Pediatric Emergencies — Part 5: Common Surgical Emergencies, Trauma & Neonatal Emergencies

1. Intussusception

Intussusception is the most common cause of intestinal obstruction in children aged 3 months to 6 years, with a peak incidence at 5-10 months. It occurs when a proximal segment of bowel (intussusceptum) telescopes into an adjacent distal segment (intussuscipiens), most commonly at the ileocolic junction. The majority of cases in children are idiopathic, thought to be triggered by hypertrophied Peyer patches following viral illness. A pathologic lead point (Meckel diverticulum, polyp, lymphoma, duplication cyst) is more likely in children <3 months or >5 years.¹

1.1 Clinical Presentation

Classic triad (present in <50% of cases):

Additional findings:

• Palpable sausage-shaped mass in right upper quadrant or epigastrium (present in 60% when carefully examined)
• Empty right lower quadrant (Dance sign)
• Lethargy (may be the sole presenting complaint in 10% — can mimic sepsis or meningitis)
• Altered mental status without other obvious cause in an infant should raise suspicion for intussusception

1.2 Diagnostic Imaging

1.3 Management

2. Pyloric Stenosis

Hypertrophic pyloric stenosis (HPS) is the most common surgical cause of vomiting in infants, typically presenting between 2-8 weeks of age (peak 3-5 weeks). It results from hypertrophy and hyperplasia of the pyloric muscle, causing progressive gastric outlet obstruction. Male infants are affected 4-5 times more frequently than females, with firstborn males at highest risk.²

2.1 Clinical Presentation

2.2 Metabolic Derangement

The hallmark metabolic abnormality is hypochloremic, hypokalemic metabolic alkalosis caused by loss of gastric HCl:

2.3 Diagnostic Criteria (Ultrasound)

Ultrasound is the imaging modality of choice (sensitivity >95%, specificity ~100%):

2.4 Management

Key point: pyloric stenosis is a medical emergency (dehydration, electrolyte imbalance) but a surgical semi-urgency — the metabolic derangement must be corrected before anesthesia (alkalosis causes respiratory depression, hypokalemia causes arrhythmias)²

3. Testicular Torsion

Testicular torsion is a urologic emergency caused by twisting of the spermatic cord, leading to ischemia and potential infarction of the testicle. It has a bimodal age distribution: neonatal period and pubertal age (12-18 years). Timely diagnosis and surgical intervention are critical — testicular salvage rates decline sharply with increasing time from symptom onset.³

3.1 Clinical Features

3.2 Time to Intervention and Salvage Rates

3.3 Management

Key point: testicular torsion is a clinical diagnosis — no imaging study should delay surgical exploration when clinical suspicion is high. The goal is time from symptom onset to detorsion <6 hours.³

4. Pediatric Trauma

Trauma is the leading cause of death in children over 1 year of age. Pediatric trauma evaluation follows the same ABCDE primary survey framework as adults, with critical pediatric-specific modifications. Key differences include proportionally larger head size, more compliant (elastic) skeleton with increased risk of internal injury without fractures, and greater body surface area-to-mass ratio increasing hypothermia risk.^{4 5}

4.1 PECARN Head CT Decision Rule

The Pediatric Emergency Care Applied Research Network (PECARN) head injury prediction rule is the largest and most well-validated clinical decision rule for identifying children at very low risk for clinically-important traumatic brain injury (ciTBI), defined as TBI causing death, neurosurgery, intubation >24 hours, or hospital admission ≥2 nights. It was derived and validated in a cohort of over 42,000 children. Application of this rule can safely reduce unnecessary CT scans by 25-30% and their associated radiation exposure.⁴

Children <2 Years of Age

                    GCS ≤14, or palpable skull fracture,
                    or altered mental status?
                           /            \
                         YES             NO
                          |               |
                    → CT recommended    Are ANY of the following present?
                      (ciTBI risk       • Occipital, parietal, or temporal
                       4.4%)              scalp hematoma
                                        • Loss of consciousness ≥5 seconds
                                        • Severe mechanism of injury*
                                        • Not acting normally per parent
                                              /              \
                                           YES               NO
                                            |                 |
                                    → CT vs observation    → CT NOT
                                      (ciTBI risk 0.9%)     recommended
                                      Observation            (ciTBI risk
                                      preferred if:          <0.02%)
                                      • Age ≥3 months
                                      • Isolated finding
                                      • Mild symptoms
                                      • Improving
                                      • Reliable follow-up

Children ≥2 Years of Age

                    GCS ≤14, or signs of basilar skull fracture,
                    or altered mental status?
                           /            \
                         YES             NO
                          |               |
                    → CT recommended    Are ANY of the following present?
                      (ciTBI risk       • Loss of consciousness
                       4.3%)            • Vomiting
                                        • Severe mechanism of injury*
                                        • Severe headache
                                              /              \
                                           YES               NO
                                            |                 |
                                    → CT vs observation    → CT NOT
                                      (ciTBI risk 0.8%)     recommended
                                      Observation            (ciTBI risk
                                      preferred if:          <0.05%)
                                      • Isolated finding
                                      • Mild symptoms
                                      • Improving
                                      • Reliable follow-up

*Severe mechanism of injury:

• Motor vehicle crash with patient ejection, rollover, or death of another passenger
• Pedestrian or bicycle rider struck by motor vehicle without helmet
• Fall >3 feet (children <2 years) or >5 feet (children ≥2 years)
• Head struck by a high-impact object

4.2 PECARN Abdominal Trauma Rule

The PECARN abdominal trauma prediction rule identifies children at very low risk for intra-abdominal injury requiring acute intervention (IAI-I), reducing unnecessary CT scans in pediatric blunt abdominal trauma.⁵

Very low risk (CT not recommended) if ALL of the following are absent:

If ALL seven factors are absent: risk of IAI-I is <0.1% — CT can be safely deferred.

If ANY factor is present: clinical judgment regarding CT; further risk stratification based on number and severity of findings.

4.3 Solid Organ Injury: Non-Operative Management

Non-operative management (NOM) is the standard of care for hemodynamically stable children with blunt splenic and hepatic injuries, with success rates exceeding 90-95% for all grades of injury. This represents a major paradigm shift from historical practice and is more aggressively applied in children than adults.⁶

Spleen Injury Grading and Management

Liver Injury Management

• Similar NOM principles apply; success rate >90%
• ICU monitoring duration and activity restriction generally parallel spleen injury guidelines by grade
• Indications for operative intervention: hemodynamic instability despite resuscitation (>40 mL/kg crystalloid + blood), peritonitis, hollow viscus injury, transfusion requirement >40 mL/kg pRBCs in 24 hours
• Angioembolization: increasingly used for active extravasation on CT (blush) in stable or transiently responding patients, as an alternative to operative management

4.4 Pediatric Trauma: Key Differences from Adults

5. Non-Accidental Trauma (Child Abuse)

Child abuse is a leading cause of injury-related death in children under 5 years of age. Emergency physicians have a legal and ethical obligation to identify and report suspected abuse. Failure to recognize abuse at the sentinel event leads to recurrent abuse in 35-50% of cases, with a mortality rate of approximately 10% on re-injury.⁷

5.1 Sentinel Injuries

Sentinel injuries are seemingly minor injuries (bruises, intraoral injuries) that precede more severe abusive injuries. Recognition of sentinel injuries is critical for early intervention.

5.2 Fractures Suspicious for Abuse

5.3 Screening Protocol

5.4 Mandatory Reporting

• All healthcare providers are mandated reporters in all 50 US states and most countries
• Report to child protective services (CPS) and/or law enforcement when there is reasonable suspicion of abuse — proof is NOT required
• Document findings meticulously: use body diagrams, photograph injuries with scale marker, record history from caregiver and child (separately when possible) using direct quotes
• Do not discharge the child to the suspected abuser; ensure safe disposition through CPS involvement
• If the child requires hospitalization for medical reasons, this provides a safe environment while the investigation proceeds⁷

6. Neonatal Emergencies

6.1 Neonatal Hypoglycemia

Neonatal hypoglycemia is one of the most common metabolic problems in newborns. Risk factors include maternal diabetes (infant of diabetic mother, IDM), small for gestational age (SGA), large for gestational age (LGA), prematurity, perinatal stress, and inborn errors of metabolism.⁸

6.2 Congenital Heart Disease (Duct-Dependent Lesions)

Critical congenital heart disease (CHD) presents in the neonatal period, often when the ductus arteriosus begins to close (typically within the first 24-72 hours but may be delayed to 1-2 weeks of life). Prostaglandin E1 (PGE1, alprostadil) maintains ductal patency and is the critical bridge to definitive surgical intervention.⁹

Duct-Dependent Lesions

PGE1 (Alprostadil) Protocol

Hyperoxia Test

6.3 Neonatal Hyperbilirubinemia

Neonatal jaundice affects 60% of term and 80% of preterm newborns. While usually benign (physiologic jaundice), severe unconjugated hyperbilirubinemia can cause acute bilirubin encephalopathy (kernicterus) with devastating neurologic consequences. Risk-based management using the Bhutani nomogram guides phototherapy and exchange transfusion thresholds.¹⁰

Risk Factors for Severe Hyperbilirubinemia

Phototherapy and Exchange Transfusion Thresholds

Thresholds are based on gestational age, postnatal age (hours), and risk factors. The following are approximate values for term infants (≥38 weeks) — use nomograms for precise management.¹⁰

Lower thresholds apply for:

• Premature infants (35-37+6 weeks: subtract ~2 mg/dL; <35 weeks: use gestational age-specific charts)
• Infants with neurotoxicity risk factors (isoimmune hemolytic disease, G6PD deficiency, asphyxia, significant lethargy, temperature instability, sepsis, acidosis, albumin <3 g/dL)

Acute Bilirubin Encephalopathy — Warning Signs

Emergency management: intensive phototherapy (irradiance ≥30 mcW/cm²/nm) with preparation for double-volume exchange transfusion (160-180 mL/kg) if TSB is at or near exchange transfusion threshold or if signs of acute bilirubin encephalopathy are present

7. Pediatric Medication Dosing Quick Reference Table

The following table provides a comprehensive quick-reference for commonly used medications in pediatric emergencies, with weight-based dosing, routes, and maximum doses.¹¹