Simulation is becoming a standard assessment modality in pediatric emergency medicine, but its use for high-stakes assessment has not been well described. We aimed to explore literature pertinent to the use of simulation for high-stakes assessment and describe applicable assessment instruments. In this article, we describe potential means by which simulation can be used in a high-stakes manner, along with future developments in assessment methodology for pediatric emergency medicine. A wide array of potentially useful simulation-based assessment instruments exists, although further validity evidence will be needed for their use to be recommended in most cases. Although many simulation-based assessment modalities exist, the evidence is limited for the majority of them. Care must be taken when choosing an appropriate instrument.