PALS Paediatric Scenario Practice

A clinician working at sea, offshore, in an expedition team or in a rural service may go years without managing a critically unwell child, and then have to do it alone. That combination — rare exposure, high consequence, no immediate help — is the textbook indication for deliberate rehearsal, and it is also the situation people are most reluctant to rehearse, because paediatric scenarios are uncomfortable to run.

This article is about doing it anyway: what genuinely differs from adult practice, which scenarios repay the effort, and the specific errors that arise from applying adult habits to a small patient.

If you want scenarios rather than a summary, run a paediatric case in the app.

What actually changes

Less than people fear, in the assessment structure. Considerably more in the logistics. Being clear about which is which reduces the anxiety that makes paediatric emergencies harder than they need to be.

The structured approach does not change. Airway, breathing, circulation, disability, exposure, reassessed in the same order for the same physiological reasons. If you can run a structured primary survey on an adult, you have the framework.

The normal ranges change with age, and so does what abnormal means. Children compensate impressively and then decompensate quickly. A heart rate that would be alarming in an adult may be appropriate; a blood pressure that looks acceptable can be maintained until very late. The practical consequence is that you weight the earlier signs — work of breathing, perfusion, level of interaction, feeding and output — more heavily than the numbers, and you treat a falling heart rate in an unwell child as an emergency rather than an improvement.

Almost everything is weight-based. Drugs, fluids, energy levels, equipment sizes. Which means a weight estimate is on the critical path of every intervention, and an error in that single number propagates through all of them.

Equipment comes in sizes and you may not have them. This is often the real problem in a remote setting. An adult kit with one paediatric mask in it is not a paediatric capability, and discovering that during the event is much worse than discovering it during a drill.

There is a family in the room. Almost always, and usually one person. Managing a distressed parent while running a resuscitation is a genuine, trainable task that adult scenarios rarely include.

Six scenarios worth rehearsing

Chosen for frequency and for the specific decisions they force, rather than for drama. Rehearse the first three before the last three.

1. The child who is working hard to breathe

The commonest genuine paediatric emergency presentation. The rehearsal value is in the assessment and the escalation timing rather than the intervention: recognising increased work of breathing, distinguishing a child who is tiring from one who is stable, and deciding when this stops being observable and starts being urgent.

2. The febrile, unwell infant

Difficult because the assessment is subtle and the consequences of getting it wrong are severe. Practise the systematic assessment, the findings that raise concern, and the threshold for treating and moving rather than observing.

3. The dehydrated child

Weight-based fluid decisions, assessment of severity, and the point at which oral management is no longer viable. High-yield because it is common and because it exercises the weight-estimate pathway without the pressure of an arrest.

4. The seizing child

Time-critical, protocol-driven, and weight-based. The rehearsal value is in the timing discipline — noting when the seizure started, and being clear about when each step is due — because that is where scenarios reliably fall apart.

5. The child in shock of unclear cause

The hardest of the six, because the management differs by cause and the cause may not be apparent. Good for practising commitment under uncertainty and for practising the remote advice call.

6. Paediatric cardiac arrest

Rare, and worth rehearsing anyway. Run it with the equipment and the number of people you would actually have. The most common finding is that the equipment is not where the team assumed it was.

Adult habits that cause paediatric errors

• Reassurance from blood pressure. A maintained blood pressure in a child is compatible with significant shock. Perfusion, conscious level and heart rate carry more weight, and a normal blood pressure should never close the assessment.
• Reading bradycardia as stability. In an unwell child a falling heart rate is usually a late and ominous sign, not a recovery. This inversion catches experienced adult clinicians.
• Estimating weight by eye. Visual estimates are unreliable, and every subsequent calculation depends on the figure. Use whatever age or length-based method your service supports, record how you obtained it, and ask the parent — they usually know a recent weight.
• Adult-sized fluid and drug thinking. The volumes are small enough that a decimal error produces a plausible-looking number. This is precisely the situation the unit-cancelling method exists for, and it is worth writing the calculation out even when you are certain.
• Managing the child and ignoring the parent. A parent who does not know what is happening becomes an obstacle; a parent who has been given a role and an explanation becomes an asset, and is often your best source of history.
• Deferring the call for advice. In adult practice, waiting for a clearer picture is sometimes reasonable. With a sick child in a remote setting the lead times are unforgiving, and the specialist advice call should be early and can be made on an incomplete picture.

Solve the equipment problem before the event

This is the highest-return thing in the article, and it takes an afternoon rather than a course.

Open your paediatric equipment and inventory it against the age range you might realistically see. Note what sizes you hold, what you do not, and where each item is stored. Then check that the weight-estimation and dosing reference you intend to use is physically present and readable in the place you would be working — not on a device that needs a connection you may not have.

Two questions consistently produce useful findings. Can you reach everything you would need for a two-year-old within sixty seconds? And if the answer to a drug dose has to be looked up, where is the reference and does it work offline? Core training and reference tools are designed to work offline after setup, but installation and updates need a connection, so the setup has to happen before you sail rather than when you need it.

Write down the gaps and escalate them through whatever your equivalent of a capability gap process is. A documented, communicated limitation is a manageable risk; an undiscovered one is not.

Running the rehearsal

Fifteen minutes, no manikin needed, though a manikin helps for the airway and compression elements. Assign roles out loud, run it in real time, include a distressed parent played by someone in the room, and finish with the transfer or advice call rather than at the outcome.

Two modifications that make paediatric rehearsal notably more useful. Require the weight to be estimated by the method you would actually use, and then require every drug volume to be calculated and stated aloud — that is where the error would be, so that is what you are training. And run at least one scenario with the equipment physically fetched from where it lives, because the walk is part of the timeline.

Finally, keep the honesty about what this is. Rehearsal maintains performance between accredited courses. Paediatric life support certification comes from recognised provider courses with assessed practical components, and doses, energy levels and sequences should always come from the current national guidance for where you work rather than from a scenario or a summary.