APLS Update 2013

Contents

Paediatric Advanced Life Support

BSPED Recommended DKA Guidelines 2009
UHCW Trust Guidelines Meningitis
EZ-IO Directions for Use
Weight Estimation
Glucose Dose

Quick Reference Contents

Paediatric Choking Treatment

Paediatric Basic Life Support
Paediatric Advanced Life Support
Anaphylaxis
Status Epilepticus
Management of VT
BTS Asthma Guidelines
Paediatric Emergency Drugs calculations ( RC UK)

APLS 5e: FAQ: Weight

Estimation
The old weight formula ([age+4] x 2) has worked well for estimating weights in 1 to 10 year
olds for about 20 years. However, evidence shows that the weights of children in richer
countries have generally increased over this time and this formula therefore underestimates
weights, especially for older children (Appendix 1). The evidence suggests that the new
formula ([agex3] + 7) is better for older children, but can overestimate for smaller children.
There has been much debate about the use of formulae, including whether it is better to
under- or over-estimate true weight, and what should be used in resource-poor populations,
given APLS is used in over 20 countries. This was debated at the Annual Instructors' Day
December 2008 (Appendix 2). It is clear that the use of any formula at a single age may
have a wide error and that weights in different populations also differ widely. Thus ALSG
decided that we would no longer advocate one method of weight estimation. As now
recommended in the 5th edition, ALSG advise that health professionals decide locally what
method provides the easiest and best method for their own needs. We recommend use of
population growth charts (which allows estimation of medians for any age, as well as 10th
and 90th centiles), Sandell or Broselow tapes, or formulae.
Regarding the latter, the traditional formula has been maintained for small children (1-5
years: [age+4]x2 = [agex2]+8 ), but the new one is used for older children. ALSG has
previously made no recommendation for infants under 1 year, but a paper from the US
shows that the formula [age x 0.5] + 4, may be used.
In line with the above, APLS courses have been modified so that less time is spent on
undertaking calculations. These are now done for the cardiac simulation alone, but provided
ready calculated in subsequent simulation practices.
Regarding children over 12, ALSG has never had a formula for this age group - the onset of
puberty from 10 years onwards means that there is an even greater range of possible
weights at any one age. A formula would therefore have a high likelihood of error. In
addition, at this age, weights are approaching the maximum weight used to calculate doses
and equipment sizes, ie weights of 40kg or 50kg. For inexperienced practitioners, we
recommend using growth charts and estimating whether the child is small, medium or large
for their age.
Please see the following for associated reading:
Appendix 1 - Luscombe, M & Owens B. 2007: Weight estimation in resuscitation: is the
current formula still valid?
Appendix 2 Oakley, P. 2008: Paediatric Weight Estimation
Appendix 3 Marlow, R. et al. 2011: Accurate Paediatric Weight Estimation by Age:
Resuscitation and Clinical Skills Department 2013
Mission Impossible?

APLS 5e: FAQ: Glucose

Dose
There is as expected a paucity of evidence for the bolus dose of glucose. The
recommendation to change the dose came from the Inherited Metabolic
Disease and Endocrinology Speciality Groups of RCPCH. The experts are
less concerned about the size of bolus, but do feel that a follow-on infusion is
a 'must'.
Large boluses without follow-on infusion are commonly followed by rebound
hypoglycaemia and do not encourage a smooth homeostasis. Experience
shows that 2mls/kg is enough to treat induced hypoglycaemia and so should
usually be sufficient to treat hypoglycaemia associated with illness or injury
(provided there is an ongoing infusion). Remember 2mls/kg of 10% glucose =
200mg/kg (not an insignificant amount of glucose).
Some international courses, especially in resource poor countries, are
concerned about dropping the bolus dose from 2mls to 5mls, as WHO
guidance is currently 5mls/kg - malnutrition is of course more common in
these settings. Even though the evidence is only anecdotal, it is reasonable to
use 2mls/kg. Ultimately, the recommendation could be 2 to 5 mls / kg (or 2 + 2
mls, or whatever), BUT it MUST be followed by an infusion.

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Notes

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