes
- Diaphragm elevated by growing uterus → decreased FRC (less air reserve)
- Increased tidal volume and minute ventilation → mild respiratory alkalosis is normal
- Increased O₂ consumption → maternal desaturation occurs faster than non-pregnant adult
- Airway edema (especially in preeclampsia/eclampsia) → difficult intubation risk; always expect a harder airway
Fundal Height Quick Reference
| FUNDAL HEIGHT | GESTATIONAL AGE | CLINICAL NOTE |
|---|---|---|
| Just above symphysis pubis | 12–16 weeks | Early pregnancy — fetal viability very limited |
| At the umbilicus | ~20 weeks | Midpoint — fetal viability begins ~22–24 wks |
| Between umbilicus and xiphoid | ~28–32 weeks | Preterm — needs NICU if delivered |
| Near xiphoid process | ~36–40 weeks | Viable and likely resuscitable neonate if delivered |
OB History — GTPAL
| TERM | MEANING |
|---|---|
| G — Gravida | Total pregnancies (including current) |
| T — Term births | Deliveries at ≥37 weeks |
| P — Preterm births | Deliveries 20–36 weeks |
| A — Abortions/miscarriages | Losses before 20 weeks (spontaneous or induced) |
| L — Living children | Number of currently living children |
Assess for crowning, urge to push, contractions <2 min apart — if any present, prepare to deliver on scene. Know the 12 delivery steps and the 4 stages of labor cold.
Deliver Here or Transport?
| DELIVER NOW ON SCENE | TRANSPORT FIRST |
|---|---|
| Crowning — presenting part visible at introitus | No signs of imminent delivery |
| Uncontrollable urge to push / bear down | Time allows safe transport |
| Perineal bulging with contractions | First-time mother with early contractions |
| "I have to poop" — rectal pressure | Breech presentation without crowning |
| Contractions < 2 min apart, lasting >60 sec | Complications requiring hospital (previa, abruption) |
| Multipara with rapid progression | Preterm <36 wks without crowning — transport preferred |
Normal Delivery Steps — First to Last
- 1Set upPPE (gloves, gown, eye protection); OB kit; warm environment; towels/blankets; bulb syringe; clamps ×2; scissors; infant BVM
- 2Position motherSupine with knees flexed/feet flat, or left lateral if preferred; pillow/towels under buttocks
- 3Coach breathingCalm, controlled pushing with contractions; panting between to prevent explosive delivery
- 4Support perineumDominant hand on head; gentle counter-pressure — control the speed; DO NOT PULL
- 5Check nuchal cordIf loose → slip over head; if tight → double clamp 5 cm apart, cut between clamps
- 6SuctionMouth then nose ONLY if copious secretions or visible obstruction — not routine
- 7ShouldersAnterior shoulder: gentle downward traction; posterior: upward guidance — do NOT forcefully pull
- 8Body deliveryDelivers rapidly after shoulders — support infant at all times; note time of delivery
- 9Clamp cord5–8 cm from infant, second clamp 2 cm further, cut between; delayed clamping 1–3 min if vigorous
- 10Assess newbornWarm, dry, stimulate — begin Apgar/NRP as needed (see Neonatal Resuscitation card)
- 11Third stageWait for placental separation: cord lengthens, uterus rises/firms, gush of blood — DO NOT pull cord
- 12Post-deliveryFundal massage; assess maternal vitals; watch for hemorrhage
NEVER pull on the umbilical cord to hasten placental delivery — causes uterine inversion
Stages of Labor
| STAGE | DEFINITION | DURATION | PREHOSPITAL NOTE |
|---|---|---|---|
| Stage 1 — Latent | Regular contractions → 6 cm dilation | Hours to days | Transport — not imminent unless multipara with rapid progression |
| Stage 1 — Active | 6 cm → 10 cm dilation | 1–4 hours | Monitor; reassess frequently; prepare for imminent delivery |
| Stage 1 — Transition | 8–10 cm; intense contractions | Minutes to 1 hour | Imminent delivery — prepare OB kit NOW |
| Stage 2 | Full dilation → delivery of infant | Minutes to 2+ hours | Deliver on scene or in ambulance |
| Stage 3 | Delivery of placenta | Up to 30 min | Do not delay transport waiting; may deliver en route |
| Stage 4 | First 1–4 hours postpartum | 1–4 hours | Monitor: hemorrhage, shock, seizure, respiratory distress |
BP ≥140/90 after 20 weeks + proteinuria or end-organ signs = preeclampsia. Add seizures = eclampsia. Only cure is delivery. Magnesium sulfate is first-line for seizure prevention and treatment.
Classification
| CONDITION | BP THRESHOLD | KEY FINDINGS |
|---|---|---|
| Gestational HTN | ≥140/90, no proteinuria | BP only; watch for progression |
| Preeclampsia | ≥140/90 + proteinuria or end-organ signs | Triad: hypertension + edema (hands/face) + hyperreflexia; headache, visual changes |
| Severe Preeclampsia | ≥160/110 or end-organ damage (HELLP, renal, CNS) | Severe HA, visual disturbances, epigastric/RUQ pain, pulmonary edema |
| Eclampsia | Preeclampsia + seizures | Grand mal seizure in pregnant or recently postpartum patient |
| HELLP | Hemolysis + Elevated LFTs + Low Platelets | RUQ/epigastric pain, nausea, malaise; life-threatening |
Prehospital Treatment — First to Last
- 1PositionLeft lateral recumbent — reduces aortocaval compression AND aspiration risk
- 2Oxygenation & accessHigh-flow O₂; IV access ×2; continuous monitoring (SpO₂, cardiac, BP)
- 3Airway protectionSeizing or about to seize: position, suction, BVM if apneic
- 4Magnesium sulfatePer protocol: 4–6 g IV loading dose over 15–20 min — prevents AND treats seizures
- 5Active seizureBenzodiazepine per protocol if Mg unavailable or seizing despite Mg
- 6Severe HTNBP ≥160/110: antihypertensive per protocol (hydralazine or labetalol IV)
- 7TransportRapid transport to facility with OB AND NICU capability; early notification
MgSO₄ TOXICITY: Monitor for respiratory depression, loss of deep tendon reflexes, lethargy. Antidote = Calcium gluconate 1 g IV
EXAM TRAP: Eclampsia seizures can occur WITHOUT markedly elevated BP — treat any seizure in a pregnant or recently postpartum patient as eclampsia until proven otherwise
Previa = painless bright red bleeding (placenta over cervical os). Abruption = painful, dark bleeding with rigid uterus. NEVER perform a vaginal exam in either case.
Side-by-Side Comparison
| FEATURE | PLACENTA PREVIA | PLACENTAL ABRUPTION |
|---|---|---|
| Bleeding | Painless, bright red, sudden onset | Painful, dark bleeding — OR concealed (no external blood) |
| Pain | PAINLESS — classic distinguishing feature | Painful — board-hard, tender uterus |
| Uterus | Soft, non-tender | Rigid, tender, "board-hard" — uterine hypertonicity |
| Fetal heart tones | May be normal initially | Often distressed — bradycardia or absent |
| Risk factors | Prior C-section, multiple gestation, advanced maternal age | Maternal HTN, cocaine use, trauma, smoking, prior abruption |
| Treatment | O₂; IV ×2; treat shock; rapid transport | O₂; IV ×2; aggressive shock management; transport |
| KEY RULE | NO vaginal exam — ever | Anticipate DIC with severe abruption; concealed hemorrhage often massive |
NEVER perform a vaginal exam in a patient with vaginal bleeding in pregnancy — can convert partial to complete previa and trigger catastrophic hemorrhage
Cord prolapse: manually elevate the presenting part off the cord and maintain that pressure all the way to the hospital. Shoulder dystocia: McRoberts first, then suprapubic pressure — never fundal pressure.
CORD PROLAPSE IS TIME-CRITICAL: Every minute of compression = fetal hypoxia and brain damage
Cord Prolapse — Management in Order
- 1PositionKnee-chest OR Trendelenburg/hips elevated — gravity takes presenting part off cord
- 2Oxygen100% O₂ to maximize fetal oxygenation
- 3Breathing instructionInstruct mother to pant with contractions — prevents bearing down and cord compression
- 4Manual elevationGloved hand in vagina: elevate the presenting part off the cord — maintain this pressure continuously during entire transport
- 5Cover exposed cordWarm saline-moistened sterile dressings — DO NOT handle cord directly (causes vasospasm)
- 6DO NOT replace cordLeave it — maintain presenting part elevation only
- 7TransportLights and sirens; constant manual elevation until hospital staff takes over
NEVER apply fundal pressure in shoulder dystocia — pushes shoulder further into pubic symphysis
Shoulder Dystocia — Maneuvers in Order
- 1RecognitionTurtle sign: head delivers then retracts back against perineum — call for help immediately; note the time
- 2McRoberts ManeuverHyperflex mother's thighs against abdomen (knee-to-chest) — flattens lumbar lordosis, opens pelvic outlet; most effective first step
- 3Suprapubic pressureFirm downward pressure just above symphysis pubis directed toward fetal face — displaces shoulder
- 4Rubin II / posterior armIf above fails: posterior pressure on anterior shoulder; or attempt delivery of posterior arm
- 5Gaskin maneuverRoll mother to hands-and-knees position — changes pelvic dimensions
Breech: allow passive delivery, Mauriceau maneuver for head. PPH: bimanual massage, oxytocin, treat the cause (4 T's). Uterine inversion: do NOT remove placenta, do NOT give oxytocin until uterus replaced.
Breech Presentation
| TYPE | DESCRIPTION | RISK |
|---|---|---|
| Frank breech | Hips flexed, knees extended — feet near head | Most common; best outcome if must deliver |
| Complete breech | Hips and knees flexed — sitting cross-legged | Manageable |
| Footling breech | One or both feet present first | Most dangerous — cord compression risk |
Breech Field Management
- 1If NOT crowning: transport immediately — do NOT attempt vaginal delivery
- 2If delivering: allow passive delivery of buttocks and legs — do NOT pull
- 3Support infant's body with warm towel; allow to hang briefly by gravity to help head align
- 4If head does not deliver: Mauriceau-Smellie-Veit maneuver (finger in mouth for gentle jaw traction + head flexion)
- 5After delivery: immediate NRP assessment — breech infants often need resuscitation
PPH — The 4 T's
| CAUSE (4 T's) | MECHANISM | CLUE | FIELD ACTION |
|---|---|---|---|
| Tone (70–80%) | Uterine atony — uterus fails to contract | Soft, "boggy" uterus | Bimanual uterine massage; oxytocin per protocol |
| Trauma (20%) | Lacerations, hematomas, uterine rupture | Bleeding despite firm uterus; visible tears | Direct pressure on external tears; treat shock; transport |
| Tissue (10%) | Retained placenta fragments | Atony that doesn't respond to massage | Do NOT attempt manual removal; transport |
| Thrombin (<1%) | Coagulopathy (DIC) | Bleeding that won't clot; oozing from IV sites | Aggressive resuscitation; blood products in-hospital |
SOFT BOGGY UTERUS = uterine atony = PPH. Fundal massage is first-line treatment
Uterine Inversion
- Sudden severe pain + rapid hemorrhage + shock immediately after delivery
- Mass visible or palpable at vaginal introitus (pink/red tissue); fundus cannot be palpated abdominally
- DO NOT remove the placenta if still attached — removing worsens hemorrhage
- Withhold oxytocin until uterus is replaced — oxytocin contracts the inverted uterus, preventing repositioning
- Cover protruding tissue with warm saline-moistened sterile dressings
- O₂; two IVs; aggressive fluid resuscitation; rapid transport with early notification
Start CPR immediately. Add Left Uterine Displacement (LUD). IV access above diaphragm only. If no ROSC within 4–5 minutes, perimortem C-section improves both maternal and fetal survival.
OB-Specific CPR Modifications
- Left Uterine Displacement (LUD): manual displacement of uterus to left during all CPR to relieve aortocaval compression — do not reduce compression quality
- Airway: higher intubation failure rate in pregnancy — have surgical airway available
- IV access: above the diaphragm ONLY — IVC compression prevents lower extremity IVs from working effectively
- Defibrillation: same energy as non-pregnant; remove fetal monitors before shock
- Perimortem C-section within 4–5 min of arrest if no ROSC — improves maternal AND fetal survival (uterus decompresses IVC)
Reversible Causes to Treat
| CAUSE | ACTION |
|---|---|
| Pulmonary embolism | Consider thrombolytics per protocol |
| Hemorrhage / PPH | Aggressive resuscitation; bimanual massage; oxytocin |
| Magnesium toxicity | Calcium gluconate 1 g IV immediately |
| Eclampsia | Benzodiazepine; MgSO₄ |
| Hypoxia | Aggressive airway management; 100% O₂ |
| Aortocaval compression | LUD throughout; consider perimortem C-section |
🔴 Never Compromise CPR
Maintain full rate (100–120) and depth (2+ inches)
DO NOT reduce quality due to pregnancy
Assign one provider ONLY to LUD
Transport immediately — do not stay on scene
✅ OB-Specific Add-Ons
LUD: continuous throughout arrest
IV access: antecubital or above
Intubation: prepare for difficult airway
Notify hospital: OB team + OR for perimortem C-section
10% of newborns need assistance; 1% need intensive resuscitation. The Golden Minute: warm, dry, stimulate → assess HR → if <100 or apneic → PPV immediately. HR is the primary indicator of effective ventilation.
Initial Assessment — 3 Questions at Birth
| QUESTION | IF YES | IF NO |
|---|---|---|
| 1. Term gestation (≥37 weeks)? | Continue to question 2 | Assume needs resuscitation → initial steps |
| 2. Good muscle tone? | Continue to question 3 | Proceed to initial steps immediately |
| 3. Breathing or crying? | Routine care: warm, dry, skin-to-skin | Proceed to initial resuscitation immediately |
NRP Algorithm — Golden 60 Seconds
- 10–30 seconds: Initial StepsWarm; dry; stimulate; position airway (neutral sniffing); suction only if needed
- 230 seconds: Assess HRAuscultate or use pulse ox — assess HR and breathing quality
- 3HR ≥100 + breathing = routine careMonitor SpO₂; keep warm; skin-to-skin if vigorous
- 4HR <100 OR apneic/gaspingSTART PPV IMMEDIATELY at 40–60 breaths/min
- 560 seconds: Reassess after 30 sec PPVRising HR = effective PPV; plateau or <60 = escalate
- 6HR <60 after effective PPVAdd chest compressions (3:1 ratio) + increase O₂ to 100%
- 7HR <60 after 60 sec compressions + PPVEpinephrine: 0.01–0.03 mg/kg IV (umbilical) or IO; 0.05–0.1 mg/kg ETT
PPV Parameters
| PARAMETER | TARGET / TECHNIQUE |
|---|---|
| Rate | 40–60 breaths/min ("breathe-two-three, breathe-two-three") |
| FiO₂ — Term (≥36 wks) | Start at 21% (room air) — increase if HR not improving |
| FiO₂ — Preterm (<36 wks) | Start at 21–30% — titrate to SpO₂ targets |
| Chest rise | Visible gentle chest rise — if not rising → MRSOPA |
| Primary indicator | HR is the primary indicator of effective ventilation — rising HR = effective PPV |
MRSOPA — Ventilation Correction Steps (if PPV not working)
| STEP | ACTION |
|---|---|
| M — Mask adjustment | Reapply mask to ensure complete seal over mouth and nose |
| R — Reposition airway | Neutral sniffing position; slight neck extension; shoulder roll |
| S — Suction | Clear any secretions blocking airway |
| O — Open mouth | Gently open mouth; ensure not breathing with mouth closed |
| P — Pressure increase | Gradually increase inflation pressure 5 cmH₂O at a time |
| A — Airway (advanced) | Consider LMA or endotracheal intubation if above fails |
Apgar Score
| SIGN | 0 | 1 | 2 |
|---|---|---|---|
| A — Appearance (color) | Blue/pale all over | Pink body, blue extremities | Pink all over |
| P — Pulse (HR) | Absent | < 100 bpm | ≥ 100 bpm |
| G — Grimace | No response | Grimace only | Cry, cough, or sneeze |
| A — Activity (tone) | Limp/flaccid | Some flexion | Active motion, good flexion |
| R — Respiration | Absent | Weak, irregular, gasping | Strong cry, regular |
| SCORE | INTERPRETATION | ACTION |
|---|---|---|
| 7–10 | Normal — good transition | Routine care; keep warm |
| 4–6 | Moderate depression | Stimulate; O₂; PPV if not responding |
| 0–3 | Severe depression | Immediate resuscitation: PPV → compressions → medications |
APGAR EXAM TRAP: Apgar scores do NOT dictate resuscitation — resuscitate based on HR and breathing assessment, not the Apgar score
Meconium & Hypothermia
- Meconium — CURRENT approach: If infant is VIGOROUS (good tone, HR >100, breathing) → NO routine intubation/suctioning. If NOT vigorous → intubate and suction trachea before stimulation.
- Evaporation is the greatest heat loss — DRY immediately and completely; replace ALL wet towels
- Premature infants (<32 wks): place in plastic bag BEFORE drying — do NOT dry first
- Hypothermia <36°C: harder to resuscitate, increased apnea, metabolic acidosis, hypoglycemia
Children are not small adults. Know normal vitals by age, use the PAT as a 30-second hands-off general impression, and TICLS to systematically assess appearance. Hypotension is a LATE sign.
Vital Signs by Age — Memorize This Table
| AGE GROUP | HEART RATE | SYSTOLIC BP | RESP RATE | CLINICAL NOTE |
|---|---|---|---|---|
| Newborn (0–1 mo) | 100–180 | 50–70 mmHg | 30–60 | Bradycardia = hypoxia first — check HR by auscultation |
| Infant (1–12 mo) | 100–160 | 70–90 mmHg | 25–50 | Diaphragm-breathers; any accessory use is abnormal |
| Toddler (1–3 yr) | 90–150 | 80–100 mmHg | 20–40 | Croup peak age; foreign body aspiration common |
| Preschool (4–5 yr) | 80–120 | 80–100 mmHg | 20–30 | Epiglottitis more common; more cooperative |
| School Age (6–12 yr) | 70–120 | 80–110 mmHg | 15–25 | Adult-like compensatory mechanisms developing |
| Adolescent (13–17 yr) | 60–100 | 90–120 mmHg | 12–20 | Near adult physiology; hypotension is a late sign |
HYPOTENSION IS A LATE SIGN IN CHILDREN: They compensate extremely well — then decompensate suddenly. Tachycardia + delayed cap refill = shock even with normal BP
Minimum Systolic BP & Weight Formulas
- Infants (1–12 months): minimum SBP = 70 mmHg
- Children 1–10 years: minimum SBP = 70 + (age × 2) mmHg
- Children >10 years: 90 mmHg (adult threshold)
- Weight 1–10 years: (age × 2) + 10 kg
- Broselow tape = gold standard for weight estimation in prehospital
Pediatric Assessment Triangle (PAT)
| SIDE | WHAT YOU ASSESS | ABNORMAL = THINK |
|---|---|---|
| APPEARANCE | Mental status & CNS perfusion (TICLS) | Hypoxia, shock, CNS problem, metabolic disorder |
| WORK OF BREATHING | Respiratory effort (retractions, nasal flaring, sounds) | Respiratory distress → failure → arrest |
| CIRCULATION TO SKIN | Peripheral perfusion (color, cap refill, mottling, cyanosis) | Circulatory failure: shock, sepsis, trauma, cardiac |
PAT Pattern Interpretation
| PAT PATTERN | CATEGORY | PRIORITY |
|---|---|---|
| Appearance normal, WOB ↑, Circulation normal | Respiratory DISTRESS (compensated) | O₂; bronchodilators if wheeze; monitor |
| Appearance ↓, WOB ↑, Circulation normal | Respiratory FAILURE (decompensating) | Immediate O₂ + BVM PPV |
| Appearance ↓, WOB normal, Circulation ↓ | SHOCK (compensated or decompensated) | IV/IO; fluids; treat cause |
| Appearance ↓, WOB normal, Circulation normal | CNS/Metabolic disorder | Glucose check; neuro assessment; ALS |
| ALL THREE ABNORMAL | Cardiopulmonary FAILURE | Immediate full resuscitation |
TICLS — Appearance Assessment
| TICLS | NORMAL | ABNORMAL |
|---|---|---|
| T — Tone | Active movement, resists exam, good tone | Flaccid, limp — serious illness, shock, hypoxia |
| I — Interactivity | Eye contact, interested in environment, tracks | Unresponsive to environment, fixed gaze |
| C — Consolability | Calmed by parent within seconds | Inconsolable OR paradoxically quiet/limp |
| L — Look/Gaze | Tracks provider, normal pupils, appropriate gaze | Glazed, vacant, sunken, abnormal gaze |
| S — Speech/Cry | Normal cry for age; appropriate words | Weak/high-pitched cry; muffled voice; hoarse |
Respiratory failure is the most common cause of pediatric cardiac arrest. Distress → failure → arrest if not intervened. Croup = barking cough + low-grade fever. Epiglottitis = 4 Ds + high fever — NEVER use tongue depressor.
Distress vs. Failure vs. Arrest
| STAGE | KEY SIGNS | IMMEDIATE ACTION |
|---|---|---|
| DISTRESS (Compensated) | Tachypnea, retractions, nasal flaring, SpO₂ 90–94% | High-flow O₂; keep calm; bronchodilators if wheeze; position of comfort |
| FAILURE (Decompensating) | Head bobbing, see-saw breathing, AMS, SpO₂ <90% despite O₂ | O₂ + immediate PPV (BVM); advanced airway if not improving |
| ARREST | Apnea or agonal breathing, absent pulse | CPR; advanced airway; treat cause |
Upper Airway Conditions
| CONDITION | AGE | KEY SIGNS | DO THIS | NEVER DO THIS |
|---|---|---|---|---|
| Croup | 6 mo–3 yr | Barking "seal-like" cough; inspiratory stridor; low-grade fever | Keep calm; blow-by O₂; upright; racemic epi if severe | Agitate; force mask; tongue depressor |
| Epiglottitis | 2–7 yr (any age) | 4 Ds: Drooling, Dysphagia, Dysphonia, Distress; tripod; HIGH fever | Calm; blow-by O₂ ONLY; prepare surgical airway; RAPID transport | TONGUE DEPRESSOR; OPA; agitate; IV access first |
| Bacterial Tracheitis | 3 mo–3 yr | Barking cough + HIGH fever + stridor NOT responding to epi | O₂; prepare for difficult intubation; transport | Expect epi to work |
| Foreign Body (complete) | Any (peak 1–3 yr) | Silent, cyanotic, unable to cry/cough | <1 yr: back blows + chest thrusts; >1 yr: abdominal thrusts; Magill if visible | Blind finger sweep; abdominal thrusts <1 yr |
EPIGLOTTITIS vs CROUP EXAM TRAP: Epiglottitis = sudden onset, HIGH fever, drooling, NO cough, tripod position. Croup = gradual, LOW-grade fever, BARKING cough, stridor.
Lower Airway Conditions
| CONDITION | AGE | KEY SIGNS | TREATMENT |
|---|---|---|---|
| Asthma (Severe) | Any (school age most common) | Wheeze (ABSENT in severe = "silent chest"); prolonged expiration; accessory muscle use | O₂; albuterol MDI/neb weight-based; ipratropium; Mg sulfate if refractory; BVM if failing |
| Bronchiolitis (RSV) | <2 yr (peak 3–6 mo) | Wheeze + crackles; nasal congestion; preceding viral URI | Supportive: O₂, positioning, suctioning; PPV if severe |
| Pertussis | Infants especially | Paroxysmal cough ending in inspiratory "whoop"; post-tussive emesis | O₂; minimize stimulation; transport; may need PPV |
Pediatric arrest is almost always ASPHYXIAL — oxygenation and ventilation are the most important interventions. Bradycardia = hypoxia first — oxygenate before atropine. Hypotension is a LATE sign of shock.
Pediatric arrest is almost always ASPHYXIAL (hypoxia/respiratory failure) — oxygenation and ventilation are the most important interventions. NOT epinephrine first.
Pediatric CPR Standards
| PARAMETER | INFANT (<1 YR) | CHILD (1 YR – PUBERTY) |
|---|---|---|
| Compression technique | Two-thumb encircling (2 rescuers) OR 2-finger (1 rescuer) | One or two hands based on child size |
| Compression depth | 1.5 inches (4 cm) or 1/3 AP diameter | 2 inches (5 cm) or 1/3 AP diameter |
| Rate | 100–120 per minute | 100–120 per minute |
| Ratio | 30:2 (1 rescuer), 15:2 (2 rescuers) | 30:2 (1 rescuer), 15:2 (2 rescuers) |
| Defibrillation (VF/pVT) | 2 J/kg initial; 4 J/kg subsequent | 2 J/kg initial; 4 J/kg subsequent (max 10 J/kg) |
Arrest Medications
| DRUG | DOSE | NOTES |
|---|---|---|
| Epinephrine | 0.01 mg/kg IV/IO q3–5 min (1:10,000) | Same all rhythms; max 1 mg; use Broselow |
| Amiodarone (refractory VF/pVT) | 5 mg/kg IV/IO; max 300 mg | After 2nd defib; may repeat to 15 mg/kg total |
| Lidocaine (alternative) | 1 mg/kg IV/IO | Alternative to amiodarone per protocol |
| Atropine | 0.02 mg/kg IV/IO; min 0.1 mg; max 0.5 mg child | After oxygenation/ventilation fails; min 0.1 mg critical |
| Dextrose D10W | 2 mL/kg IV/IO | Check glucose in ALL pediatric arrest |
| Adenosine (SVT) | 0.1 mg/kg rapid IVP (max 6 mg); 0.2 mg/kg 2nd dose | Rapid bolus + flush; same technique as adult |
Pediatric Shock — Recognition & Treatment
| SHOCK TYPE | CLUES | FLUID | OTHER |
|---|---|---|---|
| Hypovolemic (most common) | Trauma/vomiting/hemorrhage; tachycardia; delayed cap refill | 20 mL/kg NS/LR; reassess; repeat ×2–3 | Stop hemorrhage; keep warm; IO if IV failed |
| Septic | Fever or hypothermia; tachycardia; vasodilation | 20 mL/kg; repeat aggressively up to 60 mL/kg | O₂; antibiotics IV ASAP; petechial rash = emergency |
| Anaphylactic | Hives, angioedema, wheeze, stridor, hypotension | Fluids after epi | IM epinephrine 1:1000 FIRST (0.01 mg/kg, max 0.5 mg) |
| Cardiogenic | Heart failure signs; hepatomegaly; gallop rhythm | CAUTIOUS 5–10 mL/kg only | Inotrope; pediatric cardiac center |
| Tension PTX | Resp distress + absent breath sounds + tracheal deviation | N/A — decompress first | Needle decompression 2nd ICS MCL; do not delay |
Check glucose in every seizing or altered pediatric patient. Status epilepticus = seizure >5 min → midazolam IM/IN/IV. AEIOU-TIPS for AMS. Febrile neonate (<28 days) with any fever = sepsis until proven otherwise.
Seizures — Common Causes by Age
| CAUSE | AGE | CLUE |
|---|---|---|
| Febrile seizure (most common) | 6 mo–5 yr | Rapid temp rise; seizure + fever; no prior seizure history |
| Hypoglycemia | Any (infants especially) | Check glucose in EVERY seizing child immediately |
| Epilepsy / Known disorder | Any | History; may have breakthrough despite medication |
| Meningitis/Encephalitis | Any | Fever + AMS + photophobia + nuchal rigidity |
| Toxic ingestion | Toddlers / Teens | Unexplained seizure; look for pill bottles, access to meds |
| Head trauma | Any | NEVER assume febrile seizure with trauma mechanism |
Status Epilepticus — Treatment in Order
- 1AirwayPosition airway; suction; O₂ via NRB; BVM if apneic
- 2Check glucoseIf <60 mg/dL → D10W 2 mL/kg IV — do this before other interventions
- 3IV/IO accessEstablish as quickly as possible
- 4Benzodiazepine (first-line)Midazolam 0.1–0.2 mg/kg IM/IV/IN (max 10 mg) — IM or IN preferred if no IV access
- 5Second doseRepeat benzo once if seizure does not stop within 5 minutes
- 6RefractoryLevetiracetam, fosphenytoin, phenobarbital per protocol
- 7TransportAll peds seizures requiring field treatment need hospital evaluation
DO NOT give dextrose without checking glucose first — routine dextrose is not recommended
Pediatric AMS — AEIOU-TIPS
| LETTER | CAUSE | KEY CLUE |
|---|---|---|
| A — Alcohol/Toxins | Ingestion (intentional or accidental) | Odor, pill bottles, pupil abnormalities |
| E — Epilepsy/Electrolytes | Post-ictal, glucose/sodium/calcium disorders | Recent seizure; IV fluid history |
| I — Insulin/Hypoglycemia | Most common REVERSIBLE cause | CHECK GLUCOSE FIRST; diaphoresis, tremors |
| O — Overdose/Opioid | Accidental ingestion (toddlers) or teen abuse | Pinpoint pupils, respiratory depression, bradycardia |
| U — Uremia/Metabolic | Renal failure, DKA, hepatic encephalopathy | Fruity breath (DKA), dialysis patient |
| T — Trauma | Head injury, intracranial hemorrhage, abuse | Mechanism; check for non-accidental trauma |
| I — Infection | Meningitis, encephalitis, sepsis | Fever, nuchal rigidity, petechiae |
| P — Psychiatric | Diagnosis of exclusion | Rule out organic causes first |
| S — Stroke/Structural/Shunt | Stroke, space-occupying lesion, VP shunt malfunction | Focal deficits; known shunt patient with HA/vomiting |
GLUCOSE FIRST: In ANY pediatric AMS, check blood glucose before other interventions — hypoglycemia is the most common reversible cause
Pediatric Fever Thresholds
| AGE | FEVER THRESHOLD | CLINICAL CONCERN |
|---|---|---|
| Neonate (<28 days) | Any temp ≥38.0°C (100.4°F) | HIGH RISK — sepsis until proven otherwise; no tolerance for "wait and see" |
| Infant (1–3 months) | ≥38.0°C (100.4°F) | High risk; neonatal pathogens still possible |
| 3 months–2 years | ≥38.0°C (100.4°F) | Febrile seizure peak age; watch for toxic appearance |
| >2 years | ≥38.5°C (101.3°F) | Most viral; escalate if toxic appearing |
Child Abuse — Red Flags
- Mechanism inconsistent with stated history or developmental ability
- Multiple injuries in different stages of healing
- Delay in seeking care or frequent ED visits for vague complaints
- Injuries in unusual locations: torso, back, buttocks, face in non-mobile child
- Burns with sharp demarcation lines (immersion burns)
- Document all findings and exact quotes — do NOT confront caregiver; treat injuries; transport
All pediatric drug doses are weight-based. Use Broselow tape or weight formula first. Never skip glucose check. Atropine minimum dose is 0.1 mg — below this causes paradoxical bradycardia.
All doses are weight-based. Always use Broselow tape or formula to estimate weight before dosing. Minimum atropine dose = 0.1 mg (less causes paradoxical bradycardia)
Weight-Based Drug Reference
| DRUG | INDICATION | DOSE | NOTES |
|---|---|---|---|
| Epinephrine 1:1000 IM | Anaphylaxis | 0.01 mg/kg IM (max 0.5 mg) | Anterolateral thigh; repeat q5–15 min; NEVER delay for IV |
| Epinephrine 1:10,000 IV/IO | Cardiac arrest | 0.01 mg/kg IV/IO q3–5 min | Use Broselow; max 1 mg per dose |
| Atropine | Symptomatic bradycardia after O₂/ventilation | 0.02 mg/kg; min 0.1 mg; max 0.5 mg child / 1 mg adolescent | Min 0.1 mg critical — <0.1 mg causes paradoxical bradycardia |
| Albuterol | Bronchospasm (asthma, anaphylaxis) | 2.5 mg (<20 kg) / 5 mg (≥20 kg) neb; MDI 4–8 puffs | May repeat continuously; add ipratropium if moderate/severe |
| Adenosine | SVT | 0.1 mg/kg rapid IVP (max 6 mg first dose); 0.2 mg/kg second | Rapid bolus + flush; use proximal vein; brief asystole expected |
| Midazolam | Seizures | 0.1–0.2 mg/kg IM/IV/IN (max 10 mg) | IM or IN preferred for rapid access; IN via MAD device |
| Lorazepam | Seizures | 0.1 mg/kg IV/IO (max 4 mg) | Longer duration than midazolam |
| Dextrose D10W | Hypoglycemia | 2 mL/kg IV/IO | D10W in children; D25W if unavailable; dilute D50W 1:1 with NS |
| Naloxone | Opioid reversal | 0.01 mg/kg IV/IO/IM/IN; may use 0.1 mg/kg for full reversal | Titrate to avoid withdrawal; establish ventilation first |
| Normal Saline bolus | Shock/dehydration | 20 mL/kg IV/IO over 5–20 min (faster in septic shock) | Reassess after each; repeat as needed |
| Magnesium Sulfate | Refractory asthma; Torsades | 25–50 mg/kg IV over 15–20 min (max 2 g for asthma) | Monitor for hypotension and respiratory depression |
OB/Peds = 24–30% of NREMT paramedic exam. Top traps: eclampsia without elevated BP, Apgar not guiding resus, fundal pressure in shoulder dystocia, atropine before oxygenation in peds bradycardia.
High-Yield Numbers — Memorize These
| VALUE | MEANING |
|---|---|
| 140/90 mmHg | BP threshold for hypertensive disorders after 20 weeks |
| 160/110 mmHg | Severe preeclampsia — treat HTN aggressively |
| 20 weeks gestation | Threshold for aortocaval compression risk |
| >500 mL blood loss | PPH threshold (vaginal delivery) |
| 4–6 g MgSO₄ over 15–20 min | Eclampsia seizure prophylaxis loading dose |
| Calcium gluconate 1 g IV | Antidote for magnesium toxicity |
| Golden 60 seconds | Time limit to initiate PPV in neonatal resuscitation |
| HR <100 bpm (newborn) | Start PPV (with apnea or gasping) |
| HR <60 bpm (newborn) | Start chest compressions after effective PPV |
| 3:1 | Compression:ventilation ratio for neonatal CPR |
| 40–60 bpm | Neonatal PPV rate |
| 2 J/kg initial / 4 J/kg subsequent | Pediatric defibrillation doses |
| 0.01 mg/kg | Peds epinephrine (IV/IO) — arrest and anaphylaxis |
| 0.02 mg/kg; min 0.1 mg | Peds atropine (minimum dose critical) |
| 20 mL/kg NS bolus | Standard peds fluid resuscitation |
| 70 + (age × 2) | Minimum SBP formula, children 1–10 years |
| ≤2 seconds | Normal capillary refill |
| 5 minutes | Seizure duration = status epilepticus |
| 2 mL/kg D10W | Peds dextrose for hypoglycemia |
| 4–5 minutes | Perimortem C-section window in maternal arrest |
OB Rapid Review
| EMERGENCY | KEY SIGN | FIRST ACTION | DO NOT |
|---|---|---|---|
| Preeclampsia | BP ≥140/90 + edema + hyperreflexia | Left lateral; O₂; IV; prepare for seizure | Delay transport; allow agitation |
| Eclampsia | Seizure + pregnancy/postpartum | Airway; O₂; MgSO₄; lateral position | Neglect airway; forget post-ictal risk |
| Placenta Previa | Painless bright red bleeding | O₂; 2 IVs; treat shock; transport | VAGINAL EXAM — ever |
| Abruption | Painful rigid uterus ± bleeding | O₂; 2 IVs; aggressive shock; transport | Underestimate concealed hemorrhage |
| Cord Prolapse | Cord visible + fetal distress | Manual elevation of presenting part; hips elevated; O₂ | Remove cord; let it compress |
| Shoulder Dystocia | "Turtle sign" after head delivers | McRoberts + suprapubic pressure | Fundal pressure; excessive traction |
| PPH | Boggy uterus + hemorrhage | Bimanual massage; oxytocin; 2 IVs; shock tx | Vaginal packing; ignore uterine tone |
| Uterine Inversion | Tissue at introitus + rapid shock | O₂; 2 IVs; fluid resus; cover; transport | Remove placenta; give oxytocin before replacement |
| Maternal Arrest | Pulseless + pregnant | CPR + LUD; early airway; transport (4–5 min perimortem) | Reduce CPR quality; delay transport |
Pediatric Rapid Review
| EMERGENCY | KEY SIGN | FIRST ACTION | DO NOT |
|---|---|---|---|
| Respiratory Distress | Retractions + tachypnea + normal mentation | O₂; position of comfort; bronchodilators if wheeze | Agitate; force supine |
| Respiratory Failure | AMS + fatigue + SpO₂ <90% | BVM PPV immediately | Wait for intubation to fix oxygenation |
| Croup (severe) | Barking cough + stridor + distress | Keep calm; O₂; racemic epi | Tongue depressor; force mask |
| Epiglottitis | 4 Ds + fever + tripod | Position of comfort; blow-by O₂; transport | TONGUE DEPRESSOR; OPA; agitate |
| Peds Arrest | Pulseless/apneic | BVM + CPR; 2 J/kg VF; epi 0.01 mg/kg | Atropine before oxygenation in bradycardia |
| Peds Shock | Tachy + cap refill >2 sec (BP may be normal) | 20 mL/kg NS; O₂; IO if needed | Wait for hypotension to diagnose shock |
| Status Epilepticus | Seizure >5 min | Airway; glucose check; midazolam IM/IN/IV | Delay glucose; omit airway |
| Peds AMS | Altered LOC any cause | GLUCOSE FIRST; PAT; AEIOU-TIPS | Skip glucose; miss hypoglycemia |
| Child Abuse | Injury inconsistent with story | Document; treat injuries; transport | Confront caregiver; delay treatment |