Table of Contents

  • 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

Updates to PALS in 2015

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.

Updates to the 2015 PALS Guidelines
Intervention 2015 Guideline 2010 Guideline
Volume for children with febrile illness Restrictive volumes of isotonic crystalloids Aggressive volume resuscitation
Atropine for emergency tracheal intubation Controversial for neonates; no minimum dose Routine premedication prior to intubation
Arterial blood pressure monitoring If in place, may be useful to adjust CPR No guideline
Amiodarone and Lidocaine Acceptable for shock-refractory VFib or Pulseless VTach No guideline
Therapeutic hypothermia Fever should be avoided after ROSC but use of therapeutic hypothermia is controversial Therapeutic hypothermia should be used
Blood Pressure Fluids and vasoactive agents to maintain systolic blood pressure above the 5th percentile for age No guideline
Compressions 100 to 120 per minute At least 100 per minute

PALS Systematic Approach

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

First Impression

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?



  • scious-childA 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.



  • assumingAssuming 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

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

  • airwayWhile 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.

Normal Respiratory Rate by Age
Age Range Rate (BPM)
Mnemonic C-A-B: Compressions, Airway, Breathing ABC: Airway, Breathing, Circulation
Breathing Check Begin CPR if the victim is unresponsive, pulseless, and not (effectively) breathing “Look, listen and feel” plus two rescue breaths
Pulse Check For 10 seconds or less For at least 15 seconds
CPR High Quality CPR when possible, Complete recoil between compressions, rotate providers every 2 min Slower rate, less deep
Priority of CPR and Defibrillation High quality CPR and/or defibrillation take priority over venous access, advanced airways, or drugs CPR would stop for other activities

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




Normal Heart Rate by Age
Range Rate (BPM)
0-3 months 80-205
4 months – 2 years 75-190
2-10 years 60-140
Over 10 years 50-100
Normal Blood Pressure by Age Low Systolic Blood Pressure by Age
Age Range Diastolic Range
1 Day 60-76 30-45 <60
4 Days 67-84 35-53 <60
1 month 67-84 36-56 <70
1-3 months 78-103 44-65 <70
4-6 months 82-105 46-68 <70
7-12 months 67-104 20-60 <72
2-6 years 70-106 25-65 <70 + (2 X age)
7-14 years 79-115 38-78 <70 + (2 X age)
15-18 years 93-131 45-85 <90

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

AVPU paradigm
A Alert Appropriate, normal activity for the child’s age and usual status
V Verbal Responds only to voice
P Pain Responds only to pain
U Unresponsive Responds only to pain U Unresponsive Does not respond to stimuli, even pain

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

Pediatric Glasgow Coma Scale
Response Score Verbal Child Pre-verbal Child
Eye Opening 4
Spontaneously To verbal command To pain None Spontaneously To speech To pain None
Verbal Response 5
Oriented and talking Confused but talking Inappropriate words Sounds only None Cooing and babbling Crying and irritable Crying with pain only Moaning with pain only None
Motor Response 6
Obeys commands Localizes with pain Flexion and withdrawal Abnormal flexion Abnormal extension None Spontaneous movement Withdraws when touched Withdraws with pain Abnormal flexion Abnormal extension None
Mild: 13-15
Moderate: 9-12
Severe: 3-8

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.

Secondary Assessment and Diagnostic Tests

When a child is experiencing an acutely life-threatening event, such as

cardiopulmonary failure, it is appropriate to treat the child with CPR and the appropriate arrest algorithm.


When a child has a condition that may soon become life-threatening or if something does “not feel right”, continue using the Primary Assessment sequence of Evaluate-Identify-Intervene. If at any time the child’s condition worsens, treat the child with CPR and the appropriate arrest algorithm.


When a child is ill but does not likely have a life-threatening condition, you may

proceed to the Secondary Assessment. The Secondary Assessment includes a focus history and focused physical examination looking for things that might cause respiratory or cardiovascular compromise.


The focused physical examination may be quite similar to the Exposure phase of the Primary Assessment, but will be guided by the data that the provider collects during the focused history. The focused history will also help determine which diagnostic tests should be ordered.

Use SAMPLE in Secondary Assessment
S Signs/Symptoms Fever Decreased intake Vomiting/Diarrhea Bleeding Shortness of breath Altered mental status Fussiness/Agitation
A Allergies Medication allergy Environmental allergy Food allergy
M Medications Prescribed Over-the-counter New meds? Last dose?
P Past History Birth history Chronic health issues Immunization status Surgical history
L Last Meal Breast/bottle/solid? When? What? How much? New foods?
E Events/Exposures History of present illness Onset/time course
Key Diagnostic Tests Used in PALS
Test/Study Identifies Possible Intervention
Arterial Blood Gas (ABG) Hypoxemia Increase Oxygenation
Hypercarbia Increase Ventilation
Acidosis Increase Ventilation
Alkalosis Reduce Ventilation
Arterial Lactate Metabolic acidosis, Tissue hypoxia Shock Algorithm
Central Venous Oxygen Saturation Poor O2 delivery (SVO2 <70%) Poor O2 delivery (SVO2 <70%)
Central Venous Pressure Heart contractility, others Vasopressors, Shock Algorithm
Chest X-ray Respiratory conditions Specific to cause, Respiratory Algorithm
Echocardiogram Heart anatomy and function Specific to cause
Electrocardiogram Rhythm Disturbances Specific to cause
Peak Expiratory Flow Rate Respiratory conditions Specific to cause, Respiratory Algorithm
Venous Blood Gas (VBG) Acidosis Increase Ventilation
Alkalosis Reduce Ventilation

Respiratory Distress/Failure

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.



Signs and Symptoms of Worsening Respiratory Distress,
Sign/Sx Mild Moderate Severe Verge of Arrest
Accessory Muscles Use No Yes Marked Seesawing
Activity Walking, talking Talking, will sit No activity, infant will not feed Drowsy
Alert Slightly agitated Agitated Markedly agitated Lethargic
O2 Sat. >95% 91 to 95% <90% <90%
PaCO2 <45 mmHg <45 mmHg <45 mmHg <45 mmHg
PaO2 Normal >60 mmHg <60 mmHg ± Cyanosis <60 mmHg + Cyanosis
Pulse Normal 100-200 BPM >200 BPM <100 BPM
Respiratory Rate Increased Increased Markedly Increased Increased or Decreased
Speaking? Sentences Phrases Words Not talking
Wheeze Audible Loud Very Loud None

Causes of Respiratory Distress

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.

Respiratory Distress Identification and Management
Type of Respiratory Problem Possible Causes
Upper Airway Anaphylaxis
Foreign body aspiration
Lower Airway Asthma
Lung Tissue Disorder Pneumonia
Pulmonary edema
Disordered Control of Breathing Increased intracranial pressure
Neuromuscular disease
Toxic poisoning


Respiratory Distress, Key Signs and Symptoms
Upper Airway Obstruction Lower Airway Obstruction Lung Disease Disordered Control of
Air Movement Decreased Unchanged or decreased
Airway May or may not be fully patent in respiratory distress. Not patent in respiratory failure.
Breath Sounds Cough, hoarseness, stridor Wheezing Diminished breath sounds, grunting, crackles Unchanged
Heart Rate Increased in respiratory distress
Decompensates rapidly to bradycardia as respiratory failure ensues
Skin Color and Temperature Pale, cool, and clammy in respiratory distress Decompensates rapidly to cyanosis as respiratory failure ensues Varies
Level of Consciousness Agitation in respiratory distress Decompensates rapidly to decreased mentation, lethargy, and LOC as respiratory failure ensues
Respiratory Rate and Effort Increased in respiratory distress Decompensates rapidly in respiratory failure Varies

Respiratory Distress Management

Respiratory Distress Management by Type and Cause
Type Possible Causes Treatment
Upper Airway
Anaphylaxis Epinephrine Albuterol nebulizer Watch for and treat airway compromise, advanced airway as needed Watch for and treat shock
Croup Humidified oxygen Dexamethasone Nebulized epinephrine for moderate to severe croup Keep O2 sat >90%, advanced airway as needed
Foreign body aspiration Do not perform a blind finger sweep, remove foreign object if visible Infant 1 year old:Back slaps/chest thrusts
Child >1 year old: Abdominal thrusts
Lower Airway
Asthma Nebulized epinephrine or albuterol Keep O2 sat >90%, advanced airway or non-invasive positive pressure ventilation as needed Corticosteroids PO or IV as needed Nebulized ipratropium Magnesium sulfate slow IV (moderate to severe asthma) Terbutaline SQ or IV (impending respiratory failure)
Bronchiolitis Oral and nasal suctioning Keep O2 sat >90%, advanced airway as needed Nebulized epinephrine or albuterol
Lung Disease Pneumonia Empiric antibiotics and narrow antibiotic spectrum based on culture results Nebulized albuterol for wheezing Reduce the work of breathing and metabolic demand Keep O2 sat >90%, advanced airway as needed Continuous positive airway pressure (CPAP)
Pulmonary edema Reduce the work of breathing and metabolic demand Keep O2 sat >90%, advanced airway as needed Diuretics if cardiogenic CPAP
Control of
Increased intracranial pressure Pediatric neurological/neurosurgery consult Hyperventilation as directed Use medications (e.g., mannitol) as directed
Neuromuscular disease Identify and treat underlying disease CPAP or ETT and mechanical ventilation as needed
Toxic poisoning Identify toxin/poison Call Poison Control: 1.800.222.1222 Administer antidote/anti-venom when possible Maintain patent airway, advanced airway as needed Provide suctioning

Cardiac Arrest

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

  • ventricularVentricular 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.

PEA and Asystole

  • peaAs 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.

Rapid Differential Diagnosis of Cardiac Arrest

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 Hs Symptoms/Signs/Tests Intervention
Hypovolemia Rapid heart rate, narrow QRS complex, Fluid resuscitation
Hypoxia Decreased heart rate Airway management, oxygen
Hydrogen Ion (Acidosis) Low amplitude QRS complex Hyperventilation, sodium bicarb
Hypoglycemia Fingerstick glucose testing IV Dextrose
Hyperkalemia Flat T waves, pathological U wave IV Magnesium
Hyperkalemia Peaked T waves, wide QRS complex ICalcium chloride, sodium bicarb, insulin/glucose, hemodialysis
Hypothermia History of cold exposure Rewarming blankets/fluids
The Ts Symptoms/Signs/Tests Intervention
Tension Pneumothorax Slow heart rate, narrow QRS complex, acute dyspnea, history of chest trauma Thoracotomy, needle decompression
Tamponade (Cardiac) Rapid heart rate and narrow QRS complex Pericardiocentesis
Toxins Variable, prolonged QT interval, neuro deficits Antidote/antivenom (toxin-specific)
Thrombosis (pulmonary) Rapid heart rate, narrow QRS complex Fibrinolytics, embolectomy
Thrombosis (coronary) ST segment elevation/depression, abnormal T waves Fibrinolytics, Percutaneous intervention


The goals of shock management include:

  • Improving blood oxygenation
  • Easing oxygen demand
  • Improving volume and fluid distribution
  • Normalizing electrolyte and metabolic disturbances
Shock Identification and Management
Treatment Goal Key Intervention (s)
Improving blood oxygenation Supplemental O2 via face mask/non-rebreather
Mechanical ventilation through advanced airway
Packed red blood cells
Easing oxygen demand Reduce fever
Treat pain
Treat anxiety
Normalizing electrolyte and metabolic disturbances Treat imbalances promp
IV electrolytes for deficiencies
Ventilatory settings for acidosis/alkalosis
Glucose for hypoglycemia
Improving volume and fluid distribution Treatment depends on type of shock
Types of Shock, Signs and Symptoms
Hypovolemic Distributive Cardiogenic Obstructive
Mechanism Too little volume Volume distributed to tissues Heart problem Cardiac outflow impediment
Potential Causes Vomiting/Diarrhea Hemorrhage DKA Burns Poor Fluid Intake Sepsis Head/Spine Injury Anaphylaxis Congenital Heart Dz Poisoning Myocarditis Cardiomyopathy Arrhythmia Cardiac Tamponade Tension Pneumo Congenital Heart Dz Pulmonary Embolus
Preload Decreased Normal or Decreased Varies Varies
Contractility Normal/Increased Normal or Decreased Decreased Normal
Afterload Increased Varies Increased Increased
Respiratory Rate and Effort Increased rate No increased effort Increased rate +/- Increased effort Markedly increased effort Markedly increased effort
Breath Sounds Normal +/- Rales Rales and grunting
Systolic BP May be normal (compensated), but soon compromised without intervention
Pulse Pressure Narrow Varies Narrow Narrow;
Heart Rate Increased Increased Increased Increased Distant heart sounds
Peripheral Pulses Weak Bounding or Weak Weak or absent Jugular vein distention Weak
Capillary Refill Delayed Varies Delayed Delayed
Urine Output Decreased
Consciousness Irritable and anxious, early. Altered mental status, later.

Fluid Resuscitation

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.

Signs and Symptoms of Dehydration
Category Deficit ml/kg (% body wt.) Signs/Sx
Infants Adolescents
Mild 50 (5%) 30 (3%) Slightly dry buccal mucosa, increased thirst, slightly decreased urine output
Moderate 100 (10%) 50–60 (5–6%) Dry buccal mucosa, tachycardia, little or no urine output, lethargy, sunken eyes and fontanelles, loss of skin turgor
Severe 150 (15%) 70–90 (7–9%) Same as moderate plus a rapid, thready pulse; no tears; cyanosis; rapid breathing; delayed capillary refill; hypotension; mottled skin; coma
Interventions by Shock Type
Broad Type Specific Type Management
Hypovolemic Hemorrhagic Fluid resuscitation, packed red blood cells
Non-hemorrhagic Fluid resuscitation
Distributive Septic Septic Shock Algorithm
Anaphylactic Epinephrine IM, fluid resuscitation
Neurogenic Fluid resuscitation, pressors
Cardiogenic Bradyarrhythmia Bradycardia Algorithm
Tachyarrhythmia Tachycardia Algorithm
Heart Disease Fluid resuscitation, pressors, expert consult
Obstructive Ductus Arteriosis PGE1 (alprostadil), expert consult
Tension Pneumo Needle decompression, tube thoracostomy
Tamponade Pericardiocentesis
Pulmonary Embolism Fluid resuscitation, fibrinolytics, expert consult
Fluid Resuscitation
Broad Type Specific Type Volume Rate
Hypovolemic Hemorrhagic 3 ml of crystalloid for each ml blood lost Over 5-10 min
Non-hemorrhagic 20 ml/kg bolus, repeat as needed Over 5-10 min
Diabetic Ketoacidosis 10-20 ml/kg bolus, repeat as needed Over 60 min
Distributive All types 20 ml/kg bolus, repeat as needed Over 5-10 min
Cardiogenic All types 5-10 ml/kg bolus, repeat as needed Over 10-20 min
Obstructive Tamponade 20 ml/kg bolus Over 5-10 min
Pulmonary Embolism 20 ml/kg bolus, repeat as needed Over 5-10 min

Return of Spontaneous Consciousness (ROSC) and Post Arrest Care

  • restutrnIn 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

Postresuscitation Management

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.

Fluid Maintenance
Body Weight (kg) Hourly Maintainence Fluid Rate
<10 kg 4 mL/kg/hour
10-20 kg 40mL/hour + 2 mL/kg/hour for each kg >10
>20 kg 60mL/hour + 1 mL/kg/hour for each kg >20
Postresuscitation Management Priorities
System Priority Intervention
Respiratory Maintain oxygenation Titrate oxygen to maintain O2 sat: 94%-99%
Maintain ventilation Intubate and use ventilator if needed
Monitor vital signs Pulse oximetry, pO2, resp. rate, end tidal CO2
Testing CXR, ABGs
Control pain/anxiety Fentanyl or morphine as needed
Cardiovascular Testing Heart rate, blood pressure, CVP and cardiac output, blood gases, hemoglobin/hematocrit, blood glucose, electrolytes, BUN, calcium, creatinine, ECG
Maintain fluid volume Use the Shock Algorithm or maintenance fluids
Treat arrhythmias Use drugs or electrical therapy
(Bradycardia or Tachycardia Algorithms)
Neurologic Testing Avoid fever, do not re- warm a hypothermic patient unless the hypothermia is deleterious, consider therapeutic hypothermia if child remains comatose after resuscitation, neurologic exam, pupillary light reaction, blood glucose, electrolytes, calcium, lumbar puncture if child is stable to rule out CNS infection
Intracranial Pressure Support oxygenation, ventilation and cardiac output Elevate head of bed unless blood pressure is low Consider IV mannitol for increased ICP
Seizure Precautions and Treatment Treat seizures per protocol, consider metabolic/toxic causes and treat
Renal Monitor urine output Insert urinary catheter
Urine output, infants and children: > 1 ml/kg/h Urine output, adolescents: > 30 ml/h,
Testing Urine glucose, lactate, BUN, creatinine, electrolytes, urinalysis, fluids as tolerated, correct acidosis/alkalosis with ventilation (not sodium
Gastrointestinal Nasogastric tube Maintain NG tube to low suction, watch for bleeding
Testing Liver function tests, amylase, lipase, abdominal ultrasound and/or CT
Hematologic Testing Hemoglobin/Hematocrit/Platelets, PT, PTT, INR, fibrinogen and fibrin split products, type and screen
Consider blood therapy If fluid resuscitation inadequate: Tranfuse packed red blood cells Active bleeding/low platelets: Tranfuse platelets Active bleeding/abnormal coags: Tranfuse fresh frozen plasma

Transport to Tertiary Care Center

  • 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


bradyBradycardia 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.


tecchanTachycardia 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

Tachycardia with Pulse and Poor Perfusion

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.


Tachycardia with Pulse and Good Perfusion

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



ECG Characteristics of Tachyarrhythmias
Sinus Tachycardia Supraventricular tachycardia Ventricular tachycardia
Narrow QRS complex
P waves normal
PR interval constant
R-R interval may be variable
Narrow or wide QRS complex
P waves absent or abnormal
R-R interval may be constant
Wide QRS complex
P waves may not be present/seen
QRS complexes may be uniform or

PALS Tools

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.


PALS Airways

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

  • accessIntraosseus 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.

Team Dynamics/Systems of Care

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.

Team Leader Responsibilities Team Member Responsibilities
Usually stands at the foot of the bed Stands in a position dictated by role
Competent in all ACLS duties Competent in specific role (at least)
Directs Team Members in a professional, calm voice Responds with eye contact and voice affirmation
Assigns roles Clearly states when he/she cannot perform a role
Listens for confirmation from Team Member Informs Team Leader when task is complete
Ask for ideas from Team Members when needed Openly share suggestions if it does not disrupt flow
Critiques Team Performance after code Provides constructive feedback after code
Documents resuscitation in patient chart Provides information for documentation as needed


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.

ECG Rhythms

 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:



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.



Resuscitation and Life Support Medications

Drug Use(s) Dosage/Route Contraindications/Warnings
Adenosine Supraventricular Tachycardia First dose: 0.1 mg/kg IV Push
Max 1st Dose: 6 mg. First dose: 0.2 mg/kg IV Push Max 1st Dose: 12 mg.
Second or third degree heart block
Albumin Shock, trauma, burns 0.5 to 1 g/kg IV Push Blood product
Albuterol Asthma, bronchospasm, hyperkalemia Weight 20kg: 2.5 mg Weight 20kg: 5 mg Caution in tachyarrhythmias
Alprostadil Maintain ductus arteriosis First Dose: 0.05 to 0.1 mcg/kg/min Maintenance: 0.01 to 0.05 mcg/kg/min Tissue sloughing in extravasation
Amiodarone Supraventricular Tachycardia, Ventricular Tachycardia with Pulse 5 mg/kg over 20-60 min Max:300 mg max Second or third degree heart block
Ventricular Tachycardia Ventricular Fibrillation 5 mg/kg rapid bolus to 300 mg max Max:300 mg max
Atropine Symptomatic bradycardia 0.02 mg/kg IV (May give twice) Max dose: 0.5 mg 0.04-0.06 mg/kg via ETT Dose < 0.5 mg may worsen bradycardia Do not use in glaucoma, tachycardia
Toxins, poisons, and overdoses 0.02-0.05 mg/kg every 20-30 min
Dexamethasone Croup, Asthma First Dose: 0.6mg/kg Max Dose: 16 mg Can be given PO/IM/IV
Dextrose Hypoglycemia 0.5 to 1 g/kg Follow glucose
Diphenhydramine Anaphylaxis after epinephrine 1 to 2 mg/kg every 4 to 6 h Max Dose: 50 mg Use with caution in glaucoma, ulcer, hyperthyroidism
Dobutamine Ventricular dysfunction n 2 to 20 mcg/kg per min Do not mix w/ sodium bicarb
Dopamine Ventricular dysfunction, Cardiogenic or distributive shock 2 to 20 mcg/kg per min Titrate to response Do not mix w/ sodium bicarb
Epinephrine Anaphylaxis 0.01 mg/kg q15 min Max: 0.3mg Make sure to distinguish and account for 1:1000 and 1:10000 concentrations.
Croup 0.25 ml via nebulizer
Cardiac Arrest 0.01 mg/kg (1:10000) IV or 0.1 mg/kg (1:1000) ETT q3-5 min
Shock 0.1 to 1 mcg/kg per min IV
Symptomatic Bradycardia 0.01 mg/kg IV q3-5 min Max: 1 mg
Toxins Overdose 0.01 mg/kg (1:10000) IV Max Dose: 1 mg Avoid in cocaineinduced ventricular tachycardia
Etomidate Sedation for intubation 0.2 to 0.4 mg/kg IV over 30-60 s Max Dose: 20 mg Avoid in septic shock
Furosemide Pulmonary Edema Diuresis 1 mg/kg IV/IM Max Dose: 20 mg Monitor potassium
Hydrocortisone Adrenal Insufficiency 2 mg/kg IV bolus Max Dose: 100 mg Use with caution in infection
Inamrinone Myocardial Dysfunction Cardiogenic Shock CHF Loading: 0.75-1 mg/kg IV over 5-10 min. May repeat twice Max Dose: 3 mg/kg Maintenance 5-10 mcg/kg/min Monitor ECG, oxygen, BP
Ipratropium Asthma 250 to 500 mcg neb q 20 min
Lidocaine V Fib and Pulseless VT Wide Complex Tachycardia 1 mg/kg IV bolus Then 20 to 50 mcg/kg per min Contraindicated for wide complex Rapid Sequence Intubation 1-2 mg/kg IV bradycardia
Rapid Sequence Intubation 1-2 mg/kg IV
Magnesium Sulfate Asthma 25-50mg/kg IV over 15-30 min Rapid bolus may cause hypotension and bradycardia
Pulseless Torsades de pointes 25-50 mg/kg IV bolus
Ventricular Tachycardia w/ pulses 25-50 mg/kg over 10-20 m
Drug Use(s) Dosage/Route Contraindications/Warnings
Methylprednisolone Asthma Anaphylactic shock Loading: 2 mg/kg IV (up to 60mg) Maintenance: 0.5 mg/kg q 6 h Anaphylaxis possible
Milrinone Cardiogenic shock Post-surgery CHF Loading: 50 mcg/kg IV over 10-60 m Maintenance: 0.25-0.75 mcg/kg/min Watch in hypovolemia
Naloxone Narcotic reversal Total Reversal: 0.1 mg/kg IV q 2 min Max Dose: 2 mg Partial Reversal: 1-5 mcg/kg IV Consider airway before use
Nitroglycerine CHF Cardiogenic Shock Begin: 0.25-0.5 mcg/kg/min Titrate: q 15-20 minutes Max Dose: 10 mcg/kg/min Watch for hypotension in hypovolemia
Nitroprusside Cardiogenic Shock Hypertension Begin: 0.3 to 1 mcg/kg/min Max Dose: 8 mcg/kg/min Check thiocyanate and cyanide levels
Norepinephrine Shock 0.1 to 2 mcg/kg/min Titrate to target blood pressure Extravasation leads to tissue necrosis Give via central line
Procainamide Atrial Flutter Supraventricular Tachycardia; Ventricular Tachycardia w/ Pulse Loading: 15 mg/kg over 30-60 min Follow QT int., BP Consider expert consultation
Sodium Bicarb Severe Metabolic Acidosis Hyperkalemia 1 mEq/kg slow IV bolus Max: 50 mEq Support ventilation Not recommended in cardiac arrest
Terbutaline Asthma Hyperkalemia 10 mcg/kg SQ q 10-15 min until IV access 0.1-10 mcg/kg/min IV Use with cautioun in hypokalemia
Vasopressin Cardiac Arrest Septic Shock 0.4-1 unit/kg IV bolus Max Dose: 40 units Check distal pulses Water intoxication Extravasation causes tissue necrosis