Advanced Paediatric Life Support A Practical Approach To Emergencies Advanced Life Support Group 7E Oct 2 2023 - 1119716136 - Wiley Blackwell Stephanie Smith Full Chapter

Advanced Paediatric Life Support-A
Practical Approach to Emergencies

(Advanced Life Support Group), 7e (Oct
2,
2023)_(1119716136)_(Wiley-Blackwell)
Stephanie Smith
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Advanced Paediatric
Life Support
SEVENTH EDITION
Advanced
Paediatric Life
Support
A Practical Approach
to Emergencies
SEVENTH EDITION
Advanced Life Support Group
EDITED BY
Stephanie Smith
This seventh edition first published 2023
© 2023 John Wiley & Sons Ltd
Edition History
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6e © 2016 John Wiley & Sons, Ltd.
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Contents
Contributors to seventh edition vii

Forewordxi
Preface to first edition xii
Preface to seventh edition xiii
Acknowledgementsxv
Contact details and further information xix
PART 1: Introduction 1
1 Introduction and structured approach to paediatric emergencies 3
2 Getting it right: non-technical factors and communication 19
PART 2: The seriously ill child 29

3 Structured approach to the seriously ill child 31
4 Airway and Breathing 45
5 Circulation 65
6 Decreased conscious level (with or without seizures) 93
7 Exposure 115
PART 3: The seriously injured child 125

8 Structured approach to the seriously injured child 127
9 The child with chest injury 147
10 The child with abdominal injury 157
11 The child with traumatic brain injury 161
12 The child with injuries to the extremities or the spine 173
13 The burned or scalded child 183
14 The child with an electrical injury 191
15 Special considerations 195
v
vi Contents
PART 4: Life support 207

16 Basic life support 209
17 Support of the airway and ventilation 227
18 Management of cardiac arrest 245
PART 5: Practical application of APLS 259

19 Practical procedures: airway and breathing 261
20 Practical procedures: circulation 277
21 Practical procedures: trauma 295
22 Imaging in trauma 309
23 Structured approach to stabilisation and transfer 323
PART 6: Appendices 337

Appendix A Acid–base balance and blood gas interpretation 339
Appendix B Fluid and electrolyte management 357
Appendix C Paediatric major trauma 371
Appendix D Safeguarding 375
Appendix E Advance decisions and end of life 383
Appendix F General approach to poisoning and envenomation 397
Appendix G Resuscitation of the baby at birth 419
Appendix H Drowning 439
Appendix I Point of care ultrasound 445
Appendix J Formulary 455
List of algorithms 477

Working group for seventh edition 479
References and further reading 481
Index 487
How to use your textbook 508

Contributors to seventh
edition
Working group chair
Stephanie Smith BM BS FRCPCH, Honorary Emergency Paediatric Consultant, Nottingham

Children’s Hospital, Nottingham, UK
Associate editors
The seriously ill child

Andrew Baldock FRCA FFICM, Consultant Paediatric Anaesthetist and Intensivist, Southampton
Children’s Hospital, Southampton, UK
Els Duval MD PhD, Clinical Head Pediatric Intensive Care Unit, University Hospital Antwerp,
Edegem, Belgium
Jacquie Schutz MBBS FRACP DipObs, Paediatric Emergency Physician, Paediatric Emergency,
Department Women’s and Children’s Hospital, Adelaide, South Australia
The seriously injured child

Alan Charters RGN RSCN RNT DHealthSci MAEd BSc(Hons) PgDip(Ed), Consultant Practitioner,
Paediatric Emergency Care, Portsmouth, UK
Bimal Mehta MBChB BSc FRCPCH FRCEM, Consultant in Paediatric Emergency Medicine, Alder
Hey Children’s Hospital NHS Foundation Trust, Liverpool, UK
Life support
Jason Acworth MBBS FRACP (PEM), Paediatric Emergency Physician, Queensland Children’s
Hospital; Clinical Professor, Faculty of Medicine, University of Queensland, Australia
Marijke van Eerd MSc BSc RN RN(Child) PGCE, Paediatric Advanced Clinical Practitioner, Children
and Young People’s Emergency Department, Nottingham University Hospitals NHS Trust,
Nottingham, UK
Appendices
Peter Davis MRCP(UK) FRCPCH FFICM, Consultant in Paediatric Critical Care Medicine, Bristol
Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust,
Bristol, UK
Esyld Watson MBBCH FCEM FAcadMEd PgDip(Med Ed), Consultant in Paediatric and Adult
Emergency Medicine Prince Charles Hospital, Merthyr Tydfil, Wales
vii
viii Contributors to seventh edition
Contributors to chapters
James Armstrong BSc BMBS FRCA, Consultant in Paediatric Anaesthesia, Nottingham University
Hospitals NHS Trust, Nottingham
Dave Bramley FRCSEd(A&E) FRCEM FIMCRCSEd, Consultant in Emergency Medicine and Pre-
Hosptial Emergency Medicine, South Tyneside and Sunderland NHS Foundation Trust; Chief
Medical Officer for the Great North Air Ambulance Service
Andrea Burgess FRCS-ORLHNS, Consultant Paediatric ENT Surgeon, Southampton Children’s
Hospital, Southampton
Jonathan Davies MB BChir MA DCH FRCA, Consultant Paediatric Anaesthetist, Nottingham
University Hospitals NHS Trust, Nottingham
Joe Fawke MBCHB FRPCH, Consultant in Neonatal Medicine, University Hospitals Leicester NHS Trust;
National Course Director, RCUK Newborn Life Support (NLS) and Advanced Resuscitation of the
Newborn Infant Courses; ILCOR NLS Task Force Member; Head of East Midlands School of Paediatrics
Chris FitzSimmons FRCEM, Consultant in Paediatric Emergency Medicine, Sheffield Children’s
Hospital NHS Foundation Trust, Sheffield
Julie Grice MRCPCH, Consultant in Paediatric Emergency Medicine, Alder Hey Children’s Hospital
NHS Foundation Trust, Liverpool
Michael J. Griksaitis MBBS(Hons) MSc MRCPCH FFICM, Consultant Paediatric Intensivist,
Southampton Children’s Hospital; Honorary Senior Clinical Lecturer, Faculty of Medicine,
University of Southampton, Southampton
Rachel Harwood MRCS PhD, Registrar in Paediatric Surgery, Alder Hey Children’s Hospital NHS
Foundation Trust; Honorary Clinical Fellow, University of Liverpool, LIverpool
Dan B. Hawcutt BSc(Hons) MBChB(Hons) MD MRCPCH, Reader in Paediatric Clinical
Pharmacology, University of Liverpool; Honorary Consultant, Alder Hey Children’s Hospital;
Director of NIHR, Alder Hey Clinical Research Facility
Giles Haythornthwaite MRCPCH, Paediatric Emergency Medicine Consultant; Clinical Director for
Medical Specialties, Bristol Royal Children’s Hospital; Clinical Lead for Paediatric Trauma,
Southwest Operational Delivery Network, Bristol
Richard Hollander MD, Consultant in Pediatric Critical Care, Beatrix Children’s Hospital, University
Medical Centre Groningen, the Netherlands
Hasnaa Ismail-Koch DM FRCS-ORLHNS, Consultant Paediatric ENT Surgeon, Southampton
Children’s Hospital
Musa Kaleem MBBS MRCPCH FRCR, Consultant Paediatric Radiologist, Alder Hey Children’s NHS
Foundation Trust, Liverpool
Angela Lee MBE PgDip Bsc(Hons) RGN RSCN, Nurse Consultant Paediatric Trauma and
Orthopaedics, Royal Berkshire NHS Foundation Trust, Reading
Chris Moran MD FRCS, National Clinical Director for Trauma, NHS-England and NHS-
Improvement; Professor of Orthopaedic Trauma Surgery, Nottingham University Hospital;
Honorary Colonel, 144 Parachute Squadron, 16 Medical Regiment
Clare O’Connell MB BCh BAO FRCEM, Consultant in Emergency Medicine and Paediatric
Emergency Medicine, North Cumbria Intergrated Care Trust
Ahmed Osman MSc MRCPCH FHEA, Consultant Paediatric Intensivist, Southampton Children’s
Hospital, Southampton
Paul Reavley MBChB FRCEM FRCS (A&E)Ed MRCGP DipMedTox, Paediatric Emergency Medicine
Consultant, Bristol Royal Hospital for Children, Bristol
Martin Samuels MD FRCPCH, Consultant Respiratory Paediatrician, Staffordshire Children’s
Hospital and Great Ormond Street Hospital, London
Nandini Sen DTM&H FRCEM, Consultant in Emergency Medicine, Manchester University NHS
Foundation Trust, Manchester
Contributors to seventh edition ix
Andrew Simpson FRCS(Ed) FRCEM MClinEd DCH, Consultant in Emergency and Paediatric
Emergency Medicine, North Tees and Hartlepool NHS Foundation Trust
Edward Snelson MRCPCH, Consultant Paediatric Emergency Medicine, Clinical Lead, Children’s
Emergency Department, Norfolk and Norwich University Hospital, Norwich
Eleanor Sproson FRCS, Consultant Paediatric ENT Surgeon, Queen Alexandra Hospital,
Portsmouth
Sarah Stibbards FRCEM BSc(Hons), Clinical Director, Major Trauma and Consultant Paediatric
Emergency Medicine, Alder Hey Children’s Hospital NHS Foundation Trust, Liverpool
Neil Thompson BSc BMedSci BM BS RCPCH, Consultant in Paediatric Emergency Medicine,
Imperial College Healthcare NHS Trust, London, UK
Robert Tinnion RCPCH MD, Consultant Neonatologist, Royal Victoria Infirmary, Newcastle
Hospitals NHS Foundation Trust, Newcastle
Paul Turner BM BCh FRCPCH PhD, Clinical Reader and Honorary Consultant in Paediatric Allergy
and Clinical Immunology, Imperial College London; Chairperson, Anaphylaxis Committee, World
Allergy Organization
Jamie Vassallo PgCert DipIMC PhD, Emergency Medicine and Pre Hospital Emergency Medicine
Registrar, Post Doctoral Research Fellow, Academic Department of Military Emergency
Medicine
Julian White AM MB BS MD FACTM, Consultant Clinical Toxinologist and Unit Head, Toxinology
Department, Women’s and Children’s Hospital, North Adelaide; Clinical Academic, Discipline of
Paediatrics, Medical School, University of Adelaide, Australia
Andrea Whitney MRCP, Consultant Paediatric Neurologist, Southampton Children’s Hospital,
Southampton
Sarah Wood Paediatric and Neonatal Surgical Consultant, TPD and Governance Lead, Alder Hey
Childrens Hospital NHS Foundation Trust, Liverpool
Bogdana S. Zoica MD, Paediatric Critical Care Consultant, King’s College Hospital, London
Contributors to the status epilepticus algorithm
Richard Appleton Alder Hey Children’s Hospital NHS Foundation Trust, Liverpool
Melody Bacon Royal London Hospital, Barts Health NHS Trust, London
Harish Bangalore Great Ormond Street Hospital, London
Celia Brand Royal Hospital for Children and Young People, NHS Lothian, Edinburgh
Juliet Browning University Hospitals Dorset, Poole, Dorset
Richard Chin University of Edinburgh; Royal Hospital for Children and Young People, NHS
Lothian, Edinburgh
Susana Saranga Estevan Addenbrooke’s Hospital, Cambridge
Satvinder Mahal Great Ormond Street Hospital, London
Kirsten McHale Royal Alexandra Children’s Hospital, University Hospitals Sussex NHS Foundation
Trust, Brighton
Ailsa McLellan Royal Hospital for Children and Young People, NHS Lothian, Edinburgh
Nicola Milne Epilepsy Scotland, Glasgow
Suresh Pujar Great Ormond Street Hospital, London
Tekki Rao Luton and Dunstable University Hospital, Luton
Steven Short Scottish Ambulance Service, Edinburgh
Stephen Warriner Portsmouth Hospitals University Trust, Portsmouth
Michael Yoong Royal London Hospital, Barts Health NHS Trust, London
Foreword
It hardly seems possible that it is 30 years ago that I sat down as an overconfident senior registrar
and wrote the preface for the Advanced Paediatric Life Support manual. Now, three decades later:
older, even balder, definitely less overconfident and most probably a little bit wiser, I have been
given the opportunity to reflect on the evolution of the APLS manual and the APLS course by writing
the Foreword to this -the seventh edition.
Believe it or not, at the time it was first published, APLS was a disruptive intervention. By that I mean
that it challenged the status quo and sought to change the very fundamentals of emergency
paediatric practice. At the most basic level it implied quite bluntly that the old Oslerian paradigm of
history, examination, differential diagnosis, investigation and treatment was not fit for purpose in
an emergency situation. Rather the new concept of primary assessment and resuscitation followed
by secondary assessment and emergency treatment was advocated. To make matters worse it
went on to derive, publish and teach a set, algorithmic approach to many clinical problems that had
traditionally been managed by physician choice. As an example, I can well remember the conversa-
tions we, the editors, had about the algorithm for the management of status epilepticus. We finally
constructed an APLS status epilepticus treatment algorithm from the wisps of published evidence
and filled in the gaps with our best guesses. Our logic was that forearmed with an algorithm any
trained practitioner could manage the situation to the point of arrival of an expert. This approach
upset a number of established clinicians who felt that, as practitioners of the art of medicine, they
could craft personalised treatment only by having free choice, and that anything that interfered
with that free choice was bad for patients. Over the next 6 editions of APLS these arguments have
abated and, indeed, the algorithms themselves are often now owned and regularly updated by
expert sub-speciality groups. The smell of paraldehyde and the need for glass syringes has become
history, and debates continue as evidence based medicine evolves.
Most practitioners who deal with paediatric emergencies nowadays will never have known
anything other than the ‘APLS approach’ to emergency care, and that is the true success of the
disruption the manual and course started all those years ago. There are, of course, dangers in
becoming the new normal, in particular it is easy to rest on the laurels of success. Avoiding
complacency is important and is why this latest (seventh) edition is as important as the first e
dition
was all those years ago. The current APLS working group and the book editors are at the peak of
their careers and are wholly committed to keeping the content and teaching of APLS at the very
cutting edge of current practice. Knowing the energy they bring as the current custodians of APLS
is why I have no hesitation in recommending this new edition to you. It will serve you, and sick and
injured c hildren, well.
Kevin Mackway-Jones
Manchester, 2023
xi
Preface to first edition
Advanced Paediatric Life Support: The Practical Approach was written to improve the emergency
care of children, and has been developed by a number of paediatricians, paediatric surgeons,
emergency physicians and anaesthetists from several UK centres. It is the core text for the APLS
(UK) course, and will also be of value to medical and allied personnel unable to attend the course. It
is designed to include all the common emergencies, and also covers a number of less common
diagnoses that are amenable to good initial treatment. The remit is the first hour of care, because it
is during this time that the subsequent course of the child is set.
The book is divided into six parts. Part I introduces the subject by discussing the causes of child-
hood emergencies, the reasons why children need to be treated differently and the ways in which a
seriously ill child can be recognised quickly. Part II deals with the techniques of life support. Both
basic and advanced techniques are covered, and there is a separate section on resuscitation of the
newborn. Part III deals with children who present with serious illness. Shock is dealt with in detail,
because recognition and treatment can be particularly difficult. Cardiac and respiratory emergen-
cies, and coma and convulsions, are also discussed. Part IV concentrates on the child who has been
seriously injured. Injury is the most common cause of death in the 1–14-year age group and the
importance of this topic cannot be overemphasised. Part V gives practical guidance on performing
the procedures mentioned elsewhere in the text. Finally, Part VI (the appendices) deals with other
areas of importance.
Emergencies in children generate a great deal of anxiety – in the child, the parents and in the
medical and nursing staff who deal with them. We hope that this book will shed some light on the
subject of paediatric emergency care, and that it will raise the standard of paediatric life support. An
understanding of the contents will allow doctors, nurses and paramedics dealing with seriously ill
and injured children to approach their care with confidence.
Kevin Mackway-Jones
Elizabeth Molyneux
Barbara Phillips
Susan Wieteska
Editorial Board
1993
xii
Preface to seventh edition
The Advanced Paediatric Life Support (APLS) course is now delivered in 76 centres across the United
Kingdom and 17 centres on every continent across the world. This amazing achievement is due to
the small, dedicated team based at the Advanced Life Support Group (ALSG) in Manchester and
to the thousands of trained instructors from many disciplines, who give their time and expertise so
generously. Thank you all.
This manual (the seventh in the last 30 years) supports the APLS and Paediatric Life Support (PLS)
courses, as well as being used as a gold standard for acute paediatric clinical practice. It builds on
the contributions from previous authors whose names can be found on the ALSG website. Thank
you to them and to all those who have worked so hard to produce this edition.
This manual has been updated throughout. There is an increased emphasis on preparation for
effective team working to improve patient safety. The seriously ill child section has been restruc-
tured to consolidate information into chapters reflecting the ABCDE approach.
Evolving techniques such as point of care ultrasound (POCUS) are included in several chapters, and
POCUS is described in more detail in an excellent appendix at the end of the manual. APLS does not
specifically teach this skill, rather we acknowledge its place in many aspects of emergency
management and care.
The entire manual has been updated in line with the 2021 International Liaison Committee on
Resuscitation (ILCOR) guidelines as well as with consensus best practice. The international nature
of APLS means the manual is written to reflect different cultures and clinical practices wherever
possible.
Additional and detailed information for those who wish to take their learning further is included in
the 10 appendices. This information is not essential knowledge for all but we hope will be
interesting reading for many.
Since the sixth edition of APLS there has been the worldwide COVID-19 pandemic which had an
impact on the way courses were delivered as well as the timescale for this edition of the manual.
It is essential that we incorporate the lessons learned from this experience into delivery of both
healthcare and the way it is taught.
Stephanie Smith
May 2023
xiii
Acknowledgements
A great many people have put a lot of hard work into the production of this book, and the
accompanying Advanced Paediatric Life Support course. The editors would like to thank all the
contributors for their efforts and all the APLS instructors who took the time to send us their
comments on the earlier editions.
We are greatly indebted to Kirsten Baxter and Kate Denning for their exceptional hard work and
dedication towards this publication; their encouragement and guidance throughout the process
has been gratefully received.
We would like to express our special thanks to Ayşe Mehta for producing the excellent line drawings,
Jason Acworth and Children’s Health Queensland for the new photographs that illustrate the text
and Catherine Giaquinto for designing the new algorithms for this edition.
For the cover image, thank you to Russell Ashworth and his son Noah Ashworth, Chloe Donaldson,
Manivannan Manoharan, Julia Maxted, Angela Armitage and Nila Prince.
We would also like to thank Laura May for kindly allowing adaptation of the UHCW NHS Trust
Paediatric TRAUMATIC list. Rowan Pritchard Jones and Michael Watts for allowing images from the
Mersey Burns App. Michael J. Griksaitis and Bogdana Zoica for the POCUS chapter and figures.
Jamie Vassallo for the PTCA algorithm. Marijke van Eerd for the Paediatric Major Trauma and
analgesia calculation chart. Ross Smith on behalf of the Child and Young Person’s Advance Care
Plan. Tim Nutbeam and Ron Daniels on behalf of the UK Sepsis Trust. The Status Epilepticus
Guidelines development group.
For the shared use of their images, illustrations, tables and algorithms, we would like to thank:
Alder Hey Radiology Department Teaching Library
ASIA – American Spinal Injury Association
Bristol Royal Hospital for Children and RTIC Severn
British Society for Paediatric Endocrinology and Diabetes
British Thoracic Society/Scottish Intercollegiate Guidelines Network
Children’s Health Queensland
National Tracheostomy Safety Project: Paediatric Working Party
Northern Neonatal Network
Resuscitation Council UK
Royal College Paediatrics and Child Health and Harlow Printing
Safeguard Medical Technologies
Teleflex Medical Australia and New Zealand
Victorian Department of Health
ALSG gratefully acknowledge the support of the Royal College of Paediatrics and Child Health (UK).
The Specialist Groups of the RCPCH agreed to advise on the clinical content of chapters relevant to
their specialism. ALSG wish to thank the following:
xv
xvi Acknowledgements
Association of Paediatric Emergency Medicine
Anastasia Alcock FRCPCH DTM&H DRCOG PgDIP, Paediatric Emergency Medicine Consultant,
Evelina London
Jane Bayreuther FRCPCH, Consultant in Paediatric Emergency Medicine, Southampton. On behalf
of APEM
Charlotte Clements BSc(Hons) MBChB MRCPCH MSc PGCert (Darzi), Consultant Paediatrician,
Clinical Lead for the Paediatric Emergency Department, North Middlesex University Hospital NHS
Trust; Secretary, Association of Paediatric Emergency Medicine
Miki Lazner MBChB MMSc (Child Health) FRCPCH, Paediatric Emergency Medicine Consultant,
Clinical Lead Paediatric Trauma, University Hospitals Sussex NHS Foundation Trust; Paediatric Lead,
Sussex Trauma Network; Guidelines Representative and Executive Committee Member, Association
of Paediatric Emergency Medicine (APEM)
Michael Malley MA MBBS MRCPCH DTMH, Consultant in Paediatric Emergency Medicine, Bristol
Royal Hospital for Children
Rachael Mitchell MRCPCH MA (Cantab), Consultant in Paediatric Emergency Medicine, Kings
College Hospital NHS Foundation Trust
British Association General Paediatrics
Christine Brittain RCPCH, Sub-speciality PEM, Acute Paediatric Consultant, PAU Lead, Musgrove
Park Hospital Somerset Foundation Trust
British Association of Perinatal Medicine
Hannah Shore MBChB MRCPCH MD, Consultant Neonatologist, Lead Clinician for Leeds Centre for
Newborn Care
Tim J. van Hasselt MBChB BMedSc MRCPCH, Neonatal sub-specialty trainee, West Midlands, NIHR
Doctoral Research Fellow, University of Leicester
British Paediatric Allergy, Immunity and Infection Group
Alasdair Bamford MBBS FRCPCH DTM+H PhD, Consultant and Specialty Lead in Paediatric Infectious
Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust; Honorary Associate
Professor, UCL GOSH Institute of Child Health; British Paediatric Allergy Infection and Immunity
Group (BPAIIG) secretary
Enitan Carrol MBChB MD DTMH FRCPCH, Professor and Honorary Consultant in Paediatric
Immunology and Infectious Diseases, University of Liverpool and Alder Hey Children’s NHS
Foundation Trust
Saul Faust MBBS PhD FRCPCH OBE, Professor and Honorary Consultant in Paediatric Immunology
and Infectious Diseases, University of Southampton and University Hospital Southampton NHS
Foundation Trust
Paul Turner BM BCh FRCPCH PhD, Clinical Reader and Honorary Consultant in Paediatric Allergy
and Clinical Immunology, Imperial College London; Chairperson of Anaphylaxis Committee, World
Allergy Organization
Elizabeth Whittaker MB BAO BCh MRCPCH DTM&H PhD, Consultant in Paediatric Infectious
Diseases; Clinical Lead in Paediatric Infectious Diseases, Imperial College Healthcare NHS Trust,
London; Senior Clinical Lecturer in Paediatric Infectious Diseases, Imperial College London; Convenor
for British Paediatric Allergy Immunity and Infectious Diseases Group (BPAIIG)
Acknowledgements xvii
British Paediatric Respiratory Society
Elise Weir MBChB MRCPCH PGCert Child Health, Consultant in Paediatric Respiratory Medicine,
Royal Hospital for Children, Glasgow
British Society of Paediatric Radiology – trauma imaging
Judith Foster MB ChB(Hons) FRCR, Consultant Paediatric Radiologist, University Hospitals Plymouth;
Paediatric Trauma Lead for British Society of Paediatric Radiology
Child Protection Special Interest Group
David Lewis MBBS MSc(Paeds) MRCP FRCPCH, Consultant Community Paediatrician and
Designated Doctor for Child Protection (Herefordshire and Worcestershire ICB); Chair of the Child
Protection Specialist Interest Group (affiliated to the Royal College of Paediatrics and Child Health)
Paediatric Critical Care Society
David Finn MBBS MRPCH MSc, Paediatric Intensive Care Consultant, Leeds Children’s Hospital
Rum Thomas MB BS DNB (Paediatrics) FRCPCH, Consultant in Paediatric Critical Care, Sheffield
Children’s NHS Foundation Trust; Clinical Lead, Paediatric Critical Care Operational Delivery Network
Yorkshire and Humber South
Hanna Tilly BSc BMedSci BMBS, Specialist Registrar in Paediatrics, North Central and East London
Mark Worrall MB ChB FRCA MRCPCH FFICM, Consultant in Paediatric Intensive Care and Paediatric
Anaesthesia, Royal Hospital for Children, Glasgow; Consultant in Paediatric Critical Care Transport,
ScotSTAR, Scottish Ambulance Service
RCEM Intercollegiate group
Anne Frampton MPhil BSc MB ChB MRCP DipIMC DCH FRCEM, Consultant in Emergency Medicine
(Paediatrics), Bristol Royal Hospital for Children, UHBW NHS FT
Michelle Jacobs BSc MB BCh FRCEM ARSM, Consultant in Paediatric Emergency Medicine, ED
Clinical Lead for Paediatric Emergency Department, London North West University Healthcare NHS
Trust (Northwick Park Hospital)
Damian Roland B(Med)Sci BMBS FRCPCH PhD, Honorary Professor and Consultant in Emergency
Medicine, Head of Service, Children’s Emergency Department, Leicester Hospitals and University
Rob Stafford MBBS MRCA PGCertMedEd FHEA FRCEM, Consultant in Adult and Paediatric
Emergency Medicine; Chair, RCEM Paediatric Emergency Medicine Professional Advisory Group
We would like to thank, in advance, those of you who will attend the Advanced Paediatric Life
Support course and others using this text for your continued constructive comments regarding the
future development of both the course and the manual.
Contact details and
further information
ALSG: www.alsg.org
For details on ALSG courses visit the website or contact:
Advanced Life Support Group
ALSG Centre for Training and Development
29–31 Ellesmere Street
Swinton, Manchester
M27 0LA
Tel: +44 (0) 161 794 1999
Email: enquiries@alsg.org
Updates
The material contained within this book is updated on approximately a 4-yearly cycle. However,
practice may change in the interim period. We will post any changes on the ALSG website, so we
advise you to visit the website regularly to check for updates (www.alsg.org).
References
To access references, visit the ALSG website www.alsg.org – references are on the course pages as
well as at the end of this book.
On-line feedback
It is important to ALSG that the contact with our providers continues after a course is completed.
We now contact everyone 6 months after their course has taken place asking for on-line feedback
on the course. This information is then used whenever the course is updated to ensure that the
course provides optimum training to its participants.
xix
PART 1
Introduction
1
CHAPTER 1
Introduction and
structured approach to
paediatric emergencies
Learning outcomes
After reading this chapter, you will be able to:
zz Appreciate the focus and principles of the APLS course
zz Describe the structured approach to identifying and managing paediatric emergencies
zz Identify the important differences in children and the impact these have on the management
of emergencies
zz Appreciate that the absolute size and relative body proportions change with the age of the
child
zz Identify the approach to triage of a child
1.1 Introduction
The Advanced Paediatric Life Support (APLS) course equips those caring for children with the
necessary skills and structured approach to identify and safely manage ill or injured children
whenever or wherever they encounter them.
Children continue to die from preventable causes throughout the world. The reasons for their
deaths differ between countries, however the structure and principles for managing the underlying
causes are universal.
Child mortality is the lowest it has ever been and has halved in the last three decades, which is a huge
achievement (12.5 million deaths of under 5‐year‐olds worldwide in 1990 compared with 5 million in 2020).
Worldwide data from the World Health Organization (WHO) show the leading cause of death in this
age group is pneumonia, followed by preterm birth and then diarrhoeal illnesses. This compares
with recent data from the USA showing the leading cause in children to be gun‐related injuries. In
the UK, Office for National Statistics (ONS) data show that cancer is the leading cause of death in all
children followed by accidents and then congenital abnormalities.
The COVID‐19 pandemic has not directly had a significant impact on child mortality. However, there
are ongoing concerns about the indirect impact due to strained and under‐resourced health
systems; a reduction in care‐seeking behaviours; a reduced uptake of preventative measures such
as vaccination and nutritional supplements; and socioeconomic challenges.
Advanced Paediatric Life Support: A Practical Approach to Emergencies, Seventh Edition. Edited by Stephanie Smith.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
3
4 PART 1 Introduction
1.2 The APLS approach
In the structured approach it is essential to remember that:

zz The child’s family will need support from a qualified member of the team
zz Absolute size and body proportions change with age
zz Observations and therapy in children must be related to their age and weight
zz The psychological needs of children must be considered
zz It is key to support each other as the clinical team
Physiological differences
Children, especially young ones, have significantly lower physiological reserves than adults. As a
consequence, they may deteriorate rapidly when severely ill or injured and respond differently
from adults to various interventions. It is essential to manage and support their respiratory and
cardiovascular systems in a timely and structured manner to prevent further deterioration or even
cardiovascular arrest. (See normal ranges table, inside front cover.)
Relationship between disease progression and outcomes

The further a disease process is allowed to progress, the worse the outcome is likely to be. The
outcomes for children who have a cardiac arrest out of hospital are generally poor. This may be
because cardiac arrest in children is less commonly related to cardiac arrhythmia, but is more
commonly a result of hypoxaemia and/or shock with associated organ damage and dysfunction.
By the time that cardiac arrest occurs, there has already been substantial damage to various
organs. This is in contrast to situations (more common in adults) where the cardiac arrest is the
consequence of cardiac arrhythmia – with preceding normal perfusion and oxygenation. Thus the
focus of the course is on early recognition and effective management of potentially life‐threatening
problems before there is progression to respiratory and/or cardiac arrest (Figure 1.1).
Pathways to cardiac arrest
Respiratory Respiratory Fluid Fluid

obstruction depression loss maldistribution
Foreign body Convulsions Blood loss Sepsis

Asthma Poisoning Burns Anaphylaxis
Croup Raised ICP Vomiting Cardiac failure
Respiratory failure Circulatory failure
Cardiac arrest
Figure 1.1 Pathways leading to cardiac arrest in childhood (with examples of underlying causes)
ICP, intracranial pressure
C H A PTE R 1 Introduction and structured approach to paediatric emergencies 5
Standardised structure for assessment and stabilisation

A standardised approach for resuscitation enables the provision of a standard working environment
and access to the necessary equipment to manage ill or injured children. The use of the standardised
structure enables the whole team to know what is expected of them and in which sequence.
Once basic stabilisation has been achieved, it is appropriate to investigate the underlying diagnoses
and provide definitive therapy.
Definitive therapy (such as surgical intervention) may be a component of the resuscitation
Resource management
Provision of effective emergency treatment depends on the development of teams of healthcare
providers working together in a coordinated, well‐led manner (Figure 1.2). It is important that all
training in paediatric life support focuses on how to best use the equipment and human resources
available and emphasises the key nature of effective communication.
Figure 1.2 Advanced paediatric life support (APLS) in action
Early referral to appropriate teams for definitive management

Emergency departments are unlikely to be able to provide definitive management for all paediatric
emergencies, and a component of stabilisation of critically ill or injured children is the capacity to
call for help as soon as possible, and where necessary transfer the child to the appropriate site safely.
Ongoing care until admission to appropriate care

In most parts of the world it is impossible to transfer critically ill children into intensive care units or
other specialised units within a short time of their arrival in the emergency area. Therefore, it is
important to provide training in the ongoing therapy that is required for a range of relatively
common conditions once initial stabilisation has been completed.
1.3 Important differences in children
Children are a diverse group, varying enormously in weight, size, shape, intellectual ability and
emotional responses. At birth a child is, on average, a 3.5 kg, 50 cm long individual with small
respiratory and cardiovascular reserves and an immature immune system. They are capable of
limited movement, have immature emotional responses though still perceive pain and are
dependent upon adults for all their needs. At the other end of childhood, the adolescent may be
more than 60 kg, 160 cm tall and look physically like an adult, often exhibiting a high degree of
independent behaviour but who may still require support in ways that are different from adults.
Competent management of a seriously ill or injured child who may fall anywhere between these
two extremes requires a knowledge of these anatomical, physiological and emotional differences
and a strategy of how to deal with them.
Weight
The most rapid changes in weight occur during the first year of life. An average birth weight of
3.5 kg will have increased to 10 kg by the age of 1 year. After that time weight increases more slowly
until the pubertal growth spurt. This is illustrated in the weight charts shown in Figure 1.3.
As most drugs and fluids are given as the dose per kilogram of body weight, it is important to deter-
mine a child’s weight as soon as possible. The most accurate method for achieving this is to weigh
the child on scales; however, in an emergency this may be impracticable. Very often, especially with
infants, the child’s parents or carer will be aware of a recent weight. If this is not possible, various
formulae or measuring tapes are available. The Broselow or Sandell tapes use the height (or length)
of the child to estimate weight. The tape is laid alongside the child and the estimated weight read
from the calibrations on the tape. This is a quick, easy and relatively accurate method. Various
formulae may also be used although they should be validated to the population in which they are
being used.
If a child’s age is known, the normal ranges table will provide you with an approximate weight
(inside front cover) and allow you to prepare the appropriate equipment and drugs for the
child’s arrival in hospital. Whatever the method, it is essential that the carer is sufficiently
familiar with the tools to use them quickly and accurately under pressure. When the child
arrives, you should quickly review their size to check if it is much larger or smaller than predicted.
If you have a child who looks particularly large or small for their age, you can go up or down
one age group.
Figure 1.3 Example of centile chart for weight in girls (2–18 years)
©Reproduced with kind permission of RCPCH and Harlow Printing Limited
(Continued)
Figure 1.3 (Continued)

Anatomical
As the child’s weight increases with age the size, shape and proportions of various organs also
change. Particular anatomical changes are relevant to emergency care.
Airway
The airway is influenced by anatomical changes in the tissues of the mouth and neck. In a young
child the occiput is relatively large and the neck short, potentially resulting in neck flexion and
airway narrowing when the child is laid flat in the supine position. The face and mandible are small,
and teeth or orthodontic appliances may be loose. The tongue is relatively large and not only tends
to obstruct the airway in an unconscious child, but may also impede the view at laryngoscopy.
Finally, the floor of the mouth is easily compressible, requiring care in the positioning of fingers
when holding the jaw for airway positioning. These features are summarised in Figure 1.4.
Loose teeth
Narrow nostrils
Large tongue Compressible floor of mouth
Horseshoe-shaped epiglottis
High anterior larynx
Figure 1.4 Summary of significant upper airway anatomy
The anatomy of the airway itself changes with age, and consequently different problems affect dif-
ferent age groups. Infants less than 6 months old are primarily nasal breathers. As the narrow nasal
passages are easily obstructed by mucous secretions, and as upper respiratory tract infections are
common in this age group, these children are at particular risk of airway compromise. Adenotonsillar
hypertrophy may be a problem at all ages, but is more usually found between 3 and 8 years. This not
only tends to cause obstruction, but also may cause difficulty when the nasal route is used to pass
pharyngeal, gastric or tracheal tubes.
The trachea is short and soft. Overextension of the neck as well as flexion may therefore cause
tracheal compression. The short trachea and the symmetry of the carinal angles (the angle between
the right and left main bronchi) mean that not only is tube displacement more likely, but a tube or
a foreign body is also just as likely to be displaced into the left as the right main‐stem bronchus.
Breathing
The lungs are relatively immature at birth. The air–tissue interface has a relatively small total surface
area in the infant (less than 3 m2). In addition, there is a 10‐fold increase in the number of small
airways from birth to adulthood. Both the upper and lower airways are relatively small and are
consequently more easily obstructed. As resistance to flow is inversely proportional to the fourth
power of the airway radius (halving the radius increases the resistance 16‐fold), seemingly small
obstructions can have significant effects on air entry in children. This may partially explain why so
much respiratory disease in children is characterised by airway obstruction.
Infants rely mainly on diaphragmatic breathing. Their muscles are more likely to fatigue as they
have fewer type I (slow‐twitch, highly oxidative, fatigue‐resistant) fibres compared with adults.
Preterm infants’ muscles have even fewer type I fibres. These children are consequently more prone
to respiratory failure.
The ribs lie more horizontally in infants, and therefore contribute less to chest expansion. In the
injured child, the compliant chest wall may allow serious parenchymal injuries to occur without
necessarily incurring rib fractures. For multiple rib fractures to occur the force must be very large;
the parenchymal injury that results is consequently very severe and flail chest is tolerated badly.
Circulation
At birth the two cardiac ventricles are of similar weight; by 2 months of age the RV : LV weight ratio
is 0.5. These changes are reflected in the infant’s electrocardiogram (ECG). During the first months
of life the right ventricle (RV) dominance is apparent, but by 4–6 months of age the left ventricle (LV)
is dominant. As the heart develops during childhood, the sizes of the P wave and QRS complex
increase, and the P‐R interval and QRS duration become longer.
The child’s circulating blood volume per kilogram of body weight (70–80 ml/kg) is higher than that
of an adult, but the actual volume is small. This means that in infants and small children, relatively
small absolute amounts of blood loss can be critically important.
Body surface area

The body surface area (BSA) to weight ratio decreases with increasing age (Figure 1.5). Small children,
with a high ratio, lose heat more rapidly and consequently are relatively more prone to hypothermia.
At birth, the head accounts for 19% of BSA; this falls to 9% by the age of 15 years.
Figure 1.5 Differences in children

TAGSTOCK2/Adobe Stock
CH A PTE R 1 Introduction and structured approach to paediatric emergencies 11
Physiological
Respiratory
The infant has a relatively greater metabolic rate and oxygen consumption. This is one reason for an
increased respiratory rate. However, the tidal volume remains relatively constant in relation to body
weight (5–7 ml/kg) through to adulthood. The work of breathing is also relatively unchanged at
about 1% of the metabolic rate, although it is increased in the preterm infant.
In the adult, the lung and chest wall contribute equally to the total compliance. In the newborn,
most of the impedance to expansion is due to the lung, and is critically dependent on the presence
of surfactant. The lung compliance increases over the first week of life as fluid is removed from the
lung. The infant’s compliant chest wall leads to prominent sternal recession when the airways are
obstructed or lung compliance decreases. It also allows the intrathoracic pressure to be less ‘nega-
tive’. This reduces small airway patency. As a result, the lung volume at the end of expiration is simi-
lar to the closing volume (the volume at which small‐airway closure starts to take place).
The combination of high metabolic rate and oxygen consumption with low lung volumes and limited
respiratory reserve means that infants in particular will desaturate much more rapidly than adults.
This is an important consideration during procedures such as endotracheal intubation.
At birth, the oxygen dissociation curve is shifted to the left and P50 (PO2 at 50% oxygen saturation)
is greatly reduced. This is due to the fact that 70% of the haemoglobin (Hb) is in the form of fetal
haemoglobin (HbF); this gradually declines to negligible amounts by the age of 6 months.
The immature infant lung is also more vulnerable to insult. Following prolonged respiratory support
of a preterm infant, chronic lung disease of the newborn may cause prolonged oxygen depend-
ence. Many infants who have suffered from bronchiolitis remain ‘chesty’ for a year or more.
Cardiovascular
The infant has a relatively small stroke volume (1.5 ml/kg at birth) but has the highest cardiac index
seen at any stage of life (300 ml/min/kg). Cardiac index decreases with age and is 100 ml/min/kg in
adolescence and 70–80 ml/min/kg in the adult. At the same time the stroke volume increases, the
heart gets bigger and muscle mass relative to connective tissue increases. As cardiac output is the
product of stroke volume and heart rate, these changes underlie the heart rate changes seen during
childhood. In addition, the average infant is only able to increase their heart rate by approximately
30% versus the adult who may be able to increase heart rate under stress by up to 300%.
As the stroke volume is small and relatively fixed in infants, cardiac output is principally related to
heart rate. The practical importance of this is that the response to volume therapy is blunted when
normovolaemic because stroke volume cannot increase greatly to improve cardiac output. By the
age of 2 years, myocardial function and response to fluid are similar to those of an adult.
Systemic vascular resistance rises after birth and continues to do so until adulthood is reached. This
is reflected in the changes seen in blood pressure.
Immune function
At birth the immune system is immature and, consequently, babies are more susceptible than older
children to many infections such as bronchiolitis, septicaemia, meningitis and urinary tract
infections. Maternal antibodies acquired across the placenta provide some early protection but
these progressively decline during the first 6 months. These are replaced slowly by the infant’s
antibodies as they grow older. Infants may be particularly susceptible to infectious diseases in the
period between the waning of maternal antibodies and development of their own antibodies
(sometimes in response to immunisation). Breastfeeding provides increased protection against
respiratory and gastrointestinal infections.
Psychological
Fear
Children vary enormously in their intellectual ability and their emotional response. A knowledge of
child development assists in understanding a child’s behaviour and formulating an appropriate
management strategy. Particular challenges exist in communicating with children. Many situations
that adults would not classify as fearful, engender fear in children. This causes additional distress to
the child and adds to parental anxiety. Physiological parameters, such as pulse rate and respiratory
rate, are often raised because of it, and this in turn makes clinical assessment of pathological
processes such as shock more difficult.
Fear is a particular problem in the pre‐school child who often has a ‘magical’ concept of illness and
injury. This means that the child may think that the problem has been caused by some bad wish or
thought that they have had. School‐age children and adolescents may have fearsome concepts of
what might happen to them in hospital because of ideas they have picked up from adult conversa-
tion, films and television.
Knowledge allays fear and it is important to explain things as clearly as possible to the child in
language they understand
Play can be used to help with explanations (e.g. applying a bandage to a teddy first), and also helps
to maintain some semblance of normality in a strange and stressful situation. Parents must be
allowed to stay with the child at all times (including during resuscitation if at all possible); impor-
tantly, they too must be supported and fully informed at all times.
Communication
Infants and young children either have no language ability or are still developing their speech. This
causes difficulty when symptoms such as pain need to be described. Even children who are usually
fluent may remain silent in healthcare settings when unwell or injured. Information has to be
gleaned from the limited verbal communication and from the many non‐verbal cues (such as
facial expression and posture) that are available. Older children are more likely to understand
aspects of their illness and treatment and so be reassured by adequate age‐appropriate
communication.
Children with developmental differences due to pre‐existing conditions such as autism,

chromosome abnormalities or cerebral palsy may require different means of communication
1.4 Structured approach to paediatric emergencies
Structured approach to paediatric emergencies
Prepare for child’s arrival
Primary survey
ABCDE looking for
IMMEDIATE
life-threatening issues
Resuscitation
Secondary survey
looking for key features to aid
FOCUSED
diagnosis
Emergency treatment
Reassessment and
physiological system control
DETAILED
REVIEW
Continuing stabilisation
Transfer to definitive care
Figure 1.6 Structured approach to paediatric emergencies
A structured approach to paediatric emergencies will enable a clinician to manage emergencies in

a logical and effective fashion and assist in ensuring that vital steps are not forgotten even in
unfamiliar or infrequent emergency situations (Figure 1.6). This allows:
zz Identification of life‐threatening situations: closed or obstructed airway, absent or ineffective
breathing, or absent pulse or shock requiring immediate interventions which comprise resuscitation
zz Following resuscitation, looking for key features which signpost likely working diagnosis
zz Initiation of emergency treatment
zz Stabilisation and transfer for definitive care
Remember to utilise newer techniques such as point of care ultrasound (POCUS) if practitioners
have the skill set to do so (see Appendix I).
Throughout this book, in the virtual learning environment (VLE) and on APLS courses, the same
structure will be used so that the clinician will become familiar with the approach and be able to
apply it to any clinical emergency situation.
1.5 Preparation
If warning has been received of the child’s arrival then preparations can be made:
zz Ensure that appropriate help is available: critical illness and injury need a team approach
zz Work out the likely drug, fluid and equipment needs
For unexpected emergencies, ensure that all areas where children may be treated are stocked with
the drugs, fluid and equipment needed for any childhood emergencies.
1.6 Teamwork
A well‐functioning team is vital in all emergency situations. Success depends on each team member
carrying out their own tasks and being aware of the tasks and the skills of other team members. The
whole team must be under the direction of a team leader. Scenario practice by teams who work
together is an excellent way to keep up skills, knowledge and team coordination in preparation for
the ‘real thing’. See Chapter 2 on non‐technical skills.
1.7 Communication
Communication with the ill or injured child and their family has been discussed previously.
Communication is no less important with clinical colleagues. When things have gone wrong,
investigations have identified that an issue in communication has often been involved. Structured
communication tools may be useful in ensuring that all relevant information is conveyed to all the
teams involved in the child’s care. Contemporaneous recording of clinical findings, of the child’s
history and of test results and management plans seems obvious but in the emergency situation
may be overlooked. A template for note taking can be found in Chapter 8.
1.8 Triage
Triage is the process whereby each child presenting with potentially serious illness or injury is
assigned a clinical priority. It is an essential clinical risk management step, and also a tool for
optimisation of resource allocation in any emergency.
In the UK, Canada and Australia, five‐part national triage scales have been agreed. Such a scale is
shown in Table 1.1. While the names of the triage categories and the target times assigned to each
name vary from country to country, the underlying concept does not.
Table 1.1 Triage scale
Number Colour Name Maximum time to clinician

1 Red Immediate 0 min
2 Orange Very urgent 10 min
3 Yellow Urgent 60 min
4 Green Standard 240 min
5 Blue Non‐urgent N/A

CH A PTE R 1 Introduction and structured approach to paediatric emergencies 15
Triage is used to identify children who require urgent intervention.

Accuracy of triage and assigning a priority is an important basis for any triage system. However,
there are instances when even for lower acuity patients the management may be deemed urgent,
for example in an epidemic it may be important to get potentially uninfected children away from
possible infection as soon as possible but the assessed triage priority will not change, just the action
post triage. Never forget the need for repeated triage/reassessment – children can deteriorate rap-
idly and if there is no reassessment process, this may be missed.
Remember also that being triaged green does not mean that a child does not have a serious prob-
lem that requires specialist attention. It simply means the risk has been assessed and it would be
acceptable for that child to wait for definitive management.
It is important to make sure that the family understands the nature of the triage process (and why
they will see other children receiving treatment who arrived after their child).
Triage decision making

There are many models of decision making, each including: identification of a problem, determination
of the alternatives and selection of the most appropriate alternative.
Discriminators are factors normally expressed as a word or short statement that allow patients to be
allocated to one of five clinical priorities as in the algorithm in Figure 1.7. They can be general or spe-
cific. The former apply to all patients irrespective of their presentation and include life threat, pain,
haemorrhage, conscious level and temperature and appear across the priorities (e.g. very hot, hot
and warm). Specific discriminators tend to relate to key features of particular conditions, for exam-
ple an asthmatic child ‘unable to talk in sentences’. Thus severe pain is a general discriminator, but
cardiac pain and pleuritic pain are specific discriminators.
Unwell child
Airway compromise
Inadequate breathing
RED
Shock unresponsive
Currently fitting
Hypoglycaemia
Very low SpO2

New abnormal pulse
Responds to voice or pain only
Fails to react to parents
Signs of meningism
Purpura
Known or likely immunosuppression ORANGE
Special risk of infection
Non-blanching rash
Very hot
Possible sepsis
Cold
Severe pain
RISK
LIMIT
Low SpO2
Signs of dehydration
Not feeding
Not passing urine YELLOW
Inappropriate history
History of recent foreign travel
Significant haematological or metabolic
history
Hot
Moderate pain
Atypical behaviour
GREEN
Warm
Recent mild pain
Recent problem
1 2 3 4 5
BLUE
Figure 1.7 Paediatric triage for an unwell child

Secondary triage
It may not be possible to carry out all the assessments necessary at the initial triage encounter – this
is particularly so if the workload of the department is high. In such circumstances, the necessary
assessments should still be carried out, but as secondary procedures by the receiving healthcare
professional. The actual initial clinical priority cannot be set until the process is finished. More time‐
consuming assessments (e.g. blood glucose estimation and peak flow measurement) are often left
to the secondary stage.
1.9 Summary
This chapter has given an overview of management of paediatric emergencies, outlining the
structured approach which is central to APLS. Subsequent chapters will focus in depth on the
elements of the ABCDE approach in both the ill and the injured child.
CHAPTER 2
Getting it right:
non-technical factors
and communication
Learning outcomes
After reading this chapter, you will be able to:
zz Describe how clinical human factors affect the performance of individuals and teams in the
healthcare environment
2.1 Introduction
This chapter provides a brief introduction to some of the non-technical skills that can affect the
performance of individuals and teams in the healthcare environment. Non-technical skills, also
referred to as human factors or ergonomics, is an established scientific discipline and clinical
human factors have been described as:
Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment,
workspace, culture and organisation on human behaviour and abilities and application of that
knowledge in clinical settings. (Kohn et al., 2010)
2.2 Extent of healthcare error
In 2000 an influential report entitled To Err is Human: Building a Safer Health System suggested
that across the USA somewhere between 44 000 and 98 000 deaths each year could be attributed
to medical error. A pilot study in the UK demonstrated that approximately one in 10 patients
admitted to healthcare experienced an adverse event.
Healthcare has been able to learn from a number of other high-risk industries including the nuclear,
petrochemical, space exploration, military and aviation industries about how team issues have been
managed. These lessons have been gradually adopted and translated to healthcare.
Specialist working groups and national bodies have been instrumental in promoting awareness of
the importance of human factors in healthcare. One such example of this in the UK is the Human
Factors Clinical Working Group.
Advanced Paediatric Life Support: A Practical Approach to Emergencies, Seventh Edition. Edited by Stephanie Smith.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
19
2.3 Causes of healthcare error
Consider this example of an adverse event:

A child needs to receive an infusion of a particular drug. An error occurs and the child receives an
incorrect drug. There are a number of potential causes of this situation. A few of these are given
below.
Prescription error Wrong drug prescribed
Prescription error Incorrect amount prescribed
Preparation error Correct drug prescribed but misread
Preparation error Contents mislabelled during manufacture
Drawing up error Incorrect drug selected
Administration error Patient ID mix-up, drug given to wrong patient
However many checks and procedures are put in place, mistakes will still occur and may cause
harm to patients. It is vital therefore that we look to work in a way that, wherever possible, reduces
the occurrence of mistakes and ensures that when they do occur the chance of the error resulting
in harm to children in our care is minimised. Reason’s taxonomy of errors (Figure 2.1) provides further
insight by illustrating how errors can be sharp or blunt or a combination of the two.
Blunt end Sharp end

Design phase Clinical practice
Decreasing time to think
Errors in:
Policies Error types:
Procedures Mistake
Infrastructure Slip or lapse
Building layout Deliberate violation
Figure 2.1 Reason’s taxonomy of errors
Because errors are multifactorial, it is typically found that the organisational or blunt issues often
coexist with the clinical or sharp errors; in fact it is rare for an isolated error to occur – often there is
a chain of events that results in the adverse event. Apparently random, unconnected events and
organisational decisions can all make errors more likely. Conversely, a standardised system with
good defences can often capture these errors and prevent adverse events and subsequent impact
on the patient.
CH A PTE R 2 Getting it right: non-technical factors and communication 21
In the example of drug error just given, the first potential error is the doctor writing the prescription,
the second is the organisation’s drug policy, the third is the nurse who draws up the drug and the
fourth is the nurse who second checks the drug.
Now consider the following:
zz What if the doctor is very junior and not familiar with that area or drugs used?
zz What if the doctor is very senior and makes untested assumptions about drugs available?
zz What if the organisation has failed to develop a robust drug policy that is fit for purpose?
zz What if the nurse is a bank nurse who does not normally work on this ward and is not familiar
with commonly used drugs?
zz What if this area is always short of staff so that other staff do not routinely attempt to get the
drug second checked?
The end result is that multiple defences have been weakened or removed and error is not only more
likely to occur, but, if it does, there is a greater chance that it will cause harm.
2.4 Improving team and individual performance
Raising awareness of clinical human factors and being able to practise these skills and behaviours
within multiprofessional teams allows the development of effective teams in all situations. Simulation
activity allows a team to explore these new ideas, practise them and develop them. To do this we
need feedback on our performance within a safe environment where no patient is at risk and egos
and personal interests can be set aside. Consider how you developed a clinical skill. It was something
that needed to be practised again and again until eventually it started to become automatic and
routine. The same applies for our non-technical behaviours. In addition, recognising our inherent
human limitations and the situations when errors are more likely to occur, will encourage us to aim
to be hypervigilant when required. It is important to remember that paying attention alone does
not guarantee improved awareness of a situation as attentional control is subconscious and
therefore beyond volitional control.
2.5 Communication
Poor communication is a leading cause of adverse events. This is not surprising; to have an effective
team there needs to be good communication. The leader needs to communicate with the followers,
and followers need to communicate with leaders and other followers. Communication is not just
saying something – it is ensuring that information is accurately passed on and received. There are
multiple components to effective communication (Table 2.1).
Table 2.1 Elements of communication
Sender Sender Transmitted Receiver Receiver

Thinks of what to Says Through air, over phone, via Hears it Thinks about it and
say message email acts
When communicating face-to-face, in an emergency setting, a message is often announced to a

room where nobody acknowledges it. Targeting our communications towards specified individuals
in what is sometimes referred to as ‘directed communication’ is now seen to be an essential element
in improving communication. Many emergency settings, where staff change frequently, have
people’s names prominently displayed to encourage this.
Information is also transmitted non-verbally and processed in different ways by different people
dependent on cultural, linguistic, neurodivergent and contextual variables. Communication can be
more difficult when talking across professional, cultural, specialty or hierarchal barriers as we do not
always talk the same technical language, have the same levels of understanding, or even have a full
awareness of the other person’s role.
There are a variety of tools to aid communication, such as SBAR (situation, background, assessment
and recommendation) which facilitates planning and organising a message, making it succinct
and focused. A good SBAR provides a handover in a logical and expected order. It is also an empow-
erment tool allowing the sender (who may be more junior) to request an action from a more senior
individual.
Effective communication with a feedback loop

Consider a busy clinical situation and the team leader shouts ‘We need an ECG connecting’
while looking at the blood pressure – what happens? The majority of times nothing – nobody
goes to connect the electrocardiogram (ECG) because responsibility for the task has been
diffused. The larger the group, the more likely it is that no-one will take responsibility for this
vaguely phrased request. So how can this be improved? Most obviously an individual can be
identified to perform the task, by name: ‘Michael can you please connect the ECG?’ If Michael
says ‘Yes’, effective communication might be assumed, but not always. What has Michael heard
and what will he do? At the moment we do not really know what message has been received.
Michael might dash over with the defibrillator as this is what he thought he heard. This may
seem a slightly strange thing to happen, but how often in a clinical emergency have you asked
for something and been presented with something else? People are less likely to ask questions
in emergencies as everyone is busy. This could be the catalyst for an error or precipitate a missed
task. So how do we f ind out what message Michael received? The easiest way is to include a
feedback loop in which we request that the other person let us know when they’ve completed
the task.
Now the conversation goes:
Team leader ‘Michael, can you please connect the ECG, and let me know when you’ve
done it?’
Michael ‘Okay’
Michael (later) ‘I have connected the ECG’
We now know that the message has been transmitted and received correctly. For this process to
work both parties (the sender and receiver) need to understand and expect it – again demonstrating
the need for us to practise and train together.
C H A PTE R 2 Getting it right: non-technical factors and communication 23
2.6 Team working, leadership and followership
At a basic level a team is a group of individuals with a common cause. Historically we have tended
to train individually or in professional silos; the risk here is that we are making a ‘team of experts’
rather than an ‘expert team’. Often within healthcare, our teams form at short notice and arrive at
different times. Emphasis tends to be placed on the significance of the role of the leader, but a
leader cannot be a team on their own. As much emphasis should be given to developing the other
team members, the active followers. A good leader will be able to swap from the role of leader to
follower as more senior staff arrive and agree to take over.
The leader
The leader’s role is multifaceted and includes directing the team, assigning tasks and assessing
performance, motivating and encouraging the team to work together, and planning and organising.
Additionally, a leader needs to maintain standards, support others and see where needs arise. All
leadership skills and behaviours need to be developed and practised. Constructive feedback on
efficacy of communication should both be given and sought in order to facilitate continuously
improving performance.
It is important to clearly identify who is leading. The leader may change as more people arrive in an
emergency situation. If there is a scribe recording events, they should record and update who is
leading at any time.
As soon as the leader becomes hands on, and task focused, they are primarily concentrating on the
task at hand. This becomes the focus of their thoughts and they lose situation awareness, their
objective overview of the situation. The leader should be standing in an optimal position where they
can gather all the information and ideally view the patient, the team members and the monitoring
and diagnostic equipment. This enables them to recognise when a member is struggling with a
task or procedure and support them appropriately.
Team roles
Ideally, the team should meet before the event and have the opportunity to introduce themselves
to each other and clarify roles and actions in emergencies. Sometimes this can be facilitated at
the beginning of a shift but at other times it is impossible to predict or arrange. It is important,
therefore, that individuals identify themselves to the leader as they arrive and roles are agreed,
allocated and understood. Much of the time their role may be determined purely in relation to the
specific bleep the individual carries, but it is important that team members are flexible, for
example if three airway providers are first on the scene we would expect other tasks to also be
allocated and undertaken.
Followership
Followers are expected to work within their scope of practice and take the initiative. They should be
attentive to the needs of the rest of the team and know where they fit within the bigger picture. It
is important to think about the level of communication required between the leader and followers.
If it is obvious that a team member is doing a task, this does not need to be communicated, but
there are times when it is important that followers signal if they have a problem or request the
leader’s attention.
Hierarchy
Within the team there needs to be a hierarchy. This is the power gradient; the leader is at the top of
this as the person coordinating, directing and making the decisions. However, this should not be
absolute. If the power gradient is too steep the leader’s decisions cannot be questioned and
the followers blindly follow the orders. This is not safe because leaders are humans too and also
make errors – their team is their safety net. Safe practice is achieved where the followers feel they
can raise concerns or question instructions. This must always be understood by the leaders as much
as by the followers. One way to reduce the hierarchy is for the leader to invite the team’s thoughts
and concerns, particularly around patient safety issues. It is also important for the follower to learn
how to raise concerns appropriately.
One method that is sometimes used to raise concerns appropriately is PACE (probing, alerting,
challenging or declaring an emergency).
Stage Level of concern

P Probe I think you need to know what is happening
A Alert I think something bad might happen
C Challenge I know something bad will happen
E Emergency I will not let it happen
These stages are described with examples below:

zz Probe – this is used where a person notices something they think might be a problem. They
verbalise the issue, often as a question. ‘Have you noticed that this child is cyanosed?’
zz Alert – the observer strengthens and directs their statement and suggests a course of action.
‘Dr Brown, I am concerned, the child is deeply cyanosed, should we start bag–valve–mask
ventilation?’
zz Challenge – the situation requires urgent attention. One of the key protagonists needs to be
directly engaged. If possible, the speaker places themself into the eye line of the person with
whom they wish to communicate. ‘Dr Brown, you must listen to me now, this child needs help
with their ventilation’
zz Emergency – this is used where all else has failed and/or the observer perceives a critical event
is about to occur. Where possible, a physical signal or physical barrier should be employed
together with clear verbalisation. ‘Dr Brown, you are overlooking this child’s respiratory state,
please move out of the way as I am going to ventilate them’
The PACE structure can be commenced at any appropriate level and escalated until a satisfactory
response is gained. If an adverse event is imminent then it may be relevant to start at the
declaring ‘emergency’ stage, whereas a much lower level of concern may well start at a ‘probing’
question.
An alternative approach that many healthcare settings are using is CUSS. It helps if standard phrases
are used because these can act as collective triggers.
C Concerned I am concerned
U Uncomfortable I am uncomfortable
S Safety issue This is unsafe
S Stop You need to stop
At each of these levels, which increase in assertiveness, the reasoning needs to be re-stated in a
clear, unambiguous way.
CH A PTE R 2 Getting it right: non-technical factors and communication 25
2.7 Situation awareness
A key element of good team working and leadership is to be conscious of what is happening; this is
termed situation awareness. It not only involves seeing what is happening, but also captures how
this is interpreted and understood, how decisions are made and, ultimately, planning ahead. We
can distinguish between individual situation awareness, shared situation awareness and team
situation awareness.
Consider Figure 2.2 which illustrates just how easy it is to misinterpret data:
Figure 2.2 Similar package design of two different medications
We see what we expect to see, and misperceiving is particularly likely to happen when we are over-
loaded, distracted or the mental demands on us are too high.
Distractions
Within healthcare, distractions become the norm to such an extent individuals are often not even
aware of them. The risk is that mistakes are made and information is missed. It is important to try to
challenge interruptions when doing critical tasks, and when they do occur restart the task from the
beginning, rather than from where it is considered the interruption occurred. Some organisations
have specific quiet areas for critical tasks such as prescribing. Whatever the local set up, the key is
to develop and maintain everyone’s awareness of how distraction greatly increases the chance of
error.
Decision making
To make a good decision a person needs to assess all aspects of a problem and ensure they have the
key information. Good situation awareness is a basic prerequisite for this process. The whole team
should be on the alert for ambiguities or conflicting information. Any inconsistent facts should be
treated as a potential marker for faulty situation awareness. They should never be brushed off as
unimportant anomalies in the absence of evidence to support such a decision.
Where there are no time pressures, the decision-making process should not be concluded until the
team is satisfied they have all the information and have considered all the options. Where time is a
pressure, a certain amount of pragmatism must be employed. There is plenty of evidence to confirm
that practise and experience can mitigate some of the negative effects of abbreviating a decision-
making process. Those making decisions under such circumstances need to remain aware of the
shortcuts they have taken. They should be ready to receive feedback from their team, particularly if
any member of the team has significant concerns about the proposed course of action.
Mental models
Our mental models are affected by our previous experiences but also by the information/briefing
that we received before the experience. A good pre-brief, where possible, will positively influence
how the team frame the situation and which mental models they draw on. Where a briefing is
accurate it is extremely helpful, where it is inaccurate, because it influences how we interpret
information, it can lead to error. We are more likely to fit what we see to what we expect to see and
therefore make inaccurate conclusions. Practising good briefings and handovers is time well spent.
There can be a number of reasons why we might fail to have accurate situation awareness.
zz Lack of or poor mental model
zz A tendency to seek confirming evidence and ignore disconfirming evidence
zz Overload on our working memory leading to forgetting vital information
We see what we expect to see
Team situation awareness

We gather information from the world around us using our five senses. Because there is too much
information constantly assaulting us, we selectively attend to only some of it based on our previous
experiences and on what jumps out at us at the time. Different people attend to different aspects
of a complex event, so individuals in a team will have a differing awareness of the situation.
The team’s situation awareness will often be greater than any one individual’s, therefore the
leader should actively encourage this sharing of perspectives
2.8 Improving team and individual performance

In addition to effective communication, team working, situation awareness, leadership and
followership skills, there are a number of other ways that team and individual performance can be
further developed and improved.
Awareness of situations when errors are more likely

If we are aware that errors are more likely we can be more proactive in detecting them. Two common
situations that make errors more likely are stress and fatigue. Stress is not only a source of error
when we are overworked and overstimulated, but also, at the other end of the spectrum, when we
are understimulated we become inattentive.
The acronym HALT has been used to describe situations when error is more likely:
H Hungry
A Angry
L Late
T Tired
C H A PTE R 2 Getting it right: non-technical factors and communication 27
IMSAFE has been used as a checklist in the aviation industry, asking whether the individual may be
affected by:
I Illness
M Medication
S Stress
A Alcohol
F Fatigue
E Emotion
Ideally, individuals who are potentially compromised need to be supported appropriately, allowed
time to recover and the team made aware. How this can be achieved in the middle of a night shift
can be problematic.
Awareness of error traps

A common trap that people fall into is only seeing or registering the information that fits in with
their current mental model. This is known as a confirmation bias. When this occurs people favour
information that confirms their preconceptions or hypotheses regardless of whether the information
is true. This may be observed within the healthcare setting during the process of a referral or
handover. An example of this might be a clinician receiving a phone call requesting them to attend
the ward to review an acutely deteriorating child. The clinician is advised that the patient is a known
asthmatic. On their way to the ward the clinician builds up a series of preconceived expectations
around what they will find upon their arrival. They may even formulate a management plan whilst
travelling to the scene, based upon their expectations. Once this mindset is established it can be
difficult to shift.
On arrival, the clinician examines the systems affected by the presumed diagnosis. They seek to
confirm their expectation by focusing on an auscultation of the chest at the expense of a thorough
assessment. Upon hearing bilateral wheeze their preconceived ideas are confirmed and the remain-
der of the assessment is completed without due attention and more as a rehearsed exercise than
an open-minded exploration. They fail to notice that the patient also has a soft stridor and is hypo-
tensive. In this case the eventual diagnosis of anaphylaxis becomes at best a very late consideration,
or at worst a situation that requires an objective newcomer to the team to point out the obvious.
Cognitive aids: checklists, guidelines and protocols

Well-constructed cognitive aids such as guidelines and algorithms are important because the
human memory is not infallible. They also confer team understanding through the use of a
standardised response. This reduces stress. This is especially true where an uncommon emergency
event occurs. The team may be unfamiliar with one another and each member will be trying to
remember what to do, what treatments are required and in what order. A good team leader will use
the available cognitive aids as a prompt and the team members can use them as a resource so that
they can plan ahead. Safe practice is promoted through the use of these tools in an emergency
rather than relying on memory.
Calling for help early

Trainee staff are often reluctant to call for senior help, partly due to not recognising the severity of
the situation and partly due to concerns about wasting the time of seniors. With all emergency
events, and in particular with paediatric emergencies, escalation and appropriate help should be
summoned as soon as possible. Remember, help will not arrive instantly, but it is helpful to state
when help is needed and to be clear about what that help should be.
Debriefing
Wherever possible a debriefing should be facilitated following clinical events, even if brief, as this
encourages us to normalise talking about difficult situations. A debrief immediately after an event
is described as a ‘hot’ debrief and it has the aim of ensuring psychological safety. There is a place for
this at the end of a shift or difficult emergency to ensure that staff are ok as they go home. The ‘hot’
debrief is not about learning points or establishing what happened. That can wait for the ‘cold’
debrief, days or even weeks after the event. This is usually facilitated by a trained individual with the
intention of learning from the event and providing pointers moving forwards.
2.9 Summary
In this chapter we have given a brief introduction to the clinical human factors that can lead to poor
team working, patient harm and adverse events. It is important for you to use every opportunity to
reflect and develop your own performance and influence the development of others and the team.
PART 2
The seriously ill child
29
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[445] This is all we are told by Ibn al Athîr. But there is
elsewhere a not unlikely tradition that the unhappy maiden,
tearing herself from her captor’s embrace, leapt from the camel,
and found in death an escape from her humiliation. This
campaign furnishes plentiful material for many still wilder stories
in the romances of the pseudo-Wâckidy and later writers.
[446] According to some authorities, Othmân presented the
royal share of the booty as a free gift to Merwân, and they add
that this was one of the grounds of Othmân’s impeachment. But it
reads like a party calumny.
[447] Coming there in disguise, he was recognised by a
woman, who gave the alarm, and the natives rushed upon the
boat. Asked how she recognised the Saracen captain, this
woman said, ‘He came as a merchantman; but when I asked an
alms of him, he gave as a prince giveth; so I knew it was the
captain of the Saracens.’
The payment of jazia, or poll-tax, implied the corresponding
claim of protection. Zimmy signifies one who, so assessed,
becomes part and parcel of the Moslem empire, and as such
entitled to its guardianship. The Cypriots were not expected, from
their position, to take any active part on the Moslem side; but they
were bound to give their new masters warning of any hostile
expedition, and generally to facilitate their naval operations.
As the great crowd of prisoners were being shipped, one of
the Moslem warriors wept; for, said he, ‘those captives will lead
the hearts of their masters astray’—one of the few occasions on
which we see a faint perception of the evils of female slavery to
the conquerors themselves; for that I take to be the meaning.
[448] According to Theophanes, it was Constans II., grandson
of Heraclius, who perished thus for his crimes, but at a later date.
See Gibbon, ch. xlviii.
[449] Some authorities make the discontent to arise in
consequence of the failure of Abu Sarh to follow up the victory,
and give chase to the retiring enemy.
[450] See Life of Mahomet, p. 235.
[451] Abbasside tales are multiplied against the unfortunate
Welîd. He consorted with the poet Abu Zobeid, a converted
Christian of the Beni Taghlib, and was suspected of drinking wine
in company with him. Another complaint was, that a conjuring Jew
from Baghdad having been condemned in Ibn Masûd’s court for
witchcraft, Jondob, one of the factious leaders, killed him with his
own hand instead of waiting the regular course of execution; for
which unlawful act Welîd imprisoned Jondob, to the great
discontent of the people. Hostile tradition, by deep colouring, has
improved on these tales, representing Welîd as a brutal sot and
sacrilegist. E.g. by his command, the Jew performed works of
magic in the sacred precincts of the Great Mosque, assumed by
sorcery the form of various animals, cut off a man’s head, and
then putting it on, brought him to life again, &c. Jondob,
scandalised at his devilish tricks, proceeded to cut off the Jew’s
head, saying, ‘If thou canst do miracles, then bring thyself to life
again.’ Upon this Welîd imprisoned Jondob, and would have put
him to death had he not, by the connivance of the jailor, escaped.
These tales are given by Masûdi and later writers, whose
tendency to vilify Welîd by the most extravagant fiction, is
manifest.
Of the same complexion are the traditions which represent the
citizens of Medîna as in such bodily fear of Othmân that no one
dared to carry out the sentence of scourging against Welîd; so
that Aly, at last, stepped forward, and himself inflicted the stripes.
Others say that Aly ordered his son, Hasan, to do so; but he
refused, saying, ‘The lord of the hot is lord also of the cold’ (i.e.
the sweets and the bitter of office must go together), and that then
Aly compelled a grandson of Abu Tâlib (Mahomet’s uncle) to carry
out the sentence.
[452] His name was Abdallah, but to distinguish him from the
multitude of that name, he is always called Ibn Aámir.
[453] The youth, however, was not satisfied with this pair of
wives; for he left twenty sons, and as many daughters, behind
him. He was nephew of that Khâlid ibn Saîd who opened the
Syrian campaign so ingloriously.
[454] On the text of the Corân, and the history of this
recension, see the Excursus on the ‘Sources for the Biography of
Mahomet,’ in the Life of Mahomet. The manner in which the
Abbasside faction perverted the facts and turned the charge to
malignant purpose against the Omeyyad house, will be
understood from the section on the Corân in the Apology of Al
Kindy (Smith and Elder, 1882), pp. 25 et seq. The charge against
Al Hajjâj of having altered the text is equally groundless. See Ibid.
p. xi.
[455] The precise nature of the arrangement, as stated by Ibn
al Athîr, is not very clear, but its general character seems to have
been as given the text.
[456] Masûdy, an unprejudiced witness, dwells on this as one
of the causes of demoralisation and disloyalty now setting in so
rapidly, and he gives some remarkable instances. Zobeir had
1,000 slaves, male and female, and 1,000 horses. At all the great
cities he had palaces, and the one at Bussorah was still to be
seen in the fourth century. His landed estate in Irâc was rated at
1,000 golden pieces a day. Abd al Rahmân had 1,000 camels,
10,000 sheep, and 100 horses, and he left property valued at
between three and four hundred thousand dinars. Zeid left gold
and silver in great ingots, and had land valued at 10,000 dinars.
The Coreishite nobles built themselves grand palaces in
Mecca and Medîna, and in their environs such as Jorf and Ackîck.
Othmân himself had a splendid palace at Medîna, with marble
pillars, walls of costly stucco, grand gates and gardens; he is also
said to have amassed vast treasures, though we are not told what
came of them after his overthrow.
Masûdy contrasts painfully all this luxury at home and abroad
with the frugal severity that prevailed even in the Caliphate of
Omar, who grudged to spend sixteen dinars on the pilgrimage to
Mecca.
[457] Quoting from the Corân (Sura ix. 36), where these words
are applied to Christian priests and monks; but Abu Dzarr gives
them here a more general application. See Life of Mahomet, p.
470; and Sprenger’s Leben des Mohammeds, vol. ii. p. cvi.
[458] Attempts are made by Abbasside tradition to show that
Abu Dzarr was driven into opposition by the tyranny of Muâvia’s
rule in Syria, and by divers ungodly practices at Medîna, which he
denounced as certain to bring down judgment on the city. But Ibn
al Athîr justly doubts this, and distinctly says that his preaching
tended to excite the poor against the rich. Abu Dzarr’s doctrines
were based on the equality of all believers; and the danger lay in
their popularity with the socialistic faction which decried the
pretensions of the Coreish. Before Muâvia, he reasoned thus:
‘Riches, ye say, are the Lord’s; and thereby ye frustrate the
people’s right therein; for the Lord hath given them to his people.’
‘Out upon thee!’ replied Muâvia; ‘what is this but a quibble of
words? Are we not all of us the Lord’s people, and the riches
belong unto the same?’ Tradition dwells on the poverty of Abu
Dzarr’s life at Rabadza to add point to Othmân’s unkind
treatment. The Beni Ghifâr, his tribe, are said to have resented his
ill-treatment by joining the insurgents when they appeared.
[459] On this subject historians say very little; and it is chiefly
from incidental notices in fragments of early poetry that Von
Kremer has so ably traced the inroads of profligacy and the
practice of forbidden pastimes—music, wine, and gambling. The
brief notice of Ibn al Athîr on this matter is as follows: ‘The
prevalence of a worldly spirit first showed itself at Medîna in the
flying of doves and shooting with pellets (with a gaming aim); and
in the eighth year of his Caliphate Othmân appointed an officer to
stop the same, who clipped the birds’ wings, and broke the cross-
bows.’ A citizen was rebuked by the Caliph for playing at
‘oranges’ (apparently some game of chance); and he thereupon
got angry and joined the hostile party. The anti-Omeyyad
tendency of the tradition on this subject is evident from Welîd (the
drunkard) being named as the person employed by the Caliph to
administer the rebuke.
[460] As enlarged by Othmân, the Mosque was 160 cubits
long, and 150 broad. As in Omar’s time, it had six gates for
entrance.
[461] Othmân defended his innovations as based on the
practice of the pilgrims from Yemen, who recited additional
prayers on behalf of their distant homes; and he too (he said) had
a property at Tâyif, as well as at Mecca. The matter seems at first
sight altogether insignificant. But in an established ritual, the
smaller the change, the greater oftentimes the scandal and
indignation, as we need not go far to see. And although no point
of doctrine was apparently involved, yet the practice of the
Prophet had come to be regarded as an obligatory precedent in
the commonest matters of daily life.
[462] For Abu Hodzeifa, see Life of Mahomet, p. 65. He left his
infant son to be brought up by Othmân, who faithfully discharged
the trust. When he grew up he asked for a government or military
command, but was told that he was not yet fit for it, and must
prove his capacity in the wars of Egypt and Africa. He never
forgot the slight, and was active in the insurgent ranks. Various
other examples are given of personal enmity, such as citizens
alienated by the reprimand for gaming, a chief imprisoned for the
ill-treatment of a Christian tribe, whose favourite hound he had
killed, and so on.
[463] The well was at the distance of two miles from the city.
Another well, called Rûma, was bought by Othmân, during the
Prophet’s lifetime, from the Jews for the use of the Moslems. He
first purchased the half title, the well being used day about by
either party; but on their alternate days the Mussulmans emptied
the well of enough water to last them two days. Whereupon the
Jewish owner insisted on Othmân’s purchasing the entire right,
which he did; and Mahomet promised him a fountain in Paradise
for the same.
[464] For traditions regarding Mahomet’s ring, see Life of
Mahomet, pp. 544 and 596. The despatches sent by him to the
several kings in the eighth year of the Hegira were attested by it.
The most received account is that the legend on it was ‘Mahomet,
Prophet of God’ (Mohammed Rasûl Allah, in three lines,
beginning from the bottom). It was used for all documents
requiring a seal, by Mahomet and his successors. The new ring
disappeared at the time of Othmân’s assassination, and, like the
original, was never seen again.
[465] One of the four wives who survived him was Omm al
Banîn, daughter of the famous freebooter, Oyeina. Othmân had
thirteen children, and (so far as we read) no issue by slave-girls,
which, looking to the habits of the time, is somewhat remarkable.
[466] The name of this demagogue was Abdallah ibn Saba,
but he was usually called Ibn Sauda, and was supposed to come
from Yemen. It is notable that this first sect of Alyites (if it can be
so called) was founded by a Jewish convert. What led him (if the
story of his teaching be not altogether a proleptic fiction of
tradition) to magnify Aly, who had hitherto put forth no claim, nor
indeed at any time dreamed of the extravagant pretensions in
store for him after his death, it is difficult to understand. Nor did
these transcendental notions regarding Aly gain any ground
whatever till a much later period. Ibn Sauda had evidently imbibed
some extreme notions on the dignity of prophets. ‘Strange,’ he is
reported to have said;—‘strange that men should believe in the
second coming of the Messiah, and not in that of Mahomet.’ The
idea, we are told, was inspired by the verse in Sura xxviii. v. 84,
‘Verily, he who hath given thee the Corân will surely bring thee
back again;’ which, of course, referred only to Mahomet’s
returning again to Mecca. Indeed, the whole account of this man’s
teaching is obscure and uncertain; and the Alyite notices of it may
be altogether anticipatory and unreal.
[467] The youth and his father belonged to the Beni Asad. On
hearing of the riot, Toleiha (the quondam prophet), chief of that
tribe, hastened with a body of his men to the palace for their
rescue; but found that both had escaped half dead.
Another version is, that on Saîd’s giving expression to the
sentiment about ‘the Sawâd being the Garden of the Coreish,’ the
whole company sprang to their feet and shouted excitedly: ‘Nay,
but the Lord hath given the Sawâd to us and to our swords.’ On
this, the captain of the body-guard retorted angrily at their rude
reception of his master’s words; whereupon they set upon him
and left him half dead. The inflammable material was all around,
and wanted only the spark to explode. This unfortunate speech
about ‘the Garden of the Coreish’ was in the mouths of the
disaffected all through the insurrection.
[468] The chief amongst them was Mâlik al Ashtar, of whom
we shall hear more as the most sanguinary amongst the traitors;
Zeid ibn Sohan; Jondob (already noticed); Orwa; and Thâbit ibn
Cays. Yezîd, a brother of the last, another chief leader of sedition,
was not sent. Muâvia wrote to Othmân that they were an ignorant
crew, bent on sedition, and on getting possession of the property
of the Zimmies, that is of the subject races, whose rights of
occupancy had been recognised as the hereditary tenants of the
Sawâd—a policy, as we have seen, firmly upheld by Omar
throughout Chaldæa, and which it was one object of the
malcontents to upset. According to one account, the exiles were
sent back by Muâvia, after expressing penitence, at once to Kûfa
—where, however, resuming their factious courses, Othmân, as a
last resource, despatched them again to Syria, this time to
Abdallah, Khâlid’s son, at Hims. Muâvia is throughout represented
as upholding the claims of the Coreish against the Arab faction,
showing thus the real aim of the ringleaders.
A story is told that the exiles, enraged at the menaces of
Muâvia, leaped upon him and seized him by the beard;
whereupon, shaking them off, he warned them that they knew
little of the loyal spirit of the Syrians, who, if they only saw what
they were doing, would be so enraged that it would be out of his
power to save their lives.
[469] Only two or three names are given of those who kept
aloof from seditious action: as Zeid ibn Thâbit (the collector of the
Corân); Hassân, the poet, his brother; Káb ibn Mâlik, and Abu
Oseid—all natives of Medîna; so that the whole body of Refugees
(the Coreish), excepting Othmân’s immediate kinsmen, must have
joined the treasonable faction.
[470] No doubt Aly spoke the truth. Yet Othmân’s weakness
towards the seditious populace was a far greater peril than his
tender treatment of his governors.
[471] I have given all this as I find it in tradition, but not without
some misgiving; especially of the part about Merwân, whom, as
the evil genius of Othmân, the Abbasside writers are never weary
of abusing.
[472] Amru, who had become a petulant malcontent ever
since his deposition, is represented as speaking contumeliously
of Othmân to his very face; and Othmân is represented as
returning it in kind, calling him ‘a louse in his garments.’ On one
occasion the Caliph is said to have addressed the people,
‘leaning on the staff of Mahomet’ (a venerable relic that had
descended from the Prophet to Abu Bekr and Omar), when an
Arab seized and broke it over Othmân’s head. Such stories,
however much they may be tinged with Abbasside exaggeration
and prejudice, point to the fact that Othmân was falling rapidly in
popular esteem.
[473] The four were Mohammed ibn Maslama, often employed
by Omar, as he had been by Mahomet himself, on confidential
missions; Osâma ibn Zeid, commander of the Syrian expedition at
Mahomet’s death; Abdallah, son of Omar; and Ammâr, whose
injudicious appointment by Omar to the governorship of Kûfa
appears to have turned his head, for he fell into the conspirators’
toils.
[474] We have abundance of conversations professing to have
passed between Othmân and his advisers; but they have no
further authority than as they represent the sentiments
conventionally attributed to the several speakers. As, however, it
may give point to the crisis now rapidly approaching, I subjoin the
following epitome of the most received account:—
Othmân: ‘Alas, alas! what is all this I hear of you, my deputies
and governors? I greatly fear that the complaints may be true;
and it is upon me the burden falleth.’ They replied that the Caliph
had sent his own men out to see, and they had found nothing
wrong. Then he asked what they advised him to do. Sád (ex-
governor of Kûfa) would have the traitors, who were burrowing in
the dark, unearthed and slain; then sedition would subside.
Muâvia: ‘In Syria there is no disaffection, and it would be
everywhere the same were the people fairly and firmly dealt with.’
Abu Sarh proposed to work through the Dewân, increasing or
diminishing stipends by way of reward and punishment. Ibn Aámir
advised to engage the restless spirits in war, and so the crisis
would pass over. Amru, embittered by his supersession in Egypt,
is represented as addressing Othmân in coarse abuse. Othmân
replied despondingly:—‘Cruel measures he would not sanction. If
rebellion was to come, no one should, at the least, have that to
say against him. The millstone would grind round and round to
the bitter end. Good had it been, if before it began to revolve, he
had been taken to his rest. There was nought left for him but to be
quiet and to see that no wrong was done to anyone.’ So he gave
the governors leave to depart, saying only that if fresh campaigns
were set on foot, he would approve of that; otherwise he would
hold on his way.
As they took their leave, Káb, the Jewish convert, said, ‘It will
be the grey mule that wins,’ meaning Muâvia, who overheard the
saying and from that moment (so the tradition runs) kept the
Caliphate in view.
Another scene is represented, in which Othmân, surrounded
by his own advisers, sends for Aly, Zobeir, and Talha. Muâvia
pleaded before them the cause of the aged Caliph, and warned
them of the danger they ran to their own selves in allowing any
attack calculated to abate the sacredness of the Caliph’s person;
it was, he said, both their duty and their interest to support him in
his feeble old age. On this, Aly reproached Muâvia as the son of
Hind, the ‘chewer of Hamza’s liver.’ ‘Let alone my mother,’ he
responded angrily; ‘she became a good believer, and after that
was not a whit behind thine own.’ Othmân interposed: ‘My cousin
Muâvia doth speak the truth. Now tell me wherein I have gone
astray, and I will amend my ways. It may be that I have been too
open-handed towards my kinsmen. Take back that which they
have received.’ So Abu Sarh disgorged 50,000 dirhems; and
Merwân 15,000, and they all departed for the moment satisfied.
But all these accounts must be received with suspicion. In the
midst of such violent factions as were springing up, the marvel is
that tradition has preserved so consistent a narrative as we have.
[475] Adapting the words from Sura xxxix. v. 39.
[476] For the Lesser Pilgrimage, or Omra, see Life of
Mahomet, p. xii. It may be performed in any month of the year, but
preferably in Rajab (three months earlier than the commonly
received date of the attack, which I have followed); and some
traditions accordingly give this as the date of the advance upon
Medîna. That, however, would make the interval (from January to
May) too long for the intervening events, which were hurried
through within the period of a couple of months, if so long.
[477] See above, p. 313.
[478] The men of Kûfa pitched at Al Awas; the Bussorah party
at Dzu Khashab; the Egyptians at Dzu Marwa—all places in the
close neighbourhood of the city.
[479] They marched off, we are told, expecting that the
citizens would break up their armed gathering as soon as they
were gone, and concerting to return again each from their
separate road.
[480] The history of the document is obscure. On the one
hand, it certainly was sealed with the Caliph’s signet; but who
affixed the seal, and whether it was surreptitiously obtained,
cannot be told. Nobody alleges Othmân’s complicity. Most
traditions attribute the writing and sealing of the order to Merwân,
the Caliph’s unpopular cousin, who, throughout the narrative,
receives constant abuse as the author of Othmân’s troubles; but
all this is manifestly tinged by Abbasside and anti-Omeyyad
prejudice. Aly’s objection of collusion between the three insurgent
bodies appears unanswerable. There must have been some
preconcerted scheme as to the simultaneous return of the three
camps; and there is a strong presumption of something unfair as
regards the document also. Amidst conflicting evidence, it is
beyond the historian’s power to offer any conclusive explanation.
It is, of course, possible that Merwân may have taken upon
himself the issue and despatch of the rescript; and, indeed, there
was not wanting ground for his venturing on such a course (and
something perhaps also to be said for his doing it unknown to
Othmân), excepting only the deception of the insurgents by false
promises. The insurgents may also have got scent of the
document before they started ostensibly with the purpose of
returning home. But these are all mere assumptions.
The Persian version of Tabari has a different story, namely,
that the Egyptian band, on seizing the document, turned their
faces back again towards Medîna, despatching at the same time
messengers to apprise the Kûfa and Bussorah bands of Othmân’s
treachery, and to recall them, so that all should reach Medîna and
join in the attack together. Neither Ibn al Athîr nor Ibn Khallicân
have anything to this effect, and it is hardly consistent with Aly’s
speech, noticed above. The Arabic original of Tabari, now being
published, may possibly throw further light on this chapter.
[481] Mohammed ibn Maslama, a Companion (as we have
seen) highly trusted both by Mahomet and his successors; and
Zeid ibn Thâbit, the collector of the Corân, tried to speak in
confirmation of what Othmân had said, but were violently silenced
and abused by the rebels Hakam ibn Jabala and Mohammed ibn
Coteira.
[482] There are traditions, but of an entirely Abbasside stamp,
of other interviews between Aly and the Caliph, with repeated
promises of the latter to amend; Aly recriminating that these
promises were no sooner made, even from the pulpit and before
the congregation, than under the baneful influence of Merwân
they were broken. Even Nâila, his wife, is represented as blaming
her weak-minded husband for his fickleness. But were all this
true, it would go but a little way to relieve Aly, Zobeir, and Talha
from the charge of desertion, or, worse, of treasonable collusion
with rebels against the rightful monarch—a short-sighted policy
even in their own interest.
[483] He is called Al Ghâficky, the ‘Ameer,’ or Commander of
the insurgents.
[484] According to some traditions, we are told, that Othmân
prevailed on Aly to procure for him a three days’ truce, under the
pretence of issuing orders to the governors for a reform of the
administration; and that he treacherously employed the time
instead in strengthening the defences, and excused himself by
saying that the time was too short to carry out the promised
reforms. But the story is altogether of the Abbasside type.
[485] The authorities are conflicting as to the length of the
siege, though the several stages of the attack and investment are
sufficiently well defined. After the first uproar Othmân still
presided at the daily prayers for thirty days, after which he was
besieged for forty days—that is ten weeks in all. Another tradition
is that after the blockade had lasted eight and forty days, tidings
of coming succour reached the city, and then the investment
became severe. But this would leave too long an interval—
namely, three weeks—between the report of help being on its way
and the final issue, before which the columns, hurrying from Syria
and Bussorah, should have had ample time to arrive at Medîna.
The Syrian column, we are told, reached as far as Wâdy al Cora,
and that from Bussorah as far as Rabadza, when they heard that
all was over, and accordingly turned back.
[486] The talk among the courtiers of Al Mâmûn, in the third
century, as reflected in the Apology of Al Kindy, was that Aly, even
at a much earlier period, contemplated the putting of Othmân to
death (Apology, p. 25). There seems to be no proof or
presumption of this; but anyhow, one cannot but feel indignant at
the attitude of Aly, who would do so much and no more; who sent
his son to join the Caliph’s guard at the palace gate, and was
scandalised at his being denied water to drink; and yet would not
so much as raise a finger to save his life.
We have also traditions in which Othmân is represented as
reproaching Talha for encouraging the insurgents to a more strict
enforcement of the blockade; but, whatever his demerits in
deserting the Caliph, this seems incredible. The ordinary account
is that Talha as well as Zobeir, on hearing of the rebel excesses,
kept to his house; others, again, say that they both quitted
Medîna.
Omm Habîba, as daughter of Abu Sofiân, naturally
sympathised with Othmân. Hantzala, one of the citizens of Kûfa
who had accompanied the insurgents, was so indignant at their
treatment of one of ‘the Mothers of the Faithful,’ that he went off to
his home, and there gave vent to his feelings in verses expressive
of his horror at the scenes his comrades were enacting at
Medîna.
One day, we are told, Othmân, goaded by the thirst of himself
and his household, ascended the roof, and cried aloud: ‘Ye men!
know ye that I bought the well Rûma, and furnished it with gear
that the Moslems might quench their thirst thereat? and now ye
will not let me have one drop to quench my thirst. Moreover, I
builded you such and such a mosque; and now ye hinder me from
going forth to say my prayers in the Great Mosque.’ And so on,
contrasting the various benefits he had conferred upon them, and
the kind and loving words the Prophet used to address to him,
with the cruel treatment he was now receiving; whereat the hearts
of all were softened, and the word was passed round to hold back
from pressing the attack. But Ashtar, the rebel, said, ‘He is but
playing with you and practising deceit,’ and so he resumed the
attack. There are many such traditions, but they seem to possess
little authority.
[487] The pilgrims, in order to reach Mecca in time for the
pilgrimage (beginning on the 8th of Dzul Hijj, June 7), must have
left Medîna a week or ten days previously; that is, some three
weeks before the final attack on the palace.
[488] The one killed was Moghîra, a Thackîfite from Tâyif. He
was a confederate of the Beni Zohra, the same who had
persuaded that clan to retire from the Coreishite army when it
marched forth to attack Mahomet at Bedr (Life of Mahomet, p.
228).
Merwân received a sword-cut, which severed one of the
tendons of the neck, and left him, when he recovered, with his
neck stiff and shortened. The rebels were about to despatch him
when his foster-mother cried out: ‘Do ye seek to kill him? he is
dead already; if ye would sport with and mutilate his body, that
were inhuman and unlawful.’ So they left him. In after days, when
Merwân came to power, he showed his gratitude to this woman
by giving her son a command.
[489] The blood, we are told, flowed down the leaves just
touching these words: ‘If they rebel, surely they are schismatics;
thy Lord will swiftly avenge you.’ (Sura ii. v. 138.) The
appropriateness of the text, however, may of itself have
suggested the story.
When the insurgents first rushed in, he was at the moment
reading the appropriate passage in Sura iii. v. 174. Referring to
the battle of Ohod, and the danger in which Medîna was then
placed, the disaffected citizens are there represented as taunting
Mahomet and his followers in these words: ‘Verily, the men (of
Mecca) have gathered forces against you; wherefore, be afraid of
the same. But (the taunt) only increased their faith, and they said:
The Lord sufficeth for us; He is the best Protector.’ This was a
favourite text of Othmân’s, and he may perhaps have turned to it
for comfort now that vain was the help of man.
[490] The actual murderers were Al Ghâficky, the leader, and
Sudân, who was himself killed. Kinâna ibn Bishr is also named.
All these belonged to the Egyptian band, which seems to have
contained the most rabid of the insurgents. Amr ibn al Hamac
leapt upon the body, hardly yet breathless, and inflicted nine
wounds—‘three for the Lord’s cause, and six to satisfy his own
passion.’
[491] These two were among the chief men ‘whose hearts
were gained over’ by largesses from the booty after the battle of
Honein.—Life of Mahomet, p. 436. Hakîm is frequently mentioned
in the Prophet’s biography. It was Hakîm who carried supplies to
his aunt Khadîja when shut up with Mahomet in the Sheb.—Life,
p. 100.
It is said that a party of the citizens of Medîna made an
attempt to stop the funeral, but desisted on seeing that a tumult
would arise. We are also told that Aly himself, on hearing of the
design to molest the procession and cast stones at the mourners,
did his best to prevent it. Indeed, Abbasside tradition abounds
with attempts to rescue the memory of Aly from the obloquy
attaching to the heartless part he had been acting. For example,
Masûdy gives us a tradition that when Aly heard that all was over
he hastened to the palace and asked his son how it had
happened—as though he could not for many days have foreseen
the fatal termination to which the blockade was tending!
[492] The field was called Hashh Kaukab—the Garden of the
Star.
[493] My impression, on the whole, is that it was an
afterthought. The narrative of those who side with Talha and
Zobeir is as follows: After Othmân’s death the city was for some
days in the hands of the insurgents. No one ventured to accept
the Caliphate. Sád and Zobeir had already quitted the city; and all
the members of the Omeyya clan who were able had effected
their escape to Mecca. The rebels themselves were at their wits’
ends: ‘If we quit Medîna,’ they said, ‘and no Caliph is appointed,
anarchy will burst forth everywhere. It appertaineth unto you
(addressing the men of Medîna) to appoint a Caliph. Wherefore
look ye out a man for the throne, and make him Caliph. We give
you one day’s grace for the same. If ye choose him, well; but if
not, then we shall slay Aly, Zobeir, and Talha, as well as a great
number of you.’ Alarmed at these threats, the leading citizens
repaired to Aly, who, at first, bade them seek another; but they
constrained him; and, as a last resource, to rid them of the
insurgents, he consented. Then they drew Zobeir (who, by this
time, had returned) and Talha to the Mosque, and forced them, at
the point of the sword, to swear.
It seems certain that the rebels of Kûfa and Bussorah were in
favour respectively of Zobeir and Talha; but that they were
induced to accept Aly, either through fear (as the partisans of the
two pretenders hold) of the Egyptian regicides, or because the
citizens made choice of Aly.
[494] Thus Sád, the conqueror of Irâc, refused to swear till all
else had done so; whereupon, Ashtar, head of the conspirators
from Kûfa, threatened to behead him; but Aly said, ‘Leave him
alone; I will be surety for him.’ Moghîra, also, and a company of
the late Caliph’s adherents, declined to swear, and were left
unmolested. Amongst them was Hassân, the poet, and his
brother Zeid (collector of the Corân), whom Othmân had
appointed Chancellor of the Exchequer. Of the latter, it is said that
when Othmân was first attacked, he cried to his fellow-citizens,
‘Ye men of Medîna, be ye Ansârs (Helpers) of the Lord for the
second time, even as ye were Ansârs of His Prophet at the first.’
But Abu Ayûb, another of the citizens, made answer and said,
‘Verily, he shall get no help from us. Let the multitude of his train-
band slaves be his Ansârs!’
[495] This servile population (Sabâya or ‘captives’) had been
pouring for years in a continuous stream, during the campaigns,
into Medîna. They were employed as domestic servants, warders,
body-guards, &c. Some followed trades, in quasi-freedom, paying
the profits to their masters. They mostly embraced the Moslem
faith because of the privileges it conferred. On the outbreak they
became insubordinate, and broke away into a defiant attitude.
This would occur the more readily as they formed the guards of
the treasury and mansions of the great men; and, being the only
trained force at Medîna, no doubt themselves felt their power. We
find them similarly taking part in the outbreak at Bussorah. Like
the Janissaries or Memlûk of later days, they were a petulant
brood. Immediately on homage being done to Aly, they are said to
have lampooned him in minatory verses, to which Aly (not to be
outdone by the poetry even of slaves) replied in extempore
couplets. Proclamation was made that slaves not returning to
their masters would be treated as outlaws, but it had no effect.
[496] The tradition runs that Moghîra, at the first, gave sound
and sincere advice to this effect; but that, finding Aly obstinately
opposed to it, he returned next day, saying that, on reflection, he
had changed his mind. When Ibn Abbâs came, Aly told him that
Moghîra had, at the first, attempted to deceive him, but on the
second day had spoken true, and advised him to put in his own
men. ‘Not so,’ said Ibn Abbâs; ‘just the reverse. It was the truth
which he spake at the first; the last was not his true opinion.’ And
so it turned out; for Moghîra, finding his advice disregarded,
departed to join the malcontents at Mecca
[497] Life of Mahomet, pp. 324 and 527.
[498] I have given this conference fully, because, in substance
at least, it shows the impracticable bent of Aly’s mind which
quickly drew on the civil war. It is also not unlikely in itself. The
purport of such a conversation would become known; and,
moreover, besides this and one or two other uncertain
conversations, we have little or nothing to explain the early events
of Aly’s Caliphate, and the motives which actuated him.
[499] Amru, it is said, pressed this course upon Muâvia,
saying, in his proverbial style, ‘Show the dam her foal, it will stir
her bowels.’
[500] The officers appointed were his cousin Abdallah ibn
Abbâs, a faithful adherent, and his brother Cutham; Omar, son of
Abu Salma (half-brother of Omm Salma, the Prophet’s widow);
Abu Leila, nephew of Abu Obeida; Aly’s own son Mohammed,
son of his Hanifite wife, &c.
[501] For this passage in the Prophet’s life see Life of
Mahomet, pp. 311 et seq.
[502] We are treading now on specially factious ground, and
have to weigh with care the bias of tradition which represents
Ayesha as suddenly converted from a deadly enemy of Othmân
into the champion of his memory. Thus, when, on receiving the
tidings of the murder on the way back from Mecca, she declared
that she would avenge his death: ‘What!’ cried her informant,
startled by her zeal; ‘is this thy speech now, whilst but yesterday
thou wast foremost to press the attack upon him as an apostate?’
‘Yea,’ she replied; ‘but even now he repented him of that which
they laid to his charge, and yet after that they slew him.’ In reply,
her informant recited these verses: ‘Thou wast the first to foment
the discontent. Thou commandedst us to slay the prince for his
apostasy, and now, &c.’ How far this has been invented (possibly
as a foil to Aly’s equally strange and inconsistent conduct), or
whether the inconsistency in Ayesha’s conduct was really as
strange as here represented, it is difficult to say. Anyhow, it must
be admitted that Ayesha was a jealous, violent, intriguing woman,
a character that may well account for much that would otherwise
appear strange.
[503] This famous camel is an object of special interest to
tradition. Some say it was bought for Ayesha in Yemen; others,
that it belonged to the Orni guide who piloted the expedition; and
that, in addition to a large sum for his services, he got the camel
purchased for Ayesha in exchange for his own.
[504] The women of Mecca accompanied Ayesha as far as
Dzât Ire. Some of Mahomet’s widows may have been at Mecca
just then for the pilgrimage, and, in the present troubled state of
Medîna, they may have preferred to stay on there. Perhaps some
of them may have settled permanently in the Holy City, On the
other hand, we know from a previous notice that Omm Habîba, at
any rate, still resided at Medîna.
[505] Saîd inquired of Talha and Zobeir which of them was to
be the Caliph. ‘Whichever,’ was the answer, ‘the people may
choose.’ ‘But,’ replied Saîd, ‘if ye go forth as the avengers of the
blood of Othmân, then the succession should of right devolve
upon his sons,’ two of whom were with the rebel force. ‘That,’ they
answered, ‘it will be for the chief men of Medîna eventually to
settle amongst them.’
[506] Meaning Talha and Zobeir themselves, and intimating
that these had had as much hand in fomenting the insurrection,
and were as responsible for its fatal result, as anybody else.
[507] Omm al Fadhl.
[508] The incident is adduced to show the alarm of Aly. He had
sent for Abdallah, Omar’s son, who declined to pledge himself to
join the army against the rebels of Bussorah till he saw what the
other citizens of Medîna did. On this he prepared to leave for
Mecca, assuring his stepmother (Aly’s daughter) that he meant to
keep aloof from the rebels, which he did.
[509] This column, which was got up in haste and with
difficulty (for there was no enthusiasm at any time for Aly), was
composed chiefly of men belonging to Kûfa and Bussorah in Aly’s
interest. What these were doing then at Medîna does not appear.
[510] The commander of the first campaign after Mahomet’s
death.
[511] Only one man of the band from Bussorah that attacked
Othmân, the warrior Horcûs, escaped, at the intercession of the
Beni Sád.
[512] Abu Mûsa, Governor of Kûfa, abused Ammâr, the envoy
of Aly, as a murderer. When urged by Hasan (whom on his arrival
he embraced affectionately) to support his father in putting down
the dissension that rent the people, Abu Mûsa replied that he had
heard the Prophet say that ‘in the event of sedition, walking was
better than riding, standing better than walking, and sitting better
than either.’ He exhorted the citizens, therefore, to adopt this
maxim, and, following the example of the Coreish, to sit still at
home;—‘if they studied their eternal interests, they would do this;
if only their temporal interests, they would go forth and fight.’ A
tumult arose; the palace was sacked, and he was deposed.
Hasan, spite of his want of ambition, must have managed the
business well, especially after the failure of the previous
deputations, which consisted of such able men as Mohammed,
son of Abu Bekr, the sons of Abbâs and Jafar, and Ashtar the
arch-regicide.
The spiritless rôle assigned by tradition to Hasan is illustrated
by a conversation which passed between him and his father at
Dzu Câr. Hasan: ‘Thou hast ever neglected my advice, my father,
and now thou wilt be deserted all round, and slain.’ Aly: ‘And thou
never ceasest whining like a girl. What advice of thine have I not
followed?’ Hasan replied that his father should have quitted
Medîna before Othmân was slain; after the murder, he should not
have accepted the Caliphate till the provinces had agreed in his
nomination; and now that Talha and Zobeir had risen up, he
should have stayed at home, and let them take the first offensive
step. To the first point Aly answered that at the time he was
himself besieged, and could not, even if he had so wished,
escape from Medîna; that he had been regularly elected, and
would fight it out to the end; that as for staying at home, he would
have been like a hyæna, baited by enemies on all sides; and that
if he did not look after his own interests, he saw no one else who
would do so for him. The conversation may be fictitious, but it
entirely accords with Hasan’s poor and unaspiring character.
[513] Mohammed son of Abu Bekr, the regicide, was with Aly
during the impending battle, which would seem to show that all
those concerned in the insurrection against Othmân were not kept
back. Possibly the order applied only to the Bedouins from Kûfa
that were so concerned.
[514] Among other things, Aly said to Zobeir: ‘Dost thou
remember the day when we both were with the Prophet among
the Beni Ghanam; and he looked on me and smiled, and I smiled
in return; and thou saidst to him, “Do not allow the son of Abu
Tâlib to vapour thus;” and he answered, “It is no vapouring to
quarrel about; thou doest him an injustice”?’ And Zobeir was
touched.
The attitude of Talha and Zobeir is variously represented.
They both appear to have assented to Aly’s proposals; and
(notwithstanding Talha’s speech about compulsory swearing of
allegiance) to have continued peaceful negotiations.
On the other hand, Abdallah son of Zobeir manifests the same
ambitious spirit which led him many years afterwards into
rebellion, and at one time nearly gained for him the Caliphate. He
is represented as now taunting his father with faint-heartedness in
swearing to Aly that he would not fight; and even persuading him
to release himself from the oath by the legal substitution of freeing
a slave.
Again, it is said that Zobeir was staggered when he heard that
Ammâr was in the field against him, in consequence of
Mahomet’s having once said that Ammâr would be slain by an
ungodly host (a matter of which we shall hear more below). The
general tenor of tradition is, that, from whatever cause, he retired,
without fighting, into the neighbouring valley, and there met his
death.
It is very difficult to weave a narrative at once faithful and
consistent out of all this. The conversations of the rebel leaders
with Aly must have been to a great extent conjectural; and the
surprise of both armies no doubt adds to the confusion of the
narrative as given by our authorities. The general outline,
however, is established.
[515] The Eastern traveller will recognise and appreciate the
illustration.
[516] This camel is a prominent subject in tradition, as we
might expect from its having given its name to the battle, and
many tales of heroism are told both in its attacks and defence.
One says he never heard anything so fearful as the scream it
gave when hamstrung.
[517] The numbers may be exaggerated; but the loss of life
was, no doubt, immense, and it is evidence of the terrible fury
with which the battle was fought. Of one tribe, the Beni Dhabba,
alone, 1,000 men are said to have been slain. The strong partisan
feelings both of Bedouin against Coreish, and of the opposing
families of Hâshim and Omeyya, long pent up, tended to give
bitterness to the conflict; and there was in addition the new cry of
vengeance for the blood of Othmân.
[518] So carefully were Aly’s orders against plundering
observed, that whatever was found on the field, or in the
insurgent camp, was gathered together in the Great Mosque, and
every man was allowed to claim his own. To the malcontents who
complained that they were not allowed to take booty, Aly replied
that the rights of war, in this case, lasted only so long as the ranks
were arrayed against each other; and that, immediately on
submission, the insurgents resumed their rights and privileges as
brother Moslems.
[519] ‘She of the two shreds.’—Life of Mahomet, p. 145.
[520] There is a great abundance of tradition concerning
Ayesha, both in the battle and after it. In the heat of the action,
Aly’s soldiers taunted her as ‘the unnatural Mother of the Faithful.’
The soldiers on her side, in reply, extemporised a couplet,
extolling her as ‘the noblest and best of Mothers.’ When they told
it to her, she was much affected, and exclaimed, ‘Would that I had
died twenty years before this!’ Aly also, when he heard it, said,
‘Would that I too had died twenty years ago!’
Ayesha, always ready in repartee, was not very particular in
her language, and some of the speeches attributed to her are
both coarse and intemperate. Asim approaching her litter on the
field, she cursed him for the liberty he had taken. ‘It was but a
little something red and white,’ he said, impudently, ‘that I caught
a glimpse of.’ ‘The Lord uncover thy nakedness,’ she cried
angrily; ‘cut off thy hands, and make thy wife a widow!’ All which,
they say, came to pass. A saucy passage is related between her
and the aged Ammâr, whose last words were, as she was
leaving, ‘Praise be to the Lord that we shall hear no more that vile
tongue of thine!’
Aly’s conduct was forbearing and generous. Of the family with
which Ayesha was lodged at Bussorah, two sons had been killed
fighting, one on the side of Aly, the other against him. The widow
of the latter was loud in her lamentation, crying out against Aly as
the cause of her sorrow. Aly was asked to punish her; but he
refused, saying she was but a weak woman, and should not be
touched. On the other hand, some one who spoke contumeliously
of Ayesha was, by his order, beaten with shoes.
As Ayesha was starting for Mecca, Aly and a company
gathered round her. When the time came to bid farewell, she said,
‘Let us not entertain hard thoughts one against the other; for
verily, as regardeth Aly and myself, there happened not anything
between us (alluding to her misadventure in the Prophet’s
lifetime[521]) but that which is wont to happen between a wife and
her husband’s family; and verily Aly was one of the best of them
that entertained suspicions against me.’ Aly replied: ‘She
speaketh the truth; there was nought, beyond what she saith,
between her and me.’ And then he went on to say (quoting
Mahomet’s own words) that ‘she was not only the Prophet’s wife
in this world, but equally his spouse in the next.’
[521] Life of Mahomet, p. 311.
[522] A separate chapter is generally assigned by the Arabian
historians to this episode; but its interest lies almost wholly in the
intense hatred conceived by the usurper towards Othmân.
Hearing of his factious courses, Othmân, to soften and remind
him of his past care and favour, sent him from Medîna a purse,
and also a camel laden with rich garments, as a present. The
ungrateful rebel hung these up in the Great Mosque of Fostât,
and used them to point his invectives against Othmân and the
corruption of the age. Having joined the insurgent faction, he, no
doubt, hoped that Othmân’s successor would have confirmed him
in the government of Egypt. But Aly, treating him as he deserved,
showed him no favour, and appointed a man of his own to the
government.

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Advanced Paediatric Life Support-A

Practical Approach to Emergencies

Advanced Life Support Group

Limit of Liability/Disclaimer of Warranty

Library of Congress Cataloging-­in-­Publication Data applied for

Paperback ISBN: 9781119716136

Cover Design: Wiley

Set in 10/12 Montserrat by Straive, Pondicherry, India

Contributors to seventh edition vii

PART 2: The seriously ill child 29

PART 3: The seriously injured child 125

PART 4: Life support 207

PART 5: Practical application of APLS 259

PART 6: Appendices 337

List of algorithms 477

How to use your textbook 508

Working group chair

Stephanie Smith BM BS FRCPCH, Honorary Emergency Paediatric Consultant, Nottingham

The seriously ill child

The seriously injured child

Contributors to the status epilepticus algorithm

Association of Paediatric Emergency Medicine

British Association General Paediatrics

British Association of Perinatal Medicine

British Paediatric Allergy, Immunity and Infection Group

British Paediatric Respiratory Society

British Society of Paediatric Radiology – trauma imaging

Child Protection Special Interest Group

Paediatric Critical Care Society

RCEM Intercollegiate group

1.2 The APLS approach

In the structured approach it is essential to remember that:

Relationship between disease progression and outcomes

Pathways to cardiac arrest

Respiratory Respiratory Fluid Fluid

Foreign body Convulsions Blood loss Sepsis

Respiratory failure Circulatory failure

Standardised structure for assessment and stabilisation

Definitive therapy (such as surgical intervention) may be a component of the resuscitation

Figure 1.2 Advanced paediatric life support (APLS) in action

Early referral to appropriate teams for definitive management

Ongoing care until admission to appropriate care

1.3 Important differences in children

Figure 1.3 (Continued)

High anterior larynx

Figure 1.4 Summary of significant upper airway anatomy

Body surface area

Figure 1.5 Differences in children

Children with developmental differences due to pre‐­existing conditions such as autism,

1.4 Structured approach to paediatric emergencies

Structured approach to paediatric emergencies

Prepare for child’s arrival

Transfer to definitive care

Figure 1.6 Structured approach to paediatric emergencies

A structured approach to paediatric emergencies will enable a clinician to manage emergencies in

Table 1.1 Triage scale

Number Colour Name Maximum time to clinician

2 Orange Very urgent 10 min

3 Yellow Urgent 60 min

4 Green Standard 240 min

5 Blue Non‐­urgent N/A

Triage is used to identify children who require urgent intervention.

Triage decision making

Library of Congress Cataloging-in-Publication Data applied for

Contributors to seventh edition vii

PART 2: The seriously ill child 29

PART 3: The seriously injured child 125

PART 4: Life support 207

PART 5: Practical application of APLS 259

PART 6: Appendices 337

List of algorithms 477

How to use your textbook 508

Children with developmental differences due to pre‐existing conditions such as autism,

5 Blue Non‐urgent N/A

Administration error Patient ID mix-up, drug given to wrong patient

When communicating face-to-face, in an emergency setting, a message is often announced to a