Paediatric resuscitation and the sick child

• Most paediatric cardiac arrests are not primary heart problems: they follow untreated respiratory failure or shock, so recognising and treating the sick child early prevents arrest. ^[1]
• The chain of survival in children is prevention and early recognition, high-quality basic life support (BLS) with breaths, and then advanced life support (PALS) while correcting reversible causes.
• A useful bedside pattern is the "BBB" quick look: behaviour (conscious level, cry, tone), breathing (rate, work, noise, colour), and body colour (pallor, mottle, cyanosis), followed by a structured ABCDE assessment. ^[1]
• Paediatric early warning scores (PEWS) turn trends in heart rate, respiratory rate, breathing effort, oxygen saturation, oxygen delivery, blood pressure and capillary refill into a score with linked escalation actions. ^[4]
• For an arrest, Resuscitation Council UK (RCUK) 2025 recommends five initial rescue breaths, then chest compressions at one third of chest depth at 100 to 120 per minute, with a compression to ventilation ratio of 15 to 2 for those trained in paediatric BLS and 30 to 2 otherwise. ^[1]
• The AHA 2025 PALS algorithm gives epinephrine 0.01 mg per kg intravenously or intraosseously every 3 to 5 minutes, defibrillation at 2 J per kg first, 4 J per kg second, then 4 to 10 J per kg, and amiodarone 5 mg per kg for shockable rhythms. ^[2]

By the end of this topic you should be able to:

1. Recognise respiratory failure and shock in a child, and tell compensated from decompensated failure.
2. Use a paediatric early warning score and act on its escalation level.
3. Outline and perform paediatric basic life support, including high-quality CPR and automated external defibrillator (AED) use.
4. Explain the paediatric advanced life support approach to the airway, breathing, circulation and cardiac arrest rhythms, including drug and defibrillation doses.
5. Manage status epilepticus as a time-critical neurological emergency.
6. Recognise suspected sepsis in a child using current UK criteria and start the right first steps.
7. Describe post-resuscitation care and when to involve parents and specialists.

Children arrest differently from adults. In adults, cardiac arrest is often a primary cardiac event: a lethal arrhythmia. In children, arrest is most often the end point of progressive respiratory failure or circulatory failure, which means that minutes matter and that good recognition, oxygenation and fluid therapy can prevent the arrest altogether. ^[1] The Resuscitation Council UK 2025 guidelines (published 27 October 2025, drawing on the 2025 International Liaison Committee on Resuscitation consensus and the European Resuscitation Council 2025 guidelines) and the American Heart Association 2025 paediatric guidelines (published 22 October 2025) are the newest editions used here. ^[1][2] Where the two differ, both values are given.

A useful mental model is that a sick child is on a slope. At the top is good compensation: fast breathing, fast heart rate, normal blood pressure, an anxious or agitated child. Lower down is decompensation: slow or irregular breathing, bradycardia, hypotension, a falling conscious level. The job of every clinician is to spot the slide early and push the child back up, before the last step. ^[1]

Before touching the child, look from the doorway. The paediatric assessment triangle looks at three things: appearance (muscle tone, interactiveness, consolability, look or gaze, cry or speech), work of breathing, and circulation to the skin. ^[1] RCUK 2025 also teaches the BBB tool, particularly for caregivers and first responders: behaviour, breathing, body colour. ^[1]

• Behaviour. Not fully conscious or hard to rouse, floppy or rigid, convulsing, behaving abnormally with carers, inconsolable, or unable to move limbs or speak or walk as usual.
• Breathing. Unable to take a deep breath; working hard (fast breathing, grunting, nasal flaring, recessions); extra noises; breathing too fast, too slow or irregular, or stopping; an abnormal posture to breathe.
• Body colour. Cyanosed, mottled, abnormally pale or greyish. In children with darker skin, inspect the palms, soles and mucosal membranes. ^[1]

These first impressions matter because they are fast and cost nothing. They should be followed, not replaced, by a full assessment. ^[1]

Perform a structured ABCDE as soon as a child looks unwell, and intervene as each problem is found rather than waiting to finish the list. ^[1]

• Airway. Is it patent? Look, listen and feel. Stridor or snoring means partial obstruction. A conscious child should be allowed to sit in the most comfortable position and should not be forced to lie down. Open the airway with head tilt and chin lift, or jaw thrust if trauma is suspected. ^[1]
• Breathing. Look at the work of breathing (respiratory rate, recession, grunting, nasal flaring, tracheal tug, positioning), its effectiveness (chest expansion, strength of cry or speech, auscultation for air entry symmetry and added sounds, skin colour), and systemic signs (heart rate, conscious level). Monitor oxygen saturation continuously; pulse oximetry can be less reliable in darker skin tones and poor perfusion. Monitor end-tidal carbon dioxide in all patients with an advanced airway. ^[1]
• Circulation. Heart rate, pulse volume (peripheral and central), blood pressure, signs of preload (jugular veins, liver edge, chest crepitations), and organ perfusion (capillary refill time, skin colour and temperature, urine output, conscious level). Continuous electrocardiogram, non-invasive blood pressure, and serial lactate if shock is suspected. Point of care ultrasound may help distinguish the type of shock. ^[1]
• Disability. Conscious level on AVPU or the paediatric Glasgow Coma Scale, pupil size, symmetry and reactivity, posturing, focal signs, blood glucose and seizure control. Seizures are a neurological emergency. ^[1]
• Exposure. Body temperature, full skin inspection for rash, injury or signs of abuse, and a brief history using AMPLE (allergies, medicines, past history, last meal, events). Be alert to conditions where arrest is imminent: airway obstruction, flail chest, silent chest, tension pneumothorax, massive haemorrhage, tamponade, raised intracranial pressure, hypoglycaemia with coma, hypothermia, severe trauma and thrombosis. ^[1]

Two principles sit behind all of this. Use multiple variables together, because no single sign diagnoses respiratory or circulatory failure, and trends over time are more informative than a single reading. ^[1]

Values change continuously as a child grows. The table gives reference points from RCUK 2025. ^[1]

A common trap is to be reassured by a "normal" respiratory rate or blood pressure in a tiring child. A child who is bradypnoeic after a period of marked tachypnoea, or bradycardic with poor perfusion, is often decompensating, not improving. Bradycardia with signs of poor perfusion despite adequate respiratory support is, by itself, an indication to start chest compressions. ^[1]

A paediatric early warning system is the whole system, not only a number: a standardised observation chart, a score, an escalation response and the team behaviours that make it work. England's National Paediatric Early Warning System (NPEWS) was launched on 3 November 2023 as part of the System-wide Paediatric Observations Tracking programme and is endorsed by the Royal College of Paediatrics and Child Health and the Royal College of Nursing. ^[4]

What NPEWS scores: heart rate, respiratory rate, extent of respiratory distress, oxygen saturation, oxygen delivery, capillary refill time and blood pressure. Observations that are recorded but do not score include temperature, AVPU and pain score. The system includes a parent concern trigger and a clinical intuition trigger, either of which can escalate care regardless of the score. ^[4]

Escalation from NPEWS is set at four levels, triggered by the PEWS score, the AVPU level, the parent concern trigger or the clinical intuition trigger: ^[4]

Important design points for a worldwide reader: NPEWS gives oxygen delivery on high-flow, continuous positive airway pressure or bilevel ventilation its maximum score of 4, so that a child on respiratory support cannot look falsely reassuring. Low oxygen saturation scores even in children with congenital heart disease or chronic lung disease, on the reasoning that they have less reserve when unwell. Parent and carer concern is an independent route to escalation, which is especially important for children whose parents know their "normal". ^[4]

A PEWS is not a substitute for clinical judgement. A child with a low score and worried parents, or one who is simply "not right", should still be reviewed. ^[4]

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection, and it is one of the commonest routes by which a child slides into shock. The current UK guidance for children is NICE NG254, "Suspected sepsis in under 16s" (published 19 November 2025), which replaced the earlier NICE NG51 sepsis guidance. ^[3] The structure worth learning is the same across editions: think "could this be sepsis?", risk stratify by age band, treat according to risk.

Recognition points from NICE NG254: ^[3]

• Think "could this be sepsis?" whenever a child presents with symptoms or signs that indicate possible infection. People with sepsis may have non-specific, non-localised presentations (for example "very unwell") and may not have a high temperature. ^[3]
• Pay attention to concerns from the child, family and carers, such as changes from usual behaviour, and to difficulties in taking a history (language, learning disability, autism).
• In hospital and community settings, use a structured set of observations; consider an early warning score in any setting. ^[3]
• Factors that increase risk include impaired immunity, surgery or invasive procedures in the last 6 weeks, indwelling catheters, repeated antibiotics, breach of skin integrity, and social vulnerabilities. ^[3]

Risk stratification uses age-specific criteria for under 5 years, 5 to 11 years and 12 to 15 years, graded as high risk, moderate to high risk, or low risk. ^[3] Examples of high risk criteria in 12 to 15 year olds include new altered mental state, respiratory rate of 25 breaths per minute or more, new need for 40% oxygen or more to keep saturation above 92%, systolic blood pressure of 90 mmHg or less or more than 40 mmHg below normal, heart rate above 130 beats per minute, no urine in the last 18 hours (or under 0.5 mL per kg per hour if catheterised), mottled or ashen appearance, cyanosis, or a non-blanching petechial or purpuric rash. ^{[3] [1]}

Management, in outline: ^[3]

• Children with high-risk criteria need emergency medical care, pre-alerted where appropriate, and hospital transfer by the safest means. ^[3]
• In hospital, if one or more high-risk criteria are met: urgent assessment by a senior decision maker, including an alternative diagnosis; venous blood tests (blood gas with glucose and lactate, blood culture, full blood count, C-reactive protein, urea and electrolytes, creatinine, liver function tests, clotting screen); a broad-spectrum antimicrobial within 1 hour; and discussion with a consultant.
• Children under 12 with high-risk criteria and lactate above 4 mmol/L, or 12 to 15 year olds with high-risk criteria and either lactate above 4 mmol/L or systolic blood pressure of 90 mmHg or less, need an intravenous fluid bolus plus urgent critical care review, including central access and inotropes or vasopressors. ^[3]
• Lactate between 2 and 4 mmol/L warrants a fluid bolus; below 2 mmol/L, consider a bolus. ^[3]
• Continuous, or at least half-hourly, monitoring with physiological track-and-trigger systems; oxygen if the child is shocked or SpO2 is below 92% in air. ^[3]
• Monitor mental state with AVPU or the Glasgow Coma Scale.

Note the overlap with the sepsis "red flags" often taught in exams: mottled or ashen skin, non-blanching rash, unresponsiveness, and abnormal temperature. Wherever sepsis and meningococcal disease are possible, NICE refers to its bacterial meningitis and meningococcal disease guidance. ^[3]

See section 2.4 for the signs. Respiratory failure is the commonest single pathway to paediatric arrest. ^[1]

RCUK 2025 sets the following key points for respiratory failure in children. ^[1]

• In children with hypoxaemia that is not responding to low-flow oxygen but who still have adequate respiratory drive, consider humidified high-flow nasal cannula oxygen or continuous positive airway pressure / non-invasive ventilation.
• Bag-mask ventilation is the recommended first-line method to support ventilation; use a two-person technique, especially if ventilation is difficult or there is a risk of disease transmission; consider airway adjuncts.
• For tracheal intubation use cuffed tracheal tubes for paediatric life support (except in neonates, where evidence is weaker), monitor and limit cuff inflation pressure to the manufacturer's limit (usually less than 20 cm H2O). ^[1]
• Where oxygen saturation can be measured accurately, start oxygen if SpO2 is below 94%, or 3% below a known baseline in an infant or child with a chronic condition. Aim to keep SpO2 between 94 and 98% with as little supplemental oxygen as possible; avoid sustained 100% except in special circumstances such as carbon monoxide poisoning, methaemoglobinaemia, cyanide poisoning or severe anaemia. Do not give pre-emptive oxygen to children without signs of, or immediate risk of, hypoxaemia or shock. ^[1]

Ventilation rates with an advanced airway, once the tube is placed, should be close to the lower limit of normal for age: ^[1]

Additional RCUK guidance on intubation: pre-oxygenate; use a rapid-onset sedative and neuromuscular blocker unless the child is deeply comatose; cap attempts at four, each 30 to 60 seconds, stopping for bradycardia or desaturation; use video or direct laryngoscopy depending on operator experience; avoid routine atropine pre-medication. Confirm tube placement clinically and with end-tidal carbon dioxide, and monitor oxygen saturation and carbon dioxide continuously. ^[1]

See section 2.4: shock presents with tachycardia, weak peripheral pulses, prolonged capillary refill and agitation while compensated; bradycardia, weak central pulses, hypotension and a falling conscious level when decompensated. Use multiple variables and watch trends. ^[1]

RCUK 2025 sets the following for shock in children. ^[1]

• Use intravenous or intraosseous access; if intravenous access is not established within 5 minutes or two attempts, move to intraosseous access. ^[1]
• Give 10 mL per kg fluid boluses for hypovolaemic, obstructive or distributive shock. Use balanced isotonic crystalloids first if available; normal saline (0.9%) is acceptable if not. ^[1]
• In the UK system with intensive care availability, give 10 mL per kg, repeated up to 40 to 60 mL per kg in the first hour, titrated to response, with reassessment after each bolus, and stop if signs of fluid overload or cardiac failure appear (rising liver edge, lung crepitations, raised jugular venous pressure). ^[1]
• For cardiogenic shock, be more cautious: 5 mL per kg boluses, reassessing individually. ^[1]
• For haemorrhagic shock, keep crystalloid boluses to a minimum (maximum 20 mL per kg) and move early to blood products, with a strategy that improves coagulation and avoids fluid overload while awaiting definitive damage control. ^[1]
• Reassess after every bolus; if shock recedes, continue maintenance and rehydration more slowly.
• Start vasoactive drugs early, as continuous infusions, not later than after three to four fluid boluses (30 to 40 mL per kg): noradrenaline as first-line vasopressor, adrenaline as first-line inotrope, milrinone as first-line inodilator. Aim for the 5th percentile of blood pressure as a minimum, titrated to clinical signs and not to blood pressure alone. ^[1]
• Permissive hypotension (mean arterial pressure at the 5th percentile for age) may be considered in haemorrhagic shock but is contraindicated when there is associated brain injury. Always refer to established paediatric emergency drug charts for doses and beware of exceeding adult doses. ^[1]

Additional shock-specific support from the same guidelines includes treating arrhythmias, considering POCUS or echocardiography, lactate and mixed venous oxygen saturation to guide therapy, antibiotics and/or antivirals when infection is likely, and early referral for extracorporeal support in refractory shock. ^[1]

Giving repeated fluid boluses to a child in cardiac failure rather than hypovolaemia worsens pulmonary oedema. This is why reassessment, POCUS and early expert advice matter, and why RCUK 2025 stresses deciding the type of shock rather than giving fluids blindly. ^[1]

RCUK 2025 paediatric basic life support can be summarised as follows. ^[1]

1. Ensure your own safety and that of the child.
2. Check responsiveness with verbal and tactile stimulation; do not use painful stimuli.
3. Call, or have someone call, the ambulance service immediately, using speaker phone; follow the dispatcher.
4. Open the airway with head tilt and chin lift (infants in the neutral position, older children more tilt, adolescents full extension as for an adult), and assess breathing and signs of life for no more than 10 seconds.
5. Give five initial rescue breaths, each about 1 second, enough to make the chest visibly rise.
6. Start chest compressions immediately, using 15 compressions to 2 ventilations if trained in paediatric BLS, or 30 to 2 otherwise.
7. Minimise pauses. If a second rescuer is present, they should call and fetch an AED while the first rescues.
8. Continue high-quality compressions and effective ventilations, reassessing as required; put the breathing child in the recovery position if appropriate, but not after trauma.

Untrained rescuers are taught three steps to save a life: check, call, CPR, following the dispatcher's instructions, with compression-only CPR if they will not or cannot perform rescue breathing, and 30 to 2 with five initial breaths when dispatcher-assisted. ^[1]

Technique: perform compressions over the lower half of the sternum on a firm surface, using the two-thumb encircling method in infants and one or two hands in children over 1 year. Avoid interrupting compressions except for breaths or AED analysis, and change compressor every 2 minutes or sooner if fatigued. ^[1]

• Activate the paediatric mode, where available, for infants and children weighing less than 25 kg (approximately 8 years). In larger children and adolescents use standard adult mode; if no paediatric mode exists, use adult mode. ^[1]
• Use the anteroposterior pad position in infants and children weighing less than 25 kg (anterior pad mid-chest left of sternum, posterior between the scapulae), and either anterolateral or anteroposterior in larger children and adolescents. ^[1]
• Use the largest pads that fit without touching. Following a shock, restart compressions immediately without a pulse check. ^[1]

Suspect choking if the child is unable to speak or cry aloud, especially during eating or play. RCUK 2025 teaches up to 5 back blows, then up to 5 chest or abdominal thrusts, alternating, with blind sweeps avoided and a single finger sweep only for a clearly visible object; start CPR with five rescue breaths once the child becomes unconscious. ^[1] Infant technique differs from that for older children. AHA 2025 adds the point that for infants, abdominal thrusts are not recommended, and instead uses repeated cycles of 5 back blows alternating with 5 chest thrusts. ^[2]

If the child fails to respond, continue resuscitation, call for the team, limit compressions pauses, and move to advanced life support rather than stopping. Where paediatric cardiac arrest is suspected and compression quality can be monitored, RCUK advises paying attention to CPR quality and debriefing afterwards. ^[1]

PALS is teamwork around a structured assessment: airway secure, adequate oxygenation and ventilation, adequate perfusion, correction of reversible causes, and treatment of rhythm. RCUK 2025 stresses defined team roles and cognitive aids such as displayed algorithms and checklists. ^[1] The AHA 2025 guidelines are the newest full PALS guidance, superseding the 2020 editions, and are harmonised where possible with ILCOR and ERC; differences between councils are noted below. ^[2]

See section 5.2 for ventilation targets and intubation details. In PALS, support ventilation with bag-mask as first line, move to supraglottic airway or tracheal tube if needed, use cuffed tubes, and use the DOPES mnemonic (displacement, obstruction, pneumothorax, equipment, stomach/stacking/sedation) to find the cause of sudden deterioration in a ventilated child. ^[1]

Follow section 6.2 for fluids and vasoactives, plus consideration of POCUS for type of shock and of ECMO in refractory cases. A useful advanced-airway point: once a tube is in place, compressions become continuous and ventilations continue every 2 to 3 seconds. ^[1]

The PALS cardiac arrest algorithm distinguishes shockable (ventricular fibrillation and pulseless ventricular tachycardia) from non-shockable (asystole and pulseless electrical activity) rhythms. ^[2]

Drug and energy doses from AHA 2025: ^[2]

An honest disagreement between guidelines: on first-shock energy, the ILCOR 2025 consensus suggests 2 to 4 J/kg for initial defibrillation, ERC (through RCUK) recommends 4 J/kg for first and every subsequent shock, and AHA teaches 2 J/kg for the first shock. All agree that subsequent shocks need at least 4 J/kg and no more than 10 J/kg or the adult dose. ^[1][2]

• Bradycardia with a pulse in a child with poor perfusion despite adequate oxygenation and ventilation warrants chest compressions (heart rate under about 60 beats per minute with poor perfusion), plus correction of the underlying cause. Advanced options such as chronotropic drugs and pacing follow local PALS algorithms; epinephrine and atropine dosing are not reproduced here because they vary between sources and should be taken from the local paediatric emergency drug chart. ^[1][2]
• Tachyarrhythmia with a pulse (for example supraventricular tachycardia): follow the local PALS algorithm, which typically proceeds through vagal manoeuvres, adenosine and, if unstable, synchronised cardioversion. Paediatric synchronized cardioversion energy is not specified in the sources used here and should be taken from the local drug chart. ^[2]
• Post-arrest de-escalation: once a perfusing rhythm returns, stop adrenaline boluses and move into post-resuscitation care, avoiding further shocks unless the arrhythmia returns. ^[1]

Run through the 4 Hs and 4 Ts, plus hypoglycaemia, in every arrest: ^[1][2]

• H: hypoxia, hypovolaemia, hydrogen ion (acidosis), hypo- or hyperkalaemia (sometimes grouped with Hs), hypothermia, hypoglycaemia.
• T: tension pneumothorax, cardiac tamponade, toxins, thrombosis (pulmonary or coronary).

A prolonged seizure is common in childhood and is one of the "sick child" presentations that can precipitate respiratory failure. NICE NG217 (replacing the 2012 CG137) treats convulsive status epilepticus, defined as a seizure, or series of seizures without recovery of consciousness, lasting at least 5 minutes, as a medical emergency needing immediate resuscitation and treatment. ^[5]

Management outline: ^[5]

1. Resuscitate first: airway, oxygen, position; support breathing. Consider insertion of an airway if needed. This is an ABC problem before it is a brain problem.
2. Check glucose and treat hypoglycaemia (see section 6 of the RCUK resuscitation guidance above: oral glucose if possible, otherwise 0.2 g per kg glucose as 2 mL per kg of 10% glucose, or glucagon as a rescue measure).
3. First line: if the child has an individualised emergency management plan that is immediately available, follow it. Otherwise give a benzodiazepine immediately: buccal midazolam or rectal diazepam in the community, or intravenous lorazepam if intravenous access and resuscitation facilities are available. ^[5]
4. If the seizure does not stop within 5 to 10 minutes, or does not respond to the first dose: call emergency services (community) or seek expert guidance (hospital), and consider a second benzodiazepine dose. ^[5]
5. Second line if two benzodiazepine doses have failed: intravenous levetiracetam, phenytoin or sodium valproate. Levetiracetam may be quicker to administer and have fewer adverse effects. Major caveat: sodium valproate is subject to the current Medicines and Healthcare products Regulatory Agency restrictions on use in under-55s. ^[5]
6. Third line if second line fails: consider phenobarbital or general anaesthesia under expert guidance. ^[5]
7. Afterwards: agree an individualised emergency management plan if there is concern about recurrence. ^[5]

Clinical pearls and traps: ^[5]

• Status epilepticus has causes: hypoglycaemia, electrolyte disturbance, meningoencephalitis, intoxication, intracranial lesion, non-adherence to antiepileptic medication. Actively look for them rather than simply increasing anticonvulsants. ^[5]
• Not every twitching episode is epilepsy. Non-epileptic (dissociative) seizures can look similar; and tonic or decerebrate posturing from raised intracranial pressure, syncopal convulsions and movement disorders can mimic status. Treat the child, not the label, and be careful with benzodiazepine dosing. ^[5]
• Seizure duration is the clock that matters; brain injury risk rises with time. Do not spend 15 minutes fiddling with intravenous access in a seizing child: use buccal or rectal routes and an intraosseous line where needed.
• A prolonged seizure on RCUK 2025 treatment principles: treat any convulsive seizure continuing for more than 2 minutes longer than the person's usual seizure as an emergency and follow the same pathway. ^[5]

Cross-reference with paediatric neurology: severe or recurrent epilepsy, focal features or an underlying neurodisability should be referred to paediatric neurology; NICE NG51/NG127 neurological red flags (acute confusion, a new gait abnormality, sudden limb weakness, headache with red flags) are reasons for urgent same-day assessment rather than waiting. ^[3]

Once return of spontaneous circulation is achieved, the arrest is only half over. RCUK 2025 emphasises an immediate post-resuscitation bundle: ^[1][2]

• Airway: confirm tube position, ensure adequate oxygenation and ventilation, target normocapnia, aim SpO2 94 to 98% in previously healthy children.
• Breathing: avoid hypoxia and, after ROSC, avoid excessive oxygen; use lung-protective ventilation.
• Circulation: avoid hypotension; maintain blood pressure above the 10th percentile for age and sex (AHA 2025), with mean arterial pressure at least at the 5th percentile. ^[2]
• Temperature: prevent hyperthermia; avoid central temperatures above 37.5 degrees C in children who remain comatose after arrest; active normothermia or mild hypothermia with continuous invasive temperature monitoring. ^[2]
• Neurology: treat clinical and electroencephalographic seizures; neuroprotection; glucose control; normothermia. Withhold prognostication for at least 72 hours in comatose children. ^[1]
• Family: involve parents and persons with parental responsibility at every stage; assign a dedicated team member to explain what is happening; honest, empathetic communication. ^[1]
• Post-discharge: plan follow-up, rehabilitation and screening for physical, cognitive, behavioural and emotional problems after survival; a significant proportion of survivors need ongoing therapy. ^[2]

AHA 2025 also stresses family presence during CPR and a multimodal, multi-timepoint approach to neuroprognostication, because single tests in isolation carry a risk of inaccuracy. ^[2]

Trauma. In haemorrhagic shock keep crystalloids to a minimum (maximum 20 mL per kg) and move early to blood products; permissive hypotension may be considered but is contraindicated with associated brain injury. ^[1]

Bradycardia. Heart rate under 60 beats per minute with signs of inadequate perfusion despite adequate respiratory support means start CPR, and correct the cause (hypoxia, hypothermia, toxins, vagal stimuli). ^[1]

Anaphylaxis. Intramuscular adrenaline is the first-line treatment; fluid resuscitation and airway support may be needed. Dosing and pathways depend on the child's weight and local protocol; use an established paediatric emergency chart. ^[1]

Hypoglycaemia. Treat as soon as detected: 0.3 g per kg glucose orally if possible, otherwise 0.2 g per kg (2 mL per kg of 10% glucose) intravenously, rechecking after 5 to 10 minutes, with glucagon as a temporary rescue measure when intravenous access is unavailable. ^[1]

Special circumstances not detailed here (intoxication, drowning, electrocution, single-ventricle congenital heart disease, pulmonary hypertension) appear in the full RCUK 2025 and AHA 2025 guidelines and in local protocols; the approach remains ABCDE with correction of hypoxia and hypovolaemia and early expert help. ^[1][2]

• Call for the paediatric or emergency team early; RCUK 2025 explicitly says not to wait for arrest.
• Any high-risk sepsis criterion, or moderate risk with impaired immunity, needs emergency referral and transport. ^[3]
• A score on an early warning chart is not a diagnosis; parent and clinician concern escalate on its own. ^[4]
• Children in refractory shock, status epilepticus, requiring invasive ventilation, or with a complex underlying condition need transfer to a centre with paediatric intensive care. ^[1]
• RCUK recommends family-centred care at every stage, including decisions about CPR, and that parents should be allowed to stay with the child when it is safe. ^[1]

Much of the guidance quoted above comes from the UK and North American systems. In settings with fewer resources: ^[1][3][4]

• The first tools are free: the paediatric assessment triangle, behaviour, breathing, colour, and a pulse oximeter reading. If saturation cannot be measured, look at colour, work of breathing and conscious level.
• Oxygen should be given to the shocked or hypoxaemic child; where oxygen is limited, prioritise those with severe hypoxaemia or shock.
• Fluids: a bag of crystalloid and a syringe are the treatment for hypovolaemic shock. Give small boluses (10 mL per kg), reassess, and stop if overload signs appear. Where critical care is not available locally, arrange transfer early rather than stacking boluses.
• The intravenous route is preferred; intraosseous needles are cheap, reusable if sterilised, and life-saving when veins cannot be found. Use length-based rescue tapes to estimate weight where scales are absent.
• For sepsis, give a broad-spectrum antibiotic as soon as it is available and within 1 hour of recognising a high-risk child; take blood cultures first only if they can be taken without delaying antibiotics. ^[3]
• Where defibrillator pads or paediatric modes are unavailable, high-quality CPR, early airway support and transfer remain the core.
• National early warning systems may not exist locally; the principle (observe, score, escalate, review) can still be adopted on a paper chart with age-appropriate normal values.
• Use trusted regional guidance (such as national paediatric protocols and WHO emergency triage, assessment and treatment frameworks where implemented) alongside the international guidelines here, because local drug availability, referral pathways and disease patterns differ.

• Paediatric arrest is usually the end of untreated respiratory or circulatory failure; early recognition saves lives.
• Use the paediatric assessment triangle and the BBB quick look, then a structured ABCDE, intervening as problems are found.
• No single sign diagnoses failure: combine variables and watch trends.
• Compensated shock keeps blood pressure normal; bradycardia or hypotension means decompensation.
• PEWS turns observations into a score with four escalation levels, and includes parent and clinical intuition triggers that act regardless of score.
• NICE NG254 (replacing NG51 for sepsis) risk stratifies children under 16 into high, moderate-to-high and low risk, with antibiotics for high-risk children within 1 hour and critical care referral for lactate above 4 mmol/L. ^[3]
• In respiratory failure: high-flow or non-invasive support if drive is preserved; bag-mask ventilation first line; cuffed tubes; oxygen target 94 to 98%; age-specific ventilation rates with an advanced airway.
• In shock: 10 mL per kg crystalloid boluses, 40 to 60 mL per kg in the first hour if needed, 5 mL per kg in cardiogenic shock, vasoactives after three to four boluses, noradrenaline first vasopressor. ^[1]
• Paediatric BLS: five initial breaths, then 15 to 2 (or 30 to 2), rate 100 to 120, depth 4 cm infants and 5 cm children (at least one third of the chest), AED paediatric mode under 25 kg. ^[1][2]
• PALS: epinephrine 0.01 mg per kg, defibrillation 2 then 4 then at least 4 to 10 J per kg, amiodarone 5 mg per kg; reversible causes 4 Hs and 4 Ts.
• Guidelines differ on first-shock energy: AHA 2 J/kg, ERC 4 J/kg, ILCOR 2 to 4 J/kg; subsequent shocks at least 4 J/kg.
• Status epilepticus is a seizure lasting 5 minutes or more: ABC, glucose, benzodiazepine first line, second dose if needed, levetiracetam/phenytoin/valproate second line, phenobarbital or anaesthesia third line. ^[5]
• Post-ROSC: normocapnia, avoid hypotension, prevent hyperthermia above 37.5 degrees C, control seizures, and withhold prognostication for at least 72 hours in coma.
• Family-centred care, with parents kept informed and, where safe, present.

Sepsis and infection in children; pneumonia and bronchiolitis; asthma and anaphylaxis; congenital heart disease; neurological emergencies and status epilepticus; neonatal resuscitation; trauma and major haemorrhage; fluids and electrolytes. MedGrasp topic pages on these areas will be linked here once published.