EMSC Connects

January 2026; Volume 15, Issue 1

Utah Emergency Medical Services for Children

Pedi Points

Tia Dickson RN, BSN

PCH Trauma RN, Utah EMSC Nurse Clinical Consultant

Most kids have healthy hearts, which means true cardiac emergencies are uncommon, but when they happen, they often look different than adult cases. Those healthy hearts can compensate for a long time, hiding trouble until things change fast, but they also make assessment and treatment more straightforward when you know what to look for. Today we break down pediatric cardiac emergencies.

The Doc Spot

Pediatric Cardiac Emergencies

Matthew Steimle, DO

Pediatric Emergency Ultrasound Director Division of Pediatric Emergency Medicine

ED Attending, Primary Children’s Hospital

Excerpts from the December 8th, 2025 PETOS

In his PETOS presentation Dr. Steimle teaches providers how to recognize and manage acute pediatric cardiac emergencies such as abnormal heart rhythms, chest pain, myocarditis, syncope, BRUE, and blunt chest trauma. It focuses on using history, exam, ECG findings, and red flags to identify life-threatening conditions, stabilize the patient, and decide when rapid escalation or cardiology involvement is needed. He uses practical cases to support quick decision-making and does not include congenital heart disease, only acquired or sudden cardiac problems.

The BRUE

BRUE is a brief, frightening event in an infant under 1 year old that has completely resolved and has no clear cause after evaluation. The infant must be well appearing with normal vital signs. EMS should not diagnose BRUE—this is a physician diagnosis made after medical evaluation. EMS’s role is to recognize a possible BRUE, rule out immediate life threats, and transport for further assessment. If the infant has fever, abnormal vitals, breathing difficulty, or an identifiable cause (such as choking, reflux, or illness), it is not a BRUE.

EMS Risk Awareness (Low-Risk Features)

A child may be considered lower risk if all of the following are true:

• Born ≥32 weeks gestation and corrected age ≥45 weeks

• No CPR by a trained medical provider

• Event lasted <1 minute

• First event

If any criteria are missing, treat the infant as higher risk.

EMS Evaluation & Management Algorithm

1. Initial Assessment

   • ABCs, pulse oximetry, glucose if indicated

   • Confirm infant is well appearing

2. Focused History & Exam

   • Caregiver description of the event

   • Birth history, prior events, feeding, illness, trauma

3. Management (Possible Low-Risk BRUE)

   • Supportive care only

   • Brief monitoring with pulse oximetry

   • Transport for physician evaluation

4. Caregiver Education

   • Reassure but explain need for medical evaluation

   • Encourage infant CPR training resources

What EMS Should Not Do

• Do not label or diagnose BRUE in the field

• No aggressive interventions in a stable, well-appearing infant

• No medications, labs, imaging, or home monitoring decisions

Key EMS Pearl: If the infant looks sick, has abnormal vital signs, or you can explain the event, it’s not BRUE—treat the underlying problem and escalate care.

Tachyarrhythmias – Fast Rates

Key EMS Pearl: In pediatric tachyarrhythmias, stability drives treatment—treat the patient, not the monitor. If the rhythm is fast, wide, and unstable, act fast and act decisively.

Bradyarrythmia – Slow Rates

Common Causes & Risk Factors

• Extrinsic causes (most common): hypoxia, medications (beta blockers, calcium channel blockers, opioids, clonidine), hypothermia, increased ICP, increased vagal tone, sleep

• Intrinsic cardiac causes: sinus node dysfunction, AV block, myocarditis, post-surgical injury, inherited arrhythmia syndromes (long QT, Brugada)

• Normal finding: asymptomatic sinus bradycardia in healthy children

  • HR may be low during sleep and still be normal

EMS Evaluation & Management Algorithm

1. Immediate Assessment

• Assess airway, breathing, circulation

• Check perfusion, mental status, and blood pressure

• Attach monitor/ECG

2. Symptomatic Bradycardia
(signs of shock, hypotension, AMS, seizures, poor feeding)

• Ensure oxygenation and ventilation

• Begin CPR if HR <60 with poor perfusion

• Epinephrine first-line medication

• Atropine if vagal cause or AV block suspected

• Prepare for transcutaneous pacing if unresponsive

3. Asymptomatic Bradycardia

• Supportive care only

• Monitor and transport

Key EMS Pearl: In pediatric bradycardia, the problem is usually oxygenation or perfusion—fix the airway and breathing first, then treat the heart rate if the child remains unstable.

Pediatric Chest Pain

Assessment

• History + physical exam usually enough

• A normal ECG is reassuring for a non cardiac cause

• Look for red flags:

  • Collapse/syncope

  • Pain with activity

  • Known heart disease

  • Abnormal vitals

Management

• Most children do not need emergency treatment

• Reassure child & parents

• Monitor for red flags (collapse, pain with activity, abnormal vitals)

• If parents concerned → refer to PCP/cardiology

Key Point: Most pediatric chest pain is not dangerous; reassurance is the main treatment.

What It Is

• Myocarditis = inflammation of the heart muscle

• Can range from mild/subclinical to severe heart failure, arrhythmias, or sudden death

When to Suspect

• Signs of heart dysfunction:

  • Trouble breathing or respiratory distress

  • Rapid or irregular heartbeats

  • Low blood pressure or shock

• Lab/diagnostic clues (usually in hospital):

  • Elevated troponin (heart injury)

  • ECG changes (arrhythmias or heart injury)

  • Echocardiogram shows weak heart function

Other Findings

• Chest X-ray may show (half of patients may have normal X-rays):

  • Enlarged heart (cardiomegaly)

  • Pulmonary congestion

  • Sometimes pleural effusions

EMS Management

• Recognize red flags early:

  • Respiratory distress

  • Poor perfusion or shock

  • Arrhythmias

• Provide supportive care:

  • Oxygen if needed

  • IV access for fluids carefully (avoid fluid overload if heart failure suspected)

  • Cardiac monitoring if available

• Rapid transport to ED for further evaluation

• Reassure family, but emphasize seriousness if signs of heart dysfunction present

Syncope (Fainting)

Pediatric syncope is a brief loss of consciousness that usually resolves on its own and is often benign. Common causes include vasovagal episodes, breath-holding spells, low blood pressure, or low blood sugar, but serious causes like arrhythmias, structural heart disease, drug or electrolyte issues, and rarely anaphylaxis must be considered.

EMS care focuses on ensuring safety, placing the child supine with legs elevated if tolerated, providing oxygen and cardiac monitoring as needed, checking vitals and glucose, and rapidly transporting any child with abnormal findings or persistent symptoms, while reassuring the child and family when the episode appears benign.

Summary

Pediatric cardiac emergencies are rare but high risk. Early recognition is critical. Focus on high-quality CPR, early defibrillation when indicated, and good airway and oxygen management. Use age-appropriate equipment and correct dosing. Preparation, practice, and teamwork make the difference when a child’s life is on the line.

Protocols in Practice

Deep Dive

CME credit for this issue

News from National EMSC

A 2nd Recall of Broselow Tapes produced by AirLife Medical

A third error was recently found in addition to the previous Broselow tape recall regarding Ketamine dosage. Please see the attached notice here for the latest information.

• Flumazenil as 0.1 mg/kg instead of the correct 0.01 mg/kg dose.

• Vecuronium as 0.1 mg/ml instead of the correct 0.1 mg/kg dose.

• Ketamine (IV/IO for pain/analgesia)

  • The tape lists IV/IO ketamine for pain/analgesia is1mg/kg, whereas the appropriate pediatric analgesic (sub-dissociative) dose is 0.1 mg/kg.

  • The represents a 10-fold overdose and may result in a dissociative sedation dose being administered when only analgesia was intended.

• Organizations using this tape should immediately:

  • Check their supplies.

  • Put safety measures in place.

  • Educate staff about the error.

For more information, reach out to  AirLife Customer Service at 1-800-433-2797 or productquality@myairlife.com

EMSC Pulse

National EMSC has a newsletter filled with fantastic pediatric information, resources, and links. Check it out!

News from Utah EMSC

PECARN News: A New Era in Caring for Febrile Newborns: What the This Study Means for You

A major international study has just reshaped what we know about the evaluation of fever in infants in the first month of life. For decades, clinicians have been taught that all febrile infants younger than 28 days old require an automatic lumbar puncture (LP)—an invasive test done to rule out bacterial meningitis. Families find this test frightening and stressful,

A newly published pooled analysis from six countries, building on findings from the PECARN research network, provides strong evidence that a substantial group of these infants can now be safely identified as low risk for life-threatening infections using only three laboratory tests—urinalysis, procalcitonin, and absolute neutrophil count, without the lumbar puncture.

Why This Study Matters

• Febrile infants can look well even when they are harboring bacterial infections. Historically, the fear of missing bacterial meningitis led to routine performance of lumbar punctures.

• This new study, including 1537 infants ≤28 days old, shows that the updated PECARN febrile infant rule identified which infants are at low risk for invasive bacterial illnesses with no missed cases of bacterial meningitis.

• This means clinicians can have safer, more informed discussions with families about whether a lumbar puncture is truly necessary.

Key Takeaways for Practice

• Fever in the first month of life is still an emergency. Immediate medical evaluation remains critical.

• This research does not change EMS protocols but empowers systems to share updated science with local hospitals, urgent care clinics, and all physicians who care for young infants.

• The study helps hospitals safely reduce unnecessary lumbar punctures—an important step toward family-centered care.

• Policy makers / international guideline committees such as AAP and NICE in the UK

Why Families Will Hear About This

Parents frequently ask, “Does my baby really need a spinal tap?” With this new evidence, clinicians now have data to guide shared decision-making, particularly for infants in the third and fourth weeks of life, who represented most of the study population.

What’s Changing Nationally?

Professional guidelines have not yet been updated, but the article’s authors emphasize that for the new data should be incorporated into guidelines like those of the American Academy of Pediatrics (AAP) to re-evaluate recommendations in light of new high-quality evidence.

Bottom Line for EMSC

This is a major shift in the conversation about fever in the first month of life. The updated PECARN febrile infant rule offers clinicians and families a safer, evidence-based way to identify which young infants may avoid lumbar punctures—without compromising safety or missing bacterial meningitis, the infection we fear most.

EMSC teams can help families and care partners understand: “Fever in a young infant is serious, but our tools for evaluating it are getting better—and safer.”

PECC development

For Utah Hospital and EMS Agency PECCs

Pediatric Readiness Guidelines for a NEW National Assessment Webinar

Feb. 12, 12-1 pm MST

In collaboration with the Federal EMSC Program, experts from the leading organizations involved in emergency care for children will soon release an updated 2026 joint policy statement, “Pediatric Readiness in the Emergency Department.” These guidelines are the basis for the next National Pediatric Readiness Project (NPRP) Nationwide Assessment for emergency departments (EDs), launching in March 2026.

NPRP Co-leads, Dr. Marianne Gausche-Hill, Dr. Kate Remick, and Dr. Hilary Hewes will provide information about the life-saving potential and low cost of Pediatric Readiness, what’s new in the guidelines, and provide insights to help you prepare for the 2026 NPRP Assessment. ED clinicians–including nurses, physicians, and administrators–are encouraged to participate.

Register Here

Understanding the PECC role

For hospital PECCs

• EMSC has launched its first pediatric emergency care coordinator (PECC) learning module for ED-based PECCs. You are invited to view the module and provide feedback.

For EMS PECCs

• EMS PECC resources can be found on the EIIC website here.

PECC quarterly meeting

You will receive an invitation with the link through email. If you are a PECC and don’t receive this invitation, contact our program manager, Jared Wright jaredwright@utah.gov.

When?

Tuesday, February 17th,  2026, 10:00 AM

Pediatric education from Utah EMSC

Pediatric Emergency and Trauma Outreach Series (PETOS)

PETOS (pediatric emergency and trauma outreach series)

We’re thrilled to announce that our PETOS lecture series is now eligible for both RN and EMS CME credit!

CME certificates are now digital and available instantly through CloudCME, where you can also access your transcript anytime.

The lectures are presented by physicians and pediatric experts from Primary Children’s Hospital. The format is informal; inviting questions and discussion.

Upcoming topics

Jan 12th, 2026 – Seantae Jackson – A Patient Perspective

Feb 9th, 2026 – Laurie Merrick RN, BSN – Hypothermia

Mar 9th, 2026 – Kris Campbell MD – Child Maltreatment

02:00 PM Mountain Time (US and Canada)

Join Zoom Meeting
https://zoom.us/j/98193757707?pwd=UzdNeXppQUdtZ01KZUp2UFlzRk9vdz09
Meeting ID: 981 9375 7707

Password: EmscPCH

Archived presentations can be viewed and also qualify for CME credits. You can access them at https://intermountainhealthcare.org/for-professionals/PETOS.

To obtain a completion certificate—follow the instructions on the website

Emergency Pediatric Course – NAEMT

Need a Pediatric Education Course for Recertification?

Contact Jared Wright at Jared.wright@utah.gov

Other pediatric education for all

Current Concepts in Neonatal and Pediatric Transport

Overview – Feb 18-20, 2026

The transport of a critically ill neonate or child poses unique challenges and risks to both patient and provider. Patients are subject to risk from infectious diseases, injuries, adverse responses, and complications as a result of treatment or simply due to the transport itself. Providers, too, can find themselves challenged and affected by the transport environment emotionally, physically, and/or mentally. This two-day course will provide thoughtful analysis and evidence-based management of many patient- and provider-related facets of neonatal and pediatric transport.

Register Here

St. George Autism Awareness Training

University of Utah Pediatrics ECHO 2026

University of Utah Injury Prevention Learning Series

These offerings are quarterly.

Register here.

To view previous sessions for all these series visit this link.

Note the University has a new EMS education website.

Pediatric Injury Prevention Resources

EMS-focused education

University of Utah’s EMS Trauma Grand Rounds

Offered every second Wednesday of even months at 2:00pm.

Click here to join

Virtual—zoom meeting

Meeting ID: 938 0162 7994 Passcode: 561313

To view archives link here https://admin.physicians.utah.edu/trauma-education/ems-grand-rounds.

The University has a new EMS education website.

Hospital-focused pediatric education

Primary Children’s Pediatric Grand Rounds

Offered every Thursday, September-May (currently on hiatus, archives available)

Offering both RN and MD CME

The pediatric grand rounds weekly lecture series covers cutting-edge research and practical clinical applications, for hospital and community-based pediatricians, registered nurses, and other physicians and practitioners who care for children of any age.

Every Thursday, 8 a.m. to 9 a.m. from September through May in the 3rd Floor Auditorium at Primary Children’s Hospital and at Lehi a broadcast will be held in the education center (1st floor in rooms 1 & 2).The lectures are also broadcast live to locations throughout Utah and nationwide. Click on this link to view the broadcast: https://www.youtube.com/channel/UCNQP-M_3-PdPDvnICr2Fjpg 

Connect live

Click here for the PGR PCH YouTube channel to find the live broadcast. Archives (without continuing education credit) will be posted here within 1 week of the broadcast.

Need follow up from PCH?