ADVANCED PAEDIATRIC LIFE SUPPORT The Practical Approach Third edition Advanced Life Support Group BMJ Books ADVANCED PAEDIATRIC LIFE SUPPORT The Practical Approach Third edition Advanced Life Support Group Edited by Kevin Mackway-Jones Elizabeth Molyneux Barbara Phillips Susan Wieteska BMJ Paediatrics 9/11/0 9:59 pm Page iii © BMJ Books 1997, 2001 BMJ Books is an imprint of the BMJ Publishing Group, BMA House, Tavistock Square, London WC1H 9JR www.bmjbooks.com All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means electronic, mechanical, photocopying, recording, and, or otherwise, without the prior written permission of the Advanced Life Support Group. First published in 1993 by the BMJ Publishing Group Reprinted 1994 Reprinted 1995 Reprinted 1996 Second edition 1997 Reprinted 1998 Reprinted with revisions 1998 Reprinted 1999 Reprinted 2000 Third edition 2001 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 0-7279-1554-1 Typeset in Great Britain by FiSH Books, London Printed and bound by Selwood Printing Ltd, Burgess Hill, West Sussex BMJ Paediatrics 9/11/0 9:59 pm Page iv CONTENTS Working Group vii Contributors ix Preface to the Third Edition xi Preface to the First Edition xiii Acknowledgements xv Contact Details and Website Information xvi PART I: INTRODUCTION Chapter 1 Introduction 3 Chapter 2 Why treat children differently? 7 Chapter 3 Recognition of the seriously ill child 13 PART II: LIFE SUPPORT Chapter 4 Basic life support 21 Chapter 5 Advanced support of the airway and ventilation 35 Chapter 6 The management of cardiac arrest 45 Chapter 7 Resuscitation at birth 59 PART III: THE SERIOUSLY ILL CHILD Chapter 8 The structured approach to the seriously ill child 71 Chapter 9 The child with breathing difficulties 79 Chapter 10 The child in shock 99 Chapter 11 The child with an abnormal pulse rate or rhythm 117 Chapter 12 The child with a decreased conscious level 127 Chapter 13 The convulsing child 139 Chapter 14 The poisoned child 149 BMJ Paediatrics 9/11/0 9:59 pm Page v PART IV: THE SERIOUSLY INJURED CHILD Chapter 15 The structured approach to the seriously injured child 161 Chapter 16 The child with chest injury 173 Chapter 17 The child with abdominal injury 179 Chapter 18 The child with trauma to the head 183 Chapter 19 The child with injuries to the extremities or the spine 191 Chapter 20 The burnt or scalded child 199 Chapter 21 The child with electrical injury or near drowning 205 PART V: PRACTICAL PROCEDURES Chapter 22 Practical procedures – airway and breathing 213 Chapter 23 Practical procedures – circulation 221 Chapter 24 Practical procedures – trauma 233 Chapter 25 Interpreting trauma X-rays 243 Chapter 26 Transport of children 255 PART VI: APPENDICES Appendix A Acid–base balance 263 Appendix B Fluid and electrolyte management 269 Appendix C Child abuse 281 Appendix D Childhood accidents and their prevention 291 Appendix E Dealing with death 295 Appendix F Management of pain in children 297 Appendix G Triage 303 Appendix H Envenomation 307 Appendix I Formulary 313 Index 330 vi BMJ Paediatrics 9/11/0 9:59 pm Page vi WORKING GROUP A. Argent Paediatric ICU, Cape Town A. Charters Emergency Nursing, Sheffield M. Felix Paediatrics, Coimbra J. Fothergill Emergency Medicine, London G. Hughes Emergency Medicine, Wellington F. Jewkes Paediatric Nephrology, Cardiff J. Leigh Anaesthesia, Bristol K. Mackway-Jones Emergency Medicine, Manchester E. Molyneux Paediatric Emergency Medicine, Malawi P. Oakley Anaesthesia/Trauma, Stoke on Trent B. Phillips Paediatric Emergency Medicine, Liverpool and Manchester C. Tozer Emergency Nursing, Abergavenny N. Turner Anaesthesia, Amsterdam J. Walker Paediatric Surgery, Sheffield S. Wieteska Course Co-ordinator, Manchester K. Williams Paediatric Emergency Nursing, Liverpool S. Young Paediatric Emergency Medicine, Melbourne D. Zideman Paediatric Anaesthesia, London vii BMJ Paediatrics 9/11/0 9:59 pm Page vii BMJ Paediatrics 9/11/0 9:59 pm Page viii CONTRIBUTORS R. Appleton Paediatric Neurology, Liverpool P. Baines Paediatric Intensive Care, Liverpool I. Barker Paediatric Anaesthesia, Sheffield D. Bickerstaff Paediatric Orthopaedics, Sheffield R. Bingham Paediatric Anaesthesia, London P. Brennan Paediatric Emergency Medicine, Sheffield J. Britto Paediatric Intensive Care, London C. Cahill Emergency Medicine, Portsmouth H. Carty Paediatric Radiology, Liverpool M. Clarke Paediatric Neurology, Manchester J. Couriel Paediatric Respiratory Medicine, Liverpool P. Driscoll Emergency Medicine, Manchester J. Fothergill Emergency Medicine, London P. Habibi Paediatric Intensive Care, London D. Heaf Paediatric Respiratory Medicine, Liverpool F. Jewkes Paediatric Nephrology, Cardiff E. Ladusans Paediatric Cardiology, Manchester J. Leggatte Paediatric Neurosurgery, Manchester J. Leigh Anaesthesia, Bristol CONTRIBUTORS ix BMJ Paediatrics 9/11/0 9:59 pm Page ix S. Levene Child Accident Prevention Trust, London M. Lewis Paediatric Nephrology, Manchester K. Mackway-Jones Emergency Medicine, Manchester J. Madar Neonatology, Plymouth T. Martland Paediatric Neurologist, Manchester E. Molyneux Paediatric Emergency Medicine, Malawi D. Nicholson Radiology, Manchester A. Nunn Pharmacy, Liverpool P. Oakley Anaesthesia, Stoke on Trent B. Phillips Paediatric Emergency Medicine, Manchester and Liverpool J. Robson Paediatric Emergency Medicine, Liverpool D. Sims Neonatology, Manchester A. Sprigg Paediatric Radiology, Sheffield J. Stuart Emergency Medicine, Manchester J. Tibballs Paediatric Intensive Care, Melbourne J. Walker Paediatric Surgery, Sheffield W. Whitehouse Paediatric Neurologist, Birmingham S. Wieteska Course Co-ordinator, Manchester M. Williams Emergency Medicine,York B. Wilson Paediatric Radiology, Manchester J. Wyllie Neonatology, Middlesbrough S. Young Paediatric Emergency Medicine, Melbourne D. Zideman Anaesthesia, London CONTRIBUTORS x BMJ Paediatrics 9/11/0 9:59 pm Page x PREFACE TO THIRD EDITION Since this book was first published in 1993, the Advanced Paediatric Life Support (APLS) concept and courses have gone a great way towards their aim of bringing simple guidelines for the management of ill and injured children to front-line doctors and nurses. Over the years an increasing number of experts have contributed to the work and we extend our thanks both to them and also to our instructors who unceasingly provide helpful feedback.The Advanced Paediatric Life Support Course is now well established in several countries outside the United Kingdom. These include Australia, New Zealand, the Netherlands, Portugal and South Africa. APLS is also the recommended paediatric course for the European Resuscitation Council. Furthermore, material from APLS is being successfully used in countries with under-resourced health care systems such as Bosnia-Herzegovina, Malawi and Uganda. A small “family” of courses have developed from APLS in response to different training needs. One is the Paediatric Life Support (PLS) course, a one-day locally delivered course designed for doctors and nurses who have only subsidiary responsibility for seriously ill or injured children (see note, page xvi). Another is Pre- Hospital Paediatric Life Support (PHPLS), which has its own textbook and is for the pre-hospital provider. Readers will find significant changes in the third edition. The chapters on resuscitation and the management of arrhythmias have been informed by the new International Guidelines, produced by an evidence-based process from the collaboration of many international experts under the umbrella of the International Liaison Committee on Resuscitation (ILCOR). The chapters on serious illness have been rewritten both to include new knowledge and practice and also to reflect the problem-based approach used in teaching. In addition there are some new chapters. In the past the editors have been criticised for the decision not to include in the text the many references which support its assertions. We have not changed this now – but have harnessed the power of the World Wide Web to allow us (and you the reader, the candidate and the instructor) to keep the evidence available and up to date. Log on to www.bestbets.org to see how far we have got and how you can help. KMJ EM BP SW Manchester 2001 xi BMJ Paediatrics 9/11/0 9:59 pm Page xi [...]... (36) 11 65 (19 ) 215 8 (24) Number of deaths (rate) 19 98 (E&W) 19 98 (Australia) 2 418 9 (3·8) 12 07 (1 9) 722 (28) 897 (13 ) 16 19 (17 ) 842 (5·02) 410 347 376 723 (19 ·7) The rate for under ones is per 1 000 population and for over ones per 10 0 000 population England and Wales, 19 91 and 19 98 Office of National Statistics (ONS) Australia 19 98 The causes of death vary with age as shown in Table 1. 2 In the newborn... xvi PART III INTRODUCTION CHAPTER I1 I Introduction CAUSES OF DEATH IN CHILDHOOD As can be seen from Table 1. 1, the greatest mortality during childhood occurs in the first year of life with the highest death rate of all happening in the first month Table 1. 1 Number of deaths by age group Age group 0–28 days 4–52 weeks 1 4 years 5 14 years 1 14 years 19 91 (E&W) 3052 (4·4) 210 6 (3·0) 993 (36) 11 65 (19 )... release and as compensation for decreased stroke volume The rate, particularly in small infants, may be extremely high (up to 220 per minute) Normal rates are shown in Table 3.2 Bradycardia is a pre-terminal sign Table 3.2 Heart rate by age Age (years) 12 Heart rate (beats per minute) 11 0 16 0 10 0 15 0 95 14 0 80 12 0 60 10 0 15 RECOGNITION OF THE SERIOUSLY ILL CHILD Pulse volume Although... reflected in the changes seen in blood pressure – shown in Table 2.3 Table 2.3 Systolic blood pressure by age Age (years) 12 Systolic blood pressure (mmHg) 70–90 80–95 80 10 0 90 11 0 10 0 12 0 11 WHY TREAT CHILDREN DIFFERENTLY? PSYCHOLOGY Children who are ill or injured present particular problems during emergency management because of difficulties in communicating with them, and because of the... and heart rate, these changes underlie the heart rate changes seen during childhood (shown in Table 2.2) Table 2.2 Heart rate by age Age (years) Heart rate (beats per minute) 12 11 0 16 0 10 0 15 0 95 14 0 80 12 0 60 10 0 As the stroke volume is small and relatively fixed in infants, cardiac output is directly related to heart rate The practical importance of this is that the response to volume... abnormality Infection Trauma Neoplasms 239 (20) 285 (24) 228 (19 ) 53 (4) 22 (2) 5 14 years 0 (0) 10 2 (14 ) 69 (10 ) 14 3 (20) 94 (13 ) 0 (0) 66 (7) 35 (4) 219 (25) 232 (25) England and Wales, 19 98, ONS *Numbers in parentheses are the percentage After 1 year of age trauma is the most frequent cause of death, and remains so until well into adult life Deaths from trauma have been described as falling into three... +44 (0 )16 1 877 19 99 Fax: +44 (0 )16 1 877 16 66 Email:@alsg.org Clinicians practising in tropical and under-resourced health care systems are advised to read A Manual for International Child Health Care (0 7279 14 76 6) published by BMJ Books which gives details of additional relevant illnesses not included in this text NOTE Sections with the grey marginal tint are relevant for the Paediatric Life Support. .. pre-terminal sign of circulatory failure Once a child’s blood pressure has fallen cardiac arrest is imminent Expected systolic blood pressure can be estimated by the formula: Blood pressure = 80 + (Age in years ҂2) Normal systolic pressures are shown in Table 3.3 Table 3.3 Systolic blood pressure by age Age (years) 12 Systolic blood pressure (mmHg) 70–90 80–95 80 10 0 90 11 0 10 0 12 0... through to adulthood The work of breathing is also relatively unchanged at about 1% of the metabolic rate, although it is increased in the pre-term infant 10 WHY TREAT CHILDREN DIFFERENTLY? Table 2 .1 Respiratory rate by age at rest Age (years) Respiratory rate (breaths per minute) 12 30–40 25–35 25–30 20–25 15 –20 In the adult, the lung and chest wall contribute equally to the total compliance... needed because of either lung or airway disease, or metabolic acidosis Normal respiratory rates at differing ages are shown in Table 3 .1 Table 3 .1 Respiratory rate by age at rest Age (years) 12 Respiratory rate (beats per minute) 30–40 25–35 25–30 20–25 15 –20 13 RECOGNITION OF THE SERIOUSLY ILL CHILD Recession Intercostal, subcostal, or sternal recession shows increased effort of breathing . 347 5 14 years 11 65 (19 ) 897 (13 ) 376 1 14 years 215 8 (24) 16 19 (17 ) 723 (19 ·7) BMJ Paediatrics 9 /11 /0 10 : 01 pm Page 3 Table 1. 2 Common causes of death by age group England and Wales, 19 98, ONS. *Numbers. relevant for the Paediatric Life Support (PLS) Course. xvi BMJ Paediatrics 9 /11 /0 9:59 pm Page xvi PART I I I INTRODUCTION BMJ Paediatrics 9 /11 /0 10 : 01 pm Page 1 BMJ Paediatrics 9 /11 /0 10 : 01 pm Page. ADVANCED PAEDIATRIC LIFE SUPPORT The Practical Approach Third edition Advanced Life Support Group BMJ Books ADVANCED PAEDIATRIC LIFE SUPPORT The Practical Approach Third edition Advanced Life