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general medical paediatric patients, especially those who present as emergencies.
Guidelines on the management of common medical conditions
No guideline will apply to every patient, even where the diagnosis is clear-cut; there will always
be exceptions. These guidelines are not intended as a substitute for logical thought and must be
tempered by clinical judgement in the individual patient.
Prescribing regimens and nomograms
The administration of certain drugs, especially those given intravenously, requires great care if
hazardous errors are to be avoided. These guidelines do not include all guidance on the
indications, contraindications, dosage and administration for all drugs. Please refer to the British
National Formulary for Children (BNFc).
Recommendations are based on national guidance reflecting a balance between common
antibiotic sensitivities and the narrowest appropriate spectrum to avoid resistance but local
policies may reflect frequently encountered sensitivity patterns in individual local patient groups.
Recommendations are generic. Please check your local microbiology advice.
DO NOT attempt to carry out any of these practical procedures unless you have been trained to
do so and have demonstrated your competence.
Where there are different recommendations the following order of prioritisation is followed:
NICE > NPSA > SIGN > RCPCH > National specialist society > BNFc > Cochrane > Meta-
analysis > systematic review > RCT > other peer review research > review > local practice.
These have been written with reference to published medical literature and amended after
extensive consultation. Wherever possible, the recommendations made are evidence based.
Where no clear evidence has been identified from published literature the advice given
represents a consensus of the expert authors and their peers and is based on their practical
Where supporting evidence has been identified it is graded 1 to 5 according to standard criteria of
validity and methodological quality as detailed in the table below. A summary of the evidence
supporting each statement is available, with the original sources referenced. The evidence
summaries are being developed on a rolling programme which will be updated as each guideline
APLS – CARDIORESPIRATORY ARREST ● 3/3
Use hands-free paediatric pads in children, may be used anteriorly and posteriorly
Resume 2 min of cardiac compressions immediately after giving DC shock, without checking monitor or
feeling for pulse
Briefly check monitor for rhythm before next shock: if rhythm changed, check pulse
Adrenaline and amiodarone are given after the 3rd and 5th DC shock, and then adrenaline only every
other DC shock
Automatic external defibrillators (AEDs) do not easily detect tachyarrythmias in infants but may be used
at all ages, ideally with paediatric pads, which attenuate the dose to 50–80 J
Evidence suggests that presence at their child’s side during resuscitation enables parents to gain a
realistic understanding of efforts made to save their child. They may subsequently show less anxiety and
Designate 1 staff member to support parents and explain all actions
Team leader, not parents, must decide when it is appropriate to stop resuscitation
WHEN TO STOP RESUSCITATION
No time limit is given to duration of CPR
no predictors sufficiently robust to indicate when attempts no longer appropriate
cases should be managed on individual basis dependent on circumstances
Prolonged resuscitation has been successful in:
overdoses of cerebral depressant drugs (e.g. intact neurology after 24 hr CPR)
Discuss difficult cases with consultant before abandoning resuscitation
Identify and treat underlying cause
Heart rate and rhythm
Core and skin temperatures
Arterial blood gases and lactate
Central venous pressure
Arterial and central venous gases
Haemoglobin and platelets
Group and save serum for crossmatch
Sodium, potassium, U&E
Transfer to PICU
Hold team debriefing session to reflect on practice