Cover Page

Advanced Paediatric Life Support

A Practical Approach to Emergencies



Advanced Life Support Group



Martin Samuels
Sue Wieteska










Clinical conditions list

Condition Pages
abdominal injury 135–137
acidosis 269, 273–274, 275, 277–279
alkalosis 271, 272, 273, 276, 277, 279, 286, 289, 308
anaemia 78
anaphylaxis 56–57, 74–76, 75
asthma 50, 57–61
bradycardia 38, 81, 82, 83–84
bronchiolitis 50, 61–63
burns 155–160
carbon monoxide poisoning 159, 306
cardiac arrest 4, 199–207
cardiac tamponade 130
cardiomyopathy 77–78
cerebral oedema 290
chest injury 127–133
child abuse 291–298
choking 50, 53, 54, 56, 128, 180–183
coarctation 65, 69, 76, 105
coma 50, 89
congenital heart disease (duct‐dependent) 76–77
conscious level 16, 40–41, 89–98
convulsions 50, 145
croup 50, 53, 55
dehydration 282, 283–284
diabetic ketoacidosis 50, 97, 269, 289–290
diphtheria 57
drowning 162–166
electrical injury 161–163
empyema, pleural effusion 50
encephalitis 96–97
encephalopathy, hypertensive 95
envenomation 310–315
epiglottitis 50, 53–54, 55–56
extremity trauma 147–150
flail chest 129–130
foreign body aspiration 46, 49, 50, 52, 53, 54, 56, 173, 174, 180, 183
foreign body ingestion 316
gastroenteritis 69, 71, 72, 84, 283, 284, 285
haemothorax 129
head injury 21, 139–146
heart block, heart failure 63, 65–66
hypercalcaemia 289
hyperglycaemia 96, 140, 207, 259, 289, 308, 327
hyperkalaemia 202, 286–288
hypernatraemia 285
hypertension 105–106
hypocalcaemia 202, 288–289
hypoglycaemia 44, 71, 90, 93, 95, 96, 97, 98, 100, 101, 122, 140, 144, 145, 207, 257, 259, 288, 290, 327
hypokalaemia 202, 286
hyponatraemia 285–286
hypothermia 9, 37, 93, 100, 121, 125, 163–165, 202, 207, 258, 304, 306
infectious mononucleosis 57
intracranial haemorrhage 89, 144, 254
malaria (cerebral) 97–98
meningitis 96–97
meningococcaemia 72
myocarditis 77–78
non‐accidental injury (NAI) 292, 293
overhydration 284
patent ductus arteriosus 65
pleural effusion 50, 64
pneumonia 50, 63–65
pneumothorax 50, 128–129, 132, 196, 202, 253
poisoning 50, 66, 97, 202, 275, 303–310
pulmonary oedema 50
raised intracranial pressure 50, 140, 165
retropharyngeal abscess 57
salicylate poisoning 66
scalds 155–160
septic shock/septicaemia 39, 72–74
shock 50, 67–80
sickle cell disease/crisis 78
spine injury 150–153, 151
status epilepticus 40, 99, 101, 102, 104, 217, 339
stings 310–315
tachycardia, SVT, VT 81, 82, 84–87
tonsillitis, acute 57
toxic shock syndrome 72, 159
tracheitis 50, 55

Working group

Associate editors

A. Argent Paediatric Intensive Care, Cape Town

P. Arrowsmith Paediatric Resuscitation, Liverpool

A. Charters Paediatric Emergency Care, Portsmouth

E. Duval Paediatric Intensive Care, Maastricht

M. Hegardt‐JansonPaediatric Surgery, Lund

S. Lewena Paediatric Emergency Medicine, Melbourne

T. Rajka Paediatric Intensive Care, Oslo

M. Samuels Paediatrics, Stoke‐on‐Trent and London

S. Smith Emergency Paediatrics, Nottingham

Working group

A. Argent Paediatric Intensive Care, Cape Town

P. Arrowsmith  Paediatric Resuscitation, Liverpool

J. Brown Paediatrics, Wellington

A. Charters Paediatric Emergency Care, Portsmouth

E. Duval Paediatric Intensive Care, Maastricht

C. Ewing Paediatrics, Manchester

A. Hafeez Paediatrics, Islamabad

M. Hegardt‐Janson  Paediatric Surgery, Lund

A. Hutchison Paediatric Emergency Nursing, Melbourne

B. Kalkan Paediatrics, Sarajevo

S. Lewena Paediatric Emergency Medicine, Melbourne

K. Mackway‐Jones Emergency Medicine, Manchester

J. Mestrovic Paediatric Intensive Care, Split

E. Molyneux Paediatric Emergency Medicine, Blantyre, Malawi

P. Oakley Anaesthesia/Trauma, Stoke‐on‐Trent

J. Paul Paediatric Emergency Medicine, Trinidad

B. Phillips Paediatric Emergency Medicine, Liverpool

P. H. Phuc Paediatric Critical Care, Hanoi

T. Rajka Paediatric Intensive Care, Oslo

M. Samuels Paediatrics, Stoke‐on‐Trent and London

J. Sandell Paediatric Emergency Medicine, Poole

S. Smith Emergency Paediatrics, Nottingham

G. Spyridis Paediatric Surgery, Athens

N. Turner Paediatric Anaesthesia and Intensive Care, Utrecht

C. Vallis Paediatric Anaesthesia, Newcastle

I. Vidmar Paediatrics, Ljubljana

S. Wieteska ALSG CEO, Manchester

S. Wood Paediatric Surgery, Liverpool


Contributors to the sixth edition

S. Ainsworth Paediatrics and Neonatology, Kirkcaldy

R. Appleton Paediatric Neurology, Liverpool

A. Argent Paediatric Intensive Care, Cape Town

J. Armstrong Paediatric Anaesthesia, Nottingham

P. Arrowsmith Paediatric Resuscitation, Liverpool

A. Baldock Paediatric Anaesthesia, Southampton

K. Berry Paediatric Emergency Medicine, Birmingham

V. Bhole Paediatric Cardiology, Birmingham

D. Bramley Emergency Medicine, Sunderland

A. Burgess Paediatric ENT Surgery, Southampton

S. Bush Urgent Care, Leeds

A. Charters Paediatric Emergency Care, Portsmouth

R. Cheung General Paediatrics, London

F. Davies Emergency Medicine, Leicester

J. Davison Paediatric Metabolic Medicine, London

J. Doherty Paediatrics, Dorchester

I. Doull Paediatric Respiratory Medicine, Cardiff

E. Duval Paediatric Intensive Care, Maastricht

R. Fisher Paediatric Surgery, Sheffield

C. Fitzsimmons Paediatric Emergency Medicine, Sheffield

P‐M. Fortune Paediatric Intensive Care, Manchester

J. Foster Paediatric Radiology, Plymouth

A. Gandhi Paediatric Cardiology, Birmingham

J. Grice Paediatric Emergency Medicine, Liverpool

G. Haythornthwaite Paediatric Emergency Medicine, Bristol

M. Hegardt‐Janson Paediatric Surgery, Lund

M. Hellaby North West Simulation Education Network, Manchester

S. Hewitt Emergency Medicine, Derby

L. Hudson Paediatrics, London

P. Hyde Paediatric Intensive Care, Southampton

H. Ismail‐Koch Paediatric ENT Surgery, Southampton

B. Ko Community Paediatrics, London

A. Lee Paediatric Trauma and Orthopaedics, Reading

S. Lewena Paediatric Emergency Medicine, Melbourne

C. Loew Anaesthesia, Poole

M. Lyttle Paediatric Emergency Medicine, Bristol

L. Mackintosh Community Paediatrics, Bristol

K. Mackway‐Jones Emergency Medicine, Manchester

N. Makwana Paediatrics, Birmingham

W. Marriage Paediatrics, Bristol

P. McMaster Paediatric Infectious Diseases, Manchester

P. McQuillan Paediatric Intensive Care, Portsmouth

B. Mehta Paediatric Emergency Medicine, Liverpool

P. Oakley Anaesthesia, Stoke on Trent

B. Okoye Paediatric Surgery, London

F. O’Leary Paediatric Emergency Medicine, Sydney

L. Prentice Paediatric Anaesthetist, Melbourne

T. Rajka Paediatric Intensive Care, Oslo

T. Ralph Paediatric Resuscitation Training, Sheffield

G. Roberts Paediatric Allergy and Respiratory Medicine, Southampton

S. Roberts Paramedic; Pre hospital Trauma and Paediatric Care, West Midlands

M. Samuels Paediatrics, Stoke‐on‐Trent and London

D. Schenk General Paediatrics, Newcastle

N. Sen Emergency Medicine, Manchester

A. Simpson Emergency Medicine, Stockton‐on‐Tees

H. Smith Paediatrics, Southampton

S. Smith Emergency Paediatrics, Nottingham

E. Snelson Paediatric Emergency Medicine, Sheffield

K. Soanes Emergency Medicine, Birmingham

K. Thies Anaesthetics, Birmingham

R. Tinnion Neonatology, Middlesborough

Y. Tse Paediatric Nephrology, Newcastle

C. Vallis Paediatric Anaesthesia, Newcastle

A. Walker Paediatric Anaesthesia, Glasgow

L. Walton Paediatric Emergency Medicine, Nottingham

J. White Toxinologist, Adelaide

S. Wieteska ALSG CEO, Manchester

S. Wood Paediatric Surgery, Liverpool

J. Wyllie Neonatology, Middlesbrough

A. Young Paediatric Anaesthesia, Bristol

Contributors to previous editions

S. Agrawal Paediatric Intensive Care, London

R. Appleton Paediatric Neurology, Liverpool

A. Argent Paediatric Intensive Care, Cape Town

C. Baillie Paediatric Surgery, 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

G. Browne Paediatric Emergency Medicine, Sydney

C. Cahill Emergency Medicine, Portsmouth

H. Carty Paediatric Radiology, Liverpool

A. Charters Emergency Nursing, Portsmouth

M. Clarke Paediatric Neurology, Manchester

J. Couriel Paediatric Respiratory Medicine, Liverpool

P. Driscoll Emergency Medicine, Manchester

P‐M. Fortune Paediatric Intensive Care, Manchester

J. Fothergill Emergency Medicine, London

P. Habibi Paediatric Intensive Care, London

D. Heaf Paediatric Respiratory Medicine, Liverpool

J. K. Heltne Anaesthesia, Haukeland

F. Jewkes Pre‐Hospital Paediatrics, Wiltshire

E. Ladusans Paediatric Cardiology, Manchester

J. Leggatte Paediatric Neurosurgery, Manchester

J. Leigh Anaesthesia, Bristol

S. Levene Child Accident Prevention Trust, London

M. Lewis Paediatric Nephrology, Manchester

K. Mackway‐Jones Emergency Medicine, Manchester

I. Maconochie Emergency Paediatrics, London

J. Madar Neonatology, Plymouth

T. Martland Paediatric Neurologist, Manchester

D. McKimm Paediatric Intensive Care Nursing, Belfast

E. Molyneux Paediatric Emergency Medicine, Malawi

S. Nadel Paediatric Intensive Care, London

D. Nicholson Radiology, Manchester

A. Nunn Pharmacy, Liverpool

E. Oakley Paediatrics, Victoria

P. Oakley Anaesthesia, Stoke on Trent

R. Perkins Paediatric Anaesthesia, Manchester

B. Phillips Paediatric Emergency Medicine, Liverpool

T. Rajka Paediatrics, Oslo

J. Robson Paediatric Emergency Medicine, Liverpool

I. Sammy Paediatric Emergency Medicine, Trinidad

M. Samuels Paediatric Intensive Care, Stoke on Trent

D. Sims Neonatology, Manchester

A. Sprigg Paediatric Radiology, Sheffield

B. Stewart Paediatric Emergency Medicine, Liverpool

J. Stuart Emergency Medicine, Manchester

L. Teebay Child Protection and Paediatric Emergency Medicine, Liverpool

J. Tibballs Paediatric Intensive Care, Melbourne

N. Turner Paediatric Anaesthesia and Intensive Care, Utrecht

J. Walker Paediatric Surgery, Sheffield

W. Whitehouse Paediatric Neurologist, Nottingham

S. Wieteska ALSG Group Manager, 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

Preface to the first edition

Advanced Paediatric Life Support: The Practical Approach was written to improve the emergency care of children, and has been developed by a number of paediatricians, paediatric surgeons, emergency physicians and anaesthetists from several UK centres. It is the core text for the APLS (UK) course, and will also be of value to medical and allied personnel unable to attend the course. It is designed to include all the common emergencies, and also covers a number of less common diagnoses that are amenable to good initial treatment. The remit is the first hour of care, because it is during this time that the subsequent course of the child is set.

The book is divided into six parts. Part I introduces the subject by discussing the causes of childhood emergencies, the reasons why children need to be treated differently and the ways in which a seriously ill child can be recognised quickly. Part II deals with the techniques of life support. Both basic and advanced techniques are covered, and there is a separate section on resuscitation of the newborn. Part III deals with children who present with serious illness. Shock is dealt with in detail, because recognition and treatment can be particularly difficult. Cardiac and respiratory emergencies, and coma and convulsions, are also discussed. Part IV concentrates on the child who has been seriously injured. Injury is the most common cause of death in the 1–14‐year age group and the importance of this topic cannot be overemphasised. Part V gives practical guidance on performing the procedures mentioned elsewhere in the text. Finally, Part VI (the appendices) deals with other areas of importance.

Emergencies in children generate a great deal of anxiety – in the child, the parents and in the medical and nursing staff who deal with them. We hope that this book will shed some light on the subject of paediatric emergency care, and that it will raise the standard of paediatric life support. An understanding of the contents will allow doctors, nurses and paramedics dealing with seriously ill and injured children to approach their care with confidence.

Kevin Mackway‐Jones
Elizabeth Molyneux
Barbara Phillips
Susan Wieteska
Editorial Board

Preface to the sixth edition

The Advanced Paediatric Life Support (APLS) concept and courses have aimed from inception 23 years ago to bring a structured approach and simple guidelines to the emergency management of seriously ill and injured children. The manual was and continues to be an important part of the course, but it has also come to be used as a handbook in clinical practice. This has been a real tribute to the contributors of this text, both current and past editions.

The course has changed since the last edition to reflect the changes in health service provision, as well as the increasing evidence base of medical knowledge. Clinical practice has become more sophisticated and sub‐specialised, and increasingly children with complex multisystem disorders are surviving. This has been accompanied by the need to develop increasingly expert teams to provide health care. As a result, providers of emergency care are no longer expected to possess the wide‐ranging skills that were needed to treat children and young people 10–20 years ago. Trauma care has undergone the greatest revision and the importance of team working, utilising the skills of many different disciplines and knowing when and how to seek additional help are hopefully clearly reflected within the provider course.

The sixth edition of the manual reflects the pace of change of medical science and practice, the international nature of APLS and the increasing recognition of the importance of human factors in providing the best emergency care. This edition benefits from the latest guidelines for resuscitation from cardiac arrest by the International Liaison Committee on Resuscitation (ILCOR), published in October 2015.

Whilst the sixth edition is current, we hope that APLS providers will see the introduction of an app, paperless courses and an enhanced electronic learning resource with chronic and specialist conditions. Contributions and ideas are always welcome.

APLS is established in the United Kingdom, Australasia, the Caribbean, mainland Europe, the Middle and Far East, Scandinavia and South Africa. In addition, the Advanced Life Support Group (ALSG) has collaborated with many other agencies so that the course is now available in a number of resource‐poor countries, either in its original form or modified for local use. To ensure this, ALSG has had to be responsive to the different styles, languages, cultures and clinical facilities found in many different countries. It is with the help of so many enthusiastic and dedicated local health professionals that APLS has flourished.

We hope that new as well as current providers of emergency paediatric practice appreciate the changes.

The material found in these sources, as well as in this manual, is all brought together by the increasing numbers of experts that have contributed to this update. We thank them and all our instructors, who have provided helpful feedback. We ask that this process does not stop, so that we can begin the process that will support the development of the next edition.

Martin Samuels
Sue Wieteska
Manchester 2016

Preface to the modified Australia and New Zealand sixth edition

The Australia and New Zealand version of the sixth edition APLS manual is the reference resource for APLS providers in these countries. Together with the online learning, the content within this manual forms the basis of what is taught on local APLS courses.

The standard version of the sixth edition APLS manual is the result of significant international collaboration within the worldwide APLS community. The aim was to produce an evidence based reference that reflects an internationally appropriate approach to the care of sick and injured children.

The changes within this manual compared to the standard sixth edition have been restricted to those deemed to be critical and required to reflect and comply with standard practice in Australia and New Zealand. In particular, Chapters 18 and 20 have been modified to align with local resuscitation guidelines. Additional minor variations in practice due to different approaches, availability of medications and local guidelines are inevitable. These differences will be dealt with within the online learning and the face to face course.

Stuart Lewena
President, APLS Australia


A great many people have put a lot of hard work into the production of this book, and the accompanying advanced life support course. The editors would like to thank all the contributors for their efforts and all the APLS instructors who took the time to send us their comments on the earlier editions.

We are greatly indebted to Helen Carruthers, MMAA, Mary Harrison, MMAA and Kate Wieteska for producing the excellent line drawings that illustrate the text. The information in Table 6.1 is taken from Lessons from Research for Doctors in Training produced by the Meningitis Research Foundation. We would also like to thank Mark Hellaby, NW Simulation Education Network Manager for his input into the Human factors chapter.

ALSG gratefully acknowledge the support of the Royal College of Paediatrics and Child Health (UK). The Specialist Groups of the RCPCH agreed to advise on the clinical content of chapters relevant to their specialism. ALSG wish to thank the following:

Association of Paediatric Anaesthetists Dr A. Walker, Paediatric Anaesthesia, Glasgow

Association of Paediatric Emergency Medicine Dr K. Berry, Paediatric Emergency Medicine, Birmingham; Dr N. Sargant, Paediatric Emergency Medicine, Bristol

British Association for Paediatric Nephrology Dr Y. Tse, Paediatric Nephrology, Newcastle

British Association of Community Child Health Dr B. Ko, Community Paediatrics, London

British Association of Paediatric Surgeons – trauma committee Mr B. Okoye, Paediatric Surgery, London

British Inherited Metabolic Disease Group Dr J. Davison, Paediatric Metabolic Medicine, London

British Paediatric Allergy, Immunology and Infection Group Dr G. Roberts, Paediatric Allergy and Respiratory Medicine, Southampton; Dr P. McMaster, Paediatric Infectious Diseases, Manchester and Dr N. Makwana, Paediatrics, Birmingham

British Paediatric Neurology Association Dr R. Appleton, Paediatric Neurology, Liverpool

British Paediatric Respiratory Society Dr I. Doull, Paediatric Respiratory Medicine, Cardiff

British Society of Paediatric Radiology Dr J. Foster, Paediatric Radiology, Plymouth

Child Protection Special Interest Group Dr L. Mackintosh, Community Paediatrics, Bristol; Dr J. Doherty, Paediatrics, Dorchester; Dr H. Smith, Paediatrics, Southampton

Paediatric Intensive Care Society Dr P‐M. Fortune, Paediatric Intensive Care, Manchester

Paediatricians with Expertise in Cardiology Special Interest Group Dr A. Gandhi, Paediatric Cardiology, Birmingham

We are also grateful to the following groups who have advised on the clinical content of chapters relevant to their specialism:

European Resuscitation Council: European Trauma Course Mr K. Thies, Anaesthetics, Birmingham

MARSIPAN group Dr L. Hudson, Paediatrics, London

Royal College of Surgeons: Advanced Trauma Life Support Dr H. Walmsley, Anaesthetics, Eastbourne; Dr A. Duby, Military Emergency Medicine, Birmingham; Mr S. Bush, Emergency Medicine, Leeds; Mr M. Bagnall, General Surgery, Redhill; Mr J. Hambidge, Trauma and Orthopaedics, Romford; Dr R. O’Donnell, Paediatric Emergency Medicine, Cambridge; Dr L. Zibners, Paediatric Emergency Medicine, London

Finally, we would like to thank, in advance, those of you who will attend the Advanced Paediatric Life Support course and other courses using this text; no doubt, you will have much constructive criticism to offer.

We acknowledge the review process and work undertaken by the members of the Australia NZ Course Development Committee to ensure that the Australia/New Zealand 6th edition reflects clinical practice in that setting (Stuart Lewena, Jacquie Schutz, Andrew Terrey, Tom Walwyn, Tom Grattan‐Smith, Cathrin Parsch, Jane Stanford, David Watton).

Contact details and further information


For details on ALSG courses visit the website or contact:
Advanced Life Support Group
ALSG Centre for Training and Development, 29–31 Ellesmere Street, Swinton, Manchester M27 0LATel: +44 (0)161 794 1999; Fax: +44 (0)161 794 9111; Email:

Advanced Paediatric Life Support, Australia
Phillip Davies, Chief Executive Officer and General Counsel
Level 5, 505 Little Collins Street, Melbourne, Victoria 3000
Tel: +61 3 8672 2800; Fax: +61 3 8672 2888; Email:; Website:

Advanced Paediatric Life Support, NZ
Jo Jones, NZ Executive Officer
PO Box 506, Whakatane 3158
Tel: +64 7 312 9574; Email:; Website:

Clinicians practising in tropical and under‐resourced health care systems are advised to read International Maternal and Child Health Care – A Practical Manual for Hospitals Worldwide ( which gives details of additional relevant illnesses not included in this text.


The material contained within this book is updated on a 5‐yearly cycle. However, practice may change in the interim period. We will post any changes on the ALSG website, so we advise that you visit the website regularly to check for updates ( The website will provide you with a new page to download.


All references are available on the ALSG website

On‐line feedback

It is important to ALSG that the contact with our providers continues after a course is completed. We now contact everyone 6 months after their course has taken place asking for on‐line feedback on the course. This information is then used whenever the course is updated to ensure that the course provides optimum training to its participants.