Paediatric emergencies are particularly suitable for Final FRCEM single-best-answer questions because management often depends on recognising exactly where the child is within an emergency algorithm.
The difference between two apparently reasonable answers may be a single clinical feature: whether a child is perfused or shocked, whether two benzodiazepine doses have already been given, whether the third or fifth defibrillation shock has been delivered, or whether a suction catheter will pass through a tracheostomy.
The Resuscitation Council UK Paediatric Emergency Algorithms & Resources, January 2026, Version 4 states that it has been updated to reflect the 2025 guidelines. It includes emergency drug doses, basic life support, advanced life support, choking, anaphylaxis, cardiac arrhythmias, acute asthma, convulsive status epilepticus, diabetic ketoacidosis, paediatric sepsis and emergency tracheostomy management.
This article focuses on the clinical decisions, treatment sequences and numerical thresholds most likely to matter in emergency practice and FRCEM examination questions.
Recognition of paediatric cardiac arrest includes absence of signs of life or a heart rate below 60 beats/minute with poor perfusion. High-quality cardiopulmonary resuscitation should begin immediately while the resuscitation team is called and the defibrillator is attached.
For healthcare professionals performing paediatric resuscitation, the compression-to-ventilation ratio is 15 compressions to 2 breaths.
HIGH-YIELD BOX — PAEDIATRIC CARDIAC ARREST
15 compressions : 2 ventilations
Initial shock energy: 4 joules/kg
Cardiac arrest adrenaline: 10 micrograms/kg
Immediately restart cardiopulmonary resuscitation after each shock.
Ventricular fibrillation and pulseless ventricular tachycardia require defibrillation. The initial shock energy is 4 joules/kg. After delivering a shock, cardiopulmonary resuscitation should immediately recommence for 2 minutes with interruptions minimised.
One of the most important FRCEM distinctions is what happens after the third shock.
HIGH-YIELD BOX — AFTER THE THIRD SHOCK
Immediately resume cardiopulmonary resuscitation for 2 minutes.
Give adrenaline 10 micrograms/kg intravenously or intraosseously.
Give amiodarone 5 mg/kg intravenously or intraosseously.
Continue adrenaline every 3–5 minutes.
Do not pause unnecessarily after the shock simply to administer drugs. The sequence is defibrillation followed by immediate cardiopulmonary resuscitation while drug therapy is delivered.
Persistent ventricular fibrillation or pulseless ventricular tachycardia despite repeated shocks is refractory ventricular fibrillation or pulseless ventricular tachycardia.
From the fifth shock, Resuscitation Council UK advises escalating the energy stepwise up to 8 joules/kg, with a maximum of 360 joules in infants and children. Adolescents may be escalated to 360 joules.
HIGH-YIELD BOX — FIFTH SHOCK
Persistent ventricular fibrillation after four shocks → recognise refractory ventricular fibrillation.
From shock 5: escalate energy stepwise towards 8 joules/kg.
Maximum: 360 joules.
After the fifth shock, repeat amiodarone 5 mg/kg and immediately resume cardiopulmonary resuscitation.
This produces a very useful examination distinction:
SHOCKS 1–4
4 joules/kgFROM SHOCK 5
Escalate stepwise up to 8 joules/kg
For an unresponsive child, call for help, open the airway and assess breathing and signs of life.
If these are absent or uncertain, give five rescue breaths. Competent healthcare providers should use bag-mask ventilation with oxygen where possible. If no signs of life are observed during the rescue breaths, begin chest compressions immediately.
HIGH-YIELD BOX — INITIAL PAEDIATRIC BASIC LIFE SUPPORT
Unresponsive child
↓
Open airway
↓
5 rescue breaths
↓
No signs of life
↓
Start chest compressions
The five initial rescue breaths reflect the importance of respiratory causes in paediatric deterioration.
The first management decision in suspected foreign-body airway obstruction is whether the cough is effective or ineffective.
A child with an effective cough should be encouraged to continue coughing while being observed for deterioration.
If the cough becomes ineffective and the child remains conscious, physical manoeuvres are required.
HIGH-YIELD BOX — CONSCIOUS INFANT
Ineffective cough
↓
5 back blows
↓
5 chest thrusts
↓
Repeat until relieved or infant becomes unconscious.
HIGH-YIELD BOX — CONSCIOUS CHILD
Ineffective cough
↓
5 back blows
↓
5 abdominal thrusts
↓
Repeat until relieved or child becomes unconscious.
Repeated or blind finger sweeps should not be performed. If the child becomes unconscious, open the airway, attempt rescue breaths and proceed with paediatric basic life support.
The important FRCEM discriminator is therefore:
INFANT → CHEST THRUSTS
CHILD → ABDOMINAL THRUSTS
Management begins with an airway, breathing, circulation, disability and exposure assessment and determination of whether circulation is compensated or decompensated.
Features suggesting vital-organ perfusion compromise include reduced conscious level, tachypnoea, abnormal heart rate, blood pressure below the fifth centile, capillary refill longer than 2 seconds and weak or impalpable peripheral pulses.
Sinus tachycardia usually has a gradual onset and may represent a physiological response to crying, exercise, anxiety or pain, or a compensatory response to hypovolaemia, sepsis, anaemia or respiratory or circulatory failure.
Supraventricular tachycardia characteristically has an abrupt onset and is usually narrow complex. The algorithm describes typical rates above 220 beats/minute in an infant and above 180 beats/minute in a child.
HIGH-YIELD BOX — TACHYCARDIA
Gradual onset + identifiable physiological trigger → think sinus tachycardia.
Abrupt onset + narrow complex + very rapid rate → think supraventricular tachycardia.
A compensated child with supraventricular tachycardia may undergo vagal manoeuvres followed by adenosine.
A decompensated child requires synchronised cardioversion.
The first synchronised shock is 1 joule/kg. Subsequent attempts double the energy up to 4 joules/kg.
HIGH-YIELD BOX — SYNCHRONISED CARDIOVERSION
First shock: 1 joule/kg
Next shock: 2 joules/kg
Subsequent escalation: up to 4 joules/kg
Intravenous access attempts should not delay cardioversion in an unstable child.
For broad-complex tachycardia, if there is uncertainty whether the rhythm represents ventricular tachycardia or supraventricular tachycardia, the algorithm advises treating it as ventricular tachycardia.
Acute asthma severity is frequently tested through the clinical presentation rather than by explicitly giving the severity category.
The algorithm covers children aged 2–12 years and emphasises features such as recurrent wheeze, cough, breathing difficulty, chest tightness, trigger dependence and a personal or family history of atopy. Assessment in children younger than 2 years is more difficult, and diagnoses such as bronchiolitis, pneumonia, aspiration and tracheomalacia should be considered.
A child with moderate asthma maintains a normal mental state and can speak normally. Peak expiratory flow is at least 50% of best or predicted, and oxygen saturation is above 92% in air.
Features include agitation or distress, inability to complete sentences in one breath or being too breathless to talk or feed, moderate-to-marked accessory muscle use, peak expiratory flow of 33–50%, and oxygen saturation below 92% in air.
The algorithm defines life-threatening asthma as oxygen saturation below 92% together with features such as a silent chest, cyanosis, poor respiratory effort, hypotension, exhaustion, confusion or peak expiratory flow below 33%.
HIGH-YIELD BOX — LIFE-THREATENING ASTHMA
Oxygen saturation <92%
PLUS a major danger feature such as:
silent chest, cyanosis, poor respiratory effort, hypotension, exhaustion or confusion.
Treatment includes oxygen titrated to 94–98%, bronchodilators and systemic corticosteroids. For acute severe asthma, nebulised salbutamol 2.5–5 mg is used every 20 minutes with ipratropium bromide 250 micrograms during the first 2 hours.
Intravenous magnesium and aminophylline may be considered when the child remains unresponsive to maximal bronchodilator and corticosteroid treatment. The document notes that evidence is unclear regarding which of intravenous salbutamol, aminophylline or magnesium should be the first intravenous agent in severe asthma.
This is one of the most examination-relevant algorithms in the document because management depends strongly on time from seizure onset.
A convulsive seizure lasting more than 5 minutes meets the treatment threshold for convulsive status epilepticus. After 5 minutes, spontaneous termination becomes less likely and the risk of refractory status increases as seizure duration increases.
Initial management includes airway assessment, high-flow oxygen, monitoring, intravenous or intraosseous access, measurement of blood glucose and treatment of possible underlying causes. Blood glucose below 2 mmol/L should be treated.
A maximum of two benzodiazepine doses should be given, including treatment administered before arrival at hospital.
HIGH-YIELD BOX — BENZODIAZEPINES
5 minutes → first dose
10 minutes → second dose
Maximum = 2 benzodiazepine doses, including pre-hospital treatment.
At approximately 15–20 minutes, the principal second-line treatment is levetiracetam 40–60 mg/kg intravenously over 5 minutes, maximum 4.5 g.
If levetiracetam is unavailable, alternatives include phenytoin 20 mg/kg, phenobarbital 20 mg/kg or valproic acid 40 mg/kg.
HIGH-YIELD BOX — SECOND LINE
Levetiracetam 40–60 mg/kg
Intravenously over 5 minutes
Maximum 4.5 g
Phenytoin should not be infused too rapidly because this can cause bradycardia or asystole. Electrocardiogram and blood-pressure monitoring are required.
At the third-line stage, the examiner may tell you that levetiracetam has already failed and the anaesthetic team has been called.
The next decision depends on whether preparation for deeper anaesthesia with intubation and ventilation is complete.
HIGH-YIELD BOX — 30–40 MINUTES
Anaesthetic preparation complete?
YES → proceed to emergency anaesthesia.
NO → administer a different alternative second-line anticonvulsant while preparation continues.
If the seizure persists, emergency anaesthesia should occur no later than 40 minutes.
The listed anaesthetic agents include ketamine, thiopental, propofol and midazolam. The document specifically states that there is no evidence identifying a single ideal third-line agent.
STATUS EPILEPTICUS TIMELINE
5 min → first benzodiazepine
10 min → second benzodiazepine
15–20 min → second-line anticonvulsant
30–40 min → third-line stage
No later than 40 min → emergency anaesthesia if seizure persists
This sequence is substantially more useful for FRCEM preparation than memorising individual drugs in isolation.
The diabetic ketoacidosis algorithm is adapted from NICE guidance and the British Society for Paediatric Endocrinology and Diabetes guideline.
Recognition includes hyperglycaemia above 11 mmol/L, pH below 7.3 or bicarbonate below 15 mmol/L, together with significant ketonaemia or ketonuria.
One of the highest-yield distinctions concerns fluid administration.
A child who has clinical dehydration but remains alert, warm, adequately perfused and normotensive should receive:
HIGH-YIELD BOX — DEHYDRATED, NOT SHOCKED
10 mL/kg
Balanced isotonic crystalloid or 0.9% sodium chloride
Over 30 minutes
Discuss with a senior paediatrician before a second bolus.
When circulatory shock is present:
HIGH-YIELD BOX — DIABETIC KETOACIDOSIS WITH SHOCK
10 mL/kg
Balanced isotonic crystalloid or 0.9% sodium chloride
Over 5–10 minutes
Reassess after each bolus.
Repeat if required up to 40 mL/kg.
This difference is highly suitable for a single-best-answer question because both choices use 10 mL/kg; the discriminator is how quickly the fluid is given.
EXAM MEMORY BOX
Preserved circulation → 10 mL/kg over 30 minutes
Shock → 10 mL/kg over 5–10 minutes
Fluid deficit should subsequently be corrected over 48 hours.
Potassium is added once the child is passing urine and serum potassium is within the appropriate range, usually below 5.5 mmol/L. Add 5% glucose when blood glucose falls below 14 mmol/L.
Insulin is started 1–2 hours after intravenous fluids have commenced, using 0.05–0.1 units/kg/hour. For children younger than 5 years, 0.05 units/kg/hour is recommended in the document.
Intravenous bicarbonate should not be routinely administered to correct the metabolic acidosis.
Cerebral complications are a critical emergency.
Warning features include headache, confusion, irritability, abnormal posturing, falling level of consciousness and rising blood pressure with bradycardia.
Treatment should not wait for computed tomography.
HIGH-YIELD BOX — SUSPECTED RAISED INTRACRANIAL PRESSURE
Falling consciousness
- headache or behavioural change
- bradycardia / rising blood pressure
↓
Give 3% sodium chloride
↓
Seek paediatric intensive care advice
↓
Call an anaesthetist
↓
Consider computed tomography of the brain.
The key examination principle is treat first, image subsequently when cerebral deterioration is clinically suspected.
The paediatric sepsis algorithm begins with an airway, breathing, circulation, disability and exposure assessment.
Features supporting sepsis include suspected or proven infection together with abnormal temperature, inappropriate tachycardia, altered mental state, impaired peripheral perfusion, hypotension, increasing oxygen requirement or coagulation abnormalities.
Vascular access should be established and investigations may include blood cultures, full blood count, glucose, electrolytes, lactate and blood gas analysis.
Broad-spectrum antibiotics should be started, and the source of infection should be identified and controlled.
Where there are no signs of fluid overload:
HIGH-YIELD BOX — PAEDIATRIC SEPTIC SHOCK
Give 10 mL/kg balanced crystalloid
Over 5–10 minutes
Reassess after every bolus
Continue according to response, generally up to 40–60 mL/kg
Stop boluses if signs of fluid overload develop.
Therapeutic endpoints include capillary refill below 2 seconds, appropriate blood pressure for age, urine output above 1 mL/kg/hour, normal pulses and normal mental state.
If fluid overload develops, stop fluid bolus therapy and commence vasoactive support.
The algorithm advises starting vasoactive treatment when shock persists despite fluid therapy.
Adrenaline may be started at 0.05–0.3 micrograms/kg/minute, while noradrenaline has a starting infusion rate of 0.05 micrograms/kg/minute.
A particularly important point is that clinical examination is unreliable in distinguishing classical “warm” from “cold” shock in children. Treatment should therefore be guided by haemodynamic response rather than relying solely on this classification.
A deteriorating child with a tracheostomy requires a structured approach.
The initial sequence is safety, stimulation, calling for help and oxygen.
High-flow oxygen should be applied to both the tracheostomy and the face.
Attachments such as a humidifier or speaking valve should be removed. If an inner tube is present, it should be changed or removed as appropriate before assessing tracheostomy patency.
The critical diagnostic manoeuvre is attempting to pass a suction catheter.
HIGH-YIELD BOX — TRACHEOSTOMY EMERGENCY
Oxygen to face AND tracheostomy
↓
Remove attachments
↓
Deal with inner tube
↓
Can a suction catheter pass?
If the catheter passes, the tube is patent and tracheal suction should be performed while partial obstruction and other causes are considered.
If the catheter cannot pass, emergency tracheostomy tube change is required. The algorithm describes a first attempt with a same-size tube, followed by a tube approximately half a size smaller, with further guided attempts where appropriate. If tube replacement fails, remove the obstructed tube and establish emergency oxygenation.
HIGH-YIELD BOX — TUBE CHANGE
First attempt → same-size tube
Second attempt → half-size smaller tube
Unsuccessful replacement → remove the tube and oxygenate
If the upper airway is patent, oxygenation and ventilation can be provided via the mouth and nose while the stoma is appropriately managed. If the upper airway is obstructed, oxygenation may need to be delivered through the tracheostomy stoma.
The resource includes an anaphylaxis pathway, but there is an important qualification: the January 2026 document specifically states that anaphylaxis is to be reviewed in 2026.
Within the included algorithm, intramuscular adrenaline remains the central treatment and may be repeated after 5 minutes when there is inadequate response.
Ongoing respiratory or cardiovascular compromise despite two appropriate doses of intramuscular adrenaline is treated as refractory anaphylaxis.
HIGH-YIELD BOX — REFRACTORY ANAPHYLAXIS
Persistent airway, breathing or circulation compromise
despite
2 appropriate intramuscular adrenaline doses
↓
Start the refractory anaphylaxis pathway
The refractory pathway includes further fluid resuscitation and a low-dose intravenous adrenaline infusion in an appropriately monitored environment with expert support. Intravenous adrenaline boluses are not routinely recommended outside appropriate specialist circumstances.
Because this particular algorithm is flagged for review, candidates should check the latest dedicated Resuscitation Council UK anaphylaxis guidance when preparing specifically for this topic.
CARDIAC ARREST
5 rescue breaths
15:2 compression-to-ventilation ratio
Initial shock = 4 joules/kg
From fifth shock = escalate towards 8 joules/kg
Adrenaline = 10 micrograms/kg
Amiodarone after third and fifth shocks
SYNCHRONISED CARDIOVERSION
First shock = 1 joule/kg
Then double energy
Maximum = 4 joules/kg
CONVULSIVE STATUS EPILEPTICUS
Treat from 5 minutes
Maximum 2 benzodiazepine doses
Levetiracetam = 40–60 mg/kg over 5 minutes
Third-line phase = 30–40 minutes
Emergency anaesthesia = no later than 40 minutes
DIABETIC KETOACIDOSIS
Dehydrated with preserved circulation = 10 mL/kg over 30 minutes
Shock = 10 mL/kg over 5–10 minutes
Fluid deficit correction = 48 hours
Add 5% glucose when glucose <14 mmol/L
SEPTIC SHOCK
Fluid bolus = 10 mL/kg over 5–10 minutes
Reassess after every bolus
Watch carefully for fluid overload
CHOKING
Infant = 5 back blows + 5 chest thrusts
Child = 5 back blows + 5 abdominal thrusts
These algorithms should not be learnt as isolated facts.
The Final FRCEM examination is more likely to present a child part-way through an algorithm and ask what should happen next.
A child in ventricular fibrillation who has just received the third shock should trigger the sequence immediate cardiopulmonary resuscitation + adrenaline + amiodarone.
A child reaching the fifth shock with persistent ventricular fibrillation should trigger recognition of refractory ventricular fibrillation and escalation of shock energy.
A child still convulsing at 32 minutes after two benzodiazepine doses and levetiracetam should make you ask whether preparations for emergency anaesthesia are complete. If they are not, another different second-line anticonvulsant can be given while anaesthetic preparation continues. If the seizure persists towards 40 minutes, emergency anaesthesia should not be delayed.
A child with diabetic ketoacidosis who is dry and dehydrated but alert, warm, normotensive and adequately perfused receives 10 mL/kg over 30 minutes, not the faster shock bolus.
A child with a tracheostomy who suddenly deteriorates should prompt oxygen to both routes, removal of attachments, assessment with a suction catheter, and emergency tube management if that catheter cannot pass.
These small distinctions are exactly where high-quality FRCEM single-best-answer questions are won or lost.
The initial defibrillation energy for ventricular fibrillation or pulseless ventricular tachycardia is 4 joules/kg.
Immediately resume cardiopulmonary resuscitation for 2 minutes and give adrenaline 10 micrograms/kg plus amiodarone 5 mg/kg.
From the fifth shock, defibrillation energy is escalated stepwise towards 8 joules/kg, with an absolute maximum of 360 joules.
The algorithm lists levetiracetam 40–60 mg/kg intravenously over 5 minutes, maximum 4.5 g.
The third-line phase occurs at 30–40 minutes, and emergency anaesthesia should occur no later than 40 minutes if convulsive status epilepticus persists.
A dehydrated child with preserved circulation receives 10 mL/kg of balanced isotonic crystalloid or 0.9% sodium chloride over 30 minutes.
Give 10 mL/kg over 5–10 minutes, then reassess.
After oxygenation and removal of appropriate attachments, assess whether a suction catheter can pass through the tracheostomy tube.