OB / Pediatrics

• Pre-eclampsia: hypertension ≥140/90 after 20 weeks' gestation
• Severe headache (frontal; may be described as "the worst")
• Visual disturbances: blurred vision, photophobia, scotomas ("seeing spots")
• RUQ/epigastric pain (hepatic capsule distension)
• Significant edema, especially hands and face
• Eclampsia = pre-eclampsia + grand mal seizure

vs. Gestational hypertension: Gestational hypertension is elevated BP alone after 20 weeks without proteinuria or end-organ signs. Pre-eclampsia adds headache, visual changes, RUQ pain, or elevated liver enzymes — indicating end-organ involvement. Eclampsia is pre-eclampsia that has progressed to seizure.

Eclamptic seizure in a patient with known pre-eclampsia = obstetric emergency. Transport immediately in left lateral recumbent position. Magnesium sulfate is definitive treatment (hospital). In the field: protect from injury, O2, transport — do not delay for seizure medication.

• Abruption: PAINFUL dark red vaginal bleeding
• Abruption: rigid, board-like, tender uterus
• Abruption: may have concealed hemorrhage (no visible bleeding despite significant loss)
• Previa: PAINLESS bright red vaginal bleeding
• Previa: soft, non-tender uterus
• Both: fetal distress signs (abnormal fetal heart rate if monitored)

Pain is the key differentiator. Abruption = painful + rigid abdomen + dark blood (premature placental separation). Previa = painless + soft uterus + bright red blood (placenta overlying cervical os). This differential is a classic NREMT question. Abruption often has concealed blood and a worse hemodynamic picture than the visible bleeding suggests.

NEVER perform a vaginal exam in suspected placenta previa — digital examination can catastrophically increase bleeding. For both: left lateral recumbent position, O2, IV access, rapid transport. Maternal hemorrhagic shock directly threatens fetal survival.

• Croup (6 mo–3 yr): seal-bark cough, inspiratory stridor, low-grade fever, gradual onset, child can lie flat
• Epiglottitis (2–7 yr, or adults): high fever, drooling, muffled "hot potato" voice, tripod position, absent cough, rapid onset
• Bronchiolitis (infant <2 yr): wheezing, tachypnea, retractions, low-grade fever, RSV season (fall–winter), wet or crackly sounds
• All: tachypnea, accessory muscle use, nasal flaring
• Epiglottitis: patient looks toxic, anxious, refuses to swallow
• Bronchiolitis: often preceded by upper respiratory infection symptoms

Croup vs. Epiglottitis: Croup has the bark cough and the child can lie flat. Epiglottitis has drooling, tripod position, and NO cough — and the child insists on sitting upright. Critical rule: do NOT examine the throat in suspected epiglottitis — agitation or instrumentation can precipitate complete airway obstruction.

Epiglottitis with complete airway obstruction is immediately fatal. Keep the child calm and in the position of comfort (tripod/sitting). Do not agitate, do not attempt laryngoscopy unless arrest is occurring. BVM ventilation may be possible — prepare for surgical airway as last resort.

• Tachycardia is the earliest and most sensitive sign of shock in pediatric patients
• Sunken fontanelle (infants), sunken eyes, dry mucous membranes
• Decreased skin turgor (tented skin)
• Capillary refill >2 seconds (peripheral vasoconstriction)
• Decreased urine output (no wet diapers in infant)
• Late signs: hypotension, mottled skin, altered mental status — indicates decompensated shock

vs. Septic shock in children: Presentation is nearly identical — both require aggressive fluid resuscitation (20 mL/kg NS bolus). Fever + suspected source = septic shock. Vomiting/diarrhea history = hypovolemic. Hypotension in a child is a late sign — do not wait for it to call this shock.

Children compensate better than adults — then decompensate suddenly and dramatically. Hypotension in a pediatric patient means decompensated shock is already present. Treat aggressively: 20 mL/kg isotonic fluid bolus, reassess, repeat as needed. Vascular access priority: IO if IV fails after 2 attempts.

• Infant <1 year found unresponsive, apneic, and pulseless
• Typically discovered in sleep environment (crib, bed, co-sleeping surface)
• No resuscitative opportunity — found in cardiac arrest
• Livor mortis (lividity) or rigor mortis may be present
• No evidence of trauma, choking, or obvious cause of death
• Risk factors: prone sleep position, soft bedding, maternal smoking, prematurity

vs. Non-accidental trauma (NAT): SIDS has no external trauma, no bruising, and no explanation inconsistent with the history. NAT may present with bruising in protected areas (buttocks, torso, behind ears), retinal hemorrhage, inconsistent or changing parental history, or injury patterns inconsistent with the infant's developmental stage. Document scene findings thoroughly — this may be a crime scene.

Approach the family with profound compassion — this is the worst moment of their lives. Do not imply fault or guilt in your questioning. Simultaneously: document the scene exactly (sleep surface, position, items in crib, witnesses), as this scene has medical-legal significance regardless of cause. Never remove the infant from the position found without documenting first.