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
Intervention2015 Guideline2010 Guideline
Volume for children with febrile illnessRestrictive volumes of isotonic crystalloidsAggressive volume resuscitation
Atropine for emergency tracheal intubationControversial for neonates; no minimum doseRoutine premedication prior to intubation
Arterial blood pressure monitoringIf in place, may be useful to adjust CPRNo guideline
Amiodarone and LidocaineAcceptable for shock-refractory VFib or Pulseless VTachNo guideline
Therapeutic hypothermiaFever should be avoided after ROSC but use of therapeutic hypothermia is controversialTherapeutic hypothermia should be used
Blood PressureFluids and vasoactive agents to maintain systolic blood pressure above the 5th percentile for ageNo guideline
Compressions100 to 120 per minuteAt 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?

breathing

 

  • 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.

 

Evaluate­‐Identify­‐Intervene

  • 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.

breathing_new

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)
MnemonicC-A-B: Compressions, Airway, BreathingABC: Airway, Breathing, Circulation
Breathing CheckBegin CPR if the victim is unresponsive, pulseless, and not (effectively) breathing“Look, listen and feel” plus two rescue breaths
Pulse CheckFor 10 seconds or lessFor at least 15 seconds
CPRHigh Quality CPR when possible, Complete recoil between compressions, rotate providers every 2 minSlower rate, less deep
Priority of CPR and DefibrillationHigh quality CPR and/or defibrillation take priority over venous access, advanced airways, or drugsCPR 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.

cariculam_car

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

cariculam_car

 

 

Normal Heart Rate by Age
Range Rate (BPM)
0-3 months80-205
4 months – 2 years75-190
2-10 years60-140
Over 10 years50-100
Normal Blood Pressure by AgeLow Systolic Blood Pressure by Age
Age Range Diastolic Range
1 Day60-7630-45<60
4 Days67-8435-53<60
1 month67-8436-56<70
1-3 months78-10344-65<70
4-6 months82-10546-68<70
7-12 months67-10420-60<72
2-6 years70-10625-65<70 + (2 X age)
7-14 years79-11538-78<70 + (2 X age)
15-18 years93-13145-85<90

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

AVPU paradigm
AAlertAppropriate, normal activity for the child’s age and usual status
VVerbalResponds only to voice
PPainResponds only to pain
UUnresponsiveResponds 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 ChildPre-verbal Child
Eye Opening4
3
2
1
Spontaneously To verbal command To pain NoneSpontaneously To speech To pain None
Verbal Response5
4
3
2
1
Oriented and talking Confused but talking Inappropriate words Sounds only NoneCooing and babbling Crying and irritable Crying with pain only Moaning with pain only None
Motor Response6
5
4
3
2
1
Obeys commands Localizes with pain Flexion and withdrawal Abnormal flexion Abnormal extension NoneSpontaneous 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
SSigns/SymptomsFever Decreased intake Vomiting/Diarrhea Bleeding Shortness of breath Altered mental status Fussiness/Agitation
AAllergiesMedication allergy Environmental allergy Food allergy
MMedicationsPrescribed Over-the-counter New meds? Last dose?
PPast HistoryBirth history Chronic health issues Immunization status Surgical history
LLast MealBreast/bottle/solid? When? What? How much? New foods?
EEvents/ExposuresHistory of present illness Onset/time course
Key Diagnostic Tests Used in PALS
Test/StudyIdentifies Possible Intervention
Arterial Blood Gas (ABG)HypoxemiaIncrease Oxygenation
HypercarbiaIncrease Ventilation
AcidosisIncrease Ventilation
AlkalosisReduce Ventilation
Arterial LactateMetabolic acidosis, Tissue hypoxiaShock Algorithm
Central Venous Oxygen SaturationPoor O2 delivery (SVO2 <70%)Poor O2 delivery (SVO2 <70%)
Central Venous PressureHeart contractility, othersVasopressors, Shock Algorithm
Chest X-rayRespiratory conditionsSpecific to cause, Respiratory Algorithm
EchocardiogramHeart anatomy and functionSpecific to cause
ElectrocardiogramRhythm DisturbancesSpecific to cause
Peak Expiratory Flow RateRespiratory conditionsSpecific to cause, Respiratory Algorithm
Venous Blood Gas (VBG)AcidosisIncrease Ventilation
AlkalosisReduce 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.

resper

 

Signs and Symptoms of Worsening Respiratory Distress,
Sign/SxMildModerate SevereVerge of Arrest
Accessory Muscles UseNoYesMarkedSeesawing
ActivityWalking, talkingTalking, will sitNo activity, infant will not feedDrowsy
AlertSlightly agitatedAgitatedMarkedly agitatedLethargic
O2 Sat.>95%91 to 95%<90%<90%
PaCO2<45 mmHg<45 mmHg<45 mmHg<45 mmHg
PaO2Normal>60 mmHg<60 mmHg ± Cyanosis<60 mmHg + Cyanosis
PulseNormal100-200 BPM>200 BPM<100 BPM
Respiratory RateIncreasedIncreasedMarkedly IncreasedIncreased or Decreased
Speaking?SentencesPhrasesWordsNot talking
WheezeAudibleLoudVery LoudNone

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 ProblemPossible Causes
Upper AirwayAnaphylaxis
Croup
Foreign body aspiration
Lower AirwayAsthma
Bronchiolitis
Lung Tissue DisorderPneumonia
Pulmonary edema
Disordered Control of BreathingIncreased intracranial pressure
Neuromuscular disease
Toxic poisoning

 

Respiratory Distress, Key Signs and Symptoms
Upper Airway Obstruction Lower Airway Obstruction Lung Disease Disordered Control of
Air MovementDecreasedUnchanged or decreased
AirwayMay or may not be fully patent in respiratory distress. Not patent in respiratory failure.
Breath SoundsCough, hoarseness, stridorWheezingDiminished breath sounds, grunting, cracklesUnchanged
Heart RateIncreased in respiratory distress
Decompensates rapidly to bradycardia as respiratory failure ensues
Skin Color and TemperaturePale, cool, and clammy in respiratory distress Decompensates rapidly to cyanosis as respiratory failure ensuesVaries
Level of ConsciousnessAgitation in respiratory distress Decompensates rapidly to decreased mentation, lethargy, and LOC as respiratory failure ensues
Respiratory Rate and EffortIncreased in respiratory distress Decompensates rapidly in respiratory failureVaries

Respiratory Distress Management

Respiratory Distress Management by Type and Cause
TypePossible Causes Treatment
Upper Airway
Obstruction
AnaphylaxisEpinephrine Albuterol nebulizer Watch for and treat airway compromise, advanced airway as needed Watch for and treat shock
CroupHumidified oxygen Dexamethasone Nebulized epinephrine for moderate to severe croup Keep O2 sat >90%, advanced airway as needed
Foreign body aspirationDo 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
Obstruction
AsthmaNebulized 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)
BronchiolitisOral and nasal suctioning Keep O2 sat >90%, advanced airway as needed Nebulized epinephrine or albuterol
Lung DiseasePneumoniaEmpiric 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 edemaReduce the work of breathing and metabolic demand Keep O2 sat >90%, advanced airway as needed Diuretics if cardiogenic CPAP
Disordered
Control of
Breathing
Increased intracranial pressurePediatric neurological/neurosurgery consult Hyperventilation as directed Use medications (e.g., mannitol) as directed
Neuromuscular diseaseIdentify and treat underlying disease CPAP or ETT and mechanical ventilation as needed
Toxic poisoningIdentify 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 HsSymptoms/Signs/Tests Intervention
HypovolemiaRapid heart rate, narrow QRS complex,Fluid resuscitation
HypoxiaDecreased heart rateAirway management, oxygen
Hydrogen Ion (Acidosis)Low amplitude QRS complexHyperventilation, sodium bicarb
HypoglycemiaFingerstick glucose testingIV Dextrose
HyperkalemiaFlat T waves, pathological U waveIV Magnesium
HyperkalemiaPeaked T waves, wide QRS complexICalcium chloride, sodium bicarb, insulin/glucose, hemodialysis
HypothermiaHistory of cold exposureRewarming blankets/fluids
The TsSymptoms/Signs/Tests Intervention
Tension PneumothoraxSlow heart rate, narrow QRS complex, acute dyspnea, history of chest traumaThoracotomy, needle decompression
Tamponade (Cardiac)Rapid heart rate and narrow QRS complexPericardiocentesis
ToxinsVariable, prolonged QT interval, neuro deficitsAntidote/antivenom (toxin-specific)
Thrombosis (pulmonary)Rapid heart rate, narrow QRS complexFibrinolytics, embolectomy
Thrombosis (coronary)ST segment elevation/depression, abnormal T wavesFibrinolytics, Percutaneous intervention

Shock

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 GoalKey Intervention (s)
Improving blood oxygenationSupplemental O2 via face mask/non-rebreather
Mechanical ventilation through advanced airway
Packed red blood cells
Easing oxygen demandReduce fever
Treat pain
Treat anxiety
Normalizing electrolyte and metabolic disturbancesTreat imbalances promp
IV electrolytes for deficiencies
Ventilatory settings for acidosis/alkalosis
Glucose for hypoglycemia
Improving volume and fluid distributionTreatment depends on type of shock
Types of Shock, Signs and Symptoms
HypovolemicDistributive Cardiogenic Obstructive
MechanismToo little volumeVolume distributed to tissuesHeart problemCardiac outflow impediment
Potential CausesVomiting/Diarrhea Hemorrhage DKA Burns Poor Fluid IntakeSepsis Head/Spine Injury AnaphylaxisCongenital Heart Dz Poisoning Myocarditis Cardiomyopathy ArrhythmiaCardiac Tamponade Tension Pneumo Congenital Heart Dz Pulmonary Embolus
PreloadDecreasedNormal or DecreasedVariesVaries
ContractilityNormal/IncreasedNormal or DecreasedDecreasedNormal
AfterloadIncreasedVariesIncreasedIncreased
Respiratory Rate and EffortIncreased rate No increased effortIncreased rate +/- Increased effortMarkedly increased effortMarkedly increased effort
Breath SoundsNormal+/- RalesRales and grunting
Systolic BPMay be normal (compensated), but soon compromised without intervention
Pulse PressureNarrowVariesNarrowNarrow;
Heart RateIncreasedIncreasedIncreasedIncreased Distant heart sounds
Peripheral PulsesWeakBounding or WeakWeak or absent Jugular vein distentionWeak
Capillary RefillDelayedVariesDelayedDelayed
Urine OutputDecreased
ConsciousnessIrritable 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
InfantsAdolescents
Mild50 (5%)30 (3%)Slightly dry buccal mucosa, increased thirst, slightly decreased urine output
Moderate100 (10%)50–60 (5–6%)Dry buccal mucosa, tachycardia, little or no urine output, lethargy, sunken eyes and fontanelles, loss of skin turgor
Severe150 (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 TypeSpecific TypeManagement
HypovolemicHemorrhagicFluid resuscitation, packed red blood cells
Non-hemorrhagicFluid resuscitation
DistributiveSepticSeptic Shock Algorithm
AnaphylacticEpinephrine IM, fluid resuscitation
NeurogenicFluid resuscitation, pressors
CardiogenicBradyarrhythmiaBradycardia Algorithm
TachyarrhythmiaTachycardia Algorithm
Heart DiseaseFluid resuscitation, pressors, expert consult
ObstructiveDuctus ArteriosisPGE1 (alprostadil), expert consult
Tension PneumoNeedle decompression, tube thoracostomy
TamponadePericardiocentesis
Pulmonary EmbolismFluid resuscitation, fibrinolytics, expert consult
Fluid Resuscitation
Broad TypeSpecific Type Volume Rate
HypovolemicHemorrhagic3 ml of crystalloid for each ml blood lostOver 5-10 min
Non-hemorrhagic20 ml/kg bolus, repeat as neededOver 5-10 min
Diabetic Ketoacidosis10-20 ml/kg bolus, repeat as neededOver 60 min
DistributiveAll types20 ml/kg bolus, repeat as neededOver 5-10 min
CardiogenicAll types5-10 ml/kg bolus, repeat as neededOver 10-20 min
ObstructiveTamponade20 ml/kg bolusOver 5-10 min
Pulmonary Embolism20 ml/kg bolus, repeat as neededOver 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 kg4 mL/kg/hour
10-20 kg40mL/hour + 2 mL/kg/hour for each kg >10
>20 kg60mL/hour + 1 mL/kg/hour for each kg >20
Postresuscitation Management Priorities
SystemPriorityIntervention
RespiratoryMaintain oxygenationTitrate oxygen to maintain O2 sat: 94%-99%
Maintain ventilationIntubate and use ventilator if needed
Monitor vital signsPulse oximetry, pO2, resp. rate, end tidal CO2
TestingCXR, ABGs
Control pain/anxietyFentanyl or morphine as needed
CardiovascularTestingHeart rate, blood pressure, CVP and cardiac output, blood gases, hemoglobin/hematocrit, blood glucose, electrolytes, BUN, calcium, creatinine, ECG
Maintain fluid volumeUse the Shock Algorithm or maintenance fluids
Treat arrhythmiasUse drugs or electrical therapy
(Bradycardia or Tachycardia Algorithms)
NeurologicTestingAvoid 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 PressureSupport oxygenation, ventilation and cardiac output Elevate head of bed unless blood pressure is low Consider IV mannitol for increased ICP
Seizure Precautions and TreatmentTreat seizures per protocol, consider metabolic/toxic causes and treat
RenalMonitor urine outputInsert urinary catheter
Urine output, infants and children: > 1 ml/kg/h Urine output, adolescents: > 30 ml/h,
TestingUrine glucose, lactate, BUN, creatinine, electrolytes, urinalysis, fluids as tolerated, correct acidosis/alkalosis with ventilation (not sodium
bicarb)
GastrointestinalNasogastric tubeMaintain NG tube to low suction, watch for bleeding
TestingLiver function tests, amylase, lipase, abdominal ultrasound and/or CT
bicarb)
HematologicTestingHemoglobin/Hematocrit/Platelets, PT, PTT, INR, fibrinogen and fibrin split products, type and screen
Consider blood therapyIf 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

Bradycardia

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.

Tachycardia

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.

poor-perfusion

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

good_perfu

 

ECG Characteristics of Tachyarrhythmias
Sinus TachycardiaSupraventricular tachycardiaVentricular 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
variable

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_tools

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.

pal_airway

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 ResponsibilitiesTeam Member Responsibilities
Usually stands at the foot of the bedStands in a position dictated by role
Competent in all ACLS dutiesCompetent in specific role (at least)
Directs Team Members in a professional, calm voiceResponds with eye contact and voice affirmation
Assigns rolesClearly states when he/she cannot perform a role
Listens for confirmation from Team MemberInforms Team Leader when task is complete
Ask for ideas from Team Members when neededOpenly share suggestions if it does not disrupt flow
Critiques Team Performance after codeProvides constructive feedback after code
Documents resuscitation in patient chartProvides information for documentation as needed

leader

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.

1st-deg

Second degree atrioventricular block, Mobitz type I (Wenckebach)

The PR interval increases in size until a QRS complexes dropped, resulting in missed “beat.”
2nd-deg

Second degree atrioventricular block, Mobitz type II

A QRS wave will occasionally drop, though the PR interval is the same size.
qrs-2nd-deg

 

Third degree (complete) atrioventricular block

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

3rd-deg

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.

pulsess

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.

asytos

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:

ventricula123r

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:

ventyerieu

 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

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.

atrai_flutter

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.

ataials__3

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

DrugUse(s)Dosage/RouteContraindications/Warnings
Adenosine Supraventricular TachycardiaFirst 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
AlbuminShock, trauma, burns0.5 to 1 g/kg IV PushBlood product
AlbuterolAsthma, bronchospasm, hyperkalemiaWeight 20kg: 2.5 mg Weight 20kg: 5 mgCaution in tachyarrhythmias
AlprostadilMaintain ductus arteriosisFirst Dose: 0.05 to 0.1 mcg/kg/min Maintenance: 0.01 to 0.05 mcg/kg/minTissue sloughing in extravasation
Amiodarone Supraventricular Tachycardia, Ventricular Tachycardia with Pulse5 mg/kg over 20-60 min Max:300 mg maxSecond or third degree heart block
Ventricular Tachycardia Ventricular Fibrillation5 mg/kg rapid bolus to 300 mg max Max:300 mg max
AtropineSymptomatic bradycardia0.02 mg/kg IV (May give twice) Max dose: 0.5 mg 0.04-0.06 mg/kg via ETTDose < 0.5 mg may worsen bradycardia Do not use in glaucoma, tachycardia
Toxins, poisons, and overdoses0.02-0.05 mg/kg every 20-30 min
DexamethasoneCroup, AsthmaFirst Dose: 0.6mg/kg Max Dose: 16 mgCan be given PO/IM/IV
DextroseHypoglycemia0.5 to 1 g/kgFollow glucose
DiphenhydramineAnaphylaxis after epinephrine1 to 2 mg/kg every 4 to 6 h Max Dose: 50 mgUse with caution in glaucoma, ulcer, hyperthyroidism
DobutamineVentricular dysfunctionn 2 to 20 mcg/kg per minDo not mix w/ sodium bicarb
DopamineVentricular dysfunction, Cardiogenic or distributive shock2 to 20 mcg/kg per min Titrate to responseDo not mix w/ sodium bicarb
EpinephrineAnaphylaxis0.01 mg/kg q15 min Max: 0.3mgMake sure to distinguish and account for 1:1000 and 1:10000 concentrations.
Asthma
Croup0.25 ml via nebulizer
Cardiac Arrest0.01 mg/kg (1:10000) IV or 0.1 mg/kg (1:1000) ETT q3-5 min
Shock0.1 to 1 mcg/kg per min IV
Symptomatic Bradycardia0.01 mg/kg IV q3-5 min Max: 1 mg
Toxins Overdose0.01 mg/kg (1:10000) IV Max Dose: 1 mgAvoid in cocaineinduced ventricular tachycardia
EtomidateSedation for intubation0.2 to 0.4 mg/kg IV over 30-60 s Max Dose: 20 mgAvoid in septic shock
FurosemidePulmonary Edema Diuresis1 mg/kg IV/IM Max Dose: 20 mgMonitor potassium
HydrocortisoneAdrenal Insufficiency2 mg/kg IV bolus Max Dose: 100 mgUse with caution in infection
InamrinoneMyocardial Dysfunction Cardiogenic Shock CHFLoading: 0.75-1 mg/kg IV over 5-10 min. May repeat twice Max Dose: 3 mg/kg Maintenance 5-10 mcg/kg/minMonitor ECG, oxygen, BP
IpratropiumAsthma250 to 500 mcg neb q 20 min
LidocaineV Fib and Pulseless VT Wide Complex Tachycardia1 mg/kg IV bolus Then 20 to 50 mcg/kg per minContraindicated for wide complex Rapid Sequence Intubation 1-2 mg/kg IV bradycardia
Rapid Sequence Intubation1-2 mg/kg IV
Magnesium SulfateAsthma25-50mg/kg IV over 15-30 minRapid bolus may cause hypotension and bradycardia
Pulseless Torsades de pointes25-50 mg/kg IV bolus
Ventricular Tachycardia w/ pulses25-50 mg/kg over 10-20 m
DrugUse(s)Dosage/RouteContraindications/Warnings
Methylprednisolone Asthma Anaphylactic shockLoading: 2 mg/kg IV (up to 60mg) Maintenance: 0.5 mg/kg q 6 hAnaphylaxis possible
Milrinone Cardiogenic shock Post-surgery CHFLoading: 50 mcg/kg IV over 10-60 m Maintenance: 0.25-0.75 mcg/kg/minWatch in hypovolemia
Naloxone Narcotic reversalTotal Reversal: 0.1 mg/kg IV q 2 min Max Dose: 2 mg Partial Reversal: 1-5 mcg/kg IVConsider airway before use
Nitroglycerine CHF Cardiogenic ShockBegin: 0.25-0.5 mcg/kg/min Titrate: q 15-20 minutes Max Dose: 10 mcg/kg/minWatch for hypotension in hypovolemia
Nitroprusside Cardiogenic Shock HypertensionBegin: 0.3 to 1 mcg/kg/min Max Dose: 8 mcg/kg/minCheck thiocyanate and cyanide levels
Norepinephrine Shock0.1 to 2 mcg/kg/min Titrate to target blood pressureExtravasation leads to tissue necrosis Give via central line
Procainamide Atrial Flutter Supraventricular Tachycardia; Ventricular Tachycardia w/ PulseLoading: 15 mg/kg over 30-60 minFollow QT int., BP Consider expert consultation
Sodium Bicarb Severe Metabolic Acidosis Hyperkalemia1 mEq/kg slow IV bolus Max: 50 mEqSupport ventilation Not recommended in cardiac arrest
TerbutalineAsthma Hyperkalemia10 mcg/kg SQ q 10-15 min until IV access 0.1-10 mcg/kg/min IVUse with cautioun in hypokalemia
VasopressinCardiac Arrest Septic Shock0.4-1 unit/kg IV bolus Max Dose: 40 unitsCheck distal pulses Water intoxication Extravasation causes tissue necrosis