PALS Study Guide

• Updates to PALS in 2015………………………………………………….3
• PALS Systematic Approach………………………………………………….4
• First Impression………………………………………………….4
• Evaluate-Identify-Intervene………………………………………………….5
• Primary Assessment………………………………………………….6
• Airway………………………………………………….6
• Breathing………………………………………………….7
• Circulation………………………………………………….8
• Disability……………………………9
• Exposure………………………………………………….9
• Secondary Assessment and Diagnostic Tests………………………………………………….10
• Respiratory Distress/Failure………………………………………………….11
• Causes of Respiratory Distress………………………………………………….12
• Cardiac Arrest………………………………………………….14
• Ventricular Fibrillation and Pulseless Ventricular Tachycardia………………………………………………….14
• PEA and Asystole……………………………15
• Rapid Differential Diagnosis of Cardiac Arrest………………………………………………….16
• Shock………………………………………………….17
• Fluid Resuscitation………………………………………………….18
• Return of Spontaneous Consciousness (ROSC) and Post Arrest Care………………………………………………….19
• Postresuscitation Management………………………………………………….20
• Transport to Tertiary Care Center……………………………21
• Bradycardia………………………………………………….22
• Tachycardia………………………………………………….23
• Tachycardia with Pulse and Poor Perfusion………………………………………………….24
• Tachycardia with Pulse and Good Perfusion………………………………………………….25
• PALS Tools………………………………………………….26
• Broselow Pediatric Emergency Tape System……………………………26
• PALS Airways………………………………………………….26
• Intraosseus Access………………………………………………….27
• Team Dynamics/Systems of Care………………………………………………….28
• ECG Rhythms………………………………………………….29
• Atrioventricular (Heart) Block………………………………………………….29
• Pulseless Electrical Activity and Asystole………………………………………………….30
• Ventricular Fibrillation and Pulseless Ventricular Tachycardia………………………………………………….31
• Tachyarrhythmias………………………………………………….32
• Resuscitation and Life Support Medications………………………………………………….33

As we learn more about resuscitation science and medicine, physicians and researchers
realize what works best and what works fastest in a critical, life-saving situation.
Therefore, it is necessary to periodically update life-support techniques and algorithms.
If you have previously certified in pediatric advanced life support, then you will probably
be most interested in what has changed since the latest update in 2015. The table below
also includes changes proposed since the last AHA manual was published.

The PALS systematic approach is an algorithm that can be applied to every injured or
critically ill child.

The first step is to determine if the child is in imminent danger of death, specifically
cardiac arrest or respiratory failure. The PALS systematic assessment starts with a
quick, first impression. The provider or rescuer makes it very quick assessment about
the child’s condition.
Is the child in imminent danger of death? Is there time to evaluate the child to identify
and treat possible causes for the current illness? Is the child conscious? Is she
breathing? What is her color?

• A conscious child who is breathing effectively can be managed in the next steps of PALS, Evaluate-Identify-Intervene.
• A unconscious child who is breathing effectively can be managed in the next steps of PALS, Evaluate-Identify-Intervene.
• A child who is not breathing adequately but who has a pulse >60 BPM should be treated with rescue breathing.
• A child who has a pulse <60 BPM should be treated with CPR and according to the cardiac arrest algorithm.
• A child who has a pulse <60 BPM should be treated with CPR and according to the cardiac arrest algorithm.

• Assuming that the child does not need CPR, rescue breathing, or defibrillation, the next step in this systematic approach in PALS is a circular construct that includes evaluation, identification, and intervention.

• The provider will evaluate, identify, and intervene as many times as necessary until the child either stabilizes or her condition worsens, requiring CPR and other lifesaving measures.

• “Evaluate” pertains to evaluation of the child’s illness, but also to the success or failure of the intervention.

•  If the child’s condition worsens at any point, revert to CPR and emergency interventions as needed.

• After Spontaneous Return of Circulation (ROSC), use the evaluate–identify–intervene sequence.

• The evaluate phase of the sequence includes Primary Assessment, Secondary Assessment, and Diagnostic Tests that are helpful in pediatric life support situations.

Primary Assessment follows ABCDE: Airway, Breathing, Circulation, Disability, Exposure

• While CPR currently uses the C-A-B approach or compressions, airway, breathing, the Primary Assessment in PALS still begins with Airway.
• If the child airway is open, you
• may move onto the next step. However, if the airway is likely to become compromised, you may consider a basic or advanced airway.
• Often, in unresponsive patient or in someone who has a decreased level of consciousness, the airway will be partially obstructed. This instruction does not come from a foreign object, but rather from the tissues in the upper airway. You can improve a partially obstructed airway by performing a head tilt and chin lift. If there is suspected trauma to the cervical spine, use a jaw thrust instead.
•  A blocked airway would usually requires a basic or advanced airway.

The evaluation of breathing include several signs including breathing rate, breathing effort, motion of the chest and abdomen, breath sounds, and blood oxygenation levels. Normal breathing rates vary by age and are shown in the table. The breathing rate higher or lower than the normal range indicates the need for intervention.

Nasal flaring, head bobbing, seesawing, and chest retractions are all signs of increased effort of breathing. The chest may show labored movement (e.g., using the chest accessory muscles), asymmetrical movement, or no movement at all.

Stridor is a high-pitched breath sounds, usually heard on inspiration, that usually indicates a blockage in the upper airway. Rales or crackles often indicate fluid in the lower airway. Rhonchi are coarse rattling sounds usually caused by fluid in the bronchi.

Blood oxygen saturation below 90% indicate that an advanced airway, such as an endotracheal tube, is needed. Blood oxygenation can be 100% during cardiopulmonary arrest but should be titrated to between 94 and 99% after ROSC or in non-acute situations.

A heart rate that is either too fast or too slow can be problematic. In children, heart rate less than 60 bpm is equivalent to cardiac arrest. Diminished central pulses, such as in the carotid, brachial, or femoral arteries, indicate shock. The same is true for capillary refill the takes longer than 2 seconds to return, cyanosis, and blood pressure that is lower than normal for the child’s age. Bradycardia and tachycardia that are interfering with circulation and causing a loss of consciousness should be treated as cardiac arrest or shock, rather than as a bradycardia or tachycardia

Rapidly assess disability using the AVPU paradigm: Alert, Verbal, Pain, Unresponsive.

A more thorough assessment would be the Pediatric Glasgow Coma Scale.

Exposure is included in the primary assessment to remind the provider to look for causes of injury or illness that may not be readily apparent. To do this, the child’s clothes need to be removed in a ordered and systematic fashion. During the removal, the provider should look for signs of discomfort or distress that may point to an injury in that region.

The provider should look for and treat, at a minimum, hypothermia, hemorrhage, local and/or systemic infection, fractures, petechiae, bruising or hematoma.

Cardiac arrest in children can occur secondary to respiratory failure, hypotensive shock, or sudden ventricular arrhythmia. In most pediatric cases, however, respiratory failure, shock, and even ventricular arrhythmia are preceded by a milder form of cardiovascular compromise. For example, respiratory failure is usually preceded by some sort of respiratory distress. In fact, respiratory distress is the most common cause of respiratory failure and cardiac arrest in children. As you may expect, outcomes are better if one can intervene during respiratory distress rather than respiratory failure.

Respiratory distress/failure is divided into four main etiologies for the purposes of PALS:upper airway, lower airway, lung tissue disease, and disordered control of breathing.

Cardiac arrest occurs when the heart does not supply blood to the tissues. Strictly speaking, cardiac arrest occurs because of an electrical problem (i.e., arrhythmia). Shock (i.e., too little blood pressure/volume) and respiratory failure may lead to cardiopulmonary failure and hypoxic arrest.

• Ventricular fibrillation and pulseless ventricular tachycardia are shockable rhythms.
• The first shock energy is 2 J/kg.
• The second shock energy (and all subsequent shocks) is 4 J/kg.
• All subsequent shocks are 4 J/kg or greater.
• The maximum energy is 10 J/kg or the adult dose (200 J for biphasic, 360 J for monophasic).
• Epinephrine (0.01 mg/kg IV/IO) is given every 3 to 5 minutes (two 2 minute cycles of CPR).
• Amiodarone (IV/IO)
• 5 mg/kg bolus
• Can be given three times total
• If the arrest rhythm is no longer shockable, move to PEA/Asystole algorithm.
• If the patient regains consciousness, move to ROSC algorithm.

• As long as the patient is in PEA or asystole, the rhythm is not shockable.
• Chest compressions/high-quality CPR should be interrupted as little as possible during resuscitation.
• After 2 min. of high-quality CPR, give 0.01 mg/kg epinephrine IV/IO every 3 to 5 minutes (two 2 minute cycles of CPR).
• Remember, chest compressions are a means of artificial circulation, which should deliver the epinephrine to the heart. Without chest compressions, epinephrine is not likely to be effective.
• Chest compressions should be continued while epinephrine is administered.
• Rhythm checks every 2 min.
• Look for and treat reversible causes (Hs and Ts).
• If the arrest rhythm becomes shockable, move to VFib/Pulseless VTach algorithm.
• If the patient regains circulation, move to ROSC algorithm.

Many different disease processes and traumatic events can cause cardiac arrest, but in an emergency, it is important to be able to rapidly consider and eliminate or treat the most typical causes of cardiac arrest. To facilitate remembering the main, reversible causes of cardiac arrest, they can be organized as the Hs and the Ts.

The goals of shock management include:

• Improving blood oxygenation
• Easing oxygen demand
• Improving volume and fluid distribution
• Normalizing electrolyte and metabolic disturbances

Fluid resuscitation in PALS depends on the weight of the child and the severity of the situation. While dehydration and shock are separate entities, the symptoms of dehydration can help the provider to assess the level of fluid deficit and to track the effects of fluid resuscitation.  In the current guidelines, the clinician must fully evaluate the child with febrile illness since aggressive fluid resuscitation with isotonic crystalloid solution may not be indicated.

• In a successful resuscitation, there will be a spontaneous return of circulation.
• You can detect spontaneous circulation by feeling a palpable pulse at the carotid or femoral artery in children and the brachial artery in infants up to 1 year.
• Even after Return of Spontaneous Circulation (ROSC), the patient still needs close attention and support. The patient is at risk for reentering cardiac arrest at any time. Therefore, the patient should be moved to an intensive care unit.
• Titrate the patient’s blood oxygen to between 94% and 99%. Wean down supplemental oxygen for blood oxygenation of 100%.
• Does the person need an advanced airway? If so, it should be placed. Also, apply quantitative waveform capnography, if available.
• Is the patient in shock? If not, monitor and move to supportive measures. If shock is present, determine if it is hypotensive or normotensive.
• Identify and treat causes (Hs and Ts). Fluid resuscitation according to cause of shock. Consider vasopressors.
• Hypotensive Shock
  • Epinephrine IV 0.1-1.0 mcg/kg/min
  • Dopamine IV 2-20 mcg/kg/min
  • Norepinephrine IV 0.1-2 mcg/kg/min
• Normotensive Shock
  • Dobutamine 2-20 mcg/kg/min
  • Dopamine IV 2-20 mcg/kg/min
  • Epinephrine IV 0.1-1.0 mcg/kg/min
  • 50  mcg/kg  IV  over  10-60  minutes  as loading  dose,  then  0.25-0.75  mcg/kg/ minute IV infusion as maintenance dose

The child is still in a delicate condition. All major organ systems should be assessed and supported. Maintenance fluids should be given. If the child has been resuscitated in the community or at a hospital without pediatric intensive care facilities, arrange to have the child moved to an appropriate pediatric hospital.

• Prepare for Transport
  • Identify nearest tertiary pediatric facility with resources to care for condition o Follow hospital transport protocol
• Provide medications/fluids/blood products for use during transport
• Coordinate with Tertiary Pediatric Facility
  • Contact the specific receiving provider
  • Resuscitation Team Leader should “present” the patient to receiving provider
• Determine Mode of Transportation
  •  Ground ambulance
• Inexpensive and available in most weather conditions Takes longer
  • Helicopter
• Faster than ground ambulance
• More expensive than ground ambulance Weather limited
  • Fixed wing aircraft
• Best long distances/unstable child. Expensive
• Also requires ground ambulance on both ends to trip
• Prepare the Child and Family
  • Inform the family of treatments
  • Inform the family of plan
  • Obtain consent for transport
  • Answer questions and provide comfort to the child and family
• Prepare Documentation
  • Send copy of chart including labs and studies with the child o Send contact information for all pending tests/studies
• Use Precautions
  • Universal precautions
  • Isolation specific to probable pathogen
  • Obtain cultures if indicated
  • Give empirical antibiotics if infection suspected

Bradycardia is a common cause of hypoxemia and respiratory failure in infants and children. Bradycardia is a slower than normal heart rate. Since the normal heart rate in children varies, the provider must take into account the normal values for the child’s age. A heart rate less than 60 beats per minute in a child under 11 years old is worrisome for cardiac arrest (unless congenital bradycardia is present). In fact, pulseless bradycardia defines cardiac arrest.

• If bradycardia interferes with tissue perfusion, maintain the child’s airway and monitor vital signs. Obtain intravenous or intraosseous access. Obtain a 12 lead ECG and provide supplemental oxygen.
• If the above interventions help, continue to support the patient and consult an expert regarding additional management.
• If the heart rate is still less than 60 bpm despite the above interventions, begin to treat with CPR.
• If the child is still experiencing bradycardia, administer epinephrine
• IV/IO (0.01 mg/kg). May repeat every 3-5 minutes.
• Atropine can be given at a dose of 0.02 mg/kg up to two times.
• Min Dose: 0.1 mg.
• Max Dose: 0.5 mg.
• Consider transvenous or transthoracic pacing if available. You may need to move to the cardiac arrest algorithm if the bradycardia persists despite interventions.

Tachycardia is a faster than normal heart rate. Since the normal heart rate in children varies, the provider must take into account the normal values for the child’s age. Pulseless tachycardia is cardiac arrest.

• During tachycardia, maintain the child’s airway and monitor vital signs. Obtain intravenous or intraosseous access. Access. Obtain a 12 lead ECG and provide supplemental oxygen.
• If the tachycardia is causing a decreased level of consciousness, hypotension or shock, or significant chest pain, move directly to synchronized cardioversion.
• If the tachycardia is not causing a decreased level of consciousness,hypotension or shock, or significant chest pain, you may attempt vagal maneuvers, first.
  • Cooperative children can participate in a Valsalva maneuver by blowing through a narrow straw
  • Carotid sinus massage may be effective in older children. Tachycardia is a slower than normal heart rate.
  • A vagal maneuvers for an infant or small child is to place ice on the face for 15 to 20 seconds
  • Ocular pressure may injure the child and should be avoided
• If vagal maneuvers fail, you may use
  • Adenosine: 0.1 mg/kg IV push to a max of 6 mg, followed by 0.2 mg/kg IV push to a max of 12 mg
  • Procainamide: 15 mg/kg over 30-60 min
  • Amiodarone: 5mg/kg over 20-60 min to a max of 300 mg

It is important to determine if the tachycardia is narrow complex or wide complex. A QRS complex that is longer than 90 ms is wide QRS complex tachycardia. This should be considered possible ventricular tachycardia. If the child is not hemodynamically stable then provide cardioversion immediately.

• If the wide QRS complex has a regular rhythm, then you can supply synchronized cardioversion at 100 J.
• If the wide QRS complex is irregular, this is ventricular tachycardia and should be treated with unsynchronized cardioversion (i.e. shock) immediately.
• Narrow complex tachycardia may be sinus tachycardia or supraventricular tachycardia.
• Sinus tachycardia has many causes; the precise cause should be identified and treated.
• Supraventricular tachycardia can be treated with 0.1 mg/kg adenosine IV push to a max of 6 mg. If the first dose is unsuccessful, follow it with 0.2 mg/kg adenosine IV push to a max of 12 mg. If adenosine is unsuccessful, proceed to synchronized cardioversion.
• Narrow complex supraventricular tachycardia with a regular rhythm is treated with 50-100 J of synchronized cardioversion energy.
• Narrow complex supraventricular tachycardia with an irregular rhythm is treated with 120-200 J of synchronized cardioversion energy.

Again, it is important to determine if the tachycardia is narrow complex or wide complex. A QRS complex that is longer than 90 ms is wide QRS complex tachycardia.

• Narrow complex tachycardia may be sinus tachycardia or supraventricular tachycardia.
• Wide complex tachycardia may be supraventricular tachycardia or ventricular tachycardia.
•  Wide QRS complex tachycardia with good perfusion can be treated with amiodarone OR procainamide (not both). Expert consultation is recommended.
•  Wide QRS complex is irregular, this is ventricular tachycardia and should be treated with unsynchronized cardioversion (i.e. shock) immediately.
• Both wide and narrow supraventricular tachycardia with good perfusion can be treated with vagal maneuvers and adenosine by rapid bolus. If adenosine is unsuccessful, proceed to synchronized cardioversion.
• Narrow complex supraventricular tachycardia with a regular rhythm is treated with 50-100 J of synchronized cardioversion energy.
•  Narrow complex supraventricular tachycardia with an irregular rhythm is treated with 120-200 J of synchronized cardioversion energy

Broselow Pediatric Emergency Tape System

A variety of tools is available for use in PALS, each with a size adapted to the child’s size. The most commonly used system for correlating tools to the size of a child is the Broselow Pediatric Emergency Tape System. The provider can quickly measure the length/height of the child using color-coded tape. The resuscitation then uses tools (and in some hospitals, medications) proportional to the child’s size. The medication cart or crash cart is stocked using the color coding system.

Basic airways do not require specialist training; however, some proficiency is needed for oropharyngeal and nasopharyngeal airway placement. Proper bag mask technique requires a tight seal between the mask and the child’s face.

• Intraosseus access is an acceptable alternative to IV access in children because the bones are softer and the marrow can be accessed quickly and reliably in emergencies.
• IO access also permits chest compressions to continue without interruption (arm IV placement is sometimes more difficult during chest compressions).
• IO access can be obtained in the:
  • Proximal tibia
  • Distal tibia
  •  Distal femur
  • Anterior superior iliac spine
• An algorithm for obtaining IO access in the proximal tibia is shown.
•  Avoid IO access in fractured bones, near infection, or in the same bone after a failed access attempt.
•  After reaching the bone’s interior, do not aspirate and immediately flush with 5 ml of fluid.
•  Once the resuscitation is successful, replace the IO access with large bore IV access or central line as soon as possible (<24 hours) to avoid infection.

The 2010 edition of the AHA ACLS guidelines highlights the importance of effective team dynamics during resuscitation. ACLS in the hospital will be performed by several providers. These individuals must provide coordinated, organized care. Providers must organize themselves rapidly and efficiently. The AHA recommends establishing a Team Leader and several Team Members. The Team Leader is usually a physician, ideally the provider with the most experience in leading ACLS codes. Resuscitation demands mutual respect, knowledge sharing, and constructive criticism, after the code.

When performing a resuscitation, the Team Leader and Team Members should assort themselves around the patient so they can be maximally effective and have sufficient room to perform the tasks of their role.

 Atrioventricular (Heart) Block

Atrioventricular block or heart block is a failure of the heart’s electrical system to properly coordinate conduction. There are four main types of atrioventricular block: first degree, second degree type I, second degree type II, and third degree heart block. The types of second degree heart block are referred to as Mobitz type I and Mobitz type II. Second degree heart block Mobitz type I is also known as the Wenckebach phenomenon.Heart block is important because it can cause hemodynamic instability and can evolve into cardiac arrest.

First degree atrioventricular block

The PR interval is a consistent size, but longer or larger than it should be in first degree heart block.

Second degree atrioventricular block, Mobitz type I (Wenckebach)

The PR interval increases in size until a QRS complexes dropped, resulting in missed “beat.”

Second degree atrioventricular block, Mobitz type II

A QRS wave will occasionally drop, though the PR interval is the same size.

Third degree (complete) atrioventricular block

Complete dissociation between P waves and the QRS complex. No atrial impulses reach the ventricle.

Pulseless Electrical Activity and Asystole

Pulseless electrical activity or PEA is a cardiac rhythm that does not create a palpable pulse is even though it should. A PEA rhythm can be almost any rhythm except ventricular fibrillation (incl. torsade de pointes) or pulseless ventricular tachycardia.

Asystole is the “flatline” on the ECG monitor. It represents a lack of electrical activity in the heart. It is critically important not to confuse true asystole with disconnected leads or an inappropriate gain setting on an in-hospital defibrillator. Asystole may also masquerade as a very fine ventricular fibrillation. If the ECG device is optimized and is functioning properly, a flatline rhythm is diagnosed as asystole. Note that asystole is also the rhythm one would expect from a person who has died. Consider halting PALS efforts in people who have had prolonged asystole.

It is inappropriate to provide a shock to pulseless electrical activity or asystole. Cardiac function can only be recovered in PEA or asystole through the administration of medications.

 Ventricular Fibrillation and Pulseless Ventricular Tachycardia

In ventricular fibrillation or pulseless ventricular tachycardia, the heart’s conduction system exhibits a disordered rhythm that can sometimes be corrected by applying energy to it. This energy may come in the form of an automated external defibrillator (AED) defibrillator paddles, or defibrillator pads. VFib and VTach are treated with unsynchronized cardioversion, since there is no way for the defibrillator to decipher the disordered waveform. In fact, it is important not to provide synchronized shock for these rhythms.

Ventricular fibrillation is recognized by a disordered waveform, appearing as rapid peaks and valleys as shown in this ECG rhythm strip:

Ventricular tachycardia may provide waveform similar to any other tachycardia; however, the biggest difference in cardiac arrest is that the patient will not have a pulse and, consequently, will be unconscious and unresponsive. Two examples of ventricular tachycardia are shown in this ECG rhythm strips. The first is narrow complex tachycardia and the second is wide complex tachycardia:

 Tachyarrhythmias

Atrial fibrillation is the most common arrhythmia. It is diagnosed by electrocardiogram, specifically the RR intervals follow no repetitive pattern. Some leads may show P waves while most leads do not. Atrial contraction rates may exceed 300 bpm. The ventricular rate often range is between 100 to 180 bpm. The pulse may be “irregularly irregular.”

Atrial flutter is a cardiac arrhythmia that generates rapid, regular atrial depolarizations at a rate of about 300 bpm. This often translates to a regular ventricular rate of 150 bpm, but may be far less if there is a 3:1 or 4:1 conduction. By electrocardiogram, or atrial flutter is recognized by a sawtooth pattern sometimes called F waves. These waves are most notable in leads II, III, and aVF.

Narrow QRS complex tachycardias include several different tachyarrhythmias. A narrow QRS complex tachycardia is distinguished by a QRS complex of less than 90 ms. One of the more common narrow complex tachycardias is supraventricular tachycardia, shown below. The heart rate can exceed 220 bpm in infants and 180 bpm in children.

Wide complex tachycardias are difficult to distinguish from ventricular tachycardia. Ventricular tachycardia leading to cardiac arrest should be treated using the ventricular tachycardia algorithm. A wide complex tachycardia in a conscious child should be treated using the tachycardia algorithm. Tissue perfusion will dictate which algorithm to use.