See SVT.

Adenosine 150mcg/kg? 12yr 3mg

Broad complex SVT – just treat as VT.


Remove oxygen tubing for shocks unless closed circuit.

Stand clear – look at top/middle/bottom!

IM/IN ketamine plus sedation for synchronised shock.

Synchronised shocks are 1 then 2 J/kg.

Sync button needs pressed for each shock – most machines immediately reset. Press and hold – needs time to sync and give shock.


UK Resuscitation council updates guidelines from time to time.

See also anaphylaxis (now 2 guidelines, basic and refractory) and arrhythmia.

Atropine not part of guideline – neonates 10mcg/kg (no minimum). Else 20mcg/kg min 100mcg. 

Out of hospital – Shout for help AND ask for an AED.  Sudden OOH collapse likely to be cardiac, even in a child – don’t wait till after rescuer breaths!

Compressions 100-120.min for both infants and children. One third depth of chest – 4cm infant, 5 child (6 adult). 1 finger breadth above xiphisternum to avoid organs. 

40% blood volume might be lost before hypotension appears…

5th centile for systolic BP is 70 at 1yr, 80 at 10, 90 at 15yr. 

Haemothorax might be picked up in B but don’t manage until C!

C – compartments of body incl long bones. 1:1 RCC:FFP

TXA – bolus, remember 2nd dose (or double bolus). 

Log roll can be missed if suspected spinal unless penetrating back wound suspected (or found on absorbent surface…)

ATMIST – age, time, 

Parents need a senior person who understands!

CT head might be better done at trauma centre…


Raanan Gillon campaigned successfully for fairness to be added to the World Medical Association’s International code of medical ethics (with respect to both patients and professionals).

It therefore joins beneficence, non-maleficence and respect for autonomy as one of the cardinal principles (Beauchamp and Childress).

What fairness means is debatable, however. And these different principles can conflict.

But it still has value as a way of analysing ethical problems. Hopefully in advance of the problem becoming real for someone.

Aristotle’s theory of justice or fairness is a good place to start – “equals should be treated equally” is straightforward, but it also includes “unequals should be treated unequally, in proportion to their inequalities). In other words, some people may need to be treated differently (“unequally”) because they need the treatment more.

Allergies and School/Nursery

First do no harm – parents tend to overestimate risk of anaphylaxis, whereas there are clear consequences to restricting the child’s ability to sit with other children at snack/meal times, or restricting the food choices of other children.

Probably better to increase allergy awareness (which varies widely) than rely on classroom or school-wide bans [Dave Stukus editorial]

George Raptis has shown how allergy training can improve allergy awareness, not just confidence in managing an allergic emergency.


Muscle breakdown with release of products into blood stream that can cause acute renal failure.

Typically occurs with crush injuries, sometimes seen with extreme endurance sports.

Can be infectious.

Recurrent seen with fatty acid oxidation disorders and Lipin 1 mutations.

Lipin 1 mutations

Autosomal recessive – heterozygotes may have exercise induced muscle symptoms or be prone to drug induced myopathy.

Basal CK high but spikes to over 100 000 with decompensation (infection, exercise, anaesthetic).

Treat crises with carbohydrates/intralipid.


Children are small adults, when it comes to trauma!

Mortality jumps when airway management instituted more than 45 mins after 999 call. (NICE) Mortality actually rare with isolated head (7%) and abdominal (20%) trauma. But jumps to 50% for multiple sites.

Beware head impact apnoea.

Collars not required as part of immobilisation in children. Cx spine trauma v rare. Manual in line stabilisation best if necessary. Extrication maybe?

Triage tool highlights who needs to go to trauma centre eg mangled limbs, penetrating or open trauma, mechanisms eg ejection from vehicle.  But always clinical judgement.

If “hot critical” then decide on transfer to tertiary centre within 8 minutes. Airway, catastrophic haemorrhage and move.

C-ABC is catastrophic haemorrhage first.

Access above and below diaphragm if possible. Blood first line if bleeding. 10ml/kg aliquots. 1:1:1 packed cells, FFP and platelets as able.

Tranexamic acid dose 15ml/kg (same as paracetamol!). See major haemorrhage protocol. No role for permissive hypotension in children.

Avoid over resuscitation with crystalloid.

Pelvic binder problematic if moves. Fixes greater trochanters and public symphysis.

AVPU – but specify pain response!

Head injury: 3% saline preferred. Aim for high MAP, with inotropes if necessary. GGC has guideline. Adrenaline preferred.

Agitated kid – persevere with getting them into scanner without anaesthetic! In Wishaw, induction best in theatre but would then need to go in lift!  Limited expertise with waking them up! Discuss with Scotstar, maybe move, maybe tube.

Log roll 90% out, 20% in? Conrad 2012

Traumatic cardiac arrest: in adults, evidence for aggressive treatment of reversible causes. Consensus is for bundle of simultaneous interventions (not all necessary for every case), prioritised ahead of CPR!

  • Haemorrhage control
  • ETT or equivalent
  • Bilat finger thoracostomies
  • Rapid volume replacement with warmed blood NOT thoracotomy or inotropes. Persistent low ETCO2 is poor prognostic sign.

Even if death declared out of hospital, should be admitted for after care.

NAI audit – 5.2% rate of suspected child abuse. 75% under 1 yr. Often major trauma, often severe brain injury.

Major Incident

Workload should be spread out. Over 12 should go to adults (unless lots of adults too). Walking wounded to non trauma centres. Try not to separate children from injured parents – who worst affected?


Still routine practice in many parts of the world, including the USA. Last figures I can find suggest 56% of US boys circumcised, with higher rates among non-Hispanic white boys, which is down from previous decades.

The Royal Dutch Medical Association declared in 2010 that male circumcision as routine practice or for religious reasons is medically unjustified and therefore an abuse of the rights of the child.

In 2013 the Children’s ombudsmen of the Nordic countries proposed a ban. In Sweden it is illegal in the first 2 months of life, following a death from complications in 2001 (an attempt at an outright ban was watered down).

In the UK there have been legal cases where parents have disagreed on their son having the procedure.

Trials in Africa suggested that circumcision might help prevent spread of HIV (38-66% reduced risk). South African president Jacob Zuma made a point of getting circumcised, to encourage others.

Risks are low in neonates cf adults.

Muslim and Jewish cultures see it as part of cultural identity, of course.

Onion and garlic allergy

Alliums, as are leeks, shallots and chives. Part of same bigger family as asparagus but probably not co-sensitivity.

The main issue with onion is the chemicals released from cut surfaces, which can trigger eye/nose reactions and potentially asthma. But there’s actually some evidence that onion has an anti-allergy action.

With garlic, there is a well recognised contact dermatitis relating to chopping it.

Otherwise, allergy is very rare. Potentially part of celery-spice-mugwort syndrome.

As with that syndrome, the problem for the allergic person is that not only is it not one of the 14 UK recognised allergens for food labelling and restaurants, but it can be included under “spices” if less than 2% of the overall product, without further detail.

Gaming technology in healthcare

Humans, and children in particular, learn through play. Play is how we develop new models to understand the world around us.

Expert game designers are well-versed in sociology, psychology, and the cognitive sciences that underlie motivation and behavior. They know how to achieve the perfect balance between challenge and mastery – too hard is off putting, too easy is uninvolving – and they build reward-driven experiences that capture attention.

Games are ultimately how we work out rules, and hence strategy.

All these things are essential components of learning, and indeed life.

A good game requires intense concentration, and this is where maximally efficient learning occurs, which contributes to better knowledge retention and skill development. And with a game this is almost an unintended consequence.

[Eric Gantwerker]

Food allergy

Different from intolerance and sensitivity, which are not immune mediated problems. Sometimes hard to tell the difference.

2 types of food allergy, you can have both at the same time – type 1 (IgE mediated), and non-type 1 (non-IgE mediated – possibly type 4 hypersensitivity).

Most commonly (in Scotland – but varies across UK, especially with different ethnic groups), and varies widely across the world):

  • Milk
  • Egg
  • Peanut
  • Tree nuts
  • Legumes/Pulses
  • Sesame
  • Wheat
  • Crustaceans/molluscs
  • Various fruits

Patient/parent feedback pretty consistent across the world however (although most studies done in Europe and English speaking countries), and across time:

  • Parents lived in fear after the first reaction, often perceiving it as traumatic, and often feeling guilt too
  • They tried to live an ordinary family life and had to learn how to be one-step ahead and understand early signs.
  • The family’s social life was also influenced.
  • Parents asked for support and information from health professionals
  • More knowledge and skills increased parents’ confidence (and by implication quality of life – Knibb 2015)

Mothers tend to report greater impact on the child’s quality of life and experience more anxiety and stress than fathers. Mothers tend to shelter the child, whereas fathers more often express a desire to expand their child’s life, and these differences are often greater where parents are separated.

The concern for the child’s safety affected eating outside the home, with birthday parties and visits to peers’ homes particularly threatening. School and nursery are a major source of concern and often led to more parental work, preparing safe lunches.

Parents often felt they had to teach themselves about allergies, due to the lack of early information provided by health care, and then ended up having to teach family, friends and educational institutions too.

Adolescence is a particularly stressful time, as parents recognize the need for the child to become more independent, at the same time that the adolescent can see the parents as excessively controlling (at least with respect to peanut allergy). Supportive friends particularly important for adolescents.

[Larsen Moen, J Ped Nursing 2019]