PALS Certification Course
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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

  • Neonate (0 to 28 days old): SPB < 60 mmHg
  • Infants (1month to 12 montsh): SBP < 70 mmHg
  • Children (1yr to 10yrs): SBP < 70+(2xage in years) mmHg
  • Children (over 10yrs): SBP

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:

  • Patient presents with an arrhythmia.
  • Vital signs maintain patient asymptomatic without chest pain, shortness of breath, or confusion.
  • Patient remains conscious.
  • There is a high risk for patient becoming unstable.

Unstable:

  • Patient presents with an arrhythmia.
  • Vital signs cause patient to become symptomatic with chest pain, shortness of breath, or confusion.
  • Patient has a high risk of death.

Dead:

  • Patient presents with an arrhythmia.
  • Patient has no pulse, is without vital signs, and/or is unconscious.
  • Best chance for success is Electrical Therapy within 10 minutes of event!

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:

  • Stimulate and speak to the child.
  • Look at the chest and torso for movement and normal breathing.

If unresponsive:

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

  • Perform 2 minutes of CPR first then call the emergency response team and bring an AED to the patient.

If alone and collapse is witnessed:

  • (one provider) Call the emergency response team and bring an AED first, then start CPR.​
  • (two providers) Have someone near call the emergency response team and bring the AED.
  • (two providers) You start CPR.

Place patient supine on a hard flat surface.

Circulation

  • Check the patient for a carotid pulse for 5-10 seconds.
check for carotid pulse

If pulse:

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

  • Provide 12-20 rescue breaths per minute.
  • Recheck pulse every 2 minutes.

If no pulse:

Begin 5 cycles of CPR (lasts approximately 2 minutes)

Start with chest compressions:

  • Provide 100 to 120 compressions per minute. This is 30 compressions every 15 to 18 seconds.
  • Use one or two arms.
  • Place one or both of your palms midline, one over the other, on the lower sternum, between the nipples.
  • Press at least to 1/3 the depth of patient’s chest or 2 inches.
  • Press hard and fast.
  • Allow for full chest recoil with each compression.
  • Allow for only minimal interruptions to 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):

  • Place your fingers on the lower rami of the jaw.
  • Provide anterior pressure to advance the jaw forward.

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.

  • place your palm on the patient’s forehead and apply pressure to tilt the head backward.
  • place the fingers of your other hand under the mental protuberance of the chin and pull the chin forward and cephalic.

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).

  • Use a barrier device if available.
  • Pinch the patient’s nose closed.
  • Make a seal using your mouth over the mouth of the patient.
  • Each rescue breath should last approximately 1 second.
  • Watch for chest rise.
  • Allow time for the air to expel from patient.

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:

  • Provide 12-20 rescue breaths per minute (do not stop chest compressions for rescue breaths).

If patient has a pulse and no CPR is required:

  • Provide 12 -20 rescue breaths per minute.
  • Recheck pulse every 2 minutes.

If foreign body obstruction:

  • Perform abdominal thrusts.
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.

  • place the patient close to a true lateral position with the head dependent to allow fluid to drain.
  • Assure the position is stable.
  • Avoid pressure of the chest that could impairs breathing.
  • Position patient in such a way that it allows turning them onto their back easily.
  • Take precautions to stabilize the neck in case of cervical spine injury.
  • Continue to assess and maintain access of airway.
  • Avoid the recovery position if it will sustain injury to the patient.
recovery position

Defibrillate

Arrival of AED (Automated External Defibrillator)

Power:

  • Turn AED On NOW! (early defibrillation is the single most important therapy for survival of cardiac arrest. Use immediately upon its arrival to the scene).
  • Follow verbal AED prompts.

Attachment:

  • Firmly place appropriate pads (adult/pediatric) to patient’s skin to the indicated locations (pad image).

Analyze:

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

If rhythm is not shockable:

  • Initiate 5 cycles of CPR.
  • Recheck the rhythm at the end of the 5 cycles of CPR.

If shock is indicated:

  • Assure no one is touching the patient or in mutual contact of a good conductor of electricity by yelling “Clear, I’m Clear, you’re Clear!” prior to delivering a shock.
  • Press the shock button when the providers are clear of the patient.
  • Resume 5 cycles of CPR.

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:

  • (One provider) If alone and collapse is un-witnessed: First perform 2 minutes of CPR then call the emergency response team and bring an AED to the patient.
  • (One provider) If alone and collapse is witnessed: First call the emergency response team and bring an AED, then start CPR.
  • (Two providers) Have someone near call the emergency response team and bring the AED and you start CPR.
  • Place patient supine on a hard flat surface.

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.

  • Give 12-20 breaths per minute.
  • Recheck the pulse every 2 minutes.

If the infant doesn’t have a pulse:

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

Start with Chest Compressions:

  • Provide 100 to 120 compressions per minute. This is 30 compressions every 15 to 18 seconds.
  • (One provider) Place two fingers on the sternum of the lower chest. One between the nipple line and the other 1cm below.
  • (Two providers) Encircle the infant’s torso with both hands with both thumbs pointing cephalic positioned 1cm below the nipples over the sternum.
  • Chest Compressions should be at least 1.5 inches or 1/3 the depth of infant’s chest.
  • Press hard and fast.
  • Allow for full chest recoil.
  • Only allow minimal interruptions to the 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.):

  • Place your thumbs on the upper cheek bones of the infant.
  • Place your fingers on the lower rami of the jaw.
  • Provide anterior pressure to advance the jaw forward.

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

Use the Head Tilt-Chin Lift maneuver:

  • place your palm on the patient’s forehead and apply pressure to tilt the head backward.
  • place the fingers of your other hand under the mental protuberance of the chin and pull the chin forward and cephalic.
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:

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

If the infant is not breathing or is inadequately breathing:

If the infant has a pulse:

  • commence rescue breaths immediately.

If the infant doesn’t have a pulse:

  • begin CPR (go to Circulation portion of the algorithm).
  • Use a barrier device if available.
  • Make a seal using your mouth over the mouth and nose of the patient.
  • Each rescue breath should be small and last approximately 1 second.
  • Watch for chest rise.
  • Allow time for the air to expel from the patient.

During normal CPR with an advanced airway:

  • Provide 12-20 rescue breaths per minute (do not stop chest compressions for rescue breaths).

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

  • Provide 12-20 rescue breaths per minute.
  • Recheck pulse every 2 minutes.
infant rescue breaths

Recovery position for infants

  • Cradle the infant with the infant’s head tilted downward and slightly to the side to avoid choking or aspiration.
  • Continually check the infants breathing, pulse, and temperature.

Defibrillate

Arrival of AED (Automated External Defibrillator)

Power:

  • Turn AED On NOW! (early defibrillation is the single most important therapy for survival of cardiac arrest. Begin use on patient as soon as it arrives).
  • Follow verbal AED prompts.

Attachment:

  • Firmly place appropriate pads (adult/pediatric) to patient’s skin to the indicated locations (pad image).

Analyze:

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

If the rhythm is not shockable:

  • Initiate 5 cycles of CPR.
  • Recheck the rhythm at the end of the 5 cycles of CPR.

If shock is indicated:

  • Assure no one is touching the patient or in mutual contact of a good conductor of electricity by yelling “Clear, I’m Clear, you’re Clear!” prior to delivering a shock.
  • Press the shock button when the providers are clear of the patient.
  • Resume 5 cycles of CPR.

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:

  • Do not attempt Heimlich maneuver.

If complete airway obstruction:

  • (one provider) immediately call the emergency response team.
  • (one provider) Attempt Heimlich maneuver
  • (two provider) Send someone to call the emergency response team, while you attempt the Heimlich maneuver.

How to perform the Heimlich maneuver:

  • Stand directly behind the child/adult.
  • Place both of your arms around patient’s waist.
  • Make a fist with one hand and grab the fist with opposite hand.
  • Position the thumb end of the fisted hand immediately above the patient’s naval (ample distance away from the xiphoid process).
  • Perform fast upward and inward diaphragmatic abdominal thrusts.
  • Continue abdominal thrusts until the obstruction is removed.

If patient becomes unconscious:

  • Initiate CPR.

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:

  • (one provider) immediately call the emergency response team.
  • (one provider) Assess the airway for any visually present obstruction and manually remove it if possible.
  • (two provider) Send someone to call the emergency response team while you assess the airway.
  • Never use a blind finger sweep.

Position the patient:

  • Lay infant’s face and torso down on forearm (prone) with chest being supported by your palm and their head and neck by your fingers.
  • Tilt the infant’s body at a 30 degree angle, head downward (trandelenburg).
  • Use your thigh or other object for support.

Interventional Back Blows:

  • Provide 5 rapid forceful blows using a flat palm on the infant’s back between the two scapula.

Reposition the patient:

  • Rotate the infant face up (supine), head downward (trandelenburg) by switching the infant to the opposite arm.

Interventional Chest Thrusts:

  • Place your two fingers on the center of the infant’s sternum immediately below the nipple line.
  • Provide 5 rapid compressions, with thrusts equaling 1/3 to 1/2 the total depth of the chest.
  • Continue cycling back and forth between interventional back blows and chest thrusts until the obstruction is removed or until consciousness is lost.

If becomes unconscious:

  • Initiate CPR.
  • 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.

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

Airway (Two Providers)

  • Initially provide rescue breaths using an ambu bag and a mask at full flow oxygen.
  • Perform continued assessment of airway patency while giving breaths. (Condensation on mask during exhalation, chest rise, Et CO2)
  • Have the person doing chest compressions pause during the 2 rescue breaths.
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:

  • Look for condensation during exhalation.
  • Look for equal bilateral chest rise.
  • Confirming equal bilateral breath sounds with auscultation.
  • Auscultate stomach to assure esophageal intubation didn’t occur.
  • End-tidal CO2 should be verified during exhalation using monitor or ETD
  • Use portable chest x-ray.

If incorrect placement:

  • Remove the airway device, ventilate the patient using the ambu bag for a short period of time, and then reattempt placement.

If incorrect placement:

  • Secure placement of the airway device.

Continue to monitor:

  • oxygenation saturation with pulse oximeter
  • end-tidal CO2

Rescue breathing during CPR with an advanced airway:

  • 12-20 breaths per minute
  • Chest compressions should be given continuously at a rate of 100 to 120 per minute.

Circulation

  • Obtain IV or IO access.
  • Monitors (ECG, BP cuff, pulse oximeter, et CO2 monitor)

Identify:

  • heart rhythm
  • Obtain a 12 lead ECG if possible.
  • Initiate therapy of PALS algorithm corresponding with the identified heart rhythm. (Drug therapy, Electrical therapy, Pacing, etc.)

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:

  • Assure the artificial airway is the appropriate size for the patient.
  • The airway should be easily inserted with a tongue blade.
  • Avoid use in patients with an active gag reflex.

Nasal Trumpet Airway:

  • Best practice is to lube before insertion.
  • Careful not to cause trauma to nasal mucosa (results in bleeding).
  • This is reasonably tolerated by patients with an active gag reflex.

Advanced Airways

Indications:

  • When you are unable to open airway using head tilt-chin lift or jaw thrust maneuvers.
  • If you have difficulty forming a seal with the face mask.
  • If the patient requiring continued ventilatory support.
  • When the patient has a high risk for aspiration (provide an ETT or Combitube).

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)

  • Requires additional instrument for insertion (laryngoscope, glidescope, fiberoptic).
  • Laryngoscope blades (average adult size): MAC 3 or 4, Miller 2 or 3
  • Same sized laryngoscopes or smaller sizes can be used for pediatrics.
  • ETTs require mastery of technique for consistent appropriate placement.

Average size of ETT for orotracheal intubation (mm):

  • Uncuffed: tube = (age/4)+4
  • Cuffed: tube = (age/4)+3

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

  • Children over 1 year: Depth of intubation (cm) = age/2+13
  • Children under 1 year: Depth of intubation (cm) = weight/2+8

2) Tracheal cuff of the ETT is then inflated.

  • Allows for positive pressure ventilation.
  • Reduces risk of aspiration.
  • Helps maintain placement of ETT.

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.

  • When inserting the LMA have the laryngeal cuff deflated.
  • Guide in the LMA cuff without folding back the tip, pressing it against the hard palate.
  • Advance the LMA till the cuff lies in the pharynx.
  • After placement, inflate the laryngeal cuff and check for an adequate seal by using positive pressure ventilation.

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.

  • Place pads and electrodes in correct position to assure an appropriate ECG reading.
  • Set the pacer 10-20 beats per min above the patient’s intrinsic heart rate or 60 beats per min if there is no intrinsic heart rate.
  • Start at O mA and work energy level up until you have capture (heart pulsation).
  • Assure the patient is sedated and comfortable during pacer delivery.

Cardioversion

  • Used if drug therapy and vagal maneuvers fail.
  • Used when patient has a pulse.
  • Used to treat Atrial Fibrillation, Atrial Flutter, Atrial Tach, and Symptomatic VT.
  • Shock performed at peak of R wave.
  • Requires proper lead/pad placement to monitor ECG.

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

Defibrilation

  • Used to treat VF and pulseless VT.
  • Delivery within first 5 mins of cardiac arrest has best results.
  • CPR before and after each shock improves outcomes.

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

  • Dry and warm the infant
  • Position the infant supine on a hard flat surface in sniffing position
  • Suction and stimulate the infant
  • Provide oxygen therapy, IV/IO
  • Monitors: SpO2, BP, ECG

If HR < 100 BPM:

  • Assess and provide ventilation support.

If HR < 60 BPM:

  • Provide chest compressions with concurrent ventilation support.
  • If patient fails to respond to stimulus and treatment: Assess rhythm and provide appropriate drug treatment.

Tachycardias

  • Begin CABD
  • Monitors: SpO2, BP, ECG
  • Provide oxygen therapy, IV or IO.
  • Assess rhythm and possible cause.

Narrow QRS Complex

Sinus Tachycardia

Treat reversible causes:

  • Hypoxia
  • Acidosis
  • Pulmonary thrombosis
  • Tension pneumothorax
  • Coronary thrombosis
  • Cardiac tamponade
  • Hypoglycemia
  • Hyperkalemia
  • Hypokalemia
  • Hypothermia
  • Hypovolemia
  • Poisoning

SupraVentricular Tachycardia (SVT)

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

 

Stable:

  • Vagal maneuvers
  • Adenosine: 0.1 mg/kg IVP or IOP (6mg maximum dose)
  • May repeat: Adenosine 0.2 mg/kg IVP or IOP
  • Sedation and synchronized cardioversion
  • 1st Cardioversion: 0.5-1.0 J/kg
  • Following Cardioversions: 2 J/kg

Unstable:

  • Sedation and synchronized cardioversion
  • 1st Cardioversion: 0.5-1.0 J/kg.
  • Following Cardioversions: 2 J/kg

Wide QRS Complex

Ventricular Tachycardia with a pulse

stable:

 

If regular monomorphic:

  • Adenosine: 0.1 mg/kg IVP or IOP (6mg maximum dose)
  • Amiodarone: 5 mg/kg IV or IO in 20 to 60 minutes
  • Procainamide: 15mg/kg IV or IO in 30 to 60 minutes

Unstable:

  • Consider synchronized cardioversion
  • 1st Cardioversion: 0.5-1.0 J/kg.
  • Following Cardioversions: 2 J/kg

Pulseless Ventricular Tachycardia / Refractory Ventricular Fibrillation

Unstable (shock, severe hypotension)

 

Electrical therapy:

  • Initiate electrical therapy as soon as possible!
  • 1st Defibrillate: Defibrillate at 2j/kg
  • If 1st Defibrillate unsuccessful: 2nd Defibrillate at 4j/kg
  • If 2nd Defibrillate unsuccessful: following Defibrillations at 4 j/kg

Drug therapy:

  • Give Epinephrine 1:10,000: 0.01 mg/kg by IV or IO (or give Epinephrine 1:1,000: 0.1 mg/kg by ET)
  • Give Lidocaine: 1 mg/kg by IV or IO
  • Give Amiodarone: 5mg/kg by IV or IO

Toursades de Pointe or Low Magnesium Level

  • Give Magnesium: 25-50 mg/kg by IV or IO

Bradycardia (< 60 BPM)

  • Begin CABD
  • Monitors: SpO2, BP, ECG
  • Provide oxygen therapy, IV or IO
  • Assess rhythm and possible cause (Most common cause is hypoxia)
  • Treat possible causes with appropriate drug, electrolyte, and fluid therapy
  • Place defibrillator on patient for possible electrical therapy.

Drug therapy:

  • Give Epinephrine in a 1:10,000 solution: 0.01 mg/kg by IV or IO every 3 to 5 minutes (or give Epinephrine in a1:1,000 solution: 0.1mg/kg by ETT every 3 to 5 minutes)
  • Atropine: 0.02 mg/kg by IV or IO with a minimum single dose of 0.1mg and a maximum single dose of 0.5mg in a child (used for AV block and to increase vagal tone).

Electrical therapy:

  • Consider transcutaneous pacing

Asystole / Pulseless Electrical Activity (PEA)

  • Begin CABD
  • Monitors: SpO2, BP, ECG
  • Provide oxygen therapy, IV
  • Assess rhythm and possible cause

Treat reversible causes:​

  • Hypoxia
  • Acidosis
  • Pulmonary thrombosis
  • Tension pneumothorax
  • Coronary thrombosis
  • Cardiac tamponade
  • Hypoglycemia
  • Hyperkalemia
  • Hypokalemia
  • Hypothermia
  • Hypovolemia
  • Poisoning

Drug therapy:

  • Epinephrine in a 1:10,000 solution: 0.01 mg/kg by IV/IO every 3 to 5 minutes (or Epinephrine in a 1:1,000 solution: 0.1 mg/kg by ETT every 3 to 5 minutes)

Shock

  • Assess for poor perfusion and altered mental status.
  • Begin CABD
  • Monitors: SpO2, BP, ECG
  • Provide oxygen therapy, IV
  • Assess rhythm and possible cause
  • Labs: blood gas, lactate, glucose, CBC, ionized calcium, cultures.
  • Provided repeated IV bolus’ of crystalloids at 20 ml/kg. (Cease bolus’ at indication of fluid in lungs showing repiratory distress or rales. Also, cease bolus’ if hepatomegaly presents.)

Additional interventions:

  • Administer antibiotics STAT (for septic shock)
  • Correct hypoglycemia
  • Correct hypocalcemia
  • Vasopressors
  • Administer hydrocortisone if possible adrenal insufficiency.

If poor end-organ perfusion continues after fluid administration:

  • Vasopressor therapy
  • Titrate according to need (ScvO2 > 70%)
  • Central line, arterial line may be indicated
  • Warm Shock (vasodilated, hypotensive): administer Norepinephrine 0.1-2 mcg/kg/minute and titrate to BP
  • Cold Shock (vasoconstricted, hypotensive): administer Epinephrine 0.1-1 mcg/kg/minute and titrate to BP

Normal BP with poor perfusion:

  • administer dopamine 2-20 mcg/kg/minute

If ScvO2 >70% and hypotension:

 

Likely due to warm shock.

  • Continue IV fluid therapy
  • Continue administering Norepinephrine 0.1-2 mcg/kg/minute, titrate to BP
  • Consider administering Vasopressin 0.2-2 milliunits/kg/minute

If ScvO2 <70% and normotension:

  • Transfuse PRBC for a Hgb > 10g/dl
  • Continue IV fluid therapy
  • Attempt to optimize arterial oxygenation
  • Consider administering Milrinone loading dose of 50mcg/kg over 10-60 minutes and then o.25-0.75 mcg/kg/min
  • Consider administering Nitroprusside 0.3-1 mcg/kg/minute then titrate (maximum of 8 mcg/kg/minute)
  • Consider administering Dobutamine 2-20 mcg/kg/minute

If ScvO2 <70% and hypotension:

 

Likely due to cold shock.

  • Transfuse PRBC for a Hgb > 10g/dl
  • Continue IV fluid therapy
  • Attempt to optimize arterial oxygenation
  • Continue administering Epinephrine 0.1-1 mcg/kg/minute and titrate to BP and end-organ perfusion
  • Consider administering Dobutamine 2-20 mcg/kg/minute and titrate
  • Consider administering Norepinephrine 0.1-2 mcg/kg/minute and titrate