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PALS Algorithms 2023
(Pediatric Advanced Life Support)

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PALS Guidelines for Hypotension

These blood pressures defining hypotension commonly overlap with the lower normal SBP value spectrum.


It is important to be able to categorize your patients by their hemodynamic stability when choosing an appropriate treatment regimen.




ABG (Normal):

pH: 7.35-7.45
PaO2: 80-100 mmHg
PaCO2: 35-45 mmHg
HCO3: 22-26 mEq/L
O2 sat: 95-100% (on room air)
BE +/- 1
Lowest acceptable SBP for patients older than 1 yr = 70+ (2 x age in years)

Cardiac arrest in the pediatric patient is also commonly due to progressive shock. Compensated shock can be detected by evaluating the patient’s heart rate, presence of peripheral pulses, intravascular volume status, and end-organ perfusion. Sustained tachycardia can be a sign of early cardiovascular compromise. Bradycardia is a common sign of advanced shock and is frequently associated with hypotension.

Basic Treatment Associated with Stability


O: Oxygen
M: Monitor
V: vascular access

Unstable & Dead:

I: IV access
E: ET intubation
D: Defibrillator/monitor

Secondary ABCD
(Airway, Breathing, Circulation, Differential Diagnosis)

Airway (Two Providers)


If the patient is not ventilating well or if there is a presumed risk of aspiration, insert an advanced airway device when prudent:
Endotreacheal Intubation is the preferred method.
(View the advanced airway section)


Confirm correct placement of the advanced airway device:

If incorrect placement:

If incorrect placement:

Continue to monitor:

Rescue breathing during CPR with an advanced airway:



Differential Diagnosis

(needed for successful treatment of some patients)
Consider reversible causes of rhythm/arrhythmia.

Differential Diagnosis Chart:


Airway & Breathing

There are two important principles when evaluating the airway and breathing. First, is the airway patent or obstructed. Second, is there possible injury or trauma that would change the providers method of treating an obstructed airway or inefficient breathing.

If the airway is patent there should be noticeable chest rise/expansion with either spontaneous respirations or with rescue breaths. The provider may also be able to hear or feel the movement of air from the patient.
A completely obstructed airway will be silent. An awake patient will lose their ability to speak, while both a conscious or unconscious patient will not have breath sounds on evaluation. If the patient is attempting spontaneous breaths without success, there may be noticeable effort of intercostal muscles, diaphram, or other accessory muscles without significant chest rise/expansion. The provider will also not feel or hear the movement of air. If the airway is partially obstructed snoring or stridor may be heard.

Cervical Spine Injury?
If the provider evaluates the patient to have an obstructed airway, intervention should take place. If the adverse event of the patient was witnessed and there is no reason to suspect a cercival spine injury, the provider should use the head tilt-chin lift maneuver to open the airway.
If there is a reason to suspect a cervical spine injury, if the patient’s adverse event went unwitnessed, if trauma occured, or the patient suffered drowning the jaw-thrust maneuver should be used to open the airway. If the jaw-thrust proves unsuccessful in opening the patient’s airway attempt an oropharangeal or nasopharangeal airway. If neither technique works, attempt an advanced airway using inline stabilization.

Brain Injury?
The breathing center that controls respirations is found within the pons and medulla of the brain stem. If trauma, hypoxia, stroke, or any other form of injury affects this area, changes in respiratory function may occur. Some possible changes are apnea (cessation of breathing), irregular breathing patterns, or poor inspiratory volumes. If the breathing pattern or inspiratory volumes are inadequate to sustain life, rescue breathing will be required, and an advanced airway should be placed.

Oral Airway:

Nasal Trumpet Airway:

Advanced Airways


Remember, a patient should be unconscious or sedated without an active gag reflex before instrumentation of the airway occurs with an ETT, Combitube, or LMA.

Endotracheal Tube (ETT)

Average size of ETT for orotracheal intubation (mm):

1) The ETT is placed into the trachea, having direct visualization of the vocal cords.

2) Tracheal cuff of the ETT is then inflated.

3) Confirm placement of ETT.
4) Secure the ETT in place.

endotracheal tube

Laryngeal Mask Airway (LMA)

Visualization of the vocal cords is not required for insertion.

Positive pressure ventilation is generally kept under 20 CmH2O to prevent inflation of the stomach.
The patient is still at high risk of aspiration, even with an appropriately placed LMA.

Cardiac/Electrical Therapy

Transcutaneous Pacemaker (External Pacemaker)

Used to treat unstable bradycardias not responding to drug therapy. Provides temporary pacing through the skin in emergency situations.


Pediatric shock energy level:
Monophasic or Biphasic: 0.5-1.0 J/kg
Assure the patient is sedated and comfortable during shock delivery.


Pediatric shock energy level:
Monophasic or Biphasic: 2 J/kg for the first attempt and 4 J/kg for subsequent attempts.


Common Cardiac Rhythms

Normal Sinus Rhythm


Atrial Tachycardia


Supraventricular Tachycardia


Atrial Fibrillation


Atrial Flutter


Sinus Bradycardia


1° Atrioventricular Block


2° Atrioventricular Block- Type 1 (Mobitz I/Wenckebach)


2° Atrioventricular Block- Type 2 (Mobitz II/Hay)


3° Atrioventricular Block (Complete Heart Block)


Ventricular Tachycardia – Monomorphic


Ventricular Tachycardia – Polymorphic


Ventricular Tachycardia – Torsades de Pointes


Ventricular Fibrillation




Pulseless Electrical Activity (PEA)


Cardiopulmonary Resuscitation at Birth

If HR < 100 BPM:

If HR < 60 BPM:


Narrow QRS Complex

Sinus Tachycardia

Treat reversible causes:

SupraVentricular Tachycardia (SVT)

(infants: > 220 BPM; children: > 180 BPM)



Wide QRS Complex

Ventricular Tachycardia with a pulse


If regular monomorphic:


Pulseless Ventricular Tachycardia / Refractory Ventricular Fibrillation

Unstable (shock, severe hypotension)

Electrical therapy:

Drug therapy:

Toursades de Pointe or Low Magnesium Level

Bradycardia (< 60 BPM)

Drug therapy:

Electrical therapy:

Asystole / Pulseless Electrical Activity (PEA)

Treat reversible causes:​

Drug therapy:


Additional interventions:

If poor end-organ perfusion continues after fluid administration:

Normal BP with poor perfusion:

If ScvO2 >70% and hypotension:

Likely due to warm shock.

If ScvO2 <70% and normotension:

If ScvO2 <70% and hypotension:

Likely due to cold shock.


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