Resuscitation & APLS
APLS, arrest algorithms and the systematic paediatric approach.
Use as a study guide only. These notes are part of a free open-access medical education (FOAMed) project and may contain errors or outdated information. Always verify against current guidelines (e.g. eTG, RACGP, local health district policies) and reputable sources before applying anything to patient care. See the full disclaimer.
Clinical pearls & learnings
Tips and tricks collected over the years — a living list that grows with every rotation. Use as a study guide only and check current guidelines before acting on anything.
APLS: the structured approach
Starting the scenario
- Danger / safety — and in trauma, manual in-line cervical spine stabilisation
- Catastrophic external haemorrhage — control it before anything else
- A: airway with C-spine control — suction, adjuncts, positioning
- B: breathing — oxygen, look for the work and efficacy of breathing
- C: circulation — two large-bore IVs (or IO), fluids, activate MTP if bleeding
- D: disability — AVPU/GCS, pupils, and always a blood sugar
- E: exposure — temperature, rash, abdomen
Say the structure out loud as you go — in APLS scenarios you are marked on the systematic approach as much as the diagnosis. Verbalise reassessment after every intervention.
Things that catch candidates out
Common traps — and what to do instead
| Trap | Get it right |
|---|---|
| Phenytoin given too fast | Infuse over ~20 minutes, not 5 — rapid infusion causes hypotension and arrhythmia. Keep on cardiac monitoring |
| Starting compressions too early | Check for signs of life after the initial rescue breaths first |
| Adrenaline timing in a shockable rhythm | Give adrenaline after the second or third shock — not immediately |
| Forgetting calcium in massive transfusion | Citrate in stored blood chelates calcium → hypocalcaemia, worsening coagulopathy and cardiac contractility. Give calcium |
| Skipping the face and mouth in trauma | Look for broken or missing teeth — they can obstruct the airway or be aspirated |
| Antibiotics before cultures | Take blood cultures in any septic child or unexplained high lactate — before antibiotics if it does not delay them |
| No IV access in an agitated patient | Ketamine 4mg/kg IM is an option for control |
Around 5% of febrile convulsions progress to status epilepticus. A coma or reduced conscious state is a relative contraindication to lumbar puncture — as are focal neurology, signs of raised ICP, cardiorespiratory instability and coagulopathy. Give antibiotics first and defer the LP.
Handover
Lead with the problem, not the story: what they have, what you have done, and what you need. A crisp one-line summary (“3-year-old, septic shock from likely meningococcaemia, 40mL/kg in, on adrenaline, needs PICU retrieval”) beats a chronological narrative every time.
Shock & cardiorespiratory compromise
Cardiorespiratory compromise — the generic ladder
- Oxygen — non-rebreather, then airway adjuncts, then LMA/intubation as needed
- Fluids — careful, weight-based boluses with reassessment after each
- Inotropes / vasopressors if fluid-unresponsive
- Antibiotics early if sepsis is possible
Scenarios worth rehearsing
Other scenarios worth rehearsing
- Local anaesthetic systemic toxicity — follow the LAST algorithm and give intravenous lipid emulsion.
- Severe lactic acidosis — think sepsis, dehydration, and concealed abdominal bleeding; involve surgeons, take cultures, give antibiotics.
- Severe gastroenteritis — hunt for electrolyte derangement and hypovolaemia.
- Anaphylaxis, asthma, croup, opioid toxicity, neutropenic sepsis, and the surgical abdomen (trauma, bilious vomiting).
In every seriously unwell child, check the abdomen, the skin for rash, the temperature, the pupils and the blood sugar. These are the things most often skipped under pressure — and each one changes management.