Paediatric Advanced Life Support (PALS)

Quick Answer

Critical: Paediatric cardiac arrest requires immediate high-quality CPR with emphasis on oxygenation and ventilation. Survival depends on early recognition of pre-arrest states, rapid initiation of CPR with 5 initial rescue breaths, and prompt identification and treatment of reversible causes.

Paediatric cardiac arrest differs fundamentally from adult arrest. Most paediatric arrests are asphyxial (respiratory in origin), not primary cardiac events. The chain of survival therefore prioritises airway management and oxygenation. ANZCOR Guideline 12 emphasises 5 initial rescue breaths, a 15:2 compression-to-ventilation ratio with two rescuers, and aggressive management of hypoxia. Survival rates are lower than adults for out-of-hospital cardiac arrest (10-30% vs 30-50%), but neurological outcomes in survivors can be good when pre-arrest oxygenation is optimised and early intervention occurs [1,2].

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ACEM Exam Focus

Primary Exam Relevance

Anatomy:

• Paediatric airway anatomy (large occiput, large tongue, anterior/cephalad larynx, narrow cricoid ring)
• Vascular access sites (intraosseous insertion points, femoral anatomy)
• Chest wall compliance and cardiac position relative to sternum
• Age-related changes in respiratory mechanics

Physiology:

• Developmental cardiovascular physiology (cardiac output = HR × SV; HR-dependent in children)
• Oxygen consumption in children (6-8 mL/kg/min vs 3-4 mL/kg/min adults)
• Compensatory mechanisms in shock (tachycardia maintained until late decompensation)
• Cerebral autoregulation and vulnerability to hypoxia

Pharmacology:

• Adrenaline pharmacodynamics (alpha and beta adrenoceptor effects)
• Amiodarone mechanism (class III antiarrhythmic, blocks K+ channels)
• Atropine in bradycardia (antimuscarinic)
• Volume of distribution differences in children affecting drug dosing

Fellowship Exam Relevance

Written Examination:

• ANZCOR Guideline 12 algorithm (must know exactly)
• Weight-based drug dosing calculations
• Equipment sizing formulas
• Reversible causes specific to paediatrics
• Post-resuscitation care targets
• Ethical considerations (cessation of resuscitation, family presence)

OSCE Stations:

• Paediatric resuscitation team leadership (core station)
• Bradycardia with poor perfusion management
• Paediatric defibrillation technique demonstration
• Breaking bad news to parents after paediatric death
• Procedural stations (IO insertion, paediatric intubation)

Key Domains Tested:

• Medical Expert: Algorithm knowledge, drug dosing, equipment selection
• Leader: Team leadership, closed-loop communication, resource allocation
• Communicator: Family presence management, breaking bad news
• Collaborator: Multidisciplinary team coordination

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Key Points

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Definitions and Age Categories

Age Definitions (ANZCOR)

Normal Vital Signs by Age

Weight Estimation

Important Note: Australian Practice Point: The Broselow tape is widely used in Australian EDs but may underestimate weight in Australian children. Use clinical judgement and adjust doses accordingly. When in doubt, use the child's actual weight if available.

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Epidemiology

Incidence and Survival

Aetiology by Age

Primary Causes of Paediatric Cardiac Arrest

Australian/New Zealand Specific Data

• Drowning is a leading cause of paediatric OHCA in Australia (2nd behind trauma) [10]
• Indigenous children have higher rates of OHCA, particularly from respiratory infections and trauma [11]
• Rural/remote areas have delayed EMS response times significantly impacting survival
• Temperature considerations: hypothermia in southern states, hyperthermia in northern regions
• Marine envenomation in coastal areas (box jellyfish, Irukandji) - rare but important

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Indigenous Health Considerations

Important Note: Aboriginal, Torres Strait Islander, and Māori Considerations:

Health Disparities:

• Higher rates of acute respiratory infections requiring hospitalisation
• Increased risk of complications from acute gastroenteritis (dehydration, shock)
• Higher rates of rheumatic heart disease affecting cardiac function
• Higher rates of SUDI in Indigenous infants
• Limited access to paediatric tertiary care in remote communities

Cultural Considerations:

• Extended family (kinship) involvement in decision-making is critical
• Kinship structures may mean non-biological parents are primary carers
• Cultural protocols around children's illness and death must be respected
• Language barriers may exist even with English-speaking families
• Sorry Business protocols if death occurs
• Connection to Country and community is important

Practical Actions:

• Aboriginal Liaison Officers/Māori Health Workers should be notified early
• Interpreter services for language groups
• Extended whānau/family may need to be present and involved
• Cultural protocols for death may include specific practices
• Referral to Indigenous-specific grief support services
• Trauma-informed care approach given historical experiences

New Zealand - Māori Considerations:

• Whānau (extended family) involvement in all decision-making
• Karakia (prayers) may be requested at beginning and end
• Kaumātua (elders) involvement where possible
• Te Whare Tapa Whā model (physical, mental, family, spiritual dimensions)

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Pathophysiology

Why Paediatric Arrests Differ from Adult Arrests

Respiratory Predominance: Children have higher oxygen consumption (6-8 mL/kg/min vs 3-4 mL/kg/min in adults), smaller functional residual capacity, higher airway resistance, and less respiratory reserve. Hypoxia develops rapidly during apnoea - faster than in adults.

Cardiovascular Considerations:

• Cardiac output in children is heart rate dependent (limited ability to increase stroke volume)
• Bradycardia is therefore a pre-terminal sign indicating severe hypoxia or impending arrest
• Children maintain blood pressure until late in shock (compensated → decompensated rapidly)
• Hypotension is a LATE sign - indicates loss of 25-40% blood volume or severe compromise

Progression to Cardiac Arrest

Respiratory Distress → Respiratory Failure → Cardiopulmonary Failure → Cardiac Arrest
         ↓                      ↓                        ↓                    ↓
   Tachypnoea              Hypoxaemia              Bradycardia         Asystole/PEA
   Accessory muscles       Altered consciousness    Hypotension         (VF/pVT rare)
   Nasal flaring           Exhaustion               Poor perfusion
   Grunting                Bradypnoea               Acidosis

Arrest Rhythms in Children

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Recognition of the Deteriorating Child

Pre-Arrest Warning Signs

Paediatric Assessment Triangle (PAT)

Rapid "from the doorway" assessment (10-15 seconds):

Systematic ABCDE Assessment

Airway

Breathing

Circulation

Disability

Exposure

• Full exposure (maintain dignity)
• Core temperature measurement
• Rash assessment (petechiae/purpura = meningococcal)
• Signs of trauma or NAI
• Prevent hypothermia (children lose heat rapidly)

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ANZCOR Guideline 12: Paediatric Advanced Life Support Algorithm

Paediatric Basic Life Support Foundation

┌─────────────────────────────────────────────────────────────────────────────┐
│                              DANGER                                          │
│                    Check for hazards to self and child                       │
└─────────────────────────────────────────────────────────────────────────────┘
                                    ↓
┌─────────────────────────────────────────────────────────────────────────────┐
│                             RESPONSE                                         │
│         Stimulate child - call name, tap shoulders/feet                      │
│         If unresponsive → Send for help (call 000, activate MET)            │
└─────────────────────────────────────────────────────────────────────────────┘
                                    ↓
┌─────────────────────────────────────────────────────────────────────────────┐
│                              AIRWAY                                          │
│              Open airway: head tilt-chin lift                               │
│              Neutral position in infant, slight extension in child          │
│              Remove visible obstruction (only if clearly visible)           │
└─────────────────────────────────────────────────────────────────────────────┘
                                    ↓
┌─────────────────────────────────────────────────────────────────────────────┐
│                    CHECK BREATHING (10 seconds max)                          │
│             Look for chest movement                                          │
│             Listen for breath sounds                                         │
│             Feel for air movement                                            │
│                                                                              │
│     If NOT breathing normally or only gasping → Give 5 RESCUE BREATHS       │
└─────────────────────────────────────────────────────────────────────────────┘
                                    ↓
┌─────────────────────────────────────────────────────────────────────────────┐
│                     5 INITIAL RESCUE BREATHS                                 │
│           Give 5 breaths - each over 1 second with visible chest rise        │
│           Infant: mouth-to-mouth-and-nose or BVM with appropriate mask      │
│           Child: mouth-to-mouth or BVM with appropriate mask                 │
│           If chest not rising: reposition airway, reattempt                 │
└─────────────────────────────────────────────────────────────────────────────┘
                                    ↓
┌─────────────────────────────────────────────────────────────────────────────┐
│                    CHECK FOR SIGNS OF LIFE (10 seconds max)                  │
│         Healthcare providers: Check central pulse                            │
│         - Brachial artery (infant) or Carotid artery (child)                │
│         - Simultaneously assess for movement, coughing, breathing           │
│                                                                              │
│     If no signs of life OR HR below 60/min with poor perfusion → START CPR       │
└─────────────────────────────────────────────────────────────────────────────┘

Paediatric CPR Technique

┌─────────────────────────────────────────────────────────────────────────────┐
│                        PAEDIATRIC CPR                                        │
│                                                                              │
│   COMPRESSION SITE:                                                          │
│   • Infant: Lower third of sternum, just below nipple line                  │
│   • Child: Lower half of sternum, between nipples                           │
│                                                                              │
│   COMPRESSION TECHNIQUE:                                                     │
│   • Infant (2 rescuers): Two-thumb encircling technique (PREFERRED)         │
│     - Both thumbs on sternum, fingers encircle chest supporting back        │
│   • Infant (1 rescuer): Two-finger technique                                │
│     - Two fingers on lower sternum                                          │
│   • Child: One or two hands on lower half of sternum                        │
│     - Heel of hand(s), fingers interlocked or lifted off chest              │
│                                                                              │
│   DEPTH: Compress to 1/3 of anterior-posterior chest diameter               │
│          Infant: approximately 4 cm                                          │
│          Child: approximately 5 cm                                           │
│                                                                              │
│   RATE: 100-120 compressions per minute                                     │
│                                                                              │
│   RATIO:                                                                     │
│   • 15:2 (two healthcare providers) - PREFERRED                             │
│   • 30:2 (single rescuer or lay rescuers)                                   │
│                                                                              │
│   QUALITY:                                                                   │
│   • Allow full chest recoil between compressions                            │
│   • Minimise interruptions (below 10 seconds)                                     │
│   • Rotate compressors every 2 minutes to prevent fatigue                   │
└─────────────────────────────────────────────────────────────────────────────┘

ANZCOR Paediatric ALS Algorithm

                         Attach defibrillator/monitor
                                    ↓
                            ASSESS RHYTHM
                                    ↓
                 ┌──────────────────┴──────────────────┐
                 ↓                                     ↓
┌────────────────────────────┐       ┌────────────────────────────────────────┐
│     SHOCKABLE RHYTHM       │       │        NON-SHOCKABLE RHYTHM            │
│     VF / Pulseless VT      │       │         Asystole / PEA                 │
└────────────────────────────┘       └────────────────────────────────────────┘
          ↓                                          ↓
┌────────────────────────────┐       ┌────────────────────────────────────────┐
│   DEFIBRILLATION           │       │                                        │
│   4 J/kg (ALL shocks)      │       │   Resume CPR immediately               │
│                            │       │   2 minutes (5 cycles of 15:2)         │
│   Resume CPR immediately   │       │                                        │
│   after shock - 2 minutes  │       │   Adrenaline 10 mcg/kg IV/IO           │
│                            │       │   as soon as access obtained           │
│   DO NOT pause to check    │       │   then every 3-5 minutes               │
│   rhythm after shock       │       │                                        │
└────────────────────────────┘       │   Consider and treat reversible causes │
          ↓                          │   (4Hs and 4Ts)                        │
┌────────────────────────────┐       │                                        │
│   DRUG TIMING:             │       │   Consider advanced airway if          │
│                            │       │   trained operator available           │
│   After 2nd shock:         │       │                                        │
│   • Adrenaline 10 mcg/kg   │       └────────────────────────────────────────┘
│                            │                       ↓
│   After 3rd shock:         │       ┌────────────────────────────────────────┐
│   • Amiodarone 5 mg/kg     │       │   After 2 minutes:                     │
│                            │       │   • Reassess rhythm                    │
│   After 5th shock:         │       │   • If still non-shockable: repeat     │
│   • Consider 2nd dose      │       │     adrenaline, continue CPR           │
│     amiodarone 5 mg/kg     │       │   • If becomes shockable: switch       │
│                            │       │     to shockable algorithm             │
│   Adrenaline every 3-5 min │       └────────────────────────────────────────┘
│   thereafter               │
└────────────────────────────┘
          ↓
          └──────────────────┬───────────────────────┘
                             ↓
┌─────────────────────────────────────────────────────────────────────────────┐
│                     DURING CPR - CHECKLIST                                   │
│                                                                              │
│   □ High-quality CPR: correct rate, depth, full recoil, minimise pauses     │
│   □ Obtain vascular access (IO preferred if IV not immediately available)   │
│   □ Confirm weight and calculate drug doses                                  │
│   □ Give adrenaline every 3-5 minutes                                        │
│   □ Consider advanced airway when skilled operator available                 │
│   □ Continuous waveform capnography if intubated (target ETCO₂ greater than 10 mmHg)    │
│   □ Treat reversible causes systematically (4Hs and 4Ts)                    │
│   □ Rotate compressors every 2 minutes                                       │
│   □ Consider family presence with dedicated support person                   │
└─────────────────────────────────────────────────────────────────────────────┘
                             ↓
┌─────────────────────────────────────────────────────────────────────────────┐
│                      RETURN OF SPONTANEOUS CIRCULATION (ROSC)                │
│                                                                              │
│   Signs: Palpable pulse, rise in ETCO₂ (usually greater than 40 mmHg), arterial         │
│          waveform, spontaneous movement, coughing, breathing                │
│                                                                              │
│   → Proceed to POST-RESUSCITATION CARE                                       │
└─────────────────────────────────────────────────────────────────────────────┘

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Compression Techniques by Age

Infant (under 1 year)

Two-Thumb Encircling Technique (PREFERRED for 2 rescuers):

1. Place both thumbs side-by-side on lower third of sternum (just below nipple line)
2. Thumbs may overlap in very small infants
3. Encircle chest with fingers supporting the back
4. Compress with thumbs to 1/3 AP diameter (~4 cm)
5. Rate: 100-120/min
6. This technique generates superior coronary perfusion pressure [12]

Two-Finger Technique (Single rescuer alternative):

1. Place 2 fingers (index and middle) on lower third of sternum
2. One finger-breadth below nipple line
3. Other hand supports head/maintains airway position
4. Compress to 1/3 AP diameter (~4 cm)
5. Rate: 100-120/min

Child (1-8 years)

One-Hand Technique:

1. Heel of one hand on lower half of sternum (between nipples)
2. Lift fingers to avoid compressing ribs
3. Avoid xiphoid process
4. Compress to 1/3 AP diameter (~5 cm)
5. Rate: 100-120/min

Two-Hand Technique (larger children):

1. Heel of one hand on lower half of sternum
2. Second hand on top, fingers interlocked
3. Arms straight, compress vertically
4. Compress to 1/3 AP diameter (~5 cm)
5. Rate: 100-120/min

CPR Quality Metrics

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Vascular Access

Priority Hierarchy (ANZCOR)

Intraosseous Access Sites

Insertion Technique:

1. Identify landmarks, stabilise limb, clean skin
2. Insert needle perpendicular to bone (away from growth plate)
3. Advance with rotating motion until "give" or "pop" felt (cortex penetrated)
4. Remove stylet
5. Aspirate (may not always yield marrow - NOT required for confirmation)
6. Flush with 5-10 mL normal saline - should flow freely without extravasation
7. Secure and commence drug/fluid administration

IO Needle Sizes:

• Manual: 15-18G for all paediatric ages
• EZ-IO powered: Pink needle (3-39 kg), Blue needle (≥40 kg)

Contraindications:

• Fracture in target bone or proximal to site
• Previous IO in same bone within 48 hours
• Infection at insertion site
• Osteogenesis imperfecta or other bone fragility
• Previous orthopaedic hardware at site

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Equipment Sizing

Endotracheal Tube Sizing

Cuffed ETT (now acceptable for ALL ages including neonates):

Uncuffed ETT (traditional):

Important Note: Current ANZCOR Guidance: Cuffed ETT are now acceptable for all ages including neonates. Cuffed tubes may reduce aspiration risk and need for tube exchange. Maintain cuff pressure below 20-25 cmH₂O to avoid mucosal damage.

Insertion Depth (Oral):

Age-Based Equipment Sizing Table

Defibrillator Pad Selection

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Defibrillation

Energy Dosing (ANZCOR)

Key Differences from AHA

Defibrillation Technique

1. Continue CPR while preparing defibrillator
2. Apply pads - select paediatric pads if available and below 10 kg
3. Position pads - anterior-posterior preferred in small children
4. Ensure pads do not touch or overlap
5. Set energy to 4 J/kg (calculate based on weight)
6. Charge while compressions continue
7. Clear check - "I'm clear, you're clear, everyone's clear"

• visual check

8. Deliver shock with minimal hands-off time (below 5 seconds)
9. Immediately resume CPR for 2 minutes - do NOT pause to check rhythm

Defibrillation in Special Circumstances

Hypothermia (core temp below 30°C):

• Give up to 3 shocks if VF persists
• If remains in VF after 3 shocks: withhold further shocks until rewarmed to over 30°C
• Continue CPR and active rewarming
• Resume shocks once core temp over 30°C

Pacemaker/ICD in situ:

• Place pads at least 8 cm from device
• Anterior-posterior placement preferred
• Check device function post-resuscitation

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Medications in Paediatric Cardiac Arrest

Adrenaline (Epinephrine)

Weight-Based Adrenaline Dosing Table

Amiodarone

Weight-Based Amiodarone Dosing Table

Other Medications in Paediatric Resuscitation

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Reversible Causes (4Hs and 4Ts)

Paediatric-Focused 4Hs

Paediatric-Focused 4Ts

Additional Paediatric-Specific Causes

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Bradycardia with Poor Perfusion Algorithm

Recognition

• Heart rate below 60/min with poor perfusion in infant
• Heart rate below 50/min with poor perfusion in child
• AND signs of poor perfusion:
  • Altered consciousness / lethargy
  • Weak or absent peripheral pulses
  • Poor capillary refill (greater than 3 seconds)
  • Mottled skin, pallor

Management Algorithm

┌─────────────────────────────────────────────────────────────────────────────┐
│   BRADYCARDIA WITH PULSE BUT POOR PERFUSION                                 │
│                                                                              │
│   HR below 60 (infant) or below 50 (child) WITH signs of poor perfusion               │
│                                                                              │
│   1. Support ABCs - give oxygen                                              │
│   2. Attach monitor/defibrillator                                            │
│   3. Identify and treat underlying cause (MOST LIKELY HYPOXIA)              │
└─────────────────────────────────────────────────────────────────────────────┘
                                    ↓
┌─────────────────────────────────────────────────────────────────────────────┐
│   DOES BRADYCARDIA PERSIST DESPITE ADEQUATE OXYGENATION/VENTILATION?        │
│                                                                              │
│   If YES and HR below 60/min with poor perfusion despite oxygen/ventilation:     │
│                                                                              │
│   → START CPR                                                                │
│                                                                              │
│   (Bradycardia with poor perfusion = indication for CPR even with pulse)    │
└─────────────────────────────────────────────────────────────────────────────┘
                                    ↓
┌─────────────────────────────────────────────────────────────────────────────┐
│   ADRENALINE                                                                 │
│   • 10 mcg/kg (0.01 mg/kg) IV/IO                                            │
│   • Repeat every 3-5 minutes if bradycardia persists                        │
│                                                                              │
│   ATROPINE (if vagal cause suspected)                                        │
│   • Vagal causes: intubation, suctioning, gastric distension                │
│   • 20 mcg/kg IV/IO (minimum 100 mcg, max 600 mcg child, 1 mg adolescent)   │
│   • May repeat once                                                          │
└─────────────────────────────────────────────────────────────────────────────┘
                                    ↓
┌─────────────────────────────────────────────────────────────────────────────┐
│   REASSESS AFTER EACH INTERVENTION                                          │
│                                                                              │
│   If HR improves greater than 60 and perfusion improves → stop CPR, monitor             │
│                                                                              │
│   If develops pulseless arrest → full cardiac arrest algorithm              │
│                                                                              │
│   CONSIDER:                                                                  │
│   • Transcutaneous pacing (if available and heart block suspected)          │
│   • Expert consultation (cardiology, PICU)                                   │
│   • Continue to treat reversible causes                                      │
└─────────────────────────────────────────────────────────────────────────────┘

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Tachycardia Algorithms

Narrow Complex Tachycardia (QRS ≤0.09s)

Step 1: Assess Haemodynamic Stability

Stable SVT Management:

1. Vagal Manoeuvres (first-line):

   • Infant: Ice pack to face for 5-10 seconds (cover nose and mouth briefly)
   • Child: Valsalva manoeuvre (blowing into syringe, blowing up balloon)
   • Modified Valsalva (strain then lie flat with legs raised)

2. Adenosine (if vagal manoeuvres fail):

Technique: Rapid IV push through large-bore proximal IV, immediately followed by 10-20 mL rapid saline flush. Record rhythm strip during administration.

Unstable SVT:

• Synchronised cardioversion 0.5-1 J/kg → 2 J/kg if fails
• Sedate if time permits and patient conscious (ketamine 1-2 mg/kg IV)
• Ensure synchronisation mode is ON

Wide Complex Tachycardia (QRS greater than 0.09s)

Assume VT until proven otherwise

Pulseless or uncertain pulse: Treat as VF - defibrillation 4 J/kg

VT with Pulse - Unstable:

• Synchronised cardioversion 1-2 J/kg → 2-4 J/kg
• Sedate if conscious and time permits

VT with Pulse - Stable:

• Amiodarone 5 mg/kg IV over 20-60 minutes
• Expert consultation (paediatric cardiology)
• Prepare for cardioversion if deteriorates

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Airway Management in PALS

Age-Specific Considerations

Bag-Valve-Mask Ventilation

Mask Sizing: Apex at bridge of nose, base between lower lip and chin

Technique:

1. E-C clamp grip on mask (2-person technique preferred)
2. Position head appropriately for age
3. Deliver breath over 1 second
4. Watch for chest rise (avoid excessive volumes)
5. Rate: 12-20 breaths/min (younger = faster)

Troubleshooting "BONES":

• B: Bag not working or connected
• O: Obstruction (secretions, FB, tongue, laryngospasm)
• N: No seal (reposition mask, two-person technique)
• E: Equipment failure (check oxygen, bag)
• S: Stomach distension (reposition, consider NG)

Advanced Airway Considerations

When to Consider Intubation:

• Unable to ventilate adequately with BVM
• Prolonged resuscitation anticipated
• Transport with ongoing CPR
• Post-ROSC without protective airway reflexes

If Intubated:

• Ventilate at 10 breaths/min (1 breath every 6 seconds)
• Do NOT synchronise with compressions
• Do NOT pause compressions for ventilation
• Target ETCO₂ over 10 mmHg during CPR (indicates adequate CO)
• ETCO₂ over 40 mmHg may indicate ROSC

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Post-Resuscitation Care

Immediate Post-ROSC Priorities

Targeted Temperature Management (TTM)

Current ANZCOR/ILCOR Guidance (2020):

• Actively prevent fever (≥37.5°C) for at least 72 hours post-ROSC - this is standard care
• Consider TTM at 32-34°C for comatose children after OHCA or IHCA
• Duration: 24-72 hours of active temperature management
• Setting: TTM should be initiated and managed in PICU
• Evidence: THAPCA trials showed no difference between 33°C and 36.8°C for neurological outcome, but avoiding fever is beneficial [13,14]

Investigations Post-ROSC

Disposition

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Family Presence During Resuscitation

ANZCOR/ILCOR Position

Important Note: Best Practice: Family members should be offered the opportunity to be present during resuscitation of their child. Evidence demonstrates that family presence:

• Does NOT interfere with resuscitation [15]
• Does NOT increase provider stress
• Reduces anxiety and depression in family members
• Facilitates the grieving process if death occurs
• Should be supported by a designated staff member
• Is valued by most families

Practical Implementation

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Cessation of Resuscitation

Considerations for Stopping

There is no absolute time limit for paediatric resuscitation. Factors to consider:

Special Circumstances Requiring Prolonged Resuscitation

• Hypothermia: Continue until rewarmed to ≥32°C ("not dead until warm and dead")
• Toxicological: May respond after prolonged resuscitation (especially sodium channel blockers)
• Drowning in cold water: Young children may have good outcomes even after prolonged submersion
• ECPR consideration: Refer to ECMO-capable centre if available and appropriate criteria met [16]

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Shock Recognition and Management

Types of Shock in Children

Fluid Resuscitation in Shock

┌─────────────────────────────────────────────────────────────────────────────┐
│   SHOCK IDENTIFIED                                                           │
│   (Tachycardia, poor perfusion, ± hypotension)                              │
│                                                                              │
│   1. High-flow oxygen                                                        │
│   2. Vascular access (IO if IV not immediately available)                   │
│   3. Check blood glucose                                                     │
└─────────────────────────────────────────────────────────────────────────────┘
                                    ↓
┌─────────────────────────────────────────────────────────────────────────────┐
│   FLUID BOLUS                                                                │
│   • 10-20 mL/kg crystalloid (0.9% saline or balanced solution)              │
│   • Give over 5-10 minutes (push-pull or pressure bag)                      │
│   • If suspected cardiogenic: 5-10 mL/kg over 10-20 min                     │
└─────────────────────────────────────────────────────────────────────────────┘
                                    ↓
┌─────────────────────────────────────────────────────────────────────────────┐
│   REASSESS (HR, perfusion, mental status, BP, urine output)                  │
└─────────────────────────────────────────────────────────────────────────────┘
           ↓                                       ↓
     STILL SHOCKED                            IMPROVED
           ↓                                       ↓
┌─────────────────────────────┐     ┌─────────────────────────────────────────┐
│   REPEAT BOLUS              │     │   Maintenance fluids                    │
│   • 10-20 mL/kg             │     │   Ongoing monitoring                    │
│   • Up to 40-60 mL/kg in    │     │   Identify and treat underlying cause   │
│     first hour for sepsis   │     └─────────────────────────────────────────┘
│                             │
│   After 40 mL/kg if still   │
│   shocked:                  │
│   • Start vasoactive drugs  │
│   • Adrenaline or           │
│     noradrenaline infusion  │
│   • PICU referral           │
└─────────────────────────────┘

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Pitfalls & Pearls

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Viva Practice

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OSCE Scenarios

Station 1: Paediatric Resuscitation Team Leadership

Format: Resuscitation Leadership (Manikin-based simulation) Time: 11 minutes Setting: ED Resuscitation Bay

Candidate Instructions:

You are the senior registrar in a metropolitan ED. A 3-year-old child (approximately 15 kg based on Broselow tape) has been brought in by ambulance following witnessed seizure activity at home that progressed to respiratory arrest. Paramedics commenced BVM ventilation but report the child became bradycardic then pulseless 2 minutes ago. CPR is in progress. Lead the resuscitation.

Examiner Instructions:

• Manikin with monitor showing asystole
• Weight confirmed as 15 kg by Broselow tape
• If candidate follows algorithm correctly, rhythm changes to VF at 6 minutes
• If candidate provides high-quality CPR with adrenaline and defibrillation for VF, ROSC occurs at 9 minutes
• If candidate fails to recognise VF or delays defibrillation, rhythm deteriorates to asystole

Team Available:

• Nurse 1: Experienced, can assist with airway and drugs
• Nurse 2: Junior, needs clear direction
• Resident: Available to assist

Resources Available:

• Full paediatric resuscitation equipment
• Broselow tape (already measured - 15 kg)
• Defibrillator with paediatric pads
• IO drill
• Paediatric resuscitation drugs

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators: Correct CPR ratio (15:2), correct drug doses, recognition of VF, appropriate defibrillation

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Station 2: Breaking Bad News - Paediatric Death

Format: Communication Station Time: 11 minutes Setting: Relatives Room

Candidate Instructions:

You are the registrar in the ED. A 9-month-old infant was brought in by ambulance following a SUDI (Sudden Unexpected Death in Infancy). Despite 30 minutes of resuscitation, the infant did not survive. The parents are waiting in the relatives' room. Break the news of their child's death.

Actor Brief (Mother):

• 28 years old, first baby
• Found baby unresponsive in cot this morning
• Healthy pregnancy and birth, no medical problems
• Extremely distressed, tearful
• Father is silent, appears in shock
• Will ask: "Is he going to be okay?" and "Did I do something wrong?"

Expected Actions:

1. Introduce self, confirm identities, sit down
2. Establish what they know so far
3. Use a "warning shot" to prepare them ("I have some very difficult news...")
4. Deliver news clearly and compassionately using plain language
5. Allow silence and expression of emotion
6. Answer questions honestly
7. Address guilt (extremely common with SUDI - "This is not your fault")
8. Explain next steps sensitively (viewing baby, police involvement, coronial process)
9. Offer support services (chaplaincy, social work, SIDS support)

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators: Ability to deliver news clearly, demonstrate genuine empathy, address parental guilt, awareness of coronial process

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Station 3: Paediatric Defibrillation Demonstration

Format: Procedural Skills Station Time: 8 minutes Setting: Simulation Laboratory

Candidate Instructions:

You are managing a 5-year-old child (20 kg) in cardiac arrest. The rhythm on the monitor is ventricular fibrillation. Demonstrate the process of delivering a defibrillation shock. Talk through your actions as you perform them on the manikin.

Equipment Available:

• Defibrillator with paediatric and adult pads
• Paediatric manikin (5-year-old size)
• Gel pads

Expected Actions:

1. Confirm VF on monitor (not artefact)
2. Announce weight and calculate energy: "This is a 20 kg child, energy is 4 J/kg = 80 J"
3. Select appropriate pads (paediatric if available, adult acceptable)
4. Apply pads correctly (anterior-posterior or sternal-apex, ensuring no overlap)
5. State "Continue CPR while I charge the defibrillator"
6. Set energy to 80 J
7. Charge while compressions continue
8. Perform safety check: "I'm clear, you're clear, everyone's clear" with visual sweep
9. State "Delivering shock now"
10. Deliver shock with minimal pause
11. State "Resume CPR immediately, do not check rhythm"
12. Articulate drug timing: "After this 2-minute cycle, we will give adrenaline. Amiodarone after the 3rd shock."

Marking Criteria:

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SAQ Practice

Question 1 (6 marks)

Stem: A 4-year-old child (16 kg) is brought to the emergency department in cardiac arrest following drowning in a backyard pool. CPR is in progress with an asystole rhythm on the monitor.

Question: List 6 key features of high-quality CPR in paediatric resuscitation according to ANZCOR guidelines.

Model Answer:

• Compression rate of 100-120 compressions per minute (1 mark)
• Compression depth of 1/3 of anterior-posterior chest diameter (~5 cm) (1 mark)
• Full chest recoil between compressions (1 mark)
• Minimise interruptions to below 10 seconds for rhythm checks (1 mark)
• Compression-to-ventilation ratio of 15:2 with two healthcare providers (1 mark)
• Rotate compressors every 2 minutes to prevent fatigue (1 mark)

Examiner Notes:

• Accept: Avoid excessive ventilation, ensure visible chest rise with ventilations
• Do NOT accept: 30:2 ratio (this is for single rescuers or lay rescuers, not two HCPs)

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Question 2 (8 marks)

Stem: You are resuscitating a 2-year-old child (12 kg) who is in ventricular fibrillation. Three defibrillation shocks have been delivered without success.

Question (a): What medications should be given at this point, with correct doses for a 12 kg child? (4 marks)

Model Answer:

• Adrenaline 120 mcg (10 mcg/kg) IV/IO - should have been given after 2nd shock, continue every 3-5 min (2 marks)
• Amiodarone 60 mg (5 mg/kg) IV/IO - given after 3rd shock (2 marks)

Question (b): List 4 reversible causes you would actively consider in a child with refractory VF. (4 marks)

Model Answer (any 4 for full marks):

• Hypokalaemia or hyperkalaemia (1 mark)
• Hypothermia (1 mark)
• Toxins (including sodium channel blockers, tricyclic antidepressants, local anaesthetics) (1 mark)
• Channelopathies/primary cardiac cause (Long QT, Brugada, WPW) (1 mark)
• Hypertrophic cardiomyopathy (1 mark)
• Commotio cordis (if history of chest impact) (1 mark)

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Question 3 (8 marks)

Stem: A 6-month-old infant (7 kg) has a witnessed cardiac arrest in the ED. You are the team leader.

Question (a): Describe the correct compression technique for infant CPR with two healthcare providers. (4 marks)

Model Answer:

• Two-thumb encircling technique is preferred (1 mark)
• Both thumbs placed side-by-side on lower third of sternum, just below nipple line (1 mark)
• Fingers encircle chest to support the back (1 mark)
• Compress to 1/3 of anterior-posterior diameter (~4 cm) at rate of 100-120/min (1 mark)

Question (b): Calculate the correct doses and sizes for this 7 kg infant: (4 marks)

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Question 4 (6 marks)

Stem: Following successful resuscitation of an 8-year-old child (25 kg) from cardiac arrest, you are managing the post-resuscitation phase in the ED before PICU transfer.

Question: List 6 key targets or interventions for immediate post-resuscitation care.

Model Answer (any 6 for full marks):

• Maintain SpO₂ 94-98% - avoid hyperoxia (1 mark)
• Maintain normocapnia - PaCO₂ 35-45 mmHg (1 mark)
• Maintain age-appropriate blood pressure (MAP ≥5th centile for age) (1 mark)
• Maintain glucose 6-10 mmol/L - avoid hypo/hyperglycaemia (1 mark)
• Prevent fever - temperature below 37.5°C, or targeted temperature management 32-34°C (1 mark)
• 12-lead ECG to identify cause (channelopathy, ischaemia) (1 mark)
• Treat seizures aggressively if present (1 mark)
• Secure airway if not already intubated (1 mark)

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Question 5 (6 marks)

Stem: A 3-year-old child (15 kg) presents with SVT at a rate of 260/min. She is pale and lethargic with capillary refill time of 4 seconds but remains conscious.

Question (a): What is your first-line treatment for this haemodynamically compromised but conscious child? (2 marks)

Model Answer:

• Vagal manoeuvres as first-line (1 mark)
• Specifically: ice pack to face for 5-10 seconds (covers nose and mouth briefly) OR modified Valsalva in cooperative older children (1 mark)

Question (b): If vagal manoeuvres fail, describe the pharmacological treatment with doses for a 15 kg child. (4 marks)

Model Answer:

• Adenosine is first-line pharmacological treatment (1 mark)
• Escalating dose regimen:
  • 1st dose: 1.5 mg (100 mcg/kg × 15 kg) - max 6 mg (1 mark)
  • 2nd dose: 3 mg (200 mcg/kg × 15 kg) - max 12 mg (1 mark)
  • 3rd dose: 4.5 mg (300 mcg/kg × 15 kg) - max 12 mg (1 mark)
• Technique: Rapid IV push via proximal access with immediate 10-20 mL saline flush

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Remote/Rural Considerations

Challenges in Remote/Rural Paediatric Resuscitation

• Prolonged EMS response times - may be hours in remote Australia
• Limited paediatric expertise - may be sole practitioner
• Limited equipment - may not have all paediatric sizes
• Retrieval delays - RFDS/helicopter availability
• Telemedicine - variable connectivity

Strategies

Royal Flying Doctor Service (RFDS) / Retrieval Coordination

• Activate early - call retrieval for ANY paediatric cardiac arrest
• Prepare landing - airstrip/helipad ready
• Prepare handover - weight, medications given, arrest duration, suspected cause
• Prepare family - will need to travel separately in most cases

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Australian Guidelines Summary

Key ANZCOR Guidelines for PALS

Key Differences from AHA/ERC

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References

Guidelines

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2. Australian Resuscitation Council. ANZCOR Guideline 10: Basic Life Support for Infants and Children. 2021. Available from: https://resus.org.au/guidelines/

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