Approach to the Sick Child

Part A

Foundations: how to think before you act

Units 1–3 · ~5 hours

Every protocol in the next four Parts is an answer to three questions asked here: why do children die, how do you see it coming in sixty seconds, and why does a child's physiology hide the danger until late. Part A is open from the first minute.

▸Unit 1 Why children die, and where this module fits Not attempted

A child who dies in hospital usually does so within the first day, from a short list of physiological end-points, after a period in which someone could have noticed. This module exists because of that sentence.

Learning outcomes

UG State the leading causes of death in children under five, globally and in India, and explain why most are preventable at first contact.
UG Describe the deterioration continuum — well, compensated, decompensated, arrest — and name the two final common pathways to paediatric cardiac arrest.
UG/PG Distinguish recognition failure, diagnostic error and execution failure, and match each to the fix that actually addresses it.
PG Critique the evidence for structured recognition systems (ETAT, PEWS), including the negative EPOCH trial, and read it across the resource gradient.

1 · The mortality picture Must-know

Under-five mortality has fallen steeply over three decades, but the deaths that remain concentrate into a short list. Beyond the neonatal period the largest contributors are pneumonia, diarrhoea, malaria, injuries and infection in a malnourished child. Within the neonatal period, prematurity, intrapartum-related events and neonatal infection dominate.

Two facts should shape how you read the rest of this module:

Death clusters early. A large share of in-hospital paediatric deaths happen within 24 hours of arrival — many within the first few hours. The window in which recognition changes the outcome is measured in minutes to hours, not days.
The pathway is respiratory or circulatory, not primarily cardiac. Children rarely have a primary arrhythmic arrest. Paediatric cardiac arrest is usually the end of progressive respiratory failure or shock. That is good news: there is a long, visible, interruptible runway before arrest.

India lens

India's neonatal period now accounts for the majority of under-five deaths, which is why Unit 17 (the sick young infant) is core, not optional. First contact for a sick child is frequently not a paediatrician: it is an ASHA, an ANM, a PHC medical officer, a general practitioner or a private clinic. IMNCI and F-IMNCI exist precisely to push structured recognition down to that level. A module that teaches only PICU-grade assessment teaches the wrong end of the pathway — recognition at first contact and safe referral save far more lives than any single ICU intervention.

Mortality figures change every year. Quote current Sample Registration System (SRS) bulletins and national cause-of-death estimates, not a number remembered from a lecture.

2 · The deterioration continuum Must-know

The runway to arrest

  WELL
    │   insult: infection · dehydration · obstruction · toxin · trauma · metabolic
    ▼
  COMPENSATED   tachycardia · tachypnoea · cool peripheries · CRT > 2 s
    │           anxious, clingy or quiet · NORMAL blood pressure
    │           ▸ this is where you win
    ▼
  DECOMPENSATED hypotension · altered sensorium · mottling
    │           weak central pulses · falling respiratory effort
    │           ▸ hours of physiological credit already spent
    ▼
  PERI-ARREST   bradycardia · gasping · unresponsive
    ▼
  ARREST        usually asystole or PEA · survival poor

The clinically decisive point is that a child's blood pressure is a late and treacherous sign. Children hold their blood pressure with vigorous tachycardia and vasoconstriction until compensation fails — abruptly. A normal blood pressure in a tachycardic, cold, unwell child is not reassurance. It is a compensating child, and compensation is a countdown.

The error clinicians actually make

“BP was 96/60, so I wasn't worried.” Hypotension in a child is a pre-terminal sign; in haemorrhage it may not appear until roughly a third of the circulating volume is gone. Treat the heart rate, the capillary refill, the skin temperature and the sensorium — not the number on the cuff.

3 · Three different failures, three different fixes Good-to-know UG/PG

Failure	What happened	What fixes it
Recognition failure	The abnormal physiology was present and recordable, but nobody registered it as abnormal — or registered it and did not escalate.	Structured assessment (PAT, ETAT), track-and-trigger charts, mandated escalation, and permission for nurses and parents to escalate.
Diagnostic error	The physiology was noticed; the cause was misattributed — DKA called gastroenteritis, myocarditis called bronchiolitis.	Illness scripts, a forced alternative diagnosis, a diagnostic time-out, follow-up loops.
Execution failure	Recognised and diagnosed, but the treatment was late, wrongly dosed or unavailable.	Pre-calculated dose charts, checklists, simulation, and oxygen and drug supply chains.

Parts A and B of this module attack recognition failure. Parts C and D attack diagnostic and execution error for the conditions that kill most often. Part E attacks the systems around them. Deciding which of the three is your own department's real problem is a worthwhile first act of quality improvement.

4 · Does structured recognition work? Read the negative trial too Nice-to-know PG

Evidence note

ETAT in low-resource hospitals. Introducing structured emergency triage, with training and supervision, has been associated with substantial falls in early in-hospital paediatric mortality in several African and Asian hospitals. The mechanism is simple: a queue is replaced by a triage decision.

PEWS in well-resourced hospitals. The EPOCH cluster-randomised trial (Parshuram et al., JAMA 2018; 21 hospitals in 7 countries, over 144,000 admissions) found that the Bedside Paediatric Early Warning System did not reduce all-cause hospital mortality compared with usual care.

How to reconcile them. A track-and-trigger tool adds value in proportion to the surveillance gap it fills. On a tertiary ward with 1:2 nursing and a rapid response team the marginal gain is small. On a 60-bed district ward with two night nurses and no triage, the same tool can be transformative. Do not carry a negative trial's conclusion across a resource gradient — in either direction. It is a habit of appraisal you will need again for FEAST in Unit 8.

Checkpoint 1 of 2

A 3-year-old has had fever and poor feeding for three days. Heart rate 168/min, respiratory rate 46/min, BP 98/62 mmHg, capillary refill 4 seconds, cool knees; irritable but consolable. Which statement is most accurate?

Nudge

Which of the findings here does the body sacrifice first, and which does it protect to the very end?

Structured hint

Look at the perfusion findings — capillary refill, skin temperature, behaviour — separately from the blood pressure. If they are abnormal while the pressure is normal, what word describes that state?

Checkpoint 2 of 2

A registrar reviewing ward deaths finds that in three of five cases the observation charts showed rising heart and respiratory rates for six to ten hours before the arrest call, but no one was called. The correct diagnoses were made at the arrest. What is the principal failure, and the fix most likely to prevent the next one?

Nudge

The physiology was on paper for hours. The diagnosis was right. So where did the chain break?

Structured hint

Sort the failure into one of three bins: not seeing the danger, misnaming it, or acting on it too slowly. Here the numbers were seen and recorded — were they registered as abnormal and escalated?

▸Unit 2 The sixty-second assessment Not attempted

Before you touch the child, before the thermometer, before the history, you look and listen from the doorway. Done properly it takes under a minute, needs no equipment, and decides the next hour.

Learning outcomes

UG Perform a Paediatric Assessment Triangle and convert the result into a physiological category and a first move.
UG Apply WHO ETAT to sort any arriving child into emergency, priority or queue, and name every emergency sign from memory.
UG Use age-specific normal ranges for heart rate, respiratory rate and systolic blood pressure, and the formula for hypotension in children aged 1–10 years.
PG Choose and defend a track-and-trigger tool for a given ward, including its escalation response and a carer-concern trigger.

1 · The Paediatric Assessment Triangle Must-know

The PAT is purely observational and hands-off. Its three sides are Appearance, Work of breathing and Circulation to skin. It answers two questions — how sick? and which system? — before any history or investigation.

Side	What you look for
Appearance (TICLS)	Tone — limp or resisting · Interactivity — reaches, plays, tracks · Consolability — settles with the carer · Look/gaze — fixes on you, or stares blankly · Speech/cry — strong, weak, high-pitched or absent
Work of breathing	Noises without a stethoscope (stridor, grunting, wheeze) · abnormal position (tripod, sniffing, refusing to lie flat) · recession (subcostal, intercostal, suprasternal) · nasal flaring · head bobbing in infants
Circulation to skin	Pallor · mottling · cyanosis

Appearance	Breathing	Circulation	Category	First move
Normal	Normal	Normal	Stable	History and examination
Normal	Abnormal	Normal	Respiratory distress	Oxygen, position of comfort, find the cause
Abnormal	Abnormal	Normal	Respiratory failure	Support ventilation now
Normal	Normal	Abnormal	Compensated shock	Access, fluid decision, find the cause
Abnormal	Normal	Abnormal	Decompensated shock	Resuscitate immediately
Abnormal	Normal	Normal	Primary brain or metabolic problem	Glucose, seizures, toxins, infection, raised pressure
Abnormal	Abnormal	Abnormal	Cardiopulmonary failure	Full resuscitation; arrest is imminent

Pearl

The row most often missed on wards is abnormal appearance with normal breathing and normal circulation. That child has a brain or metabolic problem — hypoglycaemia, meningitis or encephalitis, poisoning, non-convulsive seizures, intussusception with lethargy, or an inborn error decompensating. Check a glucose before anything else.

2 · WHO ETAT: emergency, priority, queue Must-know

ETAT is WHO's triage system for facilities where children arrive in numbers and wait. Its strength is that a trained nurse or health worker can perform it at the door, without investigations, in under a minute.

ETAT at the door

Text version

EMERGENCY SIGNS  ▸ treat NOW, do not queue
  A  Airway      obstructed or absent breathing
  B  Breathing   severe respiratory distress · central cyanosis
  C  Circulation cold hands WITH capillary refill > 3 s
                 AND a weak, fast pulse
  C  Coma        unconscious (AVPU: responds only to pain, or not at all)
  C  Convulsing  now
  D  Dehydration severe, in a child with diarrhoea: any two of
                 lethargy · sunken eyes · very slow skin pinch
                 (Check for severe malnutrition before giving IV fluid)

PRIORITY SIGNS ("3 TPR MOB")  ▸ front of the queue, assess quickly
  Tiny baby (under 2 months) · Temperature (very high)
  Trauma or urgent surgical condition · Pallor (severe)
  Poisoning · Pain (severe) · Respiratory distress
  Restless, irritable or lethargic · Referral (urgent)
  Malnutrition (visible severe wasting) · Oedema of both feet
  Burns (major)

NON-URGENT  ▸ queue and see in turn

Evidence note

WHO's Paediatric emergency triage, assessment and treatment: care of critically-ill children (2016) updated the ETAT materials and the Pocket Book, with recommendations on oxygen, fluids for shock, and anticonvulsants. Where it has been implemented with training and supervision, ETAT has repeatedly been associated with lower early in-hospital mortality. Note the qualifier: a triage poster on a wall is not a triage system.

3 · Vital signs you must know cold Must-know

Charts are safer than memory, but at 3 a.m. with a crashing child you need approximate ranges instantly. Learn the bands, then check the chart.

Age	Heart rate, awake (/min)	Respiratory rate (/min)	Hypotension: systolic below
Under 1 month	100–205	30–60	60 mmHg
1–12 months	100–190	30–53	70 mmHg
1–2 years	98–140	22–37	70 + (2 × age in years) mmHg
3–5 years	80–120	20–28	70 + (2 × age in years) mmHg
6–10 years	75–118	18–25	70 + (2 × age in years) mmHg
Over 10 years	60–100	12–20	90 mmHg

Two things to carry without a chart: hypotension in a child aged 1–10 years is a systolic pressure below 70 + (2 × age in years) mmHg, and the IMNCI fast-breathing thresholds: ≥60/min under 2 months, ≥50/min at 2–11 months, ≥40/min at 1–5 years.

The crying child

Counting a screaming toddler's respiratory rate. Count over a full 60 seconds in a calm child — a rate counted for 15 seconds and multiplied by four is unreliable in infants, who breathe periodically. If the child settles on a parent's shoulder, count then.

4 · Track-and-trigger charts: what makes them work Good-to-know UG/PG

Paediatric Early Warning Scores turn repeated observations into an escalation trigger. Whichever tool you use, three design features matter more than the score itself:

A mandated response, not just a number. A given score must bring a named level of skill within a named time.
A carer and nurse override. “I am worried about this child” must be a legitimate trigger on its own. Parental concern independently predicts deterioration.
A feedback loop. Every arrest and unplanned PICU transfer is reviewed against the preceding twelve hours of observations.

Ideal setting

An electronic PEWS with automatic alerts to a rapid response team
Continuous monitoring on high-dependency beds; scores recalculated with every observation set
Audit of trigger-to-review time reported monthly

Resource-constrained setting

ETAT triage at the door by a trained nurse
A paper observation chart with age-specific abnormal thresholds printed in colour
A written escalation ladder at the nursing station, and a standing instruction that any emergency sign means a doctor now
A “worried” box on the chart that any nurse or parent can tick

India lens

A full electronic PEWS is unrealistic in most district hospitals. The defensible minimum — ETAT at the door, a colour-banded chart and a written escalation ladder — costs almost nothing and attacks the recognition gap directly. Several state programmes and the F-IMNCI facility package already expect triage at the point of entry; a chart makes it continue after admission.

Checkpoint 1 of 2

At the door of a busy district-hospital OPD, a 14-month-old with four days of diarrhoea is lethargic, has sunken eyes and a very slow skin pinch. Hands are warm and capillary refill is 2 seconds. There is no visible severe wasting. What is the correct ETAT category?

Nudge

ETAT's “D” is its own emergency sign, separate from “C”. What does it require?

Structured hint

Severe dehydration in a child with diarrhoea needs any two of three signs: lethargy or unconsciousness, sunken eyes, very slow skin pinch. Count how many this child has.

Checkpoint 2 of 2

A 4-year-old sits upright on her mother's lap refusing to lie down. She has audible inspiratory stridor and suprasternal recession, is alert and watching you, and her skin colour is normal. What is her PAT category, and your first move?

Nudge

Which side of the triangle tells you the brain is still getting enough oxygen?

Structured hint

Appearance is normal, work of breathing is abnormal, circulation is normal. Match that to the table — then ask what could make an upper-airway problem suddenly worse.

▸Unit 3 Why children crash late and fast Not attempted

Every difference between adult and paediatric emergency practice traces back to a handful of anatomical and physiological facts. Learn the facts and the protocols stop needing to be memorised.

Learning outcomes

UG Explain from first principles why airway obstruction, hypoxia, hypoglycaemia and hypothermia develop faster in small children.
UG Explain why infant cardiac output is rate-dependent and why bradycardia in a sick infant is an emergency.
UG/PG Recognise the tiring child — the falling respiratory rate that means exhaustion, not recovery.
PG Apply named forcing strategies against anchoring, premature closure and attribution in a paediatric emergency.

1 · Airway Must-know

Large occiput. Lying supine flexes an infant's neck and obstructs the airway. Aim for a neutral position in infants (a small roll under the shoulders) and a sniffing position in older children.
Relatively large tongue, small jaw. The tongue falling back is the commonest cause of airway obstruction in an obtunded child — and a jaw thrust often fixes it completely.
Narrow airways. Resistance to laminar flow rises with the fourth power of the fall in radius. In a 4 mm infant trachea, 1 mm of circumferential swelling halves the radius and multiplies resistance about sixteen-fold. The same swelling in an adult trachea is trivial. That one relationship explains croup, bronchiolitis and why a crying child with an inflamed airway can decompensate in seconds.
Nose-breathing in young infants. Nasal blockage alone can cause real distress and feeding failure. Saline drops and gentle suction are genuine therapy.

2 · Breathing Must-know

High oxygen consumption, small reserve. Infants consume roughly twice as much oxygen per kilogram as adults, with a proportionally smaller functional residual capacity. They desaturate on apnoea dramatically faster; pre-oxygenation buys seconds, not minutes.
Compliant chest wall, diaphragm-dependent breathing. Recession is prominent and ventilation inefficient. A distended stomach splints the diaphragm — which is why gastric decompression matters during bag-mask ventilation.
A diaphragm that tires. Sustained high work of breathing ends in exhaustion.

The most dangerous sign in paediatrics

A tiring child looks calmer. Recession lessens, the respiratory rate falls, the child goes quiet and drowsy, and inexperienced observers relax. In a child who was working hard, a falling rate with a falling level of consciousness is pre-arrest. Reassess — do not relax. Get a blood gas and senior help.

3 · Circulation Must-know

Cardiac output = stroke volume × heart rate. The infant heart has limited ability to raise stroke volume, so output depends largely on rate. Bradycardia in a sick infant is functionally an arrest state, and its commonest cause is hypoxia. Treat it with oxygen and ventilation first; atropine is for vagally mediated bradycardia or primary heart block, not the hypoxic kind.
Vigorous vasoconstriction. Blood pressure is defended at the expense of the skin and gut: cold peripheries, delayed capillary refill and a narrow pulse pressure appear long before hypotension.
Small absolute blood volume — about 80 mL/kg in infants and 70 mL/kg in children. A 10 kg child has roughly 800 mL of blood. Modest-looking bleeding or third-spacing is proportionally large; so is repeated blood sampling in a small infant.

4 · Everything else that scales with size Good-to-know

Property	Paediatric difference	What it means at the bedside
Surface area to mass	Much higher, especially in neonates	Rapid heat and water loss. Hypothermia during resuscitation and transport is common, and it worsens acidosis and coagulopathy. Cover the head.
Glycogen stores	Small, with high glucose demand	Hypoglycaemia within hours of poor intake or any critical illness. Check glucose in every sick child.
Renal concentrating ability	Immature in infants	Poor tolerance of both fluid restriction and solute load; dehydration develops fast.
Immunity	Immature, especially under 3 months	Serious bacterial infection presents non-specifically; fever may be absent or replaced by a low temperature.
Skeleton	Pliable, incompletely ossified	Serious chest or abdominal injury without fractures. Rib fractures in an infant imply major force or abuse.
Communication	Pre-verbal or limited	Behaviour is the symptom. A parent saying “he is not himself” carries diagnostic weight.

5 · How the sick child fools you Nice-to-know PG

Emergency paediatrics runs on fast, pattern-based reasoning — mostly right, and where the errors live. Telling yourself to “be less biased” does not work. Structural forcing strategies do.

Bias	How it looks in a sick child	Forcing strategy
Anchoring, premature closure	Referred as “bronchiolitis”: the 4-month-old's wheeze and big liver turn out to be myocarditis or a VSD in failure.	Ask aloud: “If this is not X, what else fits every finding?” Name one alternative before acting.
Search satisficing	A fracture found on the trauma series; the splenic injury missed.	Finish the systematic survey even after the first abnormality.
Availability	A dengue outbreak: every fever with low platelets becomes dengue, and enteric fever, malaria and rickettsial illness are missed.	“What else is in season, and what is the one I must not miss?”
Triage cueing	A “non-urgent” label at the door reduces the effort of every later examination.	Re-triage at every contact; the child at 8 p.m. is not the child at 6 p.m.
Attribution	A child with cerebral palsy: new signs attributed to the known condition.	Assume a new symptom has a new cause until proven otherwise.

Pearl

The diagnostic time-out. Before leaving any sick child, ask: What is my diagnosis? What does not fit? What is the worst thing this could be, and have I excluded it? What must happen if the child worsens, and who will do it? Thirty seconds. It catches more errors than any checklist you will be given.

Checkpoint 1 of 2

A 6-month-old with bronchiolitis has had severe recession for six hours. On review the recession is less marked, the respiratory rate has fallen from 70 to 34/min, and the infant is sleepy and not feeding. SpO₂ is 92% on oxygen. What is the most appropriate interpretation?

Nudge

What does a falling respiratory rate mean when the level of consciousness is falling with it?

Structured hint

Put the three changes together: less recession, a much slower rate, and a sleepier infant who will not feed. Does a recovering infant become less interested in feeding?

Checkpoint 2 of 2

A 2-month-old brought in with a week of cough and poor feeding has a heart rate of 54/min, is mottled and barely responsive. SpO₂ does not register. What is the first intervention?

Nudge

In infants, what is the commonest cause of a slow heart?

Structured hint

Infant cardiac output is rate-dependent, and bradycardia in a sick infant is usually hypoxic. Which option treats the cause rather than the number?

Part B

The systematic approach: ABCDE

Units 4–7 · ~9 hours

Airway before breathing, breathing before circulation — not because the later letters matter less, but because failure at each step makes the next impossible to fix. Part B builds the spine that every emergency in Parts C and D hangs on.

▸Unit 4 Airway and breathing Not attempted

A child with a patent airway and adequate oxygenation has time. Almost everything else in paediatric resuscitation is buying that time back.

Learning outcomes

UG Open and maintain a child's airway with positioning, suction and simple adjuncts, and deliver effective bag-mask ventilation.
UG Classify a breathing problem into one of four patterns and name the first action for each.
UG Distinguish respiratory distress from respiratory failure, and act on the difference.
UG/PG Choose an oxygen delivery device and a saturation target, and escalate through high-flow, CPAP and ventilation by mechanism.
PG Plan a safe paediatric intubation for a shocked or acidotic child, including the physiology that makes induction dangerous.

1 · Four patterns of respiratory illness Must-know

Classify the pattern before you name the disease. The pattern dictates the first action, often before you know the diagnosis.

Pattern	Hallmarks	Typical causes	First priority
Upper-airway obstruction	Inspiratory stridor, hoarse or muffled voice, drooling, tripod or sniffing posture	Croup, foreign body, retropharyngeal abscess, anaphylaxis, epiglottitis, inhalational burn	Do not upset the child. Position of comfort, oxygen as tolerated, airway help. Nebulised adrenaline for severe croup; IM adrenaline for anaphylaxis.
Lower-airway obstruction	Expiratory wheeze, prolonged expiration, hyperinflation	Asthma, bronchiolitis, aspiration, lower foreign body	Oxygen; bronchodilators and steroids for asthma; supportive care for bronchiolitis
Lung tissue disease	Grunting, crackles, focal signs, hypoxaemia out of proportion to effort	Pneumonia, paediatric ARDS, pulmonary oedema, drowning	Oxygen, then distending pressure (CPAP/PEEP); treat the cause
Disordered control of breathing	Irregular, shallow or apnoeic breathing, or unusually deep breathing, with effort that does not match the physiology	Raised intracranial pressure, poisoning, post-ictal state, metabolic acidosis (deep Kussmaul breathing), neuromuscular disease	Support ventilation and treat the brain or metabolic cause. Oxygen alone is not enough.

Pearl

Grunting is expiration against a partly closed glottis: the child is making their own PEEP to keep collapsing alveoli open. It means significant lung disease — or, in a young infant, sepsis, pain or acidosis. Never dismiss a grunting child.

2 · Distress or failure Must-know

	Respiratory distress	Respiratory failure
Appearance	Alert, anxious, interactive	Agitated, then drowsy, then unresponsive
Effort	Increased and sustained	Increased then falling — or inadequate from the start
Rate	Fast	Very fast, or slowing, irregular, apnoeic
Oxygenation	Maintained on modest oxygen	Hypoxaemia despite oxygen; cyanosis
Action	Oxygen, treat the cause, watch closely	Assist ventilation now — bag-mask, then an advanced airway

The transition from distress to failure is the tiring child of Unit 3. The two signs that mark it are a falling level of consciousness and a falling respiratory rate without clinical improvement.

3 · Opening and supporting the airway Must-know

The stepwise airway

 1. POSITION    infant: neutral, small shoulder roll · child: sniffing
                trauma: jaw thrust with manual in-line stabilisation
 2. CLEAR       gentle suction under direct vision · no blind finger sweep
 3. ADJUNCT     oropharyngeal airway if unconscious with no gag
                (size: incisors to angle of jaw; insert the right way up
                 in young children, with a tongue depressor)
                nasopharyngeal airway if a gag is present and no base-of-
                skull injury is suspected
 4. VENTILATE   bag-mask with reservoir and high-flow oxygen
                E-C grip · watch the CHEST rise, not the bag
                respiratory arrest with a pulse: 1 breath every 2–3 s
 5. DECOMPRESS  gastric tube · a full stomach splints the diaphragm
 6. ESCALATE    supraglottic airway or tracheal tube by a competent
                operator · confirm with waveform capnography

What current resuscitation guidance says

Current AHA/AAP paediatric guidance: ventilate infants and children in respiratory arrest with a pulse, or during CPR with an advanced airway, at one breath every 2–3 seconds (20–30/min); cuffed tracheal tubes are acceptable in infants and children, with cuff pressure monitored; routine cricoid pressure during intubation is not recommended. Cardiac arrest management itself is covered in the Vikkypaedia PALS module.

4 · Oxygen: how much, how delivered Must-know

Device	Approximate FiO₂	Use it for
Nasal prongs (0.5–1 L/min infant; 1–2 L/min child)	0.3–0.4	Mild hypoxaemia in a child who is feeding
Simple face mask (≥5 L/min, to prevent rebreathing)	0.35–0.6	Moderate distress
Non-rebreathing mask with reservoir (10–15 L/min)	0.6–0.9	Severe hypoxaemia, shock, resuscitation
High-flow nasal cannula (about 1–2 L/kg/min)	Titratable to 1.0	Bronchiolitis, pneumonia — dead-space washout and modest distending pressure
Bubble CPAP or CPAP/NIV	Titratable	Alveolar collapse, severe pneumonia or bronchiolitis in infants
Bag-mask, with or without a tracheal tube	Up to 1.0	Respiratory failure, apnoea, arrest

When to give oxygen. WHO recommends oxygen for children with emergency signs, and for any child with SpO₂ below 90%. In acutely unwell children most services target SpO₂ of 92–94% or above; aim higher during active resuscitation, and accept lower individualised targets in cyanotic heart disease. Wean deliberately, and never leave a child on high-flow oxygen without monitoring.

India lens

The commonest failure is supply, not prescription: an empty cylinder, no flow-splitter, no paediatric masks or prongs, no working pulse oximeter. WHO's 2016 ETAT update addressed oxygen flow rates and humidification for exactly this reason, and India's post-2021 investment in PSA oxygen plants changed what many district hospitals can deliver. Auditing “was oxygen available and correctly delivered?” is often a higher-yield improvement project than any protocol change.

5 · Supporting the failing airway, across settings Must-know

Ideal setting

Piped, blended oxygen; continuous pulse oximetry and waveform capnography on every supported child
Stepwise escalation: prongs, then high-flow, then CPAP or NIV, then intubation and lung-protective ventilation
A blood gas guides the decision; a video laryngoscope and an anaesthetist are minutes away
The decision to intubate is made early and electively, before exhaustion

Resource-constrained setting

Oxygen is the intervention. A concentrator or cylinder, a flow-splitter, a pulse oximeter and correctly sized interfaces — check they exist before the next sick child arrives
Position of comfort on a parent's lap does much of what equipment does
Bubble CPAP, run by trained staff, is an evidence-supported option for infants with severe pneumonia or bronchiolitis where ventilation is unavailable
If you cannot ventilate beyond bag-mask, the decision is when to transfer, not whether to intubate. Make it while the child is still compensating (Unit 20)
Bag-mask ventilation done well is a legitimate destination, not a failure. Intubating a child you then cannot ventilate or monitor can turn a survivable illness into an arrest

6 · Intubating the sick child safely Good-to-know PG

Choose support by mechanism. High-flow helps where dead-space washout and mild distending pressure are enough. CPAP treats alveolar or upper-airway collapse. NIV helps inadequate tidal ventilation with rising CO₂. Intubation is for airway protection, refractory hypoxaemia or hypercapnia, exhaustion, shock unresponsive to resuscitation, and safe transfer.

Physiological difficulty

A shocked or acidotic child can arrest at induction. Loss of sympathetic drive, positive-pressure ventilation reducing venous return, and apnoea worsening acidosis all arrive at the same moment. Resuscitate before you intubate where you possibly can: correct volume, start a vasoactive if needed, choose a haemodynamically gentler induction agent, have a push-dose vasopressor drawn up, and pre-oxygenate.

Tube size: cuffed, (age/4) + 3.5 mm; uncuffed, (age/4) + 4 mm. Depth at the lips is roughly three times the internal diameter.
Confirm with waveform capnography plus chest rise and auscultation; secure; X-ray.
DOPES for sudden deterioration in a ventilated child: Displacement · Obstruction · Pneumothorax · Equipment failure · Stomach distension.

Checkpoint 1 of 2

A 2-year-old starts coughing and has noisy breathing while eating peanuts. She is distressed but coughing forcefully and able to cry and speak. What is the best immediate action?

Nudge

What can a forceful cough do that no manoeuvre you perform can match?

Structured hint

Foreign-body manoeuvres are for an ineffective cough — silent, unable to cry, speak or breathe. Is her cough effective?

Checkpoint 2 of 2

A 9-month-old with pneumonia on nasal prong oxygen at 1 L/min has SpO₂ of 86%, grunting and severe chest indrawing, but is awake and taking a few feeds. The district hospital has no ventilator; the nearest PICU is four hours away by road. What is the most appropriate next step?

Nudge

Grunting tells you what the lungs need. What is the infant trying to generate for himself?

Structured hint

He needs distending pressure, not just more oxygen, and the decision that matters most in a setting without a ventilator is about timing. Which option does both?

▸Unit 5 Circulation: recognising shock and its types Not attempted

Shock is not low blood pressure. Shock is inadequate delivery of oxygen and fuel to tissues relative to demand. A child can be deeply shocked with a textbook blood pressure.

Learning outcomes

UG Recognise compensated and decompensated shock at the bedside without laboratory support.
UG Classify shock as hypovolaemic, distributive, cardiogenic or obstructive, and state the treatment that differs for each.
UG/PG Perform the fifteen-second cardiac check before any bolus, and explain why it prevents a recognisable category of death.
PG Use lactate and the Phoenix cardiovascular criteria appropriately, knowing what each can and cannot tell you.

1 · Recognising shock from three organs Must-know

Shock is a clinical diagnosis made from the perfusion of three organs you can examine at the bedside: the brain (level of consciousness, interaction), the skin (temperature gradient, capillary refill, mottling) and the kidney (urine output: below 1 mL/kg/h in infants and young children, below 0.5 mL/kg/h in adolescents).

Sign	Compensated	Decompensated
Heart rate	Tachycardia	Extreme tachycardia, then bradycardia (pre-terminal)
Blood pressure	Normal; narrow pulse pressure	Hypotension
Pulses	Weak peripheral pulses (bounding in warm shock)	Absent peripheral, weak central pulses
Capillary refill	Over 2–3 s (cold shock) or flash under 1 s (warm shock)	Markedly prolonged; mottling
Sensorium	Irritable, anxious, clingy	Lethargic, unresponsive
Urine output	Reduced	Anuric

Know the limits of your best sign

Capillary refill has limits. It varies with room temperature, site, pressure and observer, and performs modestly on its own. Use it as one sign in a cluster and as a trend by the same observer. Standardise: sternum or fingertip at heart level, five seconds of pressure, in a warm room.

2 · Four types of shock — because treatment diverges Must-know

Type	Mechanism	Paediatric causes	Clues	What changes
Hypovolaemic (commonest)	Low preload	Diarrhoea, DKA, burns, haemorrhage, dengue plasma leak	History of losses, dry mucosa, sunken eyes or fontanelle	Volume is the treatment
Distributive	Low vascular tone, maldistribution	Sepsis, anaphylaxis, spinal injury	Warm peripheries, flash refill, wide pulse pressure; fever, urticaria or wheeze	Fluid plus early vasoactive; IM adrenaline first in anaphylaxis
Cardiogenic	Pump failure or arrhythmia	Myocarditis, cardiomyopathy, congenital heart disease, SVT, duct-dependent lesion in a neonate, scorpion envenomation	Big liver, gallop, crackles, raised JVP; worsens with fluid	Small cautious volume or none; inotrope; treat the rhythm; prostaglandin for a duct-dependent neonate
Obstructive	Mechanical block to flow	Tension pneumothorax, tamponade, critical coarctation	Absent breath sounds with tracheal shift; muffled heart sounds with distended neck veins; weak femoral pulses	Fluid will not fix it: needle decompression, pericardiocentesis, prostaglandin

The habit that saves the most lives in this unit

The fifteen-second cardiac check. Before every bolus in an undifferentiated shocked child: feel for the liver edge, listen for a gallop, listen for crackles, look at the neck veins. A big liver in a shocked child means think cardiogenic — and a 20 mL/kg bolus may kill. This single habit prevents the recognisable death of the “septic” infant with myocarditis or a duct-dependent lesion who arrests after fluid.

3 · Warm and cold shock Good-to-know UG/PG

In septic shock, children more often present cold — high systemic resistance, low cardiac output, prolonged capillary refill and cool, mottled limbs. Adults and adolescents more often present warm — low resistance, flash refill and bounding pulses. The distinction is imperfect and can change within hours, which is why reassessment after every intervention matters more than the initial label. It remains useful for one decision: which vasoactive to start when fluid is not enough (Unit 10).

4 · Lactate and the Phoenix criteria Nice-to-know PG

The 2026 Surviving Sepsis Campaign paediatric guideline makes a strong recommendation to measure lactate as part of the initial evaluation. Use it to support recognition and to track response — never to delay treatment of a child who is clinically shocked.

The Phoenix criteria (JAMA 2024) define paediatric sepsis as suspected infection with a Phoenix Sepsis Score of at least 2, and septic shock as sepsis with at least one cardiovascular point. Cardiovascular points come from vasoactive medication, lactate and age-adjusted mean arterial pressure.

Cardiovascular component	1 point	2 points
Vasoactive medications	One	Two or more
Lactate (mmol/L)	5–10.9	11 or more
Mean arterial pressure (mmHg), by age	Below the age threshold (e.g. under 1 month: 17–30; 1–11 months: 25–38; 1–2 years: 31–43)	Below the lower threshold (e.g. under 1 month: <17; 1–11 months: <25; 1–2 years: <31)

Misusing a definition as a trigger

Using Phoenix to decide whether to treat. Phoenix was built to classify children with established organ dysfunction for research and reporting, largely from data in resourced hospitals. It is not a bedside screening tool, and a child with suspected sepsis who does not yet meet it still needs antibiotics and careful fluid decisions now. The 2026 guideline itself accepts evidence based on either the older 2005 criteria or Phoenix.

Checkpoint 1 of 2

A 5-month-old has poor feeding and fast breathing. Heart rate 210/min, cool peripheries, capillary refill 4 seconds. The liver is 4 cm below the costal margin and there is a gallop rhythm. A colleague is drawing up 20 mL/kg of saline. What do you advise?

Nudge

What did the fifteen-second cardiac check find?

Structured hint

A big liver and a gallop in a shocked infant point to one type of shock. And a heart rate of exactly 210 that does not vary — what rhythm should you exclude before anything else?

Checkpoint 2 of 2

A 7-year-old with 3 days of fever has heart rate 150/min, capillary refill 5 seconds, cool mottled legs and is drowsy. BP 102/64 mmHg. Point-of-care lactate is not available. Which statement is correct?

Nudge

Which three organs did you examine, and what did each tell you?

Structured hint

Brain (drowsy), skin (5-second refill, mottled, cool) — do these need a laboratory test to be abnormal? And cool mottled legs: warm shock or cold?

▸Unit 6 Disability: the child with altered sensorium Not attempted

A child who is not behaving normally has a brain that is not being perfused, oxygenated or fuelled — or is being poisoned, infected, compressed or is seizing. Those seven words are the differential.

Learning outcomes

UG Assess and record the level of consciousness with AVPU and the paediatric Glasgow Coma Scale, with pupils and posture.
UG Perform the first three actions in any child with altered sensorium, beginning with glucose.
UG/PG Build a structured differential for non-traumatic coma, including the causes that are seasonal and regional in India.
UG/PG Decide when a lumbar puncture is safe, and give antibiotics without waiting for it when it is not.

1 · The first three actions Must-know

In any child with altered consciousness

 1. ABC FIRST   airway at risk if responds only to pain (AVPU "P")
                 or worse · oxygen · ventilate if breathing is inadequate
 2. GLUCOSE     bedside capillary glucose in EVERY child with altered
                 consciousness, seizure or shock  ("don't ever forget glucose")
 3. LOOK FOR    pupils · posture · neck stiffness · fontanelle · rash
    THE CAUSE    · breath odour · injuries · toxidrome · temperature

If the glucose is low, treat it before anything else (Unit 7). If the child is convulsing, the time-based algorithm in Unit 13 starts now.

2 · Measuring the level of consciousness Must-know

AVPU	Approximate GCS	Meaning
Alert	15	Normal
Responds to Voice	About 13	Abnormal; find the cause
Responds only to Pain	About 8	ETAT “coma” — an emergency sign. The airway is at risk.
Unresponsive	3	Airway protection needed now

AVPU is fast and consistent between observers, which makes it ideal at triage. The paediatric GCS, with modified verbal and motor scales for pre-verbal children, is better for trending, especially after trauma. Record the components as well as the total, and record the trend: a falling score matters more than any single number.

Look also at the pupils (size, symmetry, reaction), posture (decorticate or decerebrate) and breathing pattern. A unilateral fixed dilated pupil, abnormal posturing or a Cushing response (high blood pressure, slow pulse, irregular breathing) means raised intracranial pressure with possible herniation — Unit 13.

3 · The differential for non-traumatic coma Must-know

Category	Examples	Clues
Infective	Meningitis, encephalitis (HSV, Japanese encephalitis), cerebral malaria, TB meningitis, scrub typhus, sepsis-associated encephalopathy	Fever, neck stiffness (unreliable under 18 months), bulging fontanelle, rash, eschar, focal seizures, season and region
Metabolic	Hypoglycaemia, DKA, sodium disorders, hypocalcaemia, uraemia, liver failure, inborn errors, hyperammonaemia	Deep sighing breathing, ketotic breath, jaundice, big liver, dehydration, consanguinity, decompensation after fasting or illness
Toxic	Organophosphates, kerosene, benzodiazepines, opioids, antihistamines, datura, iron, alcohol, traditional preparations	A toxidrome (Unit 12). Ask what is in the house and what was given for this illness.
Structural or vascular	Tumour, hydrocephalus or shunt block, haemorrhage, stroke, venous sinus thrombosis	Focal deficit, asymmetric pupils, morning headache and vomiting, a shunt in place
Epileptic	Post-ictal state, non-convulsive status	Subtle eye deviation, nystagmus, twitching; obtundation that does not lift
Inflammatory	ADEM, autoimmune encephalitis, MIS-C, HLH	Recent infection, movement disorder, behavioural change, multi-organ involvement
Hypoxic-ischaemic	After arrest, drowning, severe shock	The event itself

India lens

A child with fever and altered sensorium meets the Acute Encephalitis Syndrome surveillance definition and must be notified. The likely causes shift with season and region: Japanese encephalitis, dengue, scrub typhus, cerebral malaria, enteroviruses and, in particular districts and seasons, hypoglycaemic encephalopathy linked to litchi consumption in undernourished children. Scrub typhus deserves a low threshold for empirical doxycycline or azithromycin — look for the eschar (Unit 7).

4 · When is a lumbar puncture safe? Must-know UG/PG

Suspected meningitis needs cerebrospinal fluid — but not at the cost of herniation. Defer the LP if any of these are present:

Reduced or fluctuating consciousness (GCS below 9, or a fall of 3 or more)
Focal neurological signs, abnormal posture, or unequal or poorly reactive pupils
Papilloedema, or a slow pulse with high blood pressure
Shock, respiratory compromise, a recent seizure that has not settled
Low platelets or a coagulopathy, or infection over the LP site

The rule that matters more than the list

Never let a deferred LP defer the antibiotics. Take blood cultures, give the first dose of an appropriate antibiotic immediately (with antiviral cover where encephalitis is possible), and do the LP later when it is safe. Cultures after antibiotics are less often positive; PCR and CSF cell counts remain informative.

Checkpoint 1 of 2

A 4-year-old is brought in drowsy after two days of vomiting. He opens his eyes and groans to a sternal rub but not to his name. His pupils are equal and reactive. Temperature 37.2 °C. What is the single most important immediate test?

Nudge

Which cause of coma can be diagnosed in thirty seconds, treated in two minutes, and kills if missed?

Structured hint

He responds only to pain (AVPU “P”). Before any imaging or laboratory test, what does the first-three-actions rule say?

Checkpoint 2 of 2

A 6-year-old with fever and headache for a day has GCS 9, a right pupil larger than the left, heart rate 58/min and BP 138/90 mmHg. Which action is contraindicated right now?

Nudge

Put the slow pulse, the high blood pressure and the unequal pupil together. What is happening inside the skull?

Structured hint

This is a Cushing response with pupillary asymmetry. Which of the four options could precipitate herniation?

▸Unit 7 Exposure and the metabolic milieu Not attempted

“E” is where the diagnosis often hides: the purpuric rash under the vest, the eschar in the axilla, the cigarette burn, the swollen scrotum, the glucose of 1.8.

Learning outcomes

UG Perform a complete exposure survey while preventing heat loss, and say what must be looked for.
UG Recognise and treat hypoglycaemia, and know when to take a critical sample first.
UG/PG Recognise and begin treatment of the electrolyte disturbances that kill quickly.
PG Interpret a paediatric blood gas with the anion gap, and name the emergency behind it.

1 · The exposure survey Must-know

Undress fully, look everywhere, then cover and warm. What a hurried examiner misses:

Rash. A non-blanching purpuric rash is meningococcal sepsis until proven otherwise. Press with a glass. Look at soles, palms, conjunctivae and behind the ears.
Eschar. Scrub typhus. Axilla, groin, natal cleft, waistband, behind the ear. It is painless, so it is never reported.
Genitalia and hernial orifices. Torsion and incarcerated hernia. A vomiting, irritable infant needs the nappy off.
Back and scalp. Log-roll in trauma; look for injuries, a sacral dimple, lice and scabies.
Bruises in unusual places — torso, ears or neck in a child aged four or under; any bruise in an infant under four months who is not yet mobile; patterned bruises. Consider inflicted injury (Unit 20).
Temperature. Measure it. In a young infant or a malnourished child, a low temperature is as ominous as fever.
Weight. A real weight whenever possible — every dose depends on it.

2 · Glucose Must-know

	What to do
Threshold	WHO: treat a blood glucose below 2.5 mmol/L (45 mg/dL), or below 3 mmol/L (54 mg/dL) in a child with severe malnutrition. Many hospital protocols act at 3.0–3.3 mmol/L in a sick child. Neonates follow neonatal thresholds.
Treatment	10% glucose 5 mL/kg IV or IO (0.5 g/kg), then a glucose-containing infusion, and recheck in 15–30 minutes. Never give 50% glucose to a child — dilute it.
Unconscious, no access	Sugar solution or expressed breast milk by nasogastric tube, or sugar under the tongue, while access is obtained. Do not let the search for a vein delay glucose.
Critical sample	If hypoglycaemia is unexplained or recurrent, take blood before treatment when you safely can: glucose, ketones (β-hydroxybutyrate), lactate, ammonia, insulin, cortisol, growth hormone, acylcarnitines; and the first urine after the event. It can save years of diagnostic uncertainty.

Pearl

Hypoglycaemia without ketones means hyperinsulinism or a fatty-acid oxidation defect such as MCAD deficiency. Both are dangerous and both are treatable. Ketotic hypoglycaemia after a fast in a small toddler is far commoner and more benign — but only the critical sample tells them apart.

3 · Electrolytes that kill quickly Must-know UG/PG

Disturbance	Presentation	Immediate action	Trap
Hyponatraemia (symptomatic, or Na <125)	Seizures, lethargy, vomiting, coma	3% saline 3–5 mL/kg over 10–20 min, repeated until seizures stop	After symptoms settle, limit the rise to about 8–10 mmol/L in 24 h. Hypotonic maintenance fluid is a leading cause: use isotonic maintenance in hospitalised children.
Hypernatraemia (Na >150)	Doughy skin, irritability then lethargy, high-pitched cry	Resuscitate shock with isotonic fluid; then correct slowly, no faster than about 0.5 mmol/L per hour	Rapid correction causes cerebral oedema and seizures.
Hyperkalaemia (K >6.5 or ECG changes)	Peaked T waves, then wide QRS, then arrest	10% calcium gluconate 0.5 mL/kg IV (max 20 mL) to protect the heart; then insulin with glucose, nebulised salbutamol; then removal	A haemolysed sample misleads — but never assume haemolysis in an anuric or crushed child. Get an ECG.
Hypocalcaemia	Tetany, stridor from laryngospasm, seizures, long QT	10% calcium gluconate 0.5–1 mL/kg IV slowly, diluted, with ECG monitoring	Extravasation causes necrosis. Check magnesium: low magnesium makes low calcium refractory.

Verify infusion concentrations and maximum doses against your unit protocol and Appendix E before use.

4 · Reading the blood gas Good-to-know PG

Five steps

 1. pH           acidaemia (< 7.35) or alkalaemia (> 7.45)?
 2. PRIMARY      high PaCO2 with low pH   → respiratory acidosis
                 low HCO3  with low pH    → metabolic acidosis
 3. COMPENSATED? compensation is never complete. A normal pH with two
                 abnormal values suggests a MIXED disorder.
 4. ANION GAP    Na − (Cl + HCO3); normal about 8–12 mmol/L
                 RAISED gap:  Ketones (DKA, starvation) · Uraemia
                              Lactate (shock, sepsis, seizures, thiamine
                                       deficiency, inborn errors)
                              Toxins (salicylate, methanol, iron)
                 NORMAL gap:  diarrhoea · renal tubular acidosis ·
                              large volumes of 0.9% saline
 5. OXYGENATION  SpO2/FiO2 or PaO2/FiO2 — used in PARDS and Phoenix

A raised-gap metabolic acidosis in a shocked child is usually lactate — but ask whether it is ketones (DKA presenting as “gastroenteritis with fast breathing”) or a toxin. A normal-gap acidosis after several litres of saline is the saline, and a reason the 2026 sepsis guideline prefers balanced crystalloids (Unit 8).

Checkpoint 1 of 2

A 2-year-old admitted with gastroenteritis and given 0.18% saline with 5% glucose as maintenance has a generalised seizure on day two. Sodium is 118 mmol/L. What is the best immediate management?

Nudge

Will an antiseizure drug stop a seizure caused by a low sodium?

Structured hint

Symptomatic hyponatraemia needs a small, fast rise in sodium to stop the seizure — then a slow rise after that. Which option does both?

Checkpoint 2 of 2

A 9-year-old with 6 days of fever, headache and myalgia has been treated for typhoid without response. Platelets are 60,000/µL and ALT is 180 U/L. On exposure you find a painless 6 mm black-crusted lesion in the left axilla. What should you do?

Nudge

What painless lesion, hidden in a skin fold, is never mentioned by the patient?

Structured hint

An eschar plus fever, thrombocytopenia and raised transaminases is a classic cluster. Does a definite eschar need a serology result before treatment?

Part C

Resuscitating shock: the core skill

Units 8–11 · ~8 hours

More preventable child deaths pass through shock than through any other door. This Part is built around the 2026 Surviving Sepsis Campaign paediatric guideline, the FEAST trial, and the one skill that separates good from dangerous shock care: knowing when fluid helps and when it kills.

▸Unit 8 Fluids done right Not attempted

Fluid is the most commonly prescribed and least often reassessed drug in paediatric emergency care. Given well it saves the dehydrated child; given reflexively it has killed febrile children in a large randomised trial. This unit is about the difference.

Learning outcomes

UG Give a fluid bolus correctly: choice of fluid, aliquot size, speed, and the four reassessment questions after every aliquot.
UG State the 2026 Surviving Sepsis fluid recommendations for settings with and without intensive care.
UG/PG Identify the children in whom the standard bolus is wrong: cardiogenic shock, severe malnutrition, severe anaemia and dengue.
PG Read the FEAST trial critically — what it showed, where it was done, and what it does and does not change in an Indian district hospital.

1 · How to give a bolus Must-know

A fluid bolus is a test with a treatment attached. Give a measured aliquot, then ask whether the child got better, and whether the child can take more.

The bolus cycle

  CHOOSE   balanced crystalloid (Ringer's lactate, Plasma-Lyte)
           0.9% saline if balanced fluid is not available
           not albumin as a first choice · never 5% dextrose
  MEASURE  10–20 mL/kg, pushed with a syringe or pressure bag
           over 5–20 minutes (gravity is too slow in a small cannula)
  REASSESS after EVERY aliquot — four questions:
     1. Is the heart rate falling?
     2. Is perfusion improving? (refill, skin temperature, pulses)
     3. Is the child more alert? Is urine coming?
     4. STOP SIGNALS: new crackles · liver edge moving down ·
        gallop · rising respiratory rate or work of breathing ·
        falling SpO2
  REPEAT   only if 1–3 are "not yet" and 4 is "none"

Pearl

The fourth question is the one people skip. A liver edge that has moved 2 cm down since the last bolus is the child telling you the heart has had enough. Mark it on the skin with a pen before the first bolus.

2 · What the 2026 Surviving Sepsis guideline recommends Must-know

Setting and child	Recommendation (strength)
Intensive care available, septic shock	Up to 40–60 mL/kg of bolus fluid in the first hour, as 10–20 mL/kg per bolus, titrated to perfusion and stopped for signs of overload (conditional)
No intensive care, sepsis without hypotension	No fluid bolus (strong recommendation against). Give maintenance fluid and treat the cause.
No intensive care, septic shock with hypotension	Up to 40 mL/kg of bolus fluid in the first hour, 10–20 mL/kg per bolus, with reassessment (conditional)
Choice of fluid	Crystalloid rather than albumin (conditional); balanced or buffered crystalloid rather than 0.9% saline (conditional), with saline acceptable if balanced fluid is unavailable

Source

Weiss SL, Peters MJ, et al. Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026. Pediatr Crit Care Med 2026;27(4):379–434 (co-published in Intensive Care Medicine). 61 statements; only three rest on high- or moderate-certainty evidence. The strong recommendation against bolus therapy for non-hypotensive sepsis without intensive care is one of the few firm statements in the whole guideline — and it comes from FEAST.

3 · FEAST: what it showed and where Must-know UG/PG

Read the negative trial carefully

FEAST (Maitland et al., NEJM 2011) randomised 3,141 febrile African children with impaired perfusion to a 20–40 mL/kg bolus of saline or albumin, or to maintenance fluid only. Bolus therapy increased 48-hour mortality (roughly 10.6% vs 7.3%), consistently across subgroups. Later analyses pointed to cardiovascular collapse, rather than simple fluid overload, as the main mode of excess death.

Read the setting. The hospitals had no mechanical ventilation and no inotrope infusions. Many children had malaria and severe anaemia. Children with gastroenteritis, severe malnutrition and non-infectious causes of shock were excluded, and very few were hypotensive.

The defensible reading is not “fluid is bad”. It is: large boluses are dangerous in febrile children without hypotension when you cannot support the airway and heart the bolus may unmask. That is exactly the population the 2026 strong recommendation addresses.

Two errors follow from FEAST, in opposite directions. One is ignoring it and giving 60 mL/kg reflexively to every febrile child with cool hands in a hospital with no ventilator. The other is over-generalising it and withholding fluid from the child with diarrhoeal hypovolaemia or frank hypotension, in whom fluid remains life-saving and who were never in the trial.

4 · Four groups in whom the standard bolus is wrong Must-know

Group	Why	What to do instead
Cardiogenic shock	The problem is the pump; volume causes pulmonary oedema and arrest	Small aliquots (5–10 mL/kg) only if clearly under-filled; inotrope; treat arrhythmia (Unit 10)
Severe malnutrition	Heart and kidneys handle sodium and water poorly; overload kills	WHO: only for shock with lethargy or unconsciousness, 15 mL/kg over one hour with dextrose, watching pulse and respiratory rate every 5–10 minutes (Unit 16)
Severe anaemia	The problem is oxygen-carrying capacity, not volume	Transfuse; do not flood
Dengue with plasma leak	Leak is phase-dependent; fluid given in the recovery phase returns as pulmonary oedema	Follow the national dengue guideline: titrated crystalloid by haematocrit and clinical response, with early reduction as the leak stops

India lens

Dengue is the single commonest reason a paediatric ward in India faces a fluid decision, and it has its own rules. Recognise the critical phase (usually days 3–7, as the fever falls): rising haematocrit with falling platelets, abdominal pain, persistent vomiting, mucosal bleeding, lethargy, a large liver. Fluid is given as titrated infusions guided by haematocrit and perfusion, not repeated large boluses, and is tapered as the leak stops. Most deaths now come from late recognition of shock or from over-infusion — not from lack of fluid alone. Use the current national (NCVBDC) dengue guideline and your state protocol.

5 · Across settings Must-know

Ideal setting

Balanced crystalloid, 10–20 mL/kg aliquots, up to 40–60 mL/kg in the first hour if the child keeps responding
Stop signals checked after each aliquot; move to a vasoactive rather than more fluid when they appear
Point-of-care ultrasound, serial lactate and echocardiography to guide titration
Ventilation available if fluid unmasks a failing heart

Resource-constrained setting

Hypotensive shock, or obvious hypovolaemia from diarrhoea or bleeding: fluid is life-saving — give it, 10–20 mL/kg, reassessing each time, up to 40 mL/kg
Febrile child with poor perfusion but a normal blood pressure: no bolus. Maintenance fluid, antibiotics now, glucose, treat severe anaemia, keep warm, transfer
Use what you have: Ringer's lactate is on the essential medicines list and usually available; saline is acceptable
A liver edge marked in pen, a watch and a written reassessment every 15 minutes are the monitoring you can always have

6 · Maintenance fluid Must-know

Holliday–Segar (“4-2-1”), per hour: 4 mL/kg for the first 10 kg, plus 2 mL/kg for the next 10 kg, plus 1 mL/kg for each kg above 20. Per day: 100, 50 and 20 mL/kg respectively.

The lesson paid for in children's lives

Use isotonic maintenance fluid in hospitalised children — 0.9% saline or a balanced solution, with glucose as needed. Hypotonic fluids (0.18% or 0.45% saline) caused a generation of avoidable hospital-acquired hyponatraemic seizures and deaths, because sick children secrete antidiuretic hormone and retain free water. Measure electrolytes if IV fluid continues beyond 24 hours, and reduce volumes in meningitis, pneumonia and after surgery, where water retention is greatest.

Checkpoint 1 of 2

At a district hospital with no ventilator or inotrope infusions, a 3-year-old has fever, heart rate 170/min, capillary refill 4 seconds and BP 92/58 mmHg. Glucose is normal and haemoglobin 10 g/dL. The nearest PICU is three hours away. What is the most defensible fluid plan?

Nudge

Is this child hypotensive for his age? And does this hospital have intensive care?

Structured hint

70 + (2 × 3) = 76 mmHg: his pressure is above that. Now find the 2026 recommendation for sepsis without hypotension where intensive care is not available.

Checkpoint 2 of 2

In a PICU-backed emergency department, a 6-year-old in septic shock has received two 20 mL/kg boluses of Ringer's lactate. Heart rate has fallen from 165 to 150/min, but crackles have appeared at both bases and the liver edge has moved from 1 cm to 3 cm below the costal margin. Capillary refill is still 4 seconds. What next?

Nudge

Which of the four reassessment questions just returned a stop signal?

Structured hint

“Up to 60 mL/kg” is a ceiling, not a target. When crackles and a descending liver appear, what does the guideline tell you to move to instead of more fluid?

▸Unit 9 Sepsis and septic shock: the first hour Not attempted

Sepsis is the final common pathway for most preventable childhood deaths. It is also where the gap between what guidelines recommend and what a district hospital can deliver is widest — which makes intelligent adaptation, not protocol recitation, the real skill.

Learning outcomes

UG Recognise sepsis clinically and say the word aloud, so the team starts the clock.
UG Deliver the first hour: oxygen, access, cultures, antimicrobials within the recommended time, glucose, and a setting-appropriate fluid plan.
UG/PG Choose empirical antimicrobials for community-acquired sepsis in India, including when to add cover for scrub typhus, malaria and resistant organisms.
PG Explain what the 2026 guideline changed and why most of it rests on low-certainty evidence.

1 · Recognition comes before definitions Must-know

Screen clinically: an unwell-looking child with fever or a low temperature, tachycardia, poor perfusion, altered behaviour, or a rising early-warning score. Say “this could be sepsis” aloud. Naming it starts the clock for the whole team.

The 2026 guideline found insufficient evidence to recommend any particular systematic screening tool beyond established clinical pathways. What it does strongly recommend is that every hospital has a sepsis performance-improvement programme with standard operating procedures — a local pathway that people actually use.

The error clinicians actually make

Waiting for the Phoenix score, a lactate or a CRP before acting. Phoenix identifies children who already have organ dysfunction; waiting for two points means waiting for organ failure. Treat on suspicion; classify later.

2 · The first hour Must-know

Paediatric sepsis — the first hour

Text version

0 min    RECOGNISE · say "sepsis" · call senior help · start the clock
0–15     oxygen · IV or IO access (IO after 2 attempts or 90 s)
         blood culture BEFORE antibiotics (never delaying them)
         bedside GLUCOSE · LACTATE · gas · Hb · electrolytes
15–60    ANTIMICROBIALS
           septic shock ........... within 1 hour  (strong)
           sepsis without shock ... within 3 hours, after
                                    rapid evaluation
         FLUID — depends on setting and blood pressure (Unit 8)
           ICU available: 10–20 mL/kg boluses, up to 40–60 mL/kg
           no ICU, no hypotension: NO bolus — maintenance only
           no ICU, hypotension: 10–20 mL/kg boluses, up to 40 mL/kg
         VASOACTIVE if shock persists after fluid (Unit 10)
         correct glucose and calcium · treat severe anaemia
ONGOING  SOURCE CONTROL · reassess every 15 minutes
         transfer early if the setting cannot escalate

3 · Antimicrobials: time, choice and source Must-know

Time. For suspected septic shock, the 2026 guideline strongly recommends antimicrobials as soon as possible, ideally within one hour. For probable sepsis without shock, as soon as possible after appropriate evaluation, ideally within three hours. Take a blood culture first when it does not cause delay.

Choice. Empirical cover must match the likely organisms and your local resistance pattern:

Situation	A common starting point (check your antibiogram)
Community-acquired sepsis, previously well child	Third-generation cephalosporin (ceftriaxone or cefotaxime) ± an aminoglycoside
Suspected staphylococcal or toxic shock (skin focus, erythroderma)	Add an anti-staphylococcal agent; add clindamycin for toxin suppression
Hospital-acquired, recent antibiotics, known ESBL colonisation	Carbapenem or local equivalent; reserve these, do not start with them by habit
Fever with eschar, rash, transaminitis, low platelets	Add doxycycline or azithromycin for scrub typhus and other rickettsial illness
Malaria-endemic area	Test, and give IV artesunate for severe malaria
Young infant under 2 months	See Unit 17 (WHO 2024 regimens)

Source control — drain the abscess, remove the infected line, operate on the perforation. No antibiotic beats drainage.

India lens

Antimicrobial resistance in Indian community isolates, especially Gram-negative organisms, is high and regionally variable. The ICMR AMR surveillance network publishes annual reports, and ICMR's treatment guidelines for antimicrobial use are a better anchor than any textbook table. Ask your microbiology department for a one-page paediatric antibiogram and put it next to the sepsis pathway.

4 · Adjuncts: what the evidence supports Good-to-know PG

Intervention	2026 position and practical reading
Hydrocortisone	Suggested against in children whose shock responds to fluid and vasoactives. Insufficient evidence for or against in refractory shock. Give stress-dose steroids where adrenal insufficiency is known or likely (chronic steroid use, congenital adrenal hyperplasia, purpura fulminans).
Procalcitonin	Suggested against its routine use to guide stopping antibiotics.
Molecular rapid diagnostics	Insufficient evidence for routine use.
Blood transfusion	Once stabilised, a restrictive threshold (around 7 g/dL) is appropriate for most critically ill children (TRIPICU); higher in cyanotic heart disease, active bleeding or unstable shock.
IV immunoglobulin, blood purification, “metabolic resuscitation” cocktails	Not for routine use.
Glucose	Avoid hypoglycaemia and extreme hyperglycaemia; no insulin-driven tight control.

Evidence note

Of 61 statements in the 2026 guideline, only three rest on high- or moderate-certainty evidence. Almost everything you do for a septic child is a conditional recommendation built on low-certainty evidence. That is a reason to individualise and reassess constantly, and to be sceptical of anyone who presents a sepsis bundle as settled science — not a reason for nihilism.

5 · The first hour across settings Must-know

Ideal setting

Oxygen; IV or IO within 90 seconds; cultures drawn
Antimicrobials within 1 hour for septic shock
Balanced crystalloid in 10–20 mL/kg boluses to 40–60 mL/kg, stopping on overload signs
Vasoactive infusion if shock persists; serial lactate; source control; ventilation when needed

Resource-constrained setting

Oxygen; IV or IO; bedside glucose and haemoglobin
Antibiotics immediately — the intervention with the clearest benefit and the one most often delayed. Add doxycycline where scrub typhus is plausible; test for and treat malaria where endemic
No bolus in a non-hypotensive child; boluses only for hypotension or obvious hypovolaemia, up to 40 mL/kg
Correct hypoglycaemia and transfuse severe anaemia — here they change outcome more than fluid volume
Phone the receiving unit and transfer while the child is still compensating, with weight, drugs and times written down

The divergence is guideline-concordant, not a compromise: the Surviving Sepsis paediatric guidelines have issued setting-specific recommendations since 2020, precisely because of FEAST.

Checkpoint 1 of 2

A 20-month-old with fever and a spreading non-blanching rash has heart rate 180/min, capillary refill 5 seconds and is drowsy. IV access failed twice in 90 seconds. What is the correct sequence in the next ten minutes?

Nudge

What is the time target for antimicrobials in suspected septic shock, and what does the access rule say after two attempts or 90 seconds?

Structured hint

A purpuric rash with shock is meningococcal sepsis until proven otherwise. Which option gets antibiotics in within the hour without abandoning the culture?

Checkpoint 2 of 2

A 10-year-old in septic shock has responded to fluid and a low-dose adrenaline infusion: heart rate and perfusion are improving and he is more alert. A colleague suggests adding IV hydrocortisone “to be safe”. He has no history of steroid use. What does the 2026 guideline suggest?

Nudge

Is this child's shock responding, or refractory?

Structured hint

The guideline treats two situations differently: shock that is responding, and shock that remains unstable despite fluid and catecholamines. Which situation is this?

▸Unit 10 When fluid fails: vasoactives, access and the failing heart Not attempted

When a child is still shocked after appropriate fluid, the next minutes decide the outcome: a vasoactive started early through whatever line you have, an intraosseous needle instead of a fifth venous attempt, and the recognition that some shocked children have a heart problem, not a volume problem.

Learning outcomes

UG Obtain intraosseous access within the recommended time and use it for every resuscitation drug and fluid.
UG Recognise anaphylaxis and give intramuscular adrenaline at the correct dose.
UG/PG Start and titrate a vasoactive infusion through a peripheral or intraosseous line, as the 2026 guideline suggests.
UG/PG Recognise cardiogenic shock from myocarditis, SVT or a duct-dependent lesion, and change management accordingly.
PG Describe the options when shock remains refractory to catecholamines, and what the evidence does and does not support.

1 · Access in the shocked child Must-know

Access algorithm

  PERIPHERAL IV   two attempts OR 90 seconds, whichever comes first
        │         (in decompensated shock)
        ▼
  INTRAOSSEOUS    proximal tibia: 1–2 cm below and medial to the
        │         tibial tuberosity · alternatives: distal femur,
        │         distal tibia, proximal humerus (older children)
        │         anything that goes IV can go IO — fluids, blood,
        │         antibiotics, vasoactives
        │         flush firmly; push fluid with a syringe or pressure bag
        │         avoid: a fractured bone, a bone already punctured,
        │                infection over the site
        ▼
  CENTRAL VENOUS  once resuscitation is under way, by a competent
                  operator, ultrasound-guided

Pearl

IO access should be a reflex, not a last resort. It is fast, has a high first-attempt success rate, and every minute spent on a fifth peripheral attempt is a minute without drugs.

2 · Vasoactives: start early, start peripherally Must-know UG/PG

When shock persists after appropriate fluid — or fluid is stopped by overload signs — start a vasoactive infusion.

2026 Surviving Sepsis statement	What it means at the bedside
Start vasoactives through peripheral venous access rather than delay until central access is obtained (conditional)	Do not wait for a central line. Use a dilute solution in a good peripheral or IO line and watch the site.
Insufficient evidence to recommend adrenaline over noradrenaline, or vice versa, as first-line	Choose by physiology and familiarity: adrenaline where the picture is cold, low-output shock; noradrenaline where it is warm, vasodilated shock. Reassess and switch or add as needed.
For high-dose requirements, add vasopressin or further titrate catecholamines (conditional)	Refractory shock needs senior and intensive-care input.

Agent	Usual starting range	Main effect
Adrenaline (epinephrine)	0.05–0.3 microgram/kg/min	Inotropy and heart rate; vasoconstriction at higher doses
Noradrenaline (norepinephrine)	0.05–0.3 microgram/kg/min	Vasoconstriction
Dopamine	5–10 microgram/kg/min	Mixed; where adrenaline or noradrenaline are unavailable
Dobutamine	5–10 microgram/kg/min	Inotropy with vasodilatation — low-output states, myocarditis
Milrinone	0.25–0.75 microgram/kg/min (with or without load)	Inotropy and vasodilatation; specialist use

Doses and dilutions: verify against Appendix E and your unit protocol. Extravasation of vasoconstrictors causes tissue injury — check the site every 15 minutes.

3 · Anaphylaxis: the distributive shock with a specific drug Must-know

Sudden onset after exposure; skin or mucosal involvement (urticaria, angioedema) with respiratory compromise (stridor, wheeze) or hypotension — or hypotension alone after a known allergen.

Anaphylaxis

  ADRENALINE IM, anterolateral thigh, NOW
     0.01 mg/kg of 1 mg/mL (1:1000) solution · max 0.5 mg
     (practical doses: under 6 years 0.15 mg · 6–12 years 0.3 mg ·
      over 12 years 0.5 mg)
     repeat after 5 minutes if no improvement
  lie flat with legs raised (sit up if breathing is the problem)
  oxygen · IV/IO access · crystalloid 10–20 mL/kg if hypotensive
  refractory after two IM doses → adrenaline infusion, senior help
  antihistamines and steroids are ADJUNCTS — never instead of adrenaline

The error clinicians actually make

Giving chlorpheniramine and hydrocortisone and waiting. Neither treats airway swelling or shock. Delayed adrenaline is the commonest avoidable feature of fatal anaphylaxis. Also: anti-snake venom reactions are anaphylaxis — same drug, same dose (Unit 14).

4 · The failing heart Must-know UG/PG

Suspect a cardiac cause in any shocked child with a big liver, a gallop, crackles, raised neck veins, a heart rate that does not vary, or worsening after fluid.

Cause	Clues	Key action
Myocarditis	Recent viral illness; tachycardia out of proportion to fever; gallop; big liver; chest X-ray cardiomegaly; ECG changes	Minimal fluid; inotrope (dobutamine, milrinone or low-dose adrenaline); early PICU. Intubation is high-risk — most experienced operator, cardiovascular support ready.
SVT	Heart rate typically over 220/min in infants, over 180/min in children; narrow QRS; no beat-to-beat variation	Vagal manoeuvres (ice to the face in infants); adenosine 0.1 mg/kg rapid push with flush (max 6 mg), then 0.2 mg/kg (max 12 mg); synchronised cardioversion if unstable
Duct-dependent lesion in a neonate (days to weeks old)	Shock or cyanosis in the first weeks; weak femoral pulses (coarctation, hypoplastic left heart); pre- and post-ductal saturation difference	Prostaglandin E1 infusion to reopen the duct; watch for apnoea. This is a cardiology emergency.
Scorpion envenomation	Sting, sweating, priapism, cold limbs, hypertension then hypotension, pulmonary oedema	Prazosin and scorpion antivenom; dobutamine for low output (Unit 14)

Danger

Rapid sequence induction in a child with myocarditis or a failing heart is one of the highest-risk procedures in paediatrics. Sympatholytic drugs and positive-pressure ventilation can precipitate arrest. Plan it with the most experienced operator available, with an inotrope running and adrenaline drawn up.

5 · Across settings Good-to-know

Ideal setting

Infusion pumps, arterial line and echocardiography to guide the choice of vasoactive
Central access placed once the child is stabilised; vasopressin and ECMO referral for refractory shock
Paediatric cardiology on call for arrhythmia and duct-dependent lesions

Resource-constrained setting

IO access is always available: a hollow needle and a syringe are enough in an emergency
Where there is no infusion pump, a carefully calculated adrenaline or dopamine infusion by a burette with a drop counter, with the site watched constantly, is the pragmatic option
IM adrenaline for anaphylaxis needs no equipment beyond a syringe — keep a labelled ampoule with every snakebite and vaccination tray
A child with a suspected cardiac cause of shock should be discussed with the referral centre early; ask about prostaglandin before transfer of a sick neonate

Checkpoint 1 of 2

A 7-year-old in septic shock at a teaching hospital has received 40 mL/kg of Ringer's lactate. She has crackles at both bases and her liver is 3 cm below the costal margin. Capillary refill is 4 seconds and BP 78/40 mmHg. A central line is planned but the anaesthetist is 45 minutes away. What now?

Nudge

What did the 2026 guideline say about peripheral access for vasoactives?

Structured hint

She has overload signs, so more fluid is wrong. Is waiting 45 minutes for a central line compatible with ongoing hypotensive shock?

Checkpoint 2 of 2

A 4-year-old develops generalised urticaria, stridor and a BP of 70/40 mmHg five minutes into an anti-snake venom infusion. What is the first drug and dose?

Nudge

What is this reaction, and which drug treats airway swelling and shock at the same time?

Structured hint

An ASV reaction with stridor and hypotension is anaphylaxis. The first-line drug has one route and one dose that you should know without calculation.

▸Unit 11 Dehydration, diarrhoea and diabetic ketoacidosis Not attempted

Oral rehydration solution is one of the most consequential medical inventions of the twentieth century, and it is still under-used. DKA is the one place in paediatrics where being too enthusiastic with fluid and insulin is more dangerous than being too slow.

Learning outcomes

UG Classify dehydration with WHO criteria and apply Plans A, B and C correctly.
UG Recognise DKA in a child presenting with vomiting, abdominal pain or fast breathing, and start a safe first hour.
UG/PG Manage DKA through the first 24 hours, including potassium, the switch to dextrose, and clinical recognition of cerebral oedema.
PG Interpret the PECARN FLUID trial and its effect on DKA fluid practice.

1 · Assessing dehydration Must-know

Sign	No dehydration	Some dehydration	Severe dehydration
Condition	Well, alert	Restless, irritable	Lethargic or unconscious
Eyes	Normal	Sunken	Sunken
Thirst	Drinks normally	Thirsty, drinks eagerly	Drinks poorly or not able to drink
Skin pinch	Goes back quickly	Goes back slowly	Goes back very slowly (over 2 s)
WHO plan	Plan A: fluids at home, continue feeding, zinc	Plan B: ORS 75 mL/kg over 4 hours at the facility	Plan C: IV fluid

Two or more signs in a column place the child in that column. The most useful single signs of significant dehydration in children are prolonged capillary refill, abnormal skin turgor and an abnormal breathing pattern; dry mucosa alone is weak evidence — a mouth-breathing child has a dry mouth.

2 · WHO Plan C Must-know

Age	First 30 mL/kg	Then 70 mL/kg
Under 12 months	over 1 hour	over 5 hours
12 months and older	over 30 minutes	over 2½ hours

Use Ringer's lactate (or 0.9% saline if unavailable). Repeat the first portion once if the radial pulse is still weak. Reassess every 15–30 minutes; start ORS by mouth (about 5 mL/kg/h) as soon as the child can drink; reclassify at the end and switch to Plan A or B. Give zinc for 10–14 days and continue feeding.

Danger

Look for severe malnutrition before starting Plan C. In a child with severe wasting or nutritional oedema, Plan C can kill: rehydration is slower, by mouth or nasogastric tube with ReSoMal where possible, and IV fluid is reserved for shock (Unit 16).

3 · DKA: recognise it Must-know

Diagnosis: hyperglycaemia (blood glucose over 11 mmol/L, about 200 mg/dL) and ketosis (blood β-hydroxybutyrate 3 mmol/L or more, or moderate-to-large urine ketones) and acidosis (venous pH below 7.3 or bicarbonate below 18 mmol/L). Severity: mild pH below 7.3, moderate below 7.2, severe below 7.1.

India lens

A large proportion of Indian children with type 1 diabetes present in DKA at diagnosis, often after being treated for “gastroenteritis”, “acute abdomen” or “pneumonia”. Deep, sighing Kussmaul breathing is repeatedly misread as a chest problem. Check a capillary glucose in every child with unexplained vomiting, abdominal pain, dehydration or fast breathing. It costs a few rupees and prevents deaths.

4 · DKA: the first hours Must-know

DKA — first hours (ISPAD 2022)

  WEIGH · assess · but note: clinical assessment OVERESTIMATES the
  deficit in DKA. Assume about 5–7% (moderate) or 7–10% (severe).
  SHOCK (uncommon — look for another cause too):
     0.9% saline or balanced fluid, 20 mL/kg rapidly, reassess
  NO SHOCK but volume-depleted:
     10–20 mL/kg over 20–30 minutes
  THEN deficit + maintenance, replaced evenly over 24–48 h,
     isotonic (0.9% saline or balanced) initially
  POTASSIUM: add 40 mmol/L once the child passes urine and K is
     not high — total body K is ALWAYS depleted
  INSULIN: 0.05–0.1 unit/kg/hour by infusion, started at least
     1 hour AFTER fluids began · NO insulin bolus
  When glucose falls below about 14–17 mmol/L (250–300 mg/dL):
     ADD glucose to the fluid — do not stop the insulin, which is
     what clears the ketones
  NO BICARBONATE except in exceptional, life-threatening
     hyperkalaemia or cardiovascular collapse
  MONITOR hourly: glucose, neuro obs, fluid balance
          2–4 hourly: electrolytes, gas, ketones

Evidence note

PECARN FLUID (Kuppermann et al., NEJM 2018): 1,389 DKA episodes randomised in a factorial design to faster or slower rehydration with 0.9% or 0.45% saline. Neither rate nor sodium content significantly changed rates of clinically apparent cerebral injury or neurocognitive outcome. It relaxed the extreme fluid caution of earlier decades — but ISPAD still advises replacing the deficit over 24–48 hours rather than rushing, and cerebral oedema remains the leading cause of DKA death in children.

5 · Cerebral oedema: diagnose it clinically, treat it immediately Must-know

Usually 4–12 hours into treatment, but it can be present at arrival. Warning signs: headache, recurrent vomiting, slowing heart rate with rising blood pressure, falling or fluctuating consciousness, irritability, incontinence, cranial nerve palsy, abnormal posturing.

Do not wait for the scan

Treat on clinical suspicion, before imaging: mannitol 0.5–1 g/kg over 10–15 minutes, or 3% saline 2.5–5 mL/kg over 10–15 minutes; head up; reduce the fluid rate; call for help. A normal early CT does not exclude cerebral oedema.

6 · Across settings Must-know

Ideal setting

Insulin by syringe pump, fluids by volumetric pump; hourly glucose and neuro obs; 2–4-hourly gas, electrolytes and ketones
Hyperosmolar therapy drawn up and labelled at the bedside
HDU nursing ratio for moderate and severe DKA

Resource-constrained setting

ORS is the headline act, not the fallback. WHO Plans A and B with zinc and continued feeding resolve the great majority of diarrhoeal dehydration without a cannula
Without an insulin pump, hourly subcutaneous or intramuscular rapid-acting insulin regimens are a recognised alternative — never a bolus, never large intermittent doses, always with hourly glucometer checks
Without laboratory potassium, add it only once urine is passed, and watch for arrhythmia
Cerebral oedema is diagnosed and treated clinically: mannitol or 3% saline at the bedside, without waiting for imaging you may not have
Transfer moderate and severe DKA to a unit that can monitor hourly — after the first hour of fluid, with insulin plan and flow chart written down

Checkpoint 1 of 2

An 11-year-old with new-onset DKA (pH 7.05) had 10 mL/kg saline and an insulin infusion started at hour 2. At hour 6 he complains of headache, vomits twice, and his heart rate falls from 120 to 74/min while his blood pressure rises. What is the next action?

Nudge

What does a falling heart rate with a rising blood pressure mean in a child being treated for DKA?

Structured hint

Headache, vomiting and a Cushing-type response, hours into treatment. Should treatment wait for imaging?

Checkpoint 2 of 2

A 14-month-old weighing 9 kg has severe dehydration from acute watery diarrhoea and no signs of malnutrition. What is the correct initial WHO Plan C regimen?

Nudge

Plan C has two schedules. Which one applies at 14 months?

Structured hint

The slower schedule (1 hour, then 5 hours) is for infants under 12 months. This child is over 12 months.

Part D

Specific emergencies

Units 12–15 · ~8 hours

The ABCDE spine keeps a child alive; these four units tell you what to do once you know why the child is sick. They are chosen for India's burden: household poisons, seizures, snake and scorpion envenomation, and injury.

▸Unit 12 Poisoning: toxidromes, decontamination, antidotes and India's common poisons Not attempted

Most poisoned children need good supportive care and nothing else. A few need one specific drug, fast. The skill is knowing which child is which — and knowing the handful of poisons in Indian homes that change the plan.

Learning outcomes

UG Stabilise a poisoned child with the ABCDE approach, including glucose, before thinking about the poison.
UG Recognise the four common toxidromes from bedside signs.
UG/PG Decide when activated charcoal helps and when it is contraindicated; know why emesis and routine lavage are not used.
UG/PG Manage organophosphate, hydrocarbon (kerosene), paracetamol, iron and button-battery ingestions.
PG Recognise the poisons with no antidote and a high fatality rate — aluminium phosphide, paraquat, yellow phosphorus — and plan early referral.

1 · Treat the child, then the poison Must-know

The poisoned child

 1. ABCDE        airway and breathing first — most deaths are
                 from respiratory depression or aspiration
 2. GLUCOSE      in every child with altered consciousness
 3. HISTORY      what · how much (worst-case estimate) · when ·
                 what else is in the house · what was given at home
                 · bring the container
 4. TOXIDROME    pupils · skin · secretions · heart rate · BP ·
                 temperature · bowel sounds · breath odour
 5. DECONTAMINATE only if it helps and is safe (section 3)
 6. ANTIDOTE     for the few that have one (section 4)
 7. OBSERVE      for the known time course of the poison
 8. PREVENT      safe storage counselling, before discharge

Take the worst-case amount: the number of tablets missing from the strip, the full volume of the bottle. Children share, siblings hide things, and parents under-estimate.

2 · Toxidromes Must-know

Toxidrome	Pupils	Skin and secretions	Other signs	Typical agents
Cholinergic	Pinpoint	Wet: sweating, salivation, tears, bronchorrhoea	Bradycardia, wheeze, vomiting, diarrhoea, fasciculation, weakness	Organophosphate and carbamate pesticides
Anticholinergic	Dilated	Dry, hot, flushed	Delirium, tachycardia, urinary retention, absent bowel sounds	Datura (dhatura) seeds, antihistamines, tricyclics
Opioid	Pinpoint	Normal	Slow shallow breathing, coma	Opioids, some antidiarrhoeals, poppy-husk preparations
Sympathomimetic	Dilated	Sweaty	Agitation, tachycardia, hypertension, hyperthermia, seizures	Amphetamines, excess salbutamol or theophylline

Pearl

Cholinergic and anticholinergic both change the pupils and the heart rate — feel the skin. Wet means cholinergic; dry means anticholinergic. The armpit is the quickest place to check.

3 · Decontamination: less than you were taught Must-know

Method	Current position
Activated charcoal 1 g/kg (max 50 g)	Consider within about 1 hour of a potentially serious ingestion of a substance charcoal binds, only if the airway is protected (alert, or intubated). Not for hydrocarbons, corrosives, iron, alcohols or lithium.
Induced vomiting	Not used. It delays charcoal, risks aspiration and does not improve outcome.
Gastric lavage	Not routine. Rarely considered for a recent, life-threatening ingestion with no good alternative, with the airway protected. Never for hydrocarbons or corrosives.
Whole-bowel irrigation	Specialist use: iron, sustained-release preparations, packets.
Skin and eye	Remove clothing and wash skin with soap and water for organophosphates; irrigate eyes. Staff wear gloves.

The error clinicians actually make

Making a child vomit after kerosene or a corrosive. Vomiting turns a stomach problem into a lung problem (hydrocarbon aspiration pneumonitis) or burns the oesophagus a second time. Households are often advised to do this; ask, and counsel against it.

4 · Antidotes worth knowing Must-know UG/PG

Poison	Antidote	Notes
Organophosphate, carbamate	Atropine	Titrate to a clear chest and dry secretions (section 5)
Opioid	Naloxone 0.1 mg/kg IV/IO/IM (max 2 mg), repeat as needed	Short-acting — watch for re-sedation; infusion may be needed
Paracetamol	N-acetylcysteine	Best within 8 hours of ingestion; see section 6
Iron	Desferrioxamine IV	For systemic toxicity or high levels
Digoxin, oleander (cardiac glycosides)	Digoxin-specific antibody fragments where available	Otherwise atropine for bradycardia, manage potassium, pacing in specialist units
Benzodiazepines	Flumazenil — rarely	Can precipitate seizures; not for undifferentiated coma
Methaemoglobinaemia (nitrites, dapsone, some dyes)	Methylene blue	Avoid in G6PD deficiency

Doses: see Appendix E and verify against your unit protocol. Your state or regional poison information centre can advise in real time — keep the number on the resuscitation trolley.

5 · Organophosphates and carbamates Must-know

India's most important paediatric poisoning: pesticides stored in homes, in soft-drink bottles, or on clothing and skin after field work.

Atropinisation

  AIRWAY first · suction · oxygen · ventilate if weak
  DECONTAMINATE skin and clothing (staff wear gloves)
  ATROPINE  0.02–0.05 mg/kg IV, DOUBLE the dose every 5 minutes
            until ATROPINISED:
              clear chest on auscultation (no crackles, no wheeze)
              heart rate adequate for age
              adequate blood pressure · dry axillae
              pupils no longer pinpoint
  then an INFUSION of about 10–20% of the total loading dose per
  hour, titrated — watch for toxicity (delirium, fever, ileus,
  urinary retention) and for relapse
  SEIZURES → benzodiazepine

Evidence note

The endpoint is a clear chest, not pupil size and not heart rate alone: children die of bronchorrhoea and respiratory failure. Doses needed can be far larger than usual. Pralidoxime is used in many Indian units, but its benefit is uncertain — a large randomised trial in Sri Lanka (Eddleston et al., PLoS Med 2009) found no mortality benefit. Follow your local protocol; never let it delay atropine or ventilation. Watch for the intermediate syndrome — neck flexor and proximal weakness with respiratory failure 1–4 days later, after the cholinergic phase has settled.

6 · Kerosene, paracetamol, iron and button batteries Must-know UG/PG

Poison	Danger	What to do
Kerosene and other hydrocarbons	Aspiration pneumonitis; fever and chest signs can appear hours later	No emesis, no lavage, no charcoal. Oxygen. Observe at least 6 hours: a child who is symptom-free with normal oxygen saturation and chest examination at 6 hours can usually go home. Chest X-ray if symptomatic. Antibiotics and steroids are not routine.
Paracetamol	Liver failure, often after a deceptively well first day	Serious risk is generally considered above about 150 mg/kg in a single acute ingestion (thresholds vary by country). Measure a level at 4 hours or later and use the nomogram; start N-acetylcysteine without waiting for a level if it will not be available within 8 hours of ingestion, or if the ingestion is staggered or unclear.
Iron	Vomiting, bloody diarrhoea, then apparent recovery, then shock, acidosis and liver failure	Calculate elemental iron: over about 60 mg/kg is potentially serious. Abdominal X-ray may show tablets. Charcoal does not bind iron. Desferrioxamine for systemic toxicity; discuss with a poison centre.
Button battery	Oesophageal burn within 2 hours; late fistula and catastrophic bleeding	X-ray neck, chest and abdomen. A battery in the oesophagus is an emergency: endoscopic removal within hours. While awaiting removal, honey (children over 1 year) is used in some protocols to reduce injury — follow your local ENT or poison centre advice.

7 · The poisons with no antidote Good-to-know UG/PG

Recognise them, refer them early

Aluminium or zinc phosphide (rodenticide tablets; garlicky odour): refractory shock, arrhythmia, acidosis; very high fatality, no antidote. Paraquat (herbicide): mouth ulcers, then kidney, liver and progressive lung fibrosis; oxygen may worsen the lung injury. Yellow phosphorus (some rat poisons and firecrackers): delayed liver failure after a symptom-free interval. For all three: supportive care, early senior involvement and early referral to a centre with intensive care and, for yellow phosphorus, access to liver-transplant assessment. Take every such history seriously even when the child looks well.

India lens

Paediatric poisoning in India is dominated by household products and farm chemicals: kerosene stored in drink bottles, organophosphate and carbamate pesticides, rodenticides, corrosives, datura, oleander seeds, iron tablets meant for a pregnant mother, and adult medicines. In adolescents, deliberate self-poisoning with pesticides and medicines is common: every adolescent poisoning needs a confidential, non-judgemental psychosocial assessment before discharge. Unregulated traditional preparations can contain lead or other heavy metals. The IAP Standard Treatment Guidelines include a chapter on poisoning in children.

Checkpoint 1 of 2

A 4-year-old is drowsy after playing where crops were recently sprayed. He has pinpoint pupils, copious oral secretions, crackles and wheeze, heart rate 64/min and muscle twitching. After airway support and oxygen, what is the priority?

Nudge

Wet skin, wet chest, small pupils, slow heart. Which toxidrome?

Structured hint

In this toxidrome, what do children actually die of — and which drug dries it up? What is its endpoint?

Checkpoint 2 of 2

A 2-year-old drank “a mouthful” of kerosene from a soft-drink bottle 30 minutes ago. He coughed and gagged at the time but is now playing, with a respiratory rate of 28/min, SpO₂ 98% in air and a clear chest. His mother has already made him vomit once at home. What is the best plan?

Nudge

Where does kerosene do its damage — the stomach or the lungs?

Structured hint

Every option that puts more kerosene near the airway is wrong. Of the rest, which has a time course matched to how aspiration pneumonitis develops?

▸Unit 13 Status epilepticus and raised intracranial pressure Not attempted

Two neurological emergencies where the clock does the damage: a seizure that is not stopped becomes harder to stop with every minute, and a brain under pressure is injured by every minute of low blood pressure or low oxygen.

Learning outcomes

UG Manage a convulsing child with a time-based algorithm, starting benzodiazepines at five minutes by whatever route is available.
UG Recognise raised intracranial pressure and impending herniation at the bedside.
UG/PG Choose a second-line antiseizure medicine and give it at the correct dose, using the ESETT, EcLiPSE and ConSEPT evidence.
UG/PG Apply the neuroprotective measures that lower intracranial pressure or protect cerebral perfusion, and avoid the ones that harm.
PG Recognise non-convulsive status and refractory status, and plan escalation.

1 · Status epilepticus: the clock Must-know

Convulsive status epilepticus — time-based

Text version

0–5 min   ABC · recovery position · oxygen · suction
          GLUCOSE · IV/IO access · note the TIME · do not restrain
          treat hypoglycaemia: 10% glucose 5 mL/kg
5 min     FIRST BENZODIAZEPINE — by the route you have
          IV/IO: lorazepam 0.1 mg/kg (max 4 mg)
                 or diazepam 0.2–0.3 mg/kg (max 10 mg)
          No IV:  buccal or intranasal midazolam 0.3 mg/kg (max 10 mg)
                  or rectal diazepam 0.5 mg/kg (max 10–20 mg)
10 min    SECOND BENZODIAZEPINE if still seizing — ONE repeat only
~20 min   SECOND-LINE MEDICINE — choose ONE
          levetiracetam 40–60 mg/kg IV over 5–15 min (max 3–4.5 g)
          phenytoin 20 mg/kg IV over 20 min, with ECG monitoring
             (or fosphenytoin 20 mg PE/kg)
          valproate 40 mg/kg IV (max 3 g) — avoid in liver disease,
             suspected metabolic or mitochondrial disease, under 2 y
          phenobarbital 20 mg/kg IV — where others are unavailable
~40 min   REFRACTORY: senior and anaesthetic help · a second
          second-line agent, or anaesthetic induction and a
          midazolam infusion with intubation · EEG where available

Danger

Two benzodiazepine doses is the ceiling. A third and fourth dose do not stop the seizure; they stop the breathing. Move to a second-line agent. And nominate one person to call out the elapsed time aloud — without a clock, “20 minutes” becomes an hour.

2 · Choosing the second-line drug Must-know UG/PG

What the trials showed

ESETT (Kapur et al., NEJM 2019; children and adults with benzodiazepine-refractory status): levetiracetam 60 mg/kg, fosphenytoin 20 mg PE/kg and valproate 40 mg/kg each stopped seizures in roughly half of patients, with no meaningful difference between them. EcLiPSE (UK) and ConSEPT (Australia and New Zealand), both Lancet 2019, compared levetiracetam 40 mg/kg with phenytoin 20 mg/kg in children: levetiracetam was not superior, but it is quicker to give, needs no cardiac monitoring and has fewer serious adverse effects. Choose by availability, contraindications and infusion time, not by efficacy.

A seizure that will not stop is a seizure with a cause you have not found. Check glucose, sodium, calcium and magnesium; think of meningitis and encephalitis, cerebral malaria, toxins, raised pressure, and non-accidental head injury in an infant. Hyponatraemic seizures respond to 3% saline, not to antiseizure drugs (Unit 7).

3 · Raised intracranial pressure Must-know

Cerebral perfusion pressure = mean arterial pressure − intracranial pressure. Every intervention either lowers intracranial pressure or protects arterial pressure. Hypotension and hypoxia convert a survivable brain injury into a devastating one.

Recognise	Do	Avoid
Headache worse in the morning or lying down; vomiting; falling consciousness; unequal pupils; abnormal posturing; Cushing triad (high BP, slow pulse, irregular breathing — late); bulging fontanelle and “setting sun” eyes in infants	Head up 30°, neck midline · secure airway · normal oxygen (SpO₂ 94% or above) · normal CO₂ (PaCO₂ 35–40 mmHg) · maintain blood pressure · analgesia and sedation · 3% saline 3–5 mL/kg or mannitol 0.5–1 g/kg for signs of herniation · treat fever, seizures and low sodium · urgent imaging and neurosurgery	Lumbar puncture · prolonged hyperventilation (brief only, as a bridge for imminent herniation) · hypotonic fluids · steroids in traumatic brain injury · hypoglycaemia and hyperglycaemia

Pearl

Steroids have a place for vasogenic oedema around tumours and in TB meningitis — not in traumatic brain injury, where they cause harm.

4 · Across settings Must-know

Ideal setting

IV lorazepam, then levetiracetam, fosphenytoin or valproate by pump with ECG monitoring
Refractory status: intubation, midazolam or thiopental infusion, continuous EEG
ICP monitoring and neurosurgery available; CT or MRI within the hour

Resource-constrained setting

No IV is not an obstacle: buccal or intranasal midazolam and rectal diazepam need no cannula and can be given by a nurse or trained parent
The two-dose benzodiazepine ceiling matters more here — you may have no means of supporting respiratory arrest
Phenobarbital and phenytoin are often the available second-line drugs; give phenytoin slowly, counting the pulse, even without a cardiac monitor
Without EEG, prolonged unexplained unresponsiveness after a seizure should be assumed to be ongoing seizure activity and discussed with a senior
Glucose, sodium, calcium, and assessment for meningitis, cerebral malaria and scrub typhus explain more refractory seizures here than imaging would

India lens

Neurocysticercosis is a leading cause of acquired epilepsy and of first seizures in Indian children, and Japanese encephalitis and cerebral malaria remain important in endemic districts. Train families of children with epilepsy to use buccal or intranasal midazolam at home; it shortens seizures before the child reaches hospital.

Checkpoint 1 of 2

A 3-year-old has been convulsing for 12 minutes and has had two doses of IV midazolam. The seizure continues. Glucose is 5.4 mmol/L and sodium 138 mmol/L. What next?

Nudge

How many benzodiazepine doses is the ceiling?

Structured hint

He has had two. The glucose and sodium are normal. The trials compared three drugs for exactly this situation — which step is that?

Checkpoint 2 of 2

A 7-year-old with a head injury from a fall has GCS 7, a dilated left pupil and BP 70/40 mmHg. She is intubated. Which combination best protects her brain in the next 15 minutes?

Nudge

Cerebral perfusion pressure = MAP minus ICP. Which of her numbers is making that worse right now?

Structured hint

She is hypotensive and has signs of herniation. You need to raise one side of the equation and lower the other. Which option does both, without adding harm?

▸Unit 14 Envenomation: snakes and scorpions Not attempted

India carries the world's largest burden of snakebite deaths, most of them rural, many of them children, and many preventable by one decision taken early: give antivenom, and be ready to ventilate.

Learning outcomes

UG Give correct first aid for snakebite, and name the traditional practices that cause harm.
UG Recognise neurotoxic and haemotoxic envenomation, including the painless night-time krait bite.
UG/PG Give polyvalent anti-snake venom at the national-protocol dose, repeat it by the 20-minute whole blood clotting test, and manage reactions.
UG/PG Recognise the autonomic storm of scorpion envenomation and treat it with prazosin, with or without antivenom.

1 · Snakebite: first aid that works Must-know

Reassure, keep the child still, and immobilise the bitten limb like a fracture.
Transport immediately to a facility that has anti-snake venom (ASV) — by the quickest safe means.
Remove rings, anklets and tight clothing before swelling starts.

Harmful practices

Do not apply a tight tourniquet, cut or suck the wound, apply ice or chemicals, use “snake stones”, or delay transport for a traditional healer. These practices cause limb loss and death, and delayed ASV is the commonest avoidable factor in snakebite deaths.

2 · Recognise the syndrome Must-know

Syndrome	Species (India's “big four”)	Features
Neurotoxic	Cobra, common krait	Ptosis (earliest), double vision, difficulty swallowing and speaking, neck weakness, then respiratory paralysis. Krait bites are often painless, happen at night during sleep, and leave no visible mark: a child who wakes with abdominal pain and vomiting and develops ptosis in an endemic area is a krait bite until proven otherwise.
Haemotoxic (vasculotoxic)	Russell's viper, saw-scaled viper	Local swelling and blistering, bleeding from gums or bite site, incoagulable blood, acute kidney injury, shock

Pearl

20-minute whole blood clotting test (20WBCT). Put 2 mL of fresh venous blood in a new, clean, dry glass tube; leave it undisturbed for 20 minutes; tip it once. If the blood has not clotted, it is incoagulable — a haemotoxic bite — and ASV is indicated. Repeat every 6 hours to guide further doses.

3 · Anti-snake venom: national protocol Must-know UG/PG

ASV (Indian national snakebite protocol)

  INDICATIONS: any sign of systemic envenomation
     (neurotoxic signs · incoagulable 20WBCT · spontaneous bleeding ·
      shock · kidney injury) or rapidly progressive local swelling
  CHILDREN RECEIVE THE SAME NUMBER OF VIALS AS ADULTS
     (the snake injects the same amount of venom);
     only the infusion volume is adjusted — about 5–10 mL/kg
  NEUROTOXIC:  10 vials over 30 minutes as an infusion
               if no improvement after 1 hour → a second 10 vials
               (maximum 20 vials) · then VENTILATE if needed
  HAEMOTOXIC:  10 vials over 30 minutes (6 for saw-scaled viper
               in the low-dose regimen), then repeat by 20WBCT
               every 6 hours until the blood clots, per the
               protocol followed in your state
  REACTIONS:   stop the infusion · IM adrenaline 0.01 mg/kg
               (max 0.5 mg) · restart cautiously when settled
  NEUROTOXIC ADJUNCT: atropine then neostigmine trial
               (national STG: atropine 0.05 mg/kg, then neostigmine
               0.04 mg/kg; repeat neostigmine if there is a response)

Source and limits

Source: Ministry of Health and Family Welfare Standard Treatment Guidelines, Management of Snakebite (quick reference guide). Polyvalent ASV in India covers the big four only; bites from other species, such as the hump-nosed pit viper, are not neutralised by it. The neostigmine trial helps mainly in cobra (post-synaptic) envenomation; krait toxins act pre-synaptically and respond poorly — for krait, ventilation is the life-saving treatment and may be needed for days. Check the dose schedule used in your state before quoting it.

4 · Across settings Must-know

Ideal setting

ASV, adrenaline and a ventilator in the same building
Laboratory coagulation tests, creatinine and urine output monitoring
Dialysis for acute kidney injury after viper bites

Resource-constrained setting

The PHC or CHC with ASV should give it, not refer first: the first dose is the most important one
20WBCT needs only a clean glass tube and a clock
Bag-mask ventilation by relays of staff and family has kept krait-bitten children alive during transfer
Refer early for ventilation (neurotoxic) and dialysis (haemotoxic with falling urine output) — after the first ASV dose, with adrenaline drawn up for the journey

5 · Scorpion sting Must-know UG/PG

The Indian red scorpion (Mesobuthus tamulus), common in western and southern India, causes an autonomic storm: severe local pain, then sweating, salivation, vomiting, priapism, cold limbs, hypertension and tachycardia, progressing in some children to myocardial dysfunction, pulmonary oedema and shock. Children are more severely affected than adults.

Treatment	Detail
Prazosin (the specific treatment)	30 microgram/kg by mouth (or nasogastric tube), repeated at intervals according to response — commonly 3–6-hourly — until the peripheries are warm and signs of the storm settle. Watch for first-dose hypotension.
Scorpion antivenom	In a randomised trial in Indian children (Pandi et al., 2014), scorpion antivenom plus prazosin produced faster recovery than prazosin alone. Give early where available.
Dobutamine	For the low-output, hypotensive phase and pulmonary oedema, with oxygen, CPAP or ventilation
Avoid	Atropine for the parasympathetic signs, and nifedipine or other drugs that cause reflex tachycardia

India lens

The prazosin protocol was developed and popularised by Dr H.S. Bawaskar in rural Maharashtra and cut scorpion-sting mortality dramatically at low cost. It is one of the clearest examples of an Indian clinical innovation designed for resource-constrained care.

Checkpoint 1 of 2

A 7-year-old in rural Maharashtra is brought at 3 a.m. having woken with severe abdominal pain and vomiting. There is no visible bite. Over the next hour he develops ptosis and difficulty swallowing. What is the most appropriate action?

Nudge

What kind of snakebite is painless, happens at night and leaves no mark?

Structured hint

Progressive ptosis and swallowing difficulty after night-time abdominal pain in an endemic area. Is the ASV dose for a child smaller than for an adult?

Checkpoint 2 of 2

A 5-year-old stung by a scorpion two hours ago is sweating profusely, has cold extremities, priapism, heart rate 160/min and BP 140/95 mmHg. Crackles are beginning at both bases. What is the specific treatment?

Nudge

What is driving the cold limbs, high blood pressure and pulmonary oedema — too much of which part of the autonomic system?

Structured hint

The storm is a massive alpha-adrenergic surge. Which drug blocks that receptor without causing reflex tachycardia?

▸Unit 15 Trauma, burns and drowning Not attempted

Injury is now a leading cause of death in Indian children beyond infancy, and it is the area where rehearsed teamwork and a few paediatric-specific facts make the most visible difference.

Learning outcomes

UG Conduct a paediatric primary survey (<C>ABCDE) and identify immediately life-threatening injuries.
UG Estimate burn surface area in a child and calculate initial burn fluid, including maintenance.
UG Give correct first aid for burns and start resuscitation after drowning.
UG/PG Apply paediatric injury patterns and decision rules to avoid both missed injury and unnecessary CT.
PG Apply paediatric principles of haemorrhage control and blood-product resuscitation.

1 · The paediatric primary survey Must-know

ABCDE

 <C> CATASTROPHIC HAEMORRHAGE — direct pressure, tourniquet,
     pelvic binder. Blood volume is only ~70–80 mL/kg.
  A  airway with manual in-line stabilisation · jaw thrust, not head
     tilt · collars fit children badly: manual stabilisation, blocks
     and tape are often safer than a struggling child in a collar
  B  the immediately lethal chest injuries: tension pneumothorax ·
     open pneumothorax · massive haemothorax · flail chest ·
     tamponade · airway disruption. Compliant ribs mean serious lung
     contusion WITHOUT rib fractures.
  C  two IV or IO lines · cross-match · treat hypotension as major
     haemorrhage · blood products EARLY; avoid large crystalloid
     volumes (10 mL/kg aliquots while blood is obtained)
  D  AVPU/GCS · pupils · glucose — head injury is the commonest
     cause of paediatric trauma death
  E  log-roll · full survey · then WARM the child (hypothermia,
     acidosis and coagulopathy feed each other)
  ADJUNCTS  analgesia (children are under-treated) · gastric tube ·
            tetanus · and bring the parents in early

Paediatric difference	Consequence
Large head, weak neck	Head injury dominates; high cervical injuries (C1–C3); spinal cord injury without X-ray abnormality occurs
Compliant chest	Contusion without fractures; tension pneumothorax develops fast. A rib fracture means major force — or abuse.
Relatively large, less protected liver and spleen	Solid-organ injury common; most managed without surgery in a monitored setting. Bicycle handlebars injure duodenum and pancreas.
Growth plates	A “sprain” in a child is often a growth-plate fracture

2 · Head injury: who needs a CT? Good-to-know UG/PG

Validated decision rules (PECARN, CATCH, CHALICE) identify children at very low risk of clinically important brain injury who can be observed rather than scanned. PECARN, the most widely validated, separates children under and over two years; features such as altered mental status, a palpable skull fracture or signs of basal skull fracture put a child in the high-risk group for CT. Use a rule, record which one, and observe children in the intermediate group with a clear plan for re-examination.

Pearl

A decision rule protects children from unnecessary radiation and from a missed bleed. Its value is consistency, not the particular cut-offs — pick one rule for your department and use it every time.

3 · Burns Must-know

First aid that works: cool running tap water for 20 minutes (useful up to 3 hours after the burn), remove clothing and jewellery, cover with cling film, keep the child warm. Not ice, toothpaste, ink, oil, turmeric or ghee.
Surface area: the adult “rule of nines” is wrong for children — the head is proportionally larger and the legs smaller. Use a Lund–Browder chart, or the child's own palm with fingers as about 1% for scattered burns. Do not count simple erythema.
Airway: facial burns, singed nasal hair, soot in the mouth, hoarseness or stridor mean the airway will swell. Involve the most experienced airway operator early; waiting can make intubation impossible.

Burn fluid in children (Parkland-type)

  Children with burns over about 10% TBSA need IV fluid.
  RESUSCITATION  3–4 mL × weight (kg) × %TBSA of Ringer's lactate
                 over 24 hours FROM THE TIME OF THE BURN:
                 half in the first 8 hours, half over the next 16
  PLUS MAINTENANCE with glucose (children, unlike adults, need it —
                 small glycogen stores)
  TITRATE to urine output about 1 mL/kg/h (0.5 mL/kg/h in
                 adolescents) — the formula is a starting point only

The error clinicians actually make

Two classic arithmetic errors: starting the 8-hour clock at arrival instead of at the time of the burn, and forgetting maintenance fluid in a child. Over-resuscitation (“fluid creep”) is also common: titrate down when urine output is good. Consider inflicted injury when the pattern does not fit the story — sharply demarcated immersion burns, symmetrical burns of both feet or buttocks, cigarette-sized burns (Unit 20).

4 · Drowning Must-know

The primary insult is hypoxia. Start resuscitation with five rescue breaths, then compressions if there are no signs of life. There is no meaningful difference between fresh and salt water for initial management, and abdominal thrusts to “remove water” are harmful. Children rescued from cold water may survive prolonged submersion: continue resuscitation until the child is warmed and senior assessment is made. Every child who needed rescue breaths, or who has cough, breathlessness or low saturation, needs admission and observation for at least several hours — lung injury can worsen late.

India lens

Drowning is one of the leading causes of death in Indian children aged 1–4 years, largely in open wells, ponds, tanks and buckets within metres of home, and in floods. Community measures — well covers, supervised crèches, barriers — prevent more deaths than hospital care can. Road traffic injury (often unhelmeted children on two-wheelers), falls, firecracker and cooking burns, and electrocution complete the picture.

5 · Haemorrhage in children Nice-to-know PG

Hypotension in an injured child suggests the loss of a large fraction of circulating volume. Give blood early — red cells and plasma, with platelets in massive transfusion — rather than repeated crystalloid, which dilutes clotting factors and worsens acidosis. Tranexamic acid is used in significant paediatric trauma haemorrhage in many trauma systems when given early; follow your trauma protocol. Keep the child warm, calcium replaced, and the time to haemorrhage control short.

Checkpoint 1 of 2

A 6-year-old weighing 20 kg has 25% TBSA scalds from 1 hour ago. Using 4 mL/kg/%TBSA, how much Ringer's lactate is needed over the rest of the first 8 hours from the burn, and what else must be prescribed?

Nudge

Work out the 24-hour total first. What fraction is due by hour 8, counted from when?

Structured hint

4 × 20 × 25 = 2000 mL in 24 hours. Half is due in the first 8 hours from the time of the burn — and one hour has already passed. Then ask what children need that adults do not.

Checkpoint 2 of 2

A 3-year-old is pulled from a village pond after an unknown time underwater. She is not breathing and has no signs of life. What is the correct first action?

Nudge

What is the primary insult in drowning?

Structured hint

Drowning arrest is asphyxial. Which option treats hypoxia first, and which one wastes time or causes harm?

Part E

Special populations, systems and future directions

Units 16–20 · ~7 hours

The children most likely to die are the ones in whom the standard rules change: the severely malnourished child, the young infant, the not-quite-well child whose diagnosis is hiding, and the child with a complex chronic condition. Then the systems around them — referral, communication, safeguarding and improvement — and what is coming next.

▸Unit 16 Severe wasting and nutritional oedema: when the rules invert Not attempted

Almost everything you learned in Parts B and C changes in a severely malnourished child. Applying standard emergency protocols to them is one of the commonest and most lethal errors in paediatrics — and it is entirely avoidable.

Learning outcomes

UG Identify severe wasting and nutritional oedema using WHO anthropometric and clinical criteria.
UG State how fluids, feeding, antibiotics and transfusion differ in the malnourished child, and the physiology behind each.
UG/PG Recognise and prevent refeeding syndrome.
PG Structure an inpatient pathway that links to community management and to India's Nutrition Rehabilitation Centres.

1 · Recognise it Must-know

In children aged 6–59 months, severe wasting and/or nutritional oedema (the 2023 WHO terms for what used to be called severe acute malnutrition) is any one of:

weight-for-length or weight-for-height below −3 SD of the WHO standards;
mid-upper arm circumference below 115 mm;
bilateral pitting oedema of nutritional origin.

Any medical complication, failure of the appetite test, or severe oedema means inpatient care. For infants under six months, the 2023 WHO guideline uses a broader concept — infants at risk of poor growth and development — and emphasises supporting breastfeeding and the mother–infant pair.

Source

WHO guideline on the prevention and management of wasting and nutritional oedema (acute malnutrition) in infants and children under 5 years. Geneva: WHO; 2023. It is the first WHO guideline to cover moderate wasting and infants under six months in detail. Fluid management details in this unit follow the long-standing WHO hospital-care protocol, which the 2023 guideline did not replace.

2 · Why the rules invert Must-know

Adaptation	Consequence	What changes
Reductive adaptation: slowed heart, kidney and liver function	The heart cannot handle a fluid load; the kidney cannot excrete sodium	No routine boluses. Slow rehydration, watching pulse, breathing and liver size
Low body potassium and magnesium, excess body sodium	Arrhythmia; oedema worsened by sodium	Supplement potassium and magnesium; restrict sodium — hence ReSoMal instead of standard ORS
Poor heat regulation	Hypothermia is frequent and lethal	Keep warm: covered head, skin-to-skin, warm room
Low glycogen	Hypoglycaemia, especially overnight	Feed every 2–3 hours, day and night
Blunted immune response	Infection without fever or raised white count	Antibiotics for every child with complicated malnutrition
Low cardiac reserve	Transfusion can cause heart failure	Transfuse only for Hb below 4 g/dL (or below 6 g/dL with respiratory distress): 10 mL/kg slowly over 3 hours
Free iron in the absence of binding proteins	Promotes infection and oxidative injury	No iron until rehabilitation, when appetite has returned

3 · The fluid decision Must-know

Dehydration and shock in the malnourished child (WHO)

  DEHYDRATION WITHOUT SHOCK — oral or nasogastric ReSoMal
     5 mL/kg every 30 minutes for 2 hours, then
     5–10 mL/kg/hour for 4–10 hours, alternating with F-75
     STOP if: pulse or breathing rate rises, liver enlarges,
              eyelids puff up (signs of over-hydration)
  SHOCK (lethargic or unconscious, cold hands, weak fast pulse)
     IV 15 mL/kg over 1 hour: Ringer's lactate with 5% glucose
     (or half-normal saline with 5% glucose)
     check pulse and breathing every 5–10 minutes
     improving → repeat 15 mL/kg over 1 hour, then switch to
                 ReSoMal orally or by NG tube
     NOT improving → assume septic shock: maintenance IV fluid,
                 transfuse 10 mL/kg slowly if severe anaemia,
                 antibiotics, senior help
  NEVER the standard Plan C volumes

Danger

The same child who needed 100 mL/kg in Plan C if well nourished can die of heart failure from it when severely wasted. Before any IV fluid in a child with diarrhoea, look at the arms and feel the feet.

4 · The ten steps Must-know

WHO ten steps — inpatient care

  STABILISATION (days 1–7)
   1  treat and prevent HYPOGLYCAEMIA
   2  treat and prevent HYPOTHERMIA
   3  treat and prevent DEHYDRATION (ReSoMal, section 3)
   4  correct ELECTROLYTES (potassium, magnesium; restrict sodium)
   5  treat INFECTION (antibiotics for all with complications)
   6  correct MICRONUTRIENTS (no iron yet)
   7  start cautious FEEDING: F-75, small, frequent, including night
  REHABILITATION (weeks 2–6)
   8  CATCH-UP GROWTH: F-100 or RUTF once appetite returns
   9  SENSORY STIMULATION and emotional support
  10  PREPARE FOR FOLLOW-UP

The day-three death

Refeeding syndrome. Reintroducing carbohydrate drives phosphate, potassium and magnesium into cells; blood levels crash, causing arrhythmia, heart failure and death, usually on days 2–5 of feeding. It is why WHO starts with low-energy F-75 and increases slowly. Without phosphate measurement, prevent it by protocol: start low, go slow, and suspect it in any child who deteriorates on days 2–5.

5 · Across settings Must-know

Ideal setting

Daily electrolytes including phosphate and magnesium during refeeding
Prompt testing for tuberculosis and HIV; echocardiography if heart failure is suspected
Dietitian and developmental therapy input

Resource-constrained setting

The WHO ten steps were designed for this setting and need almost no technology: warmth, F-75, feeds every 2–3 hours including night, ReSoMal, potassium and magnesium, antibiotics, no iron
A MUAC tape and an oedema check are the screening tools — usable by an Anganwadi worker or ASHA with no scales
Defaulting is the main cause of treatment failure, and it is economic, not clinical. Children without complications who pass the appetite test do well with community-based management using RUTF
A child not gaining weight on correct feeding has an undiagnosed infection — tuberculosis, HIV, urinary infection — until proven otherwise

India lens

India carries a large share of the world's wasted children. Facility care runs through Nutrition Rehabilitation Centres (NRCs), following the WHO steps, linked to community identification by Anganwadi workers and ASHAs under ICDS and POSHAN Abhiyaan. Know where your nearest NRC is and how to refer to it.

Checkpoint 1 of 2

A 14-month-old with visible severe wasting and MUAC 102 mm has had watery diarrhoea for three days. She is irritable, has sunken eyes and drinks eagerly; hands are warm and pulse is normal. What is the correct rehydration plan?

Nudge

What has MUAC 102 mm just changed about every fluid rule you know?

Structured hint

She is dehydrated but not shocked. For a severely wasted child, which solution has less sodium and more potassium — and which volumes are safe for her heart?

Checkpoint 2 of 2

On day 3 of treatment with F-75, a severely wasted 2-year-old who had been improving becomes breathless and oedematous, with a heart rate of 170/min. What is the most likely cause?

Nudge

What happens to phosphate, potassium and magnesium when a starved body starts receiving carbohydrate?

Structured hint

Days 2–5 of feeding, cardiac failure, a previously improving child. Which complication has exactly that timing?

▸Unit 17 The sick young infant (under 2 months) Not attempted

In the first two months of life, serious illness looks like almost nothing: a baby who is not feeding well, who is a little quiet, a little cold. By the time it looks like something, it is late.

Learning outcomes

UG Use the WHO seven-sign algorithm to identify possible serious bacterial infection in infants aged 0–59 days.
UG Recognise the young-infant emergencies that are not infection: hypoglycaemia, hypothermia, duct-dependent heart disease, surgical and metabolic crises.
UG/PG Apply the WHO 2024 recommendations for managing serious bacterial infection, including when referral is not possible.
PG Recognise the infant presentations of inherited metabolic disease and non-accidental head injury.

1 · The seven signs Must-know

WHO sign of possible serious bacterial infection (0–59 days)
Not feeding well, or not able to feed at all
Movement only when stimulated, or no movement at all
Temperature 38 °C or above
Temperature below 35.5 °C
Severe chest indrawing
Convulsions
Fast breathing (60/min or more) in an infant aged 0–6 days

Source

WHO recommendations for management of serious bacterial infections in infants aged 0–59 days (2024) recommend this seven-sign algorithm for identifying infants who need further evaluation (strong recommendation, moderate-certainty evidence). In the source analysis it had a sensitivity of about 0.79 and specificity of about 0.77 — it will miss some infants, which is why follow-up and safety-netting still matter.

2 · What WHO 2024 recommends when referral is not possible Must-know UG/PG

Group	Recommendation
Critical illness (e.g. unable to feed, no movement, convulsions)	Refer. If referral is impossible: IM/IV ampicillin plus gentamicin for at least 10 days
Clinical severe infection (any other sign except fast breathing alone)	Refer. If impossible: oral amoxicillin for at least 7 days plus IM gentamicin for at least 7 days (or, if 7 days of injections are not feasible, gentamicin for 2 days)
Fast breathing alone, 0–6 days	Refer. If impossible: oral amoxicillin for at least 7 days
Fast breathing alone, 7–59 days	Oral amoxicillin for at least 7 days; can be managed outside hospital according to clinical judgement

Doses (Appendix E): amoxicillin 50 mg/kg twice daily in the first week of life, then three times daily; gentamicin 5 mg/kg daily in the first week, then 7.5 mg/kg daily. In hospital, follow your SNCU or paediatric ward protocol and local resistance patterns.

India lens

India's F-IMNCI, the Home-Based Newborn Care and Home-Based Young Child Care programmes, and the SNCU and NBSU network are the delivery system for exactly these infants. ASHAs visiting at home are often the first to see the seven signs; the quality of what happens next depends on whether the facility they refer to recognises the infant as an emergency.

3 · Young-infant emergencies that are not infection Must-know

Emergency	Clues	First action
Hypoglycaemia	Jittery, lethargic, poor feeding, apnoea, seizures	Glucose at the bedside; 10% glucose 2 mL/kg IV then an infusion (neonatal dosing); feed
Hypothermia	Cold to touch, lethargic, poor feeding	Skin-to-skin (Kangaroo Mother Care), warm room, cap; look for sepsis
Duct-dependent heart disease	Shock or deep cyanosis in the first weeks; weak femoral pulses; big liver	Prostaglandin E1; discuss with cardiology (Unit 10)
Surgical emergencies	Bilious (green) vomiting; distension; blood in stool; projectile vomiting at 3–6 weeks	Bilious vomiting is malrotation with volvulus until proven otherwise: nil by mouth, gastric tube, fluids, urgent surgical review
Inherited metabolic disease	Well at birth, then poor feeding, vomiting, lethargy, seizures, unusual odour, after feeds start	Glucose, gas, ammonia; stop protein feeds; glucose infusion; metabolic team
Non-accidental head injury	Irritability, vomiting, seizures, a bulging fontanelle, unexplained bruises	Treat, then safeguard (Unit 20)

Pearl

Green vomit in a baby is a surgical emergency until a surgeon says otherwise. Hours matter: a volvulus can infarct the whole midgut.

4 · Across settings Must-know

Ideal setting

SNCU or NICU care with blood cultures, CSF and inflammatory markers before antibiotics
Echocardiography, prostaglandin, paediatric surgery and metabolic testing on site

Resource-constrained setting

The seven signs need no equipment. A thermometer and a watch are enough
Give the first dose of antibiotics before referral, and keep the baby warm on the journey with skin-to-skin contact
If referral is refused or impossible, the WHO 2024 outpatient regimens are evidence-based options — not a failure of care
Keep the mother and baby together; breastfeeding continues unless the infant cannot feed

Checkpoint 1 of 2

A 20-day-old is brought by an ASHA because she has been feeding poorly for a day. Temperature 35.2 °C, respiratory rate 52/min, no chest indrawing, moves normally. Which is correct?

Nudge

Count her signs against the seven. Is a low temperature one of them?

Structured hint

Two signs are present: not feeding well, and temperature below 35.5 °C. Which group does that put her in?

Checkpoint 2 of 2

A 10-day-old has vomited green fluid three times this morning. He was well yesterday; his abdomen is soft and he is not distended. What should happen next?

Nudge

What colour of vomit makes a paediatric surgeon come to the emergency room at night?

Structured hint

Bilious vomiting in a neonate is a surgical emergency until proven otherwise — even when the abdomen looks normal. Why does a soft abdomen not reassure you?

▸Unit 18 Occult red flags in the not-quite-well child Not attempted

Not every sick child is crashing. Some come to OPD for the fourth time, after three courses of antibiotics, with a parent who keeps saying the same sentence: “He is just not the same child.” That sentence deserves more diagnostic weight than most blood tests.

Learning outcomes

UG Build a structured differential for prolonged fever, pallor, weight loss and lymphadenopathy.
UG Recognise the red flags of childhood cancer, tuberculosis and immunodeficiency.
UG Give a specific, documented safety-net to every family sent home without a diagnosis.
UG/PG Plan a staged, affordable investigation pathway, and know when to stop giving antibiotics and start investigating.

1 · The parent's concern is a vital sign Must-know

Parental concern independently predicts serious illness and deterioration, which is why it is an escalation trigger in modern early-warning systems. Phrases that should raise your suspicion:

“He is not himself.” “She is not playing.”
“He has never been like this before.”
“I have brought him three times and he is getting worse.”
“He wakes at night crying with leg pain.”

The reverse matters too: a child who is genuinely playing is rarely about to collapse. Put a toy in front of them and watch.

2 · Prolonged fever Must-know

Category	Consider	Discriminating step
Infection (about half)	Tuberculosis, enteric fever, urinary infection, endocarditis, deep abscess, osteomyelitis, malaria, kala-azar, scrub typhus, brucellosis, HIV	Contact, travel, animal and food history; urine; blood culture; chest X-ray
Malignancy	Leukaemia, lymphoma, neuroblastoma	Full blood count with a film examined by a person; LDH; imaging
Inflammatory	Systemic JIA, Kawasaki disease, SLE, inflammatory bowel disease, HLH	Rash and arthritis pattern, mucocutaneous signs, ferritin
Other	Drug fever, thyrotoxicosis, fabricated illness	Medication review; fever documented by staff

India lens

Tuberculosis is the single most important missed diagnosis in a child with prolonged fever, weight loss or faltering growth. Take a contact history in every such child; a normal chest X-ray does not exclude abdominal, nodal or CNS TB. Use the national programme's diagnostic algorithms and rapid molecular tests (CBNAAT/Truenat) on gastric aspirate, induced sputum or other specimens where available.

3 · Cancer red flags Must-know

Presentation	Red flags	Think of
Pallor, bruising, fever	Unexplained pallor, bleeding, bone pain, big liver or spleen, lymphadenopathy	Leukaemia, lymphoma
Headache	Morning headache with vomiting, neurological signs, squint, ataxia, head tilt, rising head circumference in an infant	Brain tumour
Abdominal mass	Any mass; hypertension; eyes that dart (opsoclonus); bruising around the eyes	Neuroblastoma, Wilms tumour, hepatoblastoma
Bone or limb pain	Pain waking the child at night, a limp without injury, a “sprain” that does not settle	Bone tumours, leukaemia
Eye	White pupil (leukocoria), new squint, absent red reflex	Retinoblastoma
Lymph node	Over 2 cm, hard, matted, painless, growing beyond 2–4 weeks, supraclavicular at any size, with weight loss or night sweats	Lymphoma, tuberculosis

Pearl

Two four-second habits: check the red reflex in every infant and young child, and feel the abdomen properly in every child with vague symptoms. Retinoblastoma and Wilms tumour are curable when found early.

4 · Safety-netting Must-know

Every child sent home without a diagnosis needs a specific, documented safety-net. “Come back if worse” does not work.

The four-part safety-net

  1  WHAT I THINK this is, and how long it should last
  2  EXACTLY WHAT should bring you back immediately:
       a rash that does not fade under a glass · fast breathing or
       sucking in of the ribs · refusing all feeds · floppy or hard
       to wake · a fit · cold, mottled hands and feet · no urine for
       8–12 hours · fever beyond the day I told you
  3  WHERE to go and HOW — the facility, the hours, what to do at
       2 a.m. (transport is a clinical variable)
  4  A PLANNED REVIEW at a definite time and place
  then DOCUMENT the words you used

Checkpoint 1 of 2

A 5-year-old has had three weeks of intermittent fever, has become pale, refuses to walk in the mornings because of leg pain, and has a 2.5 cm firm cervical node. What is the most appropriate next step?

Nudge

Fever, pallor, bone pain that stops a child walking, and a node over 2 cm. What cluster is that?

Structured hint

Which single test could show the answer today — and does it need to be read by a machine or a person?

Checkpoint 2 of 2

You are discharging a 3-year-old with a viral illness at 11 p.m. Which safety-net advice is most effective?

Nudge

Which answer would still work for a frightened parent at 3 a.m.?

Structured hint

A usable safety-net names what to watch for, where to go, when, and a planned review. Which option contains all four?

▸Unit 19 The child with chronic and complex illness Not attempted

Children with medical complexity are a small fraction of paediatric patients and a large fraction of emergencies, admissions and deaths. They also attract a predictable set of errors.

Learning outcomes

UG Recognise diagnostic overshadowing and take a structured baseline history from a carer.
UG Manage the common device emergencies: a blocked tracheostomy, a shunt malfunction, a dislodged gastrostomy, a febrile central line.
UG/PG Recognise condition-specific crises — adrenal, metabolic, sickle cell, febrile neutropenia, cyanotic spell — and act within the correct time.
PG Discuss ceilings of treatment and an emergency care plan with a family, within Indian law and practice.

1 · Diagnostic overshadowing Must-know

The central error

A new symptom in a child with cerebral palsy, Down syndrome, autism or a chronic condition is put down to the known diagnosis and not investigated. The child with cerebral palsy who is “irritable because of spasticity” has a fractured femur, a torsion, a corneal abrasion, dental pain or a urinary infection. Assume a new symptom has a new cause.

Ask the carer three questions: What is normal for this child? (tone, alertness, saturations, feeding, seizure frequency) What is different today? What usually works? The carer of a complex child is often the most expert person in the room.

2 · Device emergencies Must-know

Device	Emergency	Action
Tracheostomy	Blocked or displaced tube: distress with little air movement	Suction; remove the inner tube if present; if a suction catheter will not pass, change the tube (same size, then smaller). If that fails, ventilate by mask over the face or by the stoma, and call for help.
VP shunt	Blockage or infection: headache, vomiting, drowsiness, bulging fontanelle, fever	A raised-pressure emergency (Unit 13): urgent imaging and neurosurgery. Do not send home a drowsy child with a shunt.
Gastrostomy	Dislodged tube	The tract closes within hours: replace it, or keep it open with a catheter, then confirm position before use
Central line	Fever	Line infection until proven otherwise: cultures from the line and a vein, antibiotics now
Home ventilator	Circuit or power failure	Disconnect and ventilate by bag with oxygen. Do not troubleshoot a machine while the child is not breathing.

3 · Condition-specific crises Must-know UG/PG

Condition	Crisis	Immediate action
Adrenal insufficiency, CAH, long-term steroids	Shock, hypoglycaemia, low sodium, high potassium during illness	Hydrocortisone immediately IV or IM (about 25 mg under 1 year, 50 mg 1–5 years, 100 mg over 5 years), with glucose and saline. Never delay for tests.
Inherited metabolic disease	Decompensation: vomiting, encephalopathy, high ammonia	Stop protein, high glucose infusion, urgent ammonia, the family's emergency letter, metabolic team
Sickle cell disease	Pain crisis, acute chest syndrome, splenic sequestration, stroke	Prompt, adequate analgesia; oxygen; fluids; infection screen; transfusion as indicated. A suddenly enlarging spleen with falling haemoglobin is sequestration — transfuse.
Child on chemotherapy	Febrile neutropenia	Broad-spectrum IV antibiotics within one hour of arrival, before the count is back
Tetralogy of Fallot	Hypercyanotic spell	Knee-to-chest, oxygen, calm the child, morphine, fluid; then phenylephrine or a beta-blocker. Avoid inotropes that increase contractility.

Hydrocortisone stress doses vary between national guidelines; use the child's own emergency letter if they have one, and Appendix E.

4 · Ceilings of treatment and emergency care plans Good-to-know PG

For a child with a progressive, life-limiting condition, the most important conversation happens before the crisis, in clinic, unhurried. Frame it around what the family hopes for and fears, not around a list of things to withhold. Record an emergency care plan the family carries with them.

India lens

Indian law on withholding and withdrawing life-sustaining treatment has developed through Supreme Court judgments recognising advance medical directives and passive euthanasia, with procedures simplified in 2023; institutional practice still varies widely and decisions for children are made with extended families. Involve senior colleagues and your institution's ethics committee, document carefully, and prioritise palliative care and symptom relief, which remain under-provided for children.

Checkpoint 1 of 2

A 4-year-old with a tracheostomy is in severe respiratory distress. Oxygen to the tracheostomy does not help, the chest barely moves, and a suction catheter will not pass down the tube. What next?

Nudge

If a suction catheter will not pass, where is the obstruction?

Structured hint

The tube itself is blocked or displaced. A blocked tracheostomy is a complete airway obstruction. Which option removes the obstruction?

Checkpoint 2 of 2

A 6-year-old on maintenance chemotherapy has a temperature of 38.6 °C and looks reasonably well. The blood count will take two hours. What is the correct action?

Nudge

Does a child with few neutrophils look as sick as their infection is?

Structured hint

Febrile neutropenia has a time target with mortality attached. Is it measured from arrival or from the blood result?

▸Unit 20 Referral, transport, safeguarding, quality and future directions Not attempted

In a referral-dependent health system, the quality of the transfer decision often matters more than any single drug. The conversation with the parents is not the soft part of care — it is the part they will remember for the rest of their lives. And nothing in this module helps a child unless a system delivers it reliably at 3 a.m.

Learning outcomes

UG Decide when to refer, stabilise before transfer, and hand over using ISBAR.
UG Communicate serious news to a family, and support family presence during resuscitation.
UG Recognise features of abuse and neglect and know the mandatory reporting duties under POCSO.
UG/PG Design a small quality-improvement project with outcome, process and balancing measures.
PG Appraise emerging tools — machine-learning prediction, point-of-care ultrasound, host-response tests — for use in a low-resource setting.

1 · Refer while the child is still compensating Must-know

The commonest transport disaster is the child sent after decompensation, in an unequipped vehicle, without a stable airway, with staff who cannot manage deterioration on the way.

Before any transfer

  A  airway secure; if intubated, position confirmed and taped;
     suction in the vehicle
  B  oxygen for the journey PLUS 50% reserve; saturation monitored
  C  two working IV or IO lines, secured and visible
  D  glucose checked; seizures controlled; rescue drugs drawn up
  E  child WARM — cap, blankets, warm vehicle
  +  notes, drugs and times, weight, investigations
  +  ACCEPTANCE by a named person at the receiving unit, by phone
  +  parent informed and travelling if possible
  +  "what is most likely to go wrong in the next hour — and is the
     drug and equipment for it in the vehicle?"

ISBAR handover: Identify yourself and the child · Situation · Background · Assessment (with vital signs and weight) · Recommendation (what you need, by when).

Ideal setting

A paediatric retrieval team stabilises and transports with full monitoring and ventilation
The referring doctor's job is early referral, stabilisation to the team's advice and complete documentation

Resource-constrained setting

You are the retrieval team. The checklist is your work, finished before the vehicle leaves
Phone and secure acceptance from a named person first; an unannounced child may be turned away, and a family may not survive a second journey financially
Treat cost and transport as clinical variables. Ask whether the family can reach and afford the referral centre, and use 108/102 ambulance services and government scheme coverage (such as PM-JAY) where eligible
Send oxygen and a trained escort if at all possible, with a written note that includes your phone number

2 · Talking to families Must-know

SPIKES adapts well to paediatrics: Setting (private, seated, both parents if possible, an interpreter — never a sibling) · Perception (“What have you been told so far?”) · Invitation (“How much would you like me to explain?”) · Knowledge (a warning shot, then plain words; say “died”; use the child's name) · Empathy (stop talking; allow silence) · Summary and strategy (what happens next, and when you will speak again).

Family presence

Offering parents the choice to be present during their child's resuscitation is supported by resuscitation guidelines and by evidence on bereavement: parents who were present generally report less anxiety and better-adjusted grief, and they rarely obstruct care. It needs a designated staff member to stay with them and explain.

3 · Safeguarding Must-know

Features that should raise concern:

A history that is absent, changing, inconsistent between carers, or impossible for the child's development — a 3-month-old who cannot roll did not roll off the bed.
Unexplained delay in seeking care.
Any bruise in a non-mobile infant; bruises on the torso, ears or neck under 4 years; patterned bruises.
Sharply demarcated, glove-and-stocking or cigarette-shaped burns.
Rib fractures, metaphyseal fractures, fractures of different ages, retinal haemorrhages, unexplained intracranial injury.
Neglect: faltering growth that recovers in hospital, untreated dental disease, missed immunisations.
Fabricated or induced illness: symptoms seen only by one carer; findings that never match the reported severity.

India lens

The Protection of Children from Sexual Offences (POCSO) Act, 2012 makes it mandatory for anyone, including doctors, who knows of or suspects a sexual offence against a child to report it to the Special Juvenile Police Unit or local police; failure to report is itself an offence. Medical examination and treatment of a child survivor must not be refused or delayed. Beyond POCSO, report concerns about abuse or neglect to the District Child Protection Unit or Child Welfare Committee under the Juvenile Justice Act, and use Childline 1098. Know who your hospital's designated safeguarding person is before you need them.

4 · Quality improvement: closing the know–do gap Good-to-know UG/PG

Element	Example
Aim	“Increase the proportion of children with suspected sepsis receiving antibiotics within 60 minutes of recognition from 35% to 80% within 6 months.”
Outcome measure	Time from recognition to first antibiotic dose
Process measures	Documented triage category; recorded weight; time to IV or IO access
Balancing measure	Total antibiotic use — to detect over-treatment of children who were not septic
Changes to test	A sepsis grab-box; a weight-banded dose card; nurse-initiated antibiotic preparation; a run chart at the nursing station

Improvements that reliably narrow the gap: pre-calculated weight-banded emergency drug charts; checklists for intubation, transfer and sepsis; in-situ simulation in the real clinical space; structured handover; and no-blame mortality review with documented actions. Report projects using SQUIRE 2.0.

5 · Future directions Nice-to-know PG

Direction	Where it stands	The honest caveat
Machine-learning deterioration prediction	Can outperform threshold scores in high-income hospitals with rich electronic records	Mostly built on data that district hospitals do not collect; discrimination in a development set says nothing about whether outcomes improve — the EPOCH lesson again
Sepsis sub-phenotypes	Distinct biological endotypes are being identified	The most plausible route out of guidelines built on low-certainty evidence — not yet at the bedside
Point-of-care ultrasound	Handheld probes are cheap; useful for lungs, volume and heart function	Operator-dependent; needs training and governance or it produces confident errors
Rapid diagnostics and host-response tests	Could distinguish bacterial from viral illness and cut antibiotic use	Cost and supply chain, not the technology, are the constraint
Oxygen systems and pulse oximetry	Measurable mortality impact in childhood pneumonia	The highest-yield “technology” here, and the least discussed

The closing argument

Nothing in this module is hard to understand. Almost all of it is hard to do reliably at three in the morning, on the fortieth child of the shift, when the cylinder is empty and the family cannot afford the referral. That is the real clinical problem — and the reason systems matter as much as knowledge.

Checkpoint 1 of 2

A 3-month-old has a bruise on the left cheek. The parents say she rolled off a sofa. On examination she cannot yet roll over. What is the most appropriate action?

Nudge

Can a baby who cannot roll fall off a sofa by rolling?

Structured hint

Any bruise in a non-mobile infant is a red flag, and here the history does not fit the child's development. What does that combination require?

Checkpoint 2 of 2

A CHC is transferring a 2-year-old with septic shock who has responded partly to fluid and antibiotics. The ambulance is ready. Which step is most important before the vehicle leaves?

Nudge

What can a child arriving unannounced at a full tertiary centre face?

Structured hint

The two things that most often cause transfer disasters are an unstable child and an unexpected arrival. Which option prevents both?

Assessment

Final assessment and certificate

Three independent criteria

A single score is not a defensible basis for a high-stakes decision about a clinician. This module certifies on three independent criteria, each measuring something the others cannot.

Where you stand

Coverage asks whether you have met every unit. Retention asks whether the learning survived a night's sleep — it counts breadth across units, not raw items, because a raw count can be satisfied entirely from the units you met first, leaving the newest and most fragile learning untested. Applied performance asks whether you can integrate across units under closed-book conditions.

The closed-book integrated assessment

50 items sampled from a pool of 70 — your 40 unit checkpoints plus 30 fresh integrative items written for this assessment only.
Item and option order randomised on every attempt, so two attempts are never the same paper and answer-position memory is worthless.
75 minutes, no hints, no rationales, no feedback until you submit. You may move back and forth and change answers.
Two attempts, with a 24-hour lock between them — deliberately, so that the gap is filled by remediation and sleep rather than by immediate re-guessing.
Cut score 80%. Shipped labelled provisional — see the note below and the standard-setting worksheets in Appendix C.
On submission you get a per-unit remediation plan built from your actual misses, and an item-by-item review with full rationales.

—

If you do not reach the cut score

This is designed to be recoverable, not punitive. In order:

Read the remediation plan printed after your attempt. It names the units your misses clustered in, ranked.
Re-open those units and re-answer their checkpoints cold. Do not skim the prose first — attempt the questions, fail them if you are going to, and let the rationale teach you. Retrieval before re-reading is worth several passive re-readings.
Use the hints deliberately. A hinted item stays in the first spaced-retrieval box, so it will come back tomorrow and the day after until you own it.
Work the key-feature problems in Appendix A. They test the same decisions in an open-response format, which exposes gaps that multiple choice hides.
Sleep on it. The 24-hour lock is not an obstacle; it is part of the intervention.

If after two attempts you are still short, ask your faculty to reset your attempts from the panel below. There is no limit on learning, only on how many attempts count toward one certificate.

On the cut score — read this before you defend it to anyone

A cut score chosen by preference is the weakest defensible option available. Published comparisons of standard-setting methods applied to the same assessment have produced cut scores ranging from roughly 66% to 86% — which means the method you choose can matter more than the candidates' performance. This module therefore ships its cut score as provisional, and Appendix C provides modified Angoff, Ebel and Hofstee worksheets plus borderline-regression guidance so your institution can set a defensible one for your own cohort before using this for any consequential decision.

Certificate

The certificate becomes available when all three criteria above are met. That is deliberate: it is what lets the certificate say something specific rather than something vague.

Faculty settings

Change these before distributing the module, then use Export a configured copy to produce a file with your settings baked in for your learners. These settings live only in this browser until you export.

Course title on the certificate

Signatory name

Signatory designation

Cut score (%)

Items per attempt

Time limit (minutes)

Attempts allowed

Lock between attempts (hours)

Retention bar — units required of 20

Signature image (optional)

Scan or photograph your signature on white paper. It is downscaled to 600 px wide, the paper is matted out so only the ink remains, and the result is stored inside the file — so it travels with the exported copy and adds to its size. A PNG that already has a transparent background is used as-is.

Two recurring traps when publishing: uploading the unconfigured file (so the certificate carries no signatory), and embedding a full-resolution photograph (base64 adds about a third to its size — resize to roughly 400 × 400 first).

Appendices

Appendices A–G

Never locked

Open from the first minute, whatever your progress. Appendix E (drugs, fluids and equipment) and Appendix F (references) are clinical safety material, and clinical safety material behind a quiz is a patient-safety problem. Every appendix can be printed on its own.

▸A · Assessment bank

A1 · Blueprint against Miller's pyramid

No single instrument samples all four levels. This is what each part of the programme can honestly claim.

Miller level	What it means	Instrument here	Weight
Knows	Recalls facts, doses, thresholds	Unit checkpoints; final assessment	~25%
Knows how	Applies knowledge to a clinical problem	Case-vignette checkpoints; integrative items; key-feature problems	~45%
Shows how	Demonstrates in simulation	OSCE stations (A3); scenarios (Appendix B); DOPS	~20%
Does	Performs in real practice	Mini-CEX, CBD, MSF, entrustment (A4)	~10%

What the written assessment cannot do

The module's certificate covers only the top two rows. Anyone using it for a consequential decision must add the bottom two, with a mannequin, printed vital-sign cards and a faculty observer.

A2 · Key-feature problems

Short answers, no options. They test only the decisions on which the case turns. Use them in remediation clinics and vivas.

KF1 — The febrile toddler at a district hospital

A 2-year-old with fever for three days: heart rate 170/min, capillary refill 4 s, BP 90/60 mmHg, alert. No ventilator, no PICU.

Is this child hypotensive, and what is your fluid decision?
Model: threshold 74 mmHg, so not hypotensive; no bolus (SSC 2026, strong); maintenance fluid.
Name three actions in the first 30 minutes that do change outcome here.
Model: antibiotics within the hour, glucose check and correction, haemoglobin check and transfusion if severe anaemia, early transfer, warmth.

KF2 — The drowsy child with diabetes

An 11-year-old with DKA, 6 hours into treatment, develops headache and a heart rate falling from 120 to 70/min.

What is the diagnosis, and what do you give?
Model: cerebral oedema; mannitol 0.5–1 g/kg or 3% saline 2.5–5 mL/kg over 10–15 minutes, head up, reduce fluids.
Does this need a scan first?
Model: no — treat clinically; image after stabilisation.

KF3 — The wasted child with diarrhoea

An 18-month-old, MUAC 105 mm, sunken eyes, drinking eagerly, warm hands.

Which rehydration solution, how much, how fast?
Model: ReSoMal 5 mL/kg every 30 min for 2 h, then 5–10 mL/kg/h, alternating with F-75.
Name three signs that should make you stop.
Model: rising pulse, rising respiratory rate, enlarging liver, puffy eyelids.

KF4 — Night-time abdominal pain in a farming village

A 7-year-old woke at 3 a.m. with abdominal pain and vomiting; now has ptosis.

Diagnosis and first treatment?
Model: krait envenomation; 10 vials ASV, adrenaline drawn up.
What is the life-saving supportive treatment?
Model: ventilation — bag-mask if nothing else.

A3 · OSCE stations

Twelve stations, 6–8 minutes each, on a doll with printed vital-sign cards. Score with the six-domain rubric in Appendix C.

#	Station	Tests	Critical failure
1	Paediatric Assessment Triangle from a video or actor	Category and first move	Misses abnormal appearance
2	ETAT triage of six cards in 6 minutes	Emergency, priority, queue	Queues a child with an emergency sign
3	Airway opening and bag-mask ventilation	Position, adjunct, E-C grip, rate, chest rise	No chest rise, not corrected
4	Intraosseous insertion	Site, technique, confirmation, flush	Wrong site or no confirmation
5	The bolus cycle	Fluid choice, aliquot, four reassessment questions	Misses a stop signal
6	Sepsis first hour, setting-specific	Time targets, fluid decision by setting	Bolus in a non-hypotensive child without ICU
7	Status epilepticus to 20 minutes	Drugs, doses, routes, ceiling	Third benzodiazepine
8	DKA first hour and cerebral oedema recognition	Fluid, insulin timing, warning signs	Insulin bolus or bicarbonate
9	Severe wasting with shock	15 mL/kg over an hour; monitoring	Plan C volumes
10	Snakebite: 20WBCT and ASV	Test, dose, reaction management	Weight-scaled ASV
11	Anaphylaxis	IM adrenaline dose and site	Antihistamine first
12	Breaking bad news (SPIKES), with an actor	Setting, language, silence, plan	Euphemism; leaves without a plan

A4 · Workplace-based assessment

Tool	Use it for	Frequency	Note
Mini-CEX	An observed triage or first-hour assessment	2–4 per learner per year	The feedback is the intervention
DOPS	IO insertion, bag-mask ventilation, bolus administration	Until entrustment, then annually	Score the procedure, not the person
CBD	Reasoning behind a case the learner led	2–3 per year	Ask “what else did you consider?”
MSF	Teamwork and communication, from nurses and peers	Annual	Detects the behaviours that cause harm

Entrustment scale for the core EPA

EPA: Recognise, triage and lead the first hour of care of a seriously ill child, including a setting-appropriate fluid decision and timely referral.

Level	Descriptor
1	Observes only
2	Performs with direct supervision
3	Performs with indirect supervision, supervisor reachable within minutes
4	Performs unsupervised; supervisor available for the unexpected
5	Supervises and teaches others

Minimum standard for a doctor covering a paediatric emergency room alone: level 4 for triage, airway support, IO access and the sepsis first hour; level 3 or above for status epilepticus and DKA.

▸B · Simulation library

Four branching scenarios that run on a doll and printed vital-sign cards — no simulator needed. Show the next card only when the team has done, or clearly failed to do, the expected actions.

Scenario 1 — The febrile toddler without a PICU

District hospital, 2 a.m. A 2-year-old, 12 kg, fever 3 days, drowsy. One doctor, two nurses. No ventilator.

Stage	Vital-sign card	Expected actions	Facilitator trigger
1	HR 170, RR 40, CRT 4 s, BP 88/56, SpO₂ 95%, glucose 2.2	PAT, say “sepsis”, glucose 10% 5 mL/kg, access (IO if needed), antibiotics	If no glucose check after 3 min: “He is now twitching.”
2	HR 165, BP 90/58, Hb 5 g/dL	No bolus (not hypotensive, no ICU); maintenance; blood transfusion; call referral centre	If a 20 mL/kg bolus is started: next card shows crackles and SpO₂ 88%
3	Stable or deteriorating per branch	Transfer checklist, ISBAR handover by phone	Receiving unit asks: “What is his weight and what has he had?”

Debrief points: the 2026 setting-specific fluid recommendation; hypoglycaemia and anaemia as outcome-changing actions; the transfer decision as a treatment.

Scenario 2 — Status epilepticus in a toddler

PHC. An 18-month-old, 10 kg, convulsing on arrival, started 8 minutes ago at home. No IV access yet.

Stage	Vital-sign card	Expected actions	Facilitator trigger
1	Convulsing, SpO₂ 90%	Airway, oxygen, glucose, buccal/intranasal midazolam 0.3 mg/kg, note the time	If no clock: “Mother asks how long it has been.”
2	Still convulsing at 10 min	Second benzodiazepine; IO/IV access	If a third benzodiazepine is proposed: RR falls to 8
3	Still convulsing at 20 min	Second-line drug (phenobarbital/phenytoin/levetiracetam); look for cause; call for help	Sodium card: 121 mmol/L — does the team give 3% saline?

Debrief points: the two-dose ceiling; route flexibility; searching for a cause.

Scenario 3 — DKA on the ward

Paediatric ward. A 10-year-old, 28 kg, newly diagnosed DKA, pH 7.02, treated for 5 hours.

Stage	Vital-sign card	Expected actions	Facilitator trigger
1	HR 110, BP 110/70, GCS 15, glucose 14	Add glucose to fluids, continue insulin, check potassium	If insulin is stopped: ketones rise on the next card
2	Headache, vomiting, HR 68, BP 132/86	Recognise cerebral oedema; mannitol or 3% saline now; head up; reduce fluid	If CT is requested first: GCS falls to 10
3	Improving	Senior review, HDU, imaging once stable	—

Debrief points: treating cerebral oedema clinically; insulin and glucose together.

Scenario 4 — Snakebite at a CHC

CHC, 9 p.m. A 9-year-old bitten on the ankle while walking in a paddy field, 2 hours ago. Tourniquet applied by family.

Stage	Vital-sign card	Expected actions	Facilitator trigger
1	Swollen leg, gum bleeding	Remove tourniquet carefully, 20WBCT, IV access, adrenaline drawn up	20WBCT card: unclotted
2	Unclotted	10 vials ASV over 30 min	5 min into infusion: urticaria, stridor, BP 70/40
3	Anaphylaxis	Stop infusion, IM adrenaline 0.01 mg/kg, fluid; restart ASV when settled	Urine output falling at 6 h: refer for dialysis with notes

Debrief points: ASV dose not weight-scaled; reaction management; when to refer.

Debriefing — the PEARLS structure

Debrief for at least as long as the scenario ran. Sit down. Phones away.

Phase	Time	Say
Setting the scene	1 min	“We're here to learn, not to judge. What's said here stays here. I believe everyone did their best with the information they had.”
Reactions	2 min	“In a word or two — how was that?” Let everyone speak. Do not analyse yet.
Description	2 min	“Can someone walk us through what happened, clinically?” Establish shared facts before opinions.
Analysis	10–15 min	The body of the work. Choose 2–3 points, no more. Use the three methods below.
Summary	3 min	“One thing to keep, one thing to change.” From them, not from you.

Three analysis methods, chosen by what you are addressing:

Plus–delta — for performance that was broadly good. “What worked? What would you change?” Fast, safe, low yield.
Advocacy–inquiry — for a specific puzzling action. State your observation and your reasoning, then ask theirs: “I noticed compressions started while the chest wasn't moving. I was concerned because that circulates deoxygenated blood. I'm curious what you were seeing at that moment.” This is the highest-yield technique and the hardest to do well — the inquiry must be genuine.
Directive feedback with teaching — for a knowledge gap. Do not use inquiry to extract a fact somebody does not have; that is humiliating. Say the fact, explain the mechanism, move on.

Pearl — debrief the system, not only the people

At least one of your two or three analysis points should be about the environment: where the oxygen and the IO needles were, how long help took, whether the clock was visible. Those findings are the ones that improve the next real resuscitation, including the ones this team is not present for.

▸C · Faculty guide

C1 · Three delivery models

Model	Shape	Best for	Watch out for
Fully self-paced	Learners work through alone; one skills session at the end	Large cohorts, interns, CME	The skills session becoming a demonstration. Cap at 6 learners per doll.
Flipped, Part by Part	Learners master a Part before each session; sessions are simulation and discussion	PG residents, nursing cohorts	Verify mastery first, or you end up teaching content
Intensive, 2 days	Parts A–C day one with simulation; D–E day two	District outreach, visiting faculty	Retention: schedule the review checks and a 6-week follow-up

C2 · A worked flipped-classroom session — Part C, shock

90 minutes, 8–12 learners, 2 dolls, 2 facilitators. Prerequisite: Units 8–11 mastered.

Time	Activity	Purpose
0–5	Learning contract: “Nobody here is being examined.”	Psychological safety
5–15	Rapid retrieval: the four reassessment questions; the three SSC 2026 fluid recommendations; hypotension formula	Retrieval practice; shows where the cohort is
15–35	Deliberate practice: IO insertion on a model bone and the push-pull bolus technique	The highest-yield procedural skill in Part C
35–55	Scenario 1 (Appendix B), run twice — once as a district hospital, once as a PICU-backed ED	The setting-specific decision under time pressure
55–75	Debrief both runs, PEARLS, two points maximum	Consolidation
75–85	The fifteen-second cardiac check on each other and on a doll with a “big liver” card	Makes the stop signal a habit
85–90	“One thing to keep, one thing to change.”	Commitment to change

C3 · Feedback structures

R2C2 — for longer, formal feedback

Relationship — establish respect and genuine interest. “How is the rotation going for you?”
Reaction — explore their response to the data before interpreting it. “What's your reaction to this feedback?”
Content — confirm shared understanding of what the assessment actually says.
Coaching — co-create a specific plan with a date. “What would you like to work on before we meet in six weeks?”

Ask–Tell–Ask — for brief, in-the-moment feedback

Ask: “How do you think that went?” · Tell: one specific observation and one specific suggestion · Ask: “What will you do differently next time?” Ninety seconds, at the warmer, immediately afterwards.

C4 · Six-domain performance rubric

Score 1 (needs significant improvement) to 5 (exemplary). Use for OSCE stations and simulation.

Domain	Level 2	Level 4
Preparation	Glances at the trolley; no device test	Standardised checklist completed; device tested; roles assigned
Assessment	Heart rate estimated, not measured; not reported aloud	Six-second count, tapped out, reported with units; oximeter placed pre-ductally
Technical skill	Mask leak unaddressed; pressure raised before obstruction excluded	Seal achieved by jaw lift or two hands; MR SOPA in order and announced
Decision-making	Escalates on one signal; or delays past 60 seconds	States all signals aloud before acting; escalates only when preconditions met
Communication	Instructions to the room; no closed loops	Named individuals, closed loops, drug orders by name-dose-route-concentration
Leadership & situation awareness	Absorbed in a procedure; loses the clock	Thinks aloud; delegates; hands over leadership when drawn into a procedure

C5 · Standard setting — set your own cut score before you use this for anything consequential

Why this matters more than you think

Published comparisons of standard-setting methods applied to the same assessment have produced cut scores ranging from roughly 66% to 86%. That means the method you choose can matter more than how your candidates perform. A cut score chosen by preference — including the 80% this module ships with — is the weakest defensible option available. Do one of the exercises below with three to six judges before the module carries any consequence.

Modified Angoff worksheet

Define the borderline candidate in writing, as a person: “a first-year resident who would reliably triage, get access and start antibiotics and a setting-appropriate fluid plan within the hour, but would hesitate over a vasoactive dose or a second-line antiseizure drug.” Judges must agree this before seeing any item.
For each item, each judge independently estimates: out of 100 borderline candidates, how many would answer this correctly? Record as a percentage.
Discuss items where judges differ by more than 20 points. Do not force consensus; discuss, then re-rate independently.
The cut score is the mean of the judges' mean estimates.
Record the standard error and consider whether to adjust for it. Document everything.

Ebel worksheet

Classify each item on two axes, then assign an expected percentage-correct to each cell.

	Easy	Medium	Hard
Essential	—%	—%	—%
Important	—%	—%	—%
Acceptable	—%	—%	—%

Cut score = Σ(items in cell × expected % for that cell) ÷ total items. Ebel is useful here because the module already tiers content as must / good / nice-to-know, which maps onto essential / important / acceptable.

Hofstee — a sanity check on whatever you produce

Judges agree four values: the minimum and maximum acceptable cut score, and the minimum and maximum acceptable failure rate. Plot the cumulative score distribution and find where the line crosses the rectangle those four values define. If your Angoff or Ebel cut falls outside that rectangle, something is wrong — either with the standard or with the assessment. Hofstee will not give you a defensible cut on its own, but it will stop you shipping an indefensible one.

Borderline regression, for the OSCE

For each station, examiners record both a checklist score and a global rating (fail / borderline / pass / good pass). Regress checklist score on global rating; the cut score is the checklist score predicted by a global rating of “borderline”. This is more defensible than a fixed percentage because it is anchored in expert judgement of these candidates on this station, and it generates the data as a by-product of examining.

C6 · Programme evaluation — Kirkpatrick

Level	Question	How to measure	Realistic?
1 · Reaction	Did they find it useful?	Five-question post-session survey	Yes — and nearly worthless on its own
2 · Learning	Did knowledge and skill change?	The module's three criteria; OSCE scores; pre/post	Yes. This is what the module measures
3 · Behaviour	Did practice change?	Emergency-room audit: time from arrival to antibiotics, triage-to-treatment time, weight recorded, bolus decisions by setting	Yes, with effort. The most valuable level you can actually reach
4 · Results	Did outcomes change?	Deaths within 24 hours of arrival, unplanned PICU transfers, hospital-acquired hyponatraemia	Rarely attributable to training alone. Report honestly as association

Most published resuscitation training evaluations stop at level 1 or 2. If you can get to level 3 with an emergency-room audit, you are doing better than most of the literature — and you will have data worth publishing.

▸D · Curriculum mapping

Map each unit to the competency descriptors of the NMC CBME curriculum. The code column is deliberately blank: codes were revised in the September 2024 guidelines, and Volume II is the only authority. Do not invent codes; fill them in from the current document.

Unit	Competency descriptor (paraphrased)	Domain	Teaching method	Assessment
1–3	Recognise the seriously ill child; explain paediatric physiology relevant to emergencies	K, S	Self-paced module; case discussion	Checkpoints; CBD
2	Perform triage using WHO ETAT and the Paediatric Assessment Triangle	S	Simulation with cards	OSCE 1–2
4	Assess and manage the airway and breathing; deliver oxygen and bag-mask ventilation	S	Skills lab	DOPS; OSCE 3
5, 8–10	Recognise and manage shock, including fluid therapy and vascular access	K, S	Flipped session (C2)	OSCE 4–6; Mini-CEX
6, 13	Assess the child with altered sensorium; manage status epilepticus and raised ICP	K, S	Simulation	OSCE 7
7	Recognise and treat hypoglycaemia and electrolyte emergencies	K	Case-based	Checkpoints
11	Manage dehydration (WHO plans) and DKA	K, S	Case-based; simulation	OSCE 8; KF2
12, 14	Manage common poisonings and envenomations	K, S	Case-based	OSCE 10; KF4
15	Primary survey of the injured child; burns first aid and fluid	K, S	Simulation	Checkpoints
16	Manage severe wasting and nutritional oedema	K, S	Ward-based; NRC visit	OSCE 9; KF3
17	Identify and manage serious bacterial infection in young infants	K, S	IMNCI practice	Mini-CEX
18–19	Recognise red flags; manage children with complex needs	K, A	Case-based	CBD
20	Refer and transport safely; communicate with families; safeguard children	S, A, C	Role play	OSCE 12; MSF

Why the code column is empty

Invented or outdated competency codes are worse than none — they propagate into curriculum documents and audits. Fill the column from NMC CBME Volume II (2024) at your institution.

▸E · Drug, fluid and equipment annex

Verify before every use

Doses here are drawn from the cited guidelines for learning. Check every dose against your institution's protocol, a current formulary and the child in front of you. Where local protocol differs, follow local protocol. This annex is never locked.

E1 · Resuscitation and emergency drugs

Drug	Indication	Dose	Notes
Adrenaline 1 mg/mL (1:1000) IM	Anaphylaxis, ASV reaction	0.01 mg/kg (0.01 mL/kg), max 0.5 mg	Anterolateral thigh; repeat after 5 min
Adrenaline 0.1 mg/mL (1:10,000) IV/IO	Cardiac arrest	0.01 mg/kg (0.1 mL/kg), max 1 mg	Every 3–5 min (see PALS module)
Adrenaline infusion	Shock	0.05–0.3 microgram/kg/min, titrate	Peripheral or IO acceptable; watch the site
Noradrenaline infusion	Shock (vasodilated)	0.05–0.3 microgram/kg/min, titrate	As above
Dopamine infusion	Shock where others unavailable	5–10 microgram/kg/min
Dobutamine infusion	Low output, myocarditis, scorpion	5–10 microgram/kg/min (up to 20)
Adenosine	SVT	0.1 mg/kg rapid push (max 6 mg); then 0.2 mg/kg (max 12 mg)	Rapid flush; ECG running
Glucose 10%	Hypoglycaemia	5 mL/kg IV/IO (neonates 2 mL/kg)	Then glucose infusion; recheck in 15–30 min
Calcium gluconate 10%	Hyperkalaemia, hypocalcaemia	0.5 mL/kg IV slowly (max 20 mL)	ECG monitoring; avoid extravasation
Naloxone	Opioid toxicity	0.1 mg/kg (max 2 mg)	Short-acting; watch for re-sedation
Hydrocortisone	Adrenal crisis	~25 mg (<1 y), 50 mg (1–5 y), 100 mg (>5 y) IV/IM	Use the child's emergency letter if available
Prostaglandin E1	Duct-dependent lesion	Per cardiology advice	Apnoea risk; be ready to ventilate

E2 · Fluids

Situation	Fluid and volume
Septic shock, ICU available	Balanced crystalloid 10–20 mL/kg boluses, up to 40–60 mL/kg in hour 1
Sepsis without hypotension, no ICU	No bolus; maintenance
Septic shock with hypotension, no ICU	10–20 mL/kg boluses, up to 40 mL/kg
Severe dehydration (WHO Plan C)	Ringer's lactate 30 mL/kg then 70 mL/kg: under 12 m over 1 h + 5 h; 12 m and over 30 min + 2½ h
Severe wasting with shock	15 mL/kg over 1 h of Ringer's lactate with 5% glucose (or half-normal saline with 5% glucose)
DKA	Shock: 20 mL/kg rapidly; otherwise 10–20 mL/kg over 20–30 min; deficit + maintenance over 24–48 h
Burns over ~10% TBSA	3–4 mL/kg/%TBSA Ringer's lactate in 24 h (half in first 8 h from burn) plus maintenance with glucose
Maintenance (Holliday–Segar)	4/2/1 mL/kg/h; isotonic with glucose as needed

E3 · Neurological and metabolic emergencies

Drug	Dose	Notes
Lorazepam IV/IO	0.1 mg/kg (max 4 mg)	Two benzodiazepine doses maximum
Diazepam IV / rectal	0.2–0.3 mg/kg IV (max 10 mg); 0.5 mg/kg rectal (max 10–20 mg)
Midazolam buccal / intranasal	0.3 mg/kg (max 10 mg)	No IV needed
Levetiracetam IV	40–60 mg/kg (max 3–4.5 g) over 5–15 min
Phenytoin IV	20 mg/kg over 20 min	ECG or pulse monitoring
Valproate IV	40 mg/kg (max 3 g)	Avoid in liver or metabolic disease, under 2 years
Phenobarbital IV	20 mg/kg	Respiratory depression
3% saline	Raised ICP: 3–5 mL/kg; DKA cerebral oedema: 2.5–5 mL/kg; hyponatraemic seizure: 3–5 mL/kg	Over 10–20 min
Mannitol	0.5–1 g/kg over 10–15 min
Insulin (DKA)	0.05–0.1 unit/kg/h, at least 1 h after fluids start	No bolus

E4 · Poisoning and envenomation

Agent	Dose	Notes
Atropine (organophosphate)	0.02–0.05 mg/kg IV, double every 5 min to a clear chest; then infusion ~10–20% of loading dose/h	Endpoint is secretions, not pupils
Activated charcoal	1 g/kg (max 50 g)	Within ~1 h; airway protected; not for hydrocarbons, iron, corrosives, alcohols
N-acetylcysteine	Per national/local regimen	Start within 8 h of paracetamol ingestion
Anti-snake venom (polyvalent)	10 vials over 30 min (same for children); repeat per protocol	Neurotoxic: second 10 vials at 1 h if no improvement (max 20)
Neostigmine trial (neurotoxic)	Atropine 0.05 mg/kg then neostigmine 0.04 mg/kg (national STG)	Most useful in cobra bites
Prazosin (scorpion)	30 microgram/kg orally, repeat according to response	Watch for first-dose hypotension

E5 · Equipment by weight

	Formula or guide
Weight estimate (if no scale)	Use a length-based tape; formula estimates are less accurate
Tracheal tube (cuffed)	(age/4) + 3.5 mm; depth ~3 × internal diameter
IO needle sites	Proximal tibia (1–2 cm below and medial to tuberosity); distal femur; proximal humerus in older children
Systolic hypotension	Under 1 month <60; 1–12 months <70; 1–10 years <70 + 2 × age; over 10 years <90 mmHg

▸F · References

Primary guidelines — the sources this module is written to

Weiss SL, Peters MJ, Oczkowski SJW, et al. Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026. Pediatr Crit Care Med 2026;27(4):379–434. PubMed
Schlapbach LJ, et al. International consensus criteria for pediatric sepsis and septic shock (Phoenix). JAMA 2024.
Part 8: Pediatric Advanced Life Support. 2025 AHA/AAP Guidelines for CPR and ECC. Pediatrics 2026;157(1):e2025074351.
World Health Organization. Paediatric emergency triage, assessment and treatment: care of critically-ill children. Geneva: WHO; 2016. WHO
World Health Organization. Pocket book of hospital care for children, 2nd edition. Geneva: WHO; 2013.
World Health Organization. WHO guideline on the prevention and management of wasting and nutritional oedema (acute malnutrition) in infants and children under 5 years. Geneva: WHO; 2023.
World Health Organization. WHO recommendations for management of serious bacterial infections in infants aged 0–59 days. Geneva: WHO; 2024.
Glaser N, et al. ISPAD Clinical Practice Consensus Guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2022.
Emeriaud G, et al. PALICC-2: Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023.

Indian national and professional sources

Ministry of Health and Family Welfare. Standard Treatment Guidelines: Management of Snakebite (quick reference guide and full document).
Indian Academy of Pediatrics. Standard Treatment Guidelines, including Poisoning in Children and Snake Envenomation.
MoHFW. Facility-based IMNCI (F-IMNCI) and Home-Based Newborn / Young Child Care programme guidance.
National Center for Vector Borne Diseases Control. National guidelines for clinical management of dengue.
ICMR. Treatment guidelines for antimicrobial use in common syndromes; ICMR AMR surveillance network reports.
Protection of Children from Sexual Offences Act, 2012; Juvenile Justice (Care and Protection of Children) Act, 2015.
National Medical Commission. Competency-Based Medical Education curriculum, 2024 guidelines (Volume II for competencies).

Key trials worth reading in full

Maitland K, et al. Mortality after fluid bolus in African children with severe infection (FEAST). N Engl J Med 2011;364:2483–95.
Parshuram CS, et al. Effect of a pediatric early warning system on all-cause mortality (EPOCH). JAMA 2018;319:1002–12.
Kuppermann N, et al. Clinical trial of fluid infusion rates for pediatric diabetic ketoacidosis (PECARN FLUID). N Engl J Med 2018;378:2275–87.
Kapur J, et al. Randomized trial of three anticonvulsant medications for status epilepticus (ESETT). N Engl J Med 2019;381:2103–13.
Lyttle MD, et al. Levetiracetam versus phenytoin for second-line treatment of paediatric convulsive status epilepticus (EcLiPSE). Lancet 2019;393:2125–34.
Dalziel SR, et al. Levetiracetam versus phenytoin (ConSEPT). Lancet 2019;393:2135–45.
Lacroix J, et al. Transfusion strategies for patients in pediatric intensive care units (TRIPICU). N Engl J Med 2007;356:1609–19.
Eddleston M, et al. Pralidoxime in acute organophosphorus insecticide poisoning. PLoS Med 2009;6:e1000104.
Pandi K, et al. Efficacy of scorpion antivenom plus prazosin versus prazosin alone for Mesobuthus tamulus scorpion sting envenomation in children. Arch Dis Child 2014.

Educational evidence base

Stojan J, et al. BEME Guide No. 69 — technology-enhanced learning in health professions education.
Regmi K, Jones L (2020) — systematic review of e-learning in health professions education.
McGee (2024); Taylor (2023); Trumble (2024) — self-directed and asynchronous learning.
van Gaalen AEJ, et al. (2021) — gamification in health professions education.
Thompson & Hughes (2023) — spaced retrieval and retention in clinical education.
Larsen DP, Butler AC, Roediger HL (2009) — test-enhanced learning in medical education. Cepeda NJ, et al. (2006) — distributed practice. Butterfield B, Metcalfe J (2001) — the hypercorrection effect.
Ottawa 2020 Consensus Statements on programmatic assessment. McKinley RK, Norcini JJ. AMEE Guide No. 85 — standard setting.

Check the edition before you teach from anything

Paediatric emergency guidance changes often: the sepsis guideline changed in 2026, resuscitation in 2025, malnutrition in 2023, young-infant infection in 2024. Before using any figure from this module in teaching or a protocol, confirm it against the current edition of the primary source. If you are reading this more than three years after the build date in the footer, assume something here is out of date and check.

▸G · Evidence-governed design

G1 · Design decisions and the evidence behind them

Decision	Why
Mastery, not completion — no “mark as read” control exists	Completion tracking measures exposure, not learning. A control that lets a learner record progress without demonstrating anything corrupts every downstream figure, including the certificate
Two checkpoint items per unit, answered correctly currently	Mastery is a state, not an event. Failing an item later removes the unit's mastered status, which is what makes the coverage criterion meaningful at the moment of certification
Sequential Part unlocking	Later content genuinely depends on earlier content — Part C's fluid decisions make no sense without Part B's recognition of shock. Gating also prevents the common self-paced failure of skimming to the topic that looks most interesting
Spaced retrieval at 1, 3, 7, 21, 60 days	Retrieval practice at expanding intervals produces substantially better long-term retention than re-reading. Interleaving across units rather than blocking by unit further improves discrimination
Confidence rating before each answer; “confident and wrong” flagged	High-confidence errors, once corrected with feedback, are corrected more durably than low-confidence ones (the hypercorrection effect; Butterfield & Metcalfe 2001). Rating confidence also exposes miscalibration, which in clinical work is the profile that harms patients. Confidence-based marking in medical schools (Gardner-Medwin) is the educational precedent. The module reports calibration; it does not score it
A review queue with a due count, and a single “next step”	The testing effect is robust in medical education (Larsen, Butler & Roediger 2009) and spacing outperforms massing (Cepeda et al. 2006). A visible due count invites the retrieval that is otherwise the least-performed part of a self-paced course; one named next action reduces the decision cost that stalls self-directed learners
Recognition tied to mastery only — no points, badges, leaderboards or streak resets	Short, informative acknowledgement of a mastered unit or an unlocked Part uses the goal-gradient effect without rewarding clicks. Study days are counted but never reset to zero or shamed: learners in Indian postings work rotating nights and irregular duty, and a punitive streak penalises the schedule, not the learning. Gamification reviews in health-professions education report mixed effects, weakest where rewards are decoupled from the learning objective
A failed item returns in 10 minutes at box 1	Immediate re-exposure after an error, followed by expanding intervals, is more effective than either immediate repetition alone or long delay
Hinted items stay in box 1	A hint changes what the item measured. Advancing the interval would record retrieval strength the learner has not demonstrated
Rationales explain why wrong options are wrong	Distractor-level feedback corrects the specific misconception that produced the error; “the answer is B” corrects nothing
Distractors are errors clinicians actually make	Implausible distractors inflate scores and teach nothing. Several items here are built around a specific documented failure mode
Three independent certification criteria	A single score conflates coverage, retention and integration. Separating them lets the certificate state what was actually demonstrated
Retention counts breadth across units, not raw items	A raw count can be satisfied entirely from units met earliest, leaving the newest and most fragile learning untested
Randomised item and option order; 24-hour lock between attempts	Defeats answer-position memory; the lock forces the gap to be filled with remediation and sleep rather than immediate re-guessing
Cut score shipped as provisional with worksheets	Method choice can move a cut score by ~20 points on the same assessment. Shipping a preference-based cut without saying so would be dishonest
Dual-track ideal / resource-constrained panels as equals	Guidance written for well-resourced settings is routinely taught unmodified where the equipment does not exist, which teaches learners that correct practice is impossible for them
Emergency dosing never gated	Clinical safety material behind a quiz is a patient-safety problem
All state local; no account, no telemetry	Collecting nothing is the only fully reliable way to protect learner data, and satisfies the DPDP Act 2023 by construction. It also means the file works offline, which is the difference between usable and unusable in much of India
Single self-contained HTML file	No CDN, no framework, no network request. Survives being emailed, copied to a phone, and opened three years from now
Learner-controlled priority, level, setting, text size and theme	UDL 3.0: multiple means of representation and engagement, with the learner in control rather than an algorithm

G2 · Accessibility conformance

Semantic landmarks, skip link, keyboard-operable accordions with role="button", Enter/Space activation and aria-expanded.
Scrollable regions given tabindex="0" and role="region" with labels, so keyboard users can reach wide tables and algorithms.
aria-pressed on all toggles; visible :focus-visible outlines; minimum 44 px touch targets.
Learner-controlled text scaling; prefers-reduced-motion respected; three-state theme (light / dark / system) that works in all three.
No meaning conveyed by colour alone — every status colour is paired with a text label or a symbol.
Tables receive data-label attributes by script and reflow to labelled cards below 560 px.
Mobile-first CSS with desktop enhancement at 900 px; no horizontal page scrolling at 400 px.
Targets WCAG 2.2 AA. Not independently audited — see limitations.

G3 · Where this design is weaker than it looks

Published honestly, because a module claiming to be evidence-governed must be willing to

Fixed intervals, not fitted forgetting curves. The Leitner schedule (1-3-7-21-60) is a crude approximation. A genuinely adaptive system would fit each learner's forgetting curve per item. This does not, and cannot, without collecting the data it deliberately does not collect. That is a real trade-off, not a free lunch.
Thin item sampling per unit. Two checkpoint items cannot reliably sample a unit's content. Mastery of a unit here means “answered these two specific items correctly”, which is a weaker claim than it appears. The final assessment partially compensates; it does not eliminate the problem.
Rule-based placement, not adaptive testing. The three placement questions set defaults by simple rules. They are not a measurement, and they do not adjust as evidence accumulates about what the learner actually knows.
Limited form-to-form equivalence. Attempts sample 50 items from a pool of 70 with randomised order, so two attempts are not statistically equated. A score of 88% on one attempt is not strictly the same as 88% on another.
Unproctored assessment. Nothing prevents a learner opening the module in another tab, or working with a colleague. The module is honest about this: it is a self-assessment with a certificate attached, and any high-stakes use requires proctoring and the skills assessment in Appendices A and B.
The verification code is not tamper-proof. It is a deterministic hash of the displayed figures, re-derivable by anyone with the same inputs. It helps detect transcription error. It is not a security feature and is described as such on the certificate.
The cut score is provisional and was chosen by preference. Appendix C exists because this is the weakest defensible option. Until your institution does the standard setting, treat the pass/fail line as an approximation.
Kirkpatrick levels 3 and 4 are unmeasured. This module has no evidence that it changes emergency-room behaviour or child outcomes. Nor does almost any comparable resource — but the absence should be stated rather than implied away.
Accessibility is targeted, not audited. WCAG 2.2 AA conformance has not been independently verified, and has not been tested with real screen-reader users. Automated checks and manual keyboard testing are not the same as a user audit.
Clinical content has not been externally peer reviewed. It is written to the current primary guidelines and cross-checked, but it carries no editorial board and no formal review process. Corrections are welcomed and should be treated as expected rather than exceptional — see CONTRIBUTING.
India-specific epidemiology moves. The figures quoted are from the most recent sources available at build; verify against the current SRS bulletin and national cause-of-death estimates before quoting them in teaching.
One author, one perspective. Every choice about what is must-know versus nice-to-know reflects a single clinician's judgement about what matters at a district hospital at 2 a.m. Reasonable educators would tier some of it differently.

G4 · Frameworks this module aligns itself to

WHO ETAT, IMCI and hospital care guidance for children · WFME standards for medical education · NMC CBME (India, 2024 revision) · ICMR and MoHFW national programme guidance · CAST Universal Design for Learning 3.0 · WCAG 2.2 · Digital Personal Data Protection Act 2023 (India) · Ottawa consensus statements on programmatic assessment.

Your mastery

Retention check 0

How this module works

Your privacy

Clinical safety — read this once

Foundations: how to think before you act

▸Unit 1 Why children die, and where this module fits Not attempted

Learning outcomes

1 · The mortality picture Must-know

India lens

2 · The deterioration continuum Must-know

The error clinicians actually make

3 · Three different failures, three different fixes Good-to-know UG/PG

4 · Does structured recognition work? Read the negative trial too Nice-to-know PG

Evidence note

Nudge

Structured hint

Why the answer is what it is

Nudge

Structured hint

Why the answer is what it is

▸Unit 2 The sixty-second assessment Not attempted

Learning outcomes

1 · The Paediatric Assessment Triangle Must-know

Pearl

2 · WHO ETAT: emergency, priority, queue Must-know

Evidence note

3 · Vital signs you must know cold Must-know

The crying child

4 · Track-and-trigger charts: what makes them work Good-to-know UG/PG

Ideal setting

Resource-constrained setting

India lens

Nudge

Structured hint

Why the answer is what it is

Nudge

Structured hint

Why the answer is what it is

▸Unit 3 Why children crash late and fast Not attempted

Learning outcomes

1 · Airway Must-know

2 · Breathing Must-know

The most dangerous sign in paediatrics

3 · Circulation Must-know

4 · Everything else that scales with size Good-to-know

5 · How the sick child fools you Nice-to-know PG

Pearl

Nudge

Structured hint

Why the answer is what it is

Nudge

Structured hint

Why the answer is what it is

The systematic approach: ABCDE

▸Unit 4 Airway and breathing Not attempted

Learning outcomes

1 · Four patterns of respiratory illness Must-know

Pearl

2 · Distress or failure Must-know

3 · Opening and supporting the airway Must-know

What current resuscitation guidance says

4 · Oxygen: how much, how delivered Must-know

India lens

5 · Supporting the failing airway, across settings Must-know

Ideal setting

Resource-constrained setting

6 · Intubating the sick child safely Good-to-know PG

Physiological difficulty

Nudge

Structured hint

Why the answer is what it is

Nudge

Structured hint

Why the answer is what it is

▸Unit 5 Circulation: recognising shock and its types Not attempted

Learning outcomes

1 · Recognising shock from three organs Must-know

Know the limits of your best sign

2 · Four types of shock — because treatment diverges Must-know