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?
A conscious child who is breathing effectively can be managed in the next steps of PALS, Evaluate-Identify-Intervene.
A unconscious child who is breathing effectively can be managed in the next steps of PALS, Evaluate-Identify-Intervene.
A child who is not breathing adequately but who has a pulse >60 BPM should be treated with rescue breathing.
A child who has a pulse <60 BPM should be treated with CPR and according to the cardiac arrest algorithm.
A child who has a pulse <60 BPM should be treated with CPR and according to the cardiac arrest algorithm.
Evaluate‐Identify‐Intervene
Assuming that the child does not need CPR, rescue breathing, or defibrillation, the next step in this systematic approach in PALS is a circular construct that includes evaluation, identification, and intervention.
The provider will evaluate, identify, and intervene as many times as necessary until the child either stabilizes or her condition worsens, requiring CPR and other lifesaving measures.
“Evaluate” pertains to evaluation of the child’s illness, but also to the success or failure of the intervention.
If the child’s condition worsens at any point, revert to CPR and emergency interventions as needed.
After Spontaneous Return of Circulation (ROSC), use the evaluate–identify–intervene sequence.
The evaluate phase of the sequence includes Primary Assessment, Secondary Assessment, and Diagnostic Tests that are helpful in pediatric life support situations.
While CPR currently uses the C-A-B approach or compressions, airway, breathing, the Primary Assessment in PALS still begins with Airway.
If the child airway is open, you
may move onto the next step. However, if the airway is likely to become compromised, you may consider a basic or advanced airway.
Often, in unresponsive patient or in someone who has a decreased level of consciousness, the airway will be partially obstructed. This instruction does not come from a foreign object, but rather from the tissues in the upper airway. You can improve a partially obstructed airway by performing a head tilt and chin lift. If there is suspected trauma to the cervical spine, use a jaw thrust instead.
A blocked airway would usually requires a basic or advanced airway.
The evaluation of breathing include several signs including breathing rate, breathing effort, motion of the chest and abdomen, breath sounds, and blood oxygenation levels. Normal breathing rates vary by age and are shown in the table. The breathing rate higher or lower than the normal range indicates the need for intervention.
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 3 2 1
Spontaneously To verbal command To pain None
Spontaneously To speech To pain None
Verbal Response
5 4 3 2 1
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 5 4 3 2 1
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
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
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 Obstruction
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 Obstruction
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
Disordered Control of Breathing
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
Ventricular fibrillation and pulseless ventricular tachycardia are shockable rhythms.
The first shock energy is 2 J/kg.
The second shock energy (and all subsequent shocks) is 4 J/kg.
All subsequent shocks are 4 J/kg or greater.
The maximum energy is 10 J/kg or the adult dose (200 J for biphasic, 360 J for monophasic).
Epinephrine (0.01 mg/kg IV/IO) is given every 3 to 5 minutes (two 2 minute cycles of CPR).
Amiodarone (IV/IO)
5 mg/kg bolus
Can be given three times total
If the arrest rhythm is no longer shockable, move to PEA/Asystole algorithm.
If the patient regains consciousness, move to ROSC algorithm.
PEA and Asystole
As long as the patient is in PEA or asystole, the rhythm is not shockable.
Chest compressions/high-quality CPR should be interrupted as little as possible during resuscitation.
After 2 min. of high-quality CPR, give 0.01 mg/kg epinephrine IV/IO every 3 to 5 minutes (two 2 minute cycles of CPR).
Remember, chest compressions are a means of artificial circulation, which should deliver the epinephrine to the heart. Without chest compressions, epinephrine is not likely to be effective.
Chest compressions should be continued while epinephrine is administered.
Rhythm checks every 2 min.
Look for and treat reversible causes (Hs and Ts).
If the arrest rhythm becomes shockable, move to VFib/Pulseless VTach algorithm.
If the patient regains circulation, move to ROSC algorithm.
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.
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.
Return of Spontaneous Consciousness (ROSC) and Post Arrest Care
In a successful resuscitation, there will be a spontaneous return of circulation.
You can detect spontaneous circulation by feeling a palpable pulse at the carotid or femoral artery in children and the brachial artery in infants up to 1 year.
Even after Return of Spontaneous Circulation (ROSC), the patient still needs close attention and support. The patient is at risk for reentering cardiac arrest at any time. Therefore, the patient should be moved to an intensive care unit.
Titrate the patient’s blood oxygen to between 94% and 99%. Wean down supplemental oxygen for blood oxygenation of 100%.
Does the person need an advanced airway? If so, it should be placed. Also, apply quantitative waveform capnography, if available.
Is the patient in shock? If not, monitor and move to supportive measures. If shock is present, determine if it is hypotensive or normotensive.
Identify and treat causes (Hs and Ts). Fluid resuscitation according to cause of shock. Consider vasopressors.
Hypotensive Shock
Epinephrine IV 0.1-1.0 mcg/kg/min
Dopamine IV 2-20 mcg/kg/min
Norepinephrine IV 0.1-2 mcg/kg/min
Normotensive Shock
Dobutamine 2-20 mcg/kg/min
Dopamine IV 2-20 mcg/kg/min
Epinephrine IV 0.1-1.0 mcg/kg/min
50 mcg/kg IV over 10-60 minutes as loading dose, then 0.25-0.75 mcg/kg/ minute IV infusion as maintenance dose
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.
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
Urine glucose, lactate, BUN, creatinine, electrolytes, urinalysis, fluids as tolerated, correct acidosis/alkalosis with ventilation (not sodium bicarb)
Gastrointestinal
Nasogastric tube
Maintain NG tube to low suction, watch for bleeding
Testing
Liver function tests, amylase, lipase, abdominal ultrasound and/or CT bicarb)
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
Bradycardia
Bradycardia is a common cause of hypoxemia and respiratory failure in infants and children. Bradycardia is a slower than normal heart rate. Since the normal heart rate in children varies, the provider must take into account the normal values for the child’s age. A heart rate less than 60 beats per minute in a child under 11 years old is worrisome for cardiac arrest (unless congenital bradycardia is present). In fact, pulseless bradycardia defines cardiac arrest.
If bradycardia interferes with tissue perfusion, maintain the child’s airway and monitor vital signs. Obtain intravenous or intraosseous access. Obtain a 12 lead ECG and provide supplemental oxygen.
If the above interventions help, continue to support the patient and consult an expert regarding additional management.
If the heart rate is still less than 60 bpm despite the above interventions, begin to treat with CPR.
If the child is still experiencing bradycardia, administer epinephrine
IV/IO (0.01 mg/kg). May repeat every 3-5 minutes.
Atropine can be given at a dose of 0.02 mg/kg up to two times.
Min Dose: 0.1 mg.
Max Dose: 0.5 mg.
Consider transvenous or transthoracic pacing if available. You may need to move to the cardiac arrest algorithm if the bradycardia persists despite interventions.
Tachycardia
Tachycardia is a faster than normal heart rate. Since the normal heart rate in children varies, the provider must take into account the normal values for the child’s age. Pulseless tachycardia is cardiac arrest.
During tachycardia, maintain the child’s airway and monitor vital signs. Obtain intravenous or intraosseous access. Access. Obtain a 12 lead ECG and provide supplemental oxygen.
If the tachycardia is causing a decreased level of consciousness, hypotension or shock, or significant chest pain, move directly to synchronized cardioversion.
If the tachycardia is not causing a decreased level of consciousness,hypotension or shock, or significant chest pain, you may attempt vagal maneuvers, first.
Cooperative children can participate in a Valsalva maneuver by blowing through a narrow straw
Carotid sinus massage may be effective in older children. Tachycardia is a slower than normal heart rate.
A vagal maneuvers for an infant or small child is to place ice on the face for 15 to 20 seconds
Ocular pressure may injure the child and should be avoided
If vagal maneuvers fail, you may use
Adenosine: 0.1 mg/kg IV push to a max of 6 mg, followed by 0.2 mg/kg IV push to a max of 12 mg
Procainamide: 15 mg/kg over 30-60 min
Amiodarone: 5mg/kg over 20-60 min to a max of 300 mg
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 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 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
Intraosseus access is an acceptable alternative to IV access in children because the bones are softer and the marrow can be accessed quickly and reliably in emergencies.
IO access also permits chest compressions to continue without interruption (arm IV placement is sometimes more difficult during chest compressions).
IO access can be obtained in the:
Proximal tibia
Distal tibia
Distal femur
Anterior superior iliac spine
An algorithm for obtaining IO access in the proximal tibia is shown.
Avoid IO access in fractured bones, near infection, or in the same bone after a failed access attempt.
After reaching the bone’s interior, do not aspirate and immediately flush with 5 ml of fluid.
Once the resuscitation is successful, replace the IO access with large bore IV access or central line as soon as possible (<24 hours) to avoid infection.
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:
Tachyarrhythmias
Atrial fibrillation is the most common arrhythmia. It is diagnosed by electrocardiogram, specifically the RR intervals follow no repetitive pattern. Some leads may show P waves while most leads do not. Atrial contraction rates may exceed 300 bpm. The ventricular rate often range is between 100 to 180 bpm. The pulse may be “irregularly irregular.”
Atrial flutter is a cardiac arrhythmia that generates rapid, regular atrial depolarizations at a rate of about 300 bpm. This often translates to a regular ventricular rate of 150 bpm, but may be far less if there is a 3:1 or 4:1 conduction. By electrocardiogram, or atrial flutter is recognized by a sawtooth pattern sometimes called F waves. These waves are most notable in leads II, III, and aVF.
Narrow QRS complex tachycardias include several different tachyarrhythmias. A narrow QRS complex tachycardia is distinguished by a QRS complex of less than 90 ms. One of the more common narrow complex tachycardias is supraventricular tachycardia, shown below. The heart rate can exceed 220 bpm in infants and 180 bpm in children.
Wide complex tachycardias are difficult to distinguish from ventricular tachycardia. Ventricular tachycardia leading to cardiac arrest should be treated using the ventricular tachycardia algorithm. A wide complex tachycardia in a conscious child should be treated using the tachycardia algorithm. Tissue perfusion will dictate which algorithm to use.
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.
Asthma
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