Paediatric Resuscitation Basics

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Why are we scared of Sick Kids?

Life-threatening presentations, whether it be medical or surgical emergencies, are rare in the paediatric population.  Hardly any doctors see really sick kids everyday.

As a result, inevitably there is a ‘fear factor’ but we need to get over it.

You don’t have the pathology, it is the child in front of you who is sick!

We like to be comfortable and confident so we often wait for someone else to take the reigns. However, it really is our job if we are a true Resuscitation Practitioner.

The adult skill set and training do cross over to Paediatrics.  If we stick to the basics (ABC), share our mental model and resuscitate things will go well.

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How to get ready for a ‘Sick Kid’ coming to the ED?

Preparation – Remember the P.A.E.D.S. mnemonic

  • People, Area, Equipment. Drugs, Send for external help.
  • This is a reasonable approach to the preparation of any sick patient coming to the Emergency Department.  Assessment of the infant or child requires gentle care, good communication with the parents and a thorough examination.


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What about the definitions of different ages?

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How does the overall approach to ALS compare?

There are some differences between the Advanced Life Support (ALS) algorithm.

The main 3 differences to remember are the drugs (doses), ratio of compressions to breaths (15:2) and joules required for defibrillation (4 joules/Kg):

Paediatric ALS

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What does W.E.T.F.L.A.G. stand for?

WETFLAG outlines a widespread basic approach to the sick kid derived from the APLS course.  The purpose of WETFLAG is to work out (quickly) appropriate weight based drugs and equipment for the child you are looking after.

Do NOT calculate doses in your head. Use a computer, calculators or Broselow tape.


  • Weight
    • General Formula
      • Estimated Weight = (Age+4) x 2
    • In ‘larger‘ countries like Australia and USA
    • Broselow Tape
    • Ask Parents the weight of their child
  • Electricity
    • Generally Defibrillation = 4 joules/kg
      • You may need to go higher
      • AEDs can be used for kids


  • Endotracheal Tube Size and Length
    • Size:
      • Birth (at Term) = Size 3.5 (+/-0.5)
      • 1 year approximately size 4.0 tube
      • Beyond 1 year: Use the APLS tube formula: Tube = (Age / 4 + 4) 
    • Length:
      • At birth = 9cm
      • 6 months = 11cm
      • 1 year = 12cm
      • Then later use a formula such as Length = (Age/2 +12)
      • Add 2cm for Nasal
  • Fluid Dosing
    • Boluses are 20ml/Kg of Normal saline

Maintenance fluid is calculated as:

  • 4ml/kg/hour for the first 10kg of weight
  • For the second 11-20kg – an additional 2ml/Kg/hour is added
  • Thereafter, for every kilo over 20kg an extra 1ml/kg/hour is added to the maintenance fluid
  • Lorazepam Dosing
    • Treatment of seizures
      • 1) STOP the seizure
      • 2) Use your local benzodiazepine of choice in moderate doses (e.g. Lorazepam / Midazolam 0.1- 0.2mg/kg IV/IO/IM or 0.3mg/kg buccal)
  • Adrenaline Dosing
    • In Cardiac Arrest 0.1mls/kg of 1:10000 Adrenaline
  • Glucose Dosing
    • Generally use 10% Glucose for hypoglycaemia rather than 50% which is toxic to cute baby veins
    • Dose is 2-2.5ml/kg of 10% Glucose

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What is normal in kids in terms of observations compared with adults?

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What do you do if you cannot get IV access promptly?

If you are unable to obtain IV access after 2 attempts or more than 2 minutes you should place an intraosseous (IO) needle.

Put in an “IO“:


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What is the Paediatric Assessment Triangle?

Consider using the Paediatric Assessment Triangle in the work up of sick small children:

  • Appearance
    • ‘TICLS’Approach
    • Tone Irritability, Consolablity, Look (Gaze), Speech (Cry)
  • Circulation
    • Cap refill, Colour, Mottling, Cyanosis, Pallor
  • Work of Breathing
    • Accessory Muscle Use, Grunting, Nasal Flare, Tripoding, Stridor, Stertor

Paeds assessment

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How should I approach management of the airway? 

We are generally able to intubate most children in the ED without problems.  However, there is a ‘fear factor‘ and some differences to remember in anatomy and physiology which can make the Paediatric airway challenging:


  • Increase in chest wall compliance and reduction in lung compliance due to smaller numbers of alveoli.
  • Reduced ‘Functional Residual Capacity
  • This promotes collapse and lower residual volumes.
  • This combination of factors leads to rapid desaturation.
  • Increased vagal tone makes bradycardia and hypotension common post induction.
  • Cardiovascular stability is dependent on heart rate (LV stroke volume is fixed)


  • Cricothyroidotomy is not indicated in children less than 10
  • The narrowest part of the airway is at the cricoid cartilage in children less than 5 which traditionally has led to ‘uncuffed‘ tubes being used in small children.
  • Having said this, cuffed tubes are probably okay in most children and are increasingly used.
  • Large Occiput, Large Tongue and Large Epiglottis (generally they are nose breathers)
  • Larynx is often ‘Anterior’ –  manual pressure / BURP application / ELM may help

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