United Medical Education Logo

PALS Certification Course
(Pediatric Advanced Life Support)

Welcome to the PALS Certification Course by United Medical Education. Unlike with adults, pediatric cardiac arrest is usually due to primary respiratory failure. Respiratory failure can lead to a secondary circulatory failure or cardiac arrest caused by hypoxia and respiratory acidosis. As a result, cardiac arrest in pediatrics is rarely a sudden event. We will be covering early recognition and management of respiratory distress and failure, along with how to treat complete cardiopulmonary arrest in the pediatric patient.

Hemodynamics: infants and children

general-pediatric-vital-signs-and-guidelines

PALS Guidelines for Hypotension

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

Hemodynamic Assessment

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

 

Stable:

Unstable:

Dead:

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

Stable:

 

O: Oxygen
M: Monitor
V: vascular access

 

Unstable & Dead:

 

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

CPR: for a child older than 1 year of age to puberty

CABD (Circulation, Airway, Breathing, Defibrillate)

You find a child lying on the ground.

Assess to make sure the scene is safe for you to respond to the down patient.

Assess Unresponsiveness:

If unresponsive:

(One provider) If alone and collapse is un-witnessed:

If alone and collapse is witnessed:

Place patient supine on a hard flat surface.

Circulation

check for carotid pulse

If pulse:

Move to the airway and rescue breathing portion of the algorithm:

If no pulse:

Begin 5 cycles of CPR (lasts approximately 2 minutes)

Start with chest compressions:

(One Provider: 1 cycle is 30 chest compressions to 2 rescue breaths) (Two Providers: 1 cycle is 15 chest compressions to 2 rescue breaths)

If you have two providers: switch rolls between compressor and rescue breather every 2 minutes or 5 cycles of CPR.

child one arm chest compressions
chest compressions top view

Airway

In the event of an unwitnessed collapse, drowning, or trauma: Use the Jaw-Thrust maneuver. (this maneuver is used when cervical spine injury cannot be ruled out):

In the event of a witnessed collapse and there’s no reason to assume a C-spine injury: Use the Head Tilt-Chin Lift maneuver.

Breathing

Scan the patients chest and torso for possible movement during the “assess unresponsiveness” portion of the algorithm. Watch for abnormal breathing or gasping that will require additional ventilatory support.

If adequate breathing:

Continue to assess and maintain a patent airway and place the child in the recovery position. (Only use the recovery position if its unlikely to worsen patient injury)

If not or inadequate breathing:
has a pulse: Commence rescue breaths immediately.
no pulse: Begin CPR (go to Circulation portion of the algorithm).

During normal CPR without an advanced airway:
(One provider) Provide at least 6 rescue breaths per minute.
(Two provider) Provide at least 12 rescue breaths per minute.

During normal CPR with an advanced airway:

If patient has a pulse and no CPR is required:

If foreign body obstruction:

rescue breaths
rescue breaths with mask and ambu bag

Recovery position (lateral recumbent or 3/4 prone position)

This position is used to maintain a patent airway in the unconscious person.

recovery position

Defibrillate

Arrival of AED (Automated External Defibrillator)

Power:

Attachment:

Analyze:

A short pause in CPR is required to allow the AED to analyze the rhythm.

If rhythm is not shockable:

If shock is indicated:

An AED with a pediatric attenuator should be used in children under 8 years of age if available. An AED without a pediatric attenuator can also be used.

AED
top photo for infant AED use

CPR: for infants 0-1 in age

CABD (Circulation, Airway, Breathing, Defibrillate)

An infant is found lying on the ground.

Assess to make sure the scene is safe for you to respond to the down patient.

Assess Unresponsiveness: Lightly shake or tap the infant’s foot and say their name. Look at the chest and torso for movement and normal breathing.

If the infant is unresponsive:

Circulation

Feel for either the brachial or femoral pulse (Do not check for more than 10 seconds).

brachial and femoral pulse

If the infant has a pulse:

Move to the airway and rescue breathing portion of the algorithm.

If the infant doesn’t have a pulse:

Begin 5 cycles of CPR (lasts approximately 2 minutes).

Start with Chest Compressions:

(One Provider: 1 cycle is 30 chest compressions to 2 rescue breaths) (Two Providers: 1 cycle is 15 chest compressions to 2 rescue breaths)

If you have two providers: switch rolls between compressor and rescue breather every 2 minutes or 5 cycles of CPR.

infant chest compressions

Airway

In the event of an unwitnessed collapse, drowning, or trauma:

Use the Jaw-Thrust maneuver. (This maneuver is used when cervical spine injury cannot be ruled out.):

In the event of a witnessed collapse and there’s no reason to assume C-spine injury:

Use the Head Tilt-Chin Lift maneuver:

infant chin lift

Breathing

Scan the patients chest and torso for possible movement during the “assess unresponsiveness” portion of the algorithm. Watch for abnormal breathing or gasping.

If the infant has adequate breathing:

If the infant is not breathing or is inadequately breathing:

If the infant has a pulse:

If the infant doesn’t have a pulse:

During normal CPR with an advanced airway:

If the patient has a pulse and no CPR is required:

infant rescue breaths

Recovery position for infants

Defibrillate

Arrival of AED (Automated External Defibrillator)

Power:

Attachment:

Analyze:

A short pause in CPR is required to allow the AED to analyze the rhythm.

If the rhythm is not shockable:

If shock is indicated:

Manual defibrillators are preferred for infant use. If the manuals defibrillator is not available the next best option is an AED with a pediatric attenuator. An AED without a pediatric attenuator can also be used.

AED
AED for infant use

Choking: Adult to Child Over 1 Year Old

Heimlich maneuver

Signs and symptoms of a child/adult choking:

Universal signal for choking:
patient has both hands wrapped around the base of their throat.
With complete airway obstruction, the child is unable to speak, cry, or provide any sounds of respiration.
The patient may be confused, weak, obtunded, or cyanotic.

Partial airway obstruction may result in stridor or a high-pitched audible noise during respiration. Partial airway obstruction may allow for a productive cough or allow the patient to speak.

Get the patient’s attention and ask them if they are choking.
Assess for signs and symptoms of airway obstruction.

If partial airway obstruction:

If complete airway obstruction:

How to perform the Heimlich maneuver:

If patient becomes unconscious:

Before attempting rescue breaths during normal CPR, assess the airway, removing any visually present obstruction.
Do not use a blind finger sweep in an attempt to remove an obstruction.

Choking: Infant Under 1 Year Old

choking infant

Signs and symptoms of an infant choking:

With complete airway obstruction, the infant is unable to speak, cry, or provide any sounds of respiration. The infant may be confused, weak, obtunded, or cyanotic.

Partial airway obstruction may result in stridor or a high-pitched audible noise during respiration. If the child has a partial airway obstruction, powerful cough, or strong audible cry, do not attempt the Heimlich maneuver.

If signs and symptoms of choking are present and infant is conscious:

Position the patient:

Interventional Back Blows:

Reposition the patient:

Interventional Chest Thrusts:

If becomes unconscious:

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

Airway (Two Providers)

mask-600x400

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)

Breathing

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:

Circulation

Identify:

Differential Diagnosis

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

Differential Diagnosis Chart:

differential-diagnosis

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.

 

Patent/obstructed
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

Indications:

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.

laryngoscope
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.

Cardioversion

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

Defibrilation

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

defibrilation

Common Cardiac Rhythms

Normal Sinus Rhythm

normal-sinus-rythm

Atrial Tachycardia

atrial-tachycardia

Supraventricular Tachycardia

supraventricular-tachycardia

Atrial Fibrillation

atrial-fibrillation

Atrial Flutter

atrial-flutter

Sinus Bradycardia

sinus-bradycardia

1° Atrioventricular Block

first-degree-atrioventricular-block

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

second-degree-atrioventricular-block-type-1-mobitz-1-wenckebach

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

second-degree-atrioventricular-block-type-2-mobitz-2-hay

3° Atrioventricular Block (Complete Heart Block)

third-degree-atrioventricular-block-complete-heart-block

Ventricular Tachycardia – Monomorphic

ventricular-tachycardia-monomorphic

Ventricular Tachycardia – Polymorphic

ventricular-tachycardia-polymorphic

Ventricular Tachycardia – Torsades de Pointes

ventricular-tachycardia-torsades-de-pointes

Ventricular Fibrillation

ventricular-fibrillation

Asystole

asystole

Pulseless Electrical Activity (PEA)

pulseless-electrical-activity-pea

Cardiopulmonary Resuscitation at Birth

If HR < 100 BPM:

If HR < 60 BPM:

Tachycardias

Narrow QRS Complex

Sinus Tachycardia

Treat reversible causes:

SupraVentricular Tachycardia (SVT)

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

 

Stable:

Unstable:

Wide QRS Complex

Ventricular Tachycardia with a pulse

stable:

 

If regular monomorphic:

Unstable:

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:

Shock

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.