PEDIATRIC ADVANCED LIFE SUPPORT (PALS) 2020

IDENTIFY INTERVENE
Initial Impression of the Patient
Call for Help/Activate Emergency Response/Call 911
Appearance
Life Breathing
Threatening Condition
Or Administer Oxygen
Non - Life Threatening Condition
Monitor

-------------------------------------------------------------------------- Pulse Oximeter

Circulation
Pediatric Assessment Triangle
----------------------------------------------------------------------
Appearance – Skin Tone, Interactivity, Severity
---- Type
Consolability, Look/Gaze, Speech/Cry. Upper Airway
Breathing – Work of Breathing, Abnormal Obstruction,
Breathing Sounds, Positioning. Oxygen – Support Ventilation AirwayLower
Obstruction,
Circulation – Skin Color Distress or
Respiratory IV/IO Access Lung Tissue
Failure
Disease,
Primary Assessment Medication/Treatment Disordered
control of
Airway – Open, Clear, Maintainable, Breathing
Unmaintainable, Partial/Complete Obstruction. Compensated Hypovolemic,
----------------------------------------------------------------------
Breathing – RR, Breath Sound, Effort, O2 Sat, or
---- Distributive,
Circulatory
ETCO2. Decompensated Cardiogenic,
Circulation – HR, BP, Central & Peripheral Shock Obstructive
Pulses, Capillary Refill Time (CRT) Perform BASIC LIFE SUPPORT (BLS)
Cardio Respiratory Failure:
Disability – AVPU, Pupil Response, RBS
Respiratory Arrest or Cardiac Arrest
Exposure – Injuries, Rashes/Hives, Temperature,
Weight, MIT

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Emergency. Be Trained.
Save a Life.
PEDIATRIC ADVANCED LIFE SUPPORT (PALS) 2020

RECOGNITION AND MANAGEMENT OF RESPIRATORY EMERGENCIES

TYPE SIGN AND SYMPTOMS POSSIBLE CAUSES INTERVENTIONS
Upper Airway Increase respiratory rate and effort, inspiratory - Foreign Body Airway Obstruction - Ensure Patent Airway, Remove Obstruction,
Obstruction retractions, stridor, snoring respiration, poor (FBAO) - For Anaphylaxis administer Epinephrine via
chest rise, barking cough - Anaphylaxis, Autoinjector, IM or IV
- Epiglottitis - Epinephrine (Croup)
- Croup - Administer Dexamethasone, Consider Hellox
Lower Airway Increase respiratory rate and effort, Prolong - Asthma - Administer O2
Obstruction expiratory phase with increase expiratory effort, - Bronchiolitis - Albuterol via MDI or Nebulizer
Wheezing, Cough - Epinephrine (Asthma)
- Ipratropium Bromide (Asthma)
- Magnesium Sulfate (Status Asthmaticus)
Lung Tissue Disease Increase respiratory rate and effort and heart - Pneumonia - Labs, antibiotic therapy (within 1 hour of
rate, grunting, crackles (rales). - Pulmonary Edema from ARDS & medical contact)
Decrease breath sounds, hypoxia despite Congestive Heart Failure - Albuterol via MDI or Nebulized
administration of O2 - Trauma - Consider CPAP and advanced airway
- Toxins management
Disordered Control of Irregular Respiratory Rate and pattern, - Seizures - Ensure patent airway
Breathing commonly clear breath sounds, Apnea w/o any - Brain injury or trauma - Provide Ventilatory Support
respiratory effort - Brain Tumor - Administer specific medication as needed
- Neuromuscular Disease

EVALUATION RESPIRATORY DISTRESS RESPIRATORY FAILURE INTERVENSIONS

Airway Open and maintainable Not maintainable - Position of Comfort and Administer O2
Breathing Tachypnea, increased to decreased respiratory Bradypnea, decreased respiratory effort, - Basic and advanced airway
effort, good air effort and entry. poor to absent air movement, Apnea maneuvers /management.
Circulation Tachycardia, Pallor Bradycardia, cyanosis - Administered medication/s as needed
Disability Anxiety, Agitation Lethargy, unconscious, unresponsive -IV/IO access and Fluid therapy as needed

Please refer to your PALS eBook and PALS Digital Reference Card for more information on pharmacological interventions and medication administration

Be Prepared for an
Emergency. Be Trained.
Save a Life.
PEDIATRIC ADVANCED LIFE SUPPORT (PALS) 2020

RECOGNITION AND MANAGEMENT OF SHOCK

CONDITION SIGNS & SYMPTOMS ETIOLOGY INTERVENTIONS
Tachypnea, Tachycardia, Adequate to low Severe trauma and/or - Isotonic Fluid 20 ml/kg bolus over 5 – 10
Blood Pressure with narrow pulse pressure, hemorrhage, burns, severe mins.
Hypovolemic Shock
delayed Capillary Refill Time (CRT) diarrhea and vomiting, Diuresis, - Transfuse pRBC, 10 ml/kg
Gastroenteritis
Respiratory Distress with increased Tension Pneumothorax, Cardiac - Isotonic Fluid 20 ml/kg bolus over 5 – 20
Respiratory rate and effort, Tachycardia, Tamponade, Massive Pulmonary mins.
muffled heart sounds, pulsus paradoxus, Embolism - Needle Decompression or Chest tube
Obstructive Shock
jugular vein distension (JVD) Thoracostomy (CTT)
- Pericardiocentesis

Tachypnea, Petechiae/rash/hives, fever, Sepsis, Anaphylaxis, Spinal Cord - Isotonic Fluid 20 ml/kg bolus over 5 – 10
hypotension Injury, Neurogenic Shock mins.
Distributive Shock - Antibiotics (Sepsis)
-Epinephrine, Albuterol, Antihistamine
(Anaphylaxis)
Increased Respiratory Rate and effort, weak Congenital Heart Diseases, - Isotonic Fluid 20 ml/kg bolus over 5 – 10
peripheral pulses, hepatomegaly, Jugular Vein Myocarditis, Cardiac Arrhythmias, mins.
Cardiogenic Shock
Distention (JVD), cyanosis, mottling Cardiomyopathy - Assess for development of Pulmonary
Edema

Compensated Shock Altered Mental Status, Normal and within - Ensure patent airway
range Blood Pressure, Tachycardia, Compensated (potentially hours) - Administer O2 (ventilate as needed)
Tachypnea and shallow breathing, Thirst. - Established IV/IO access
Decompensated Shock Decreased Mental Status, Labored irregular Decompensated (potentially within minutes) - Fluid resuscitation if necessary
breathing, weak central and/or weak/absent - Continuous Monitoring and re-
distal pulses, Hypotension with SBP below Respiratory Arrest/Cardiac Arrest assessment of Vital Signs
normal levels for pediatrics. Obtain laboratories, provide medication
therapy and refer to expert consult

Be Prepared for an
Emergency. Be Trained.
Save a Life.
PEDIATRIC ADVANCED LIFE SUPPORT (PALS) 2020

PEDIATRIC VITAL SIGNS

RESPIRATORY
AGE HEART RATE SYSTOLIC BP DEFINITION OF HYPOTENSION BY SYSTOLIC BP AND AGE IN PEDIATRICS
RATE
Neonate (1-28 days) 100 – 205 bpm 40 – 60 bpm 67 – 84 mm Hg AGE SYSTOLIC BP
Infant (1 – 12 months) 100 – 180 bpm 30 – 53 bpm 72 – 104 mm Hg Term Neonates < 60
Toddler (1 – 2 y/o) 98 – 140 bpm 22 – 37 bpm 86 – 106 mm Hg Infants < 70
Pre-Schooler (3 – 5 y/o) 80 – 120 bpm 20 – 28 bpm 89 – 112 mm Hg Children (1 – 10 years old) < 70 + (age in years x 2)
School Age (6 – 9 y/o) 75 – 118 bpm 18 – 25 bpm 97 – 115 mm Hg Children (> 10 years old) < 90
Adolescent 60 – 100 bpm 12 – 20 bpm 110 – 130 mm Hg

SECONDARY ASSESSMENT
FOCUSED MEDICAL HISTORY – SAMPLE History DIAGNOSTIC ASSESSMENT
S – Sign and Symptoms
A – Allergies - ABG, VBG, Arterial lactate
M – Medications - Hemoglobin concentration
P – Past Medical History - CVP monitoring, Intra-arterial pressure
L – Last oral intake monitoring
E – Events leading to illness or injury - ECG, Chest x-ray, Echocardiogram, PEFR
FOCUSED PHYSICAL EXAMINATION
Illness Areas to Evaluate
Nose & Mouth – Check for signs of airway obstruction,
nasal congestion, stridor, mucosal edema
Respiratory Distress
Heart – check for tachycardia, galloping and
murmuring sounds
Heart – Check for galloping and murmuring sounds
Lungs – Crackles
Suspected Heart Failure and or Cardiac Arrythmias
Abdomen – check for evidence of Hepatomegaly
Extremities – Check for Peripheral edema
Abdomen and Back – Inspect and palpate for any signs
Trauma
of trauma

Be Prepared for an
Emergency. Be Trained.
Save a Life.
PEDIATRIC ADVANCED LIFE SUPPORT (PALS) 2020

RECOGNITION AND MANAGEMENT OF PEDIATRIC BRADYARRYTHMIAS

TYPE CHARACTERISTIC POSSIBLE CAUSES MANAGEMENT

Most common brady arrythmia in children. Develop in response to hypoxia and Atropine IV/IO Dose
Sinus Bradycardia
HR < 60 bpm acidosis
0.02 mg/kg, (min 0.1 mg, max dose 0.5
mg), may repeat dose once after 5
Myocarditis, Hypokalemia, minutes.
1st Degree AV Block Prolong PR Interval Drug/Medication, Acute Rheumatic
Fever Epinephrine IV/IO Dose (Symptomatic
Bradycardia)

2nd Degree Type I AV Block Progressively prolonging PR interval followed by a Drugs/Medication, stimulation of the 0.01 mg/kg (0.1 ml/kg of the 0.1 mg/ml
(Wenckebach) skip/drop beat vagal tone, MI concentration) repeat every 3 – 5
minutes.
For persistent bradycardia: 0.1 – 0.3
2nd Degree Type II AV Block Intrinsic conduction system mcg/kg/minute via infusion.
Same PR Interval with skip/drop beats
(Mobitz Type II) abnormalities, Cardiac surgery, MI
Consider: Transcutaneous Pacing and
seek expert advice
No atrial impulses have reached the ventricles. Extensive conduction system disease,
3rd Degree AV Block
More P waves than QRS complexes, AV dissociation congenital complete heart block

Be Prepared for an
Emergency. Be Trained.
Save a Life.
PEDIATRIC ADVANCED LIFE SUPPORT (PALS) 2020

RECOGNITION AND MANAGEMENT OF PEDIATRIC TACHYARRYTHMIAS

TYPE CHARACTERISTIC POSSIBLE CAUSES MANAGEMENT
Sinus Tachycardia HR > 160 – 170 bpm for Infants Fever, Sepsis, Dehydration, Search for and treat underlying cause/s’
HR > 120 bpm for Children Pain
STABLE PATIENT:
Supraventricular HR > 220 bpm for Infants History of vague/non-specific Vagal Maneuvers
Tachycardia (SVT) HR > 180 bpm for Children symptoms of palpitations, Adenosine rapid IV push
sudden onset - 1st Dose: 0.1 mg/kg rapid IV/IO maximum single dose of 6mg
P waves absent or abnormal, narrow - 2nd Dose: 0.2 mg/kg rapid IV/IO maximum single dose of 12 mg
QRS complexes
UNSTABLE PATIENT:
Inverted P waves in lead II/III/AVF Synchronized Cardioversion. Start with 0.5 – 1 joules/kg followed
by 2 joules/kg for subsequent doses. Provide sedation or
analgesia for hemodynamically stable patients. DO NOT Delay
Synchronized Cardioversion in hemodynamically unstable patients.
STABLE PATIENT:
Monomorphic Broad/wide QRS of more than 0.09 Cardiac surgery, Amiodarone: 5 mg/kg IV push given over 20 – 60 minutes (max of
Ventricular Tachycardia seconds, fusion complexes. Ventricular Cardiomyopathy, Electrolyte 300 mg), Repeat to daily max dose of 15mg/kg (2.2 grams in
Rate may vary from near normal to Disturbance, Drug Toxicity adolescent)
greater than 200 bpm
Consider Adenosine for consistent VT and seek further expert
advice

UNSTABLE PATIENT:
Synchronized Cardioversion. Start with 0.5 – 1 joules/kg followed
by 2 joules/kg for subsequent doses. Provide sedation or
analgesia for hemodynamically stable patients. DO NOT Delay
Synchronized Cardioversion in hemodynamically unstable patients.
Polymorphic ECG looks like row after row of twisted Inherited Long QT syndrome Magnesium Sulfate: 25 – 50 mg/kg IV/IO bolus (maximum of 2
Ventricular Tachycardia ribbon, or like twisting points or peaks Certain Antibiotics, Drugs, grams) given over 10 – 20 minutes.
(Torsades De Pointes) Tricyclic Antidepressants,
Kidney Disease

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Emergency. Be Trained.
Save a Life.
PEDIATRIC ADVANCED LIFE SUPPORT (PALS) 2020

Pediatric Cardiac Arrest Management

Rhythms Medication
Vasoconstrictor Anti-Arrhythmic
Shckable Rhythm Non-Shockable Rhythm
Epinephrine Amiodarone Lidocaine
 Ventricular Fibrillation  Asystole
5 mg/kg IV/IO bolus max.
 Pulseless Monomorphic  Pulseless Electrical Activity 0.01 mg/kg (0.1 ml/kg of the 0.1 1mg/kg IV/IO bolus
300 mg, repeat to daily max
Vtach (PEA) mg/ml concentration) repeat 2 -3 mg/kg via ETT
of 15mg/kg
 Pulseless Polymorphic every 3 – 5 minutes.
Vtach
Priority Priority
1. Defibrillation/Shock 1. Epinephrine  1st medication to be  2nd medication to be administered for cardiac arrest with
2. Resume CPR after 2. Resume CPR after no shock administered on cardiac shockable rhythms.
Defibrillation/shock advice. arrest.  Not to be administered for non-shockable rhythms.
3. Epinephrine 3. Advanced Airway  Only medication to be given  Preferred for refracctory VF.
4. Advanced Airway 4. Rule out H’s and T’s for a non-shockable rhythm.  Maximum of 2 doses only.
5. Amiodarone or Lidocaine  PRN (no max. dose)
6. Rule out H’s and T’s Maintenance Dose of 20 – 50 mcg/kg per minute IV/IO
Infusion (repeat bolus dose if infusion is initiated >15 minutes
Don’t’s Don’ts
after initial bolus.
 No pulse checks after  No to Shock
Shock  No to Amiodarone or
Lidocaine

Pediatric Shock/Defibrillation Dose Reversible Causes (H’s & T’s) Estimating ETT Size
Hypoxia Tension Pneumothorax
1st Dose 2 joules/kg
Hypovolemia Tamponade (Cardiac) Uncuffed ETT Size = (age in years/4) + 4
Hyperkalemia/Hypokalemia Thrombosis (Pulmonary)
2nd Dose 4 joules/kg
Hydrogen Ion (Metabolic or Respiratory) Thrombosis (Cardiac)
≥ 4 joules/kg maximum Hypothermia Toxins Cuffed ETT Size = (age in years/4) + 3.5
Subsequent Doses
of 10 joules/kg Also: Check and treat for Hypoglycemia

Be Prepared for an
Emergency. Be Trained.
Save a Life.
PEDIATRIC ADVANCED LIFE SUPPORT (PALS) 2020

PEDIATRIC POST CARDIAC ARREST MANAGEMENT

COMPONENT MANAGEMENT
 Measure oxygenation and target 94% - 99% o2 saturation (or child’s normal/appropriate O2 Sat).
Oxygen and Ventilation  Measure and target PaCO2, appropriate to the patients underlying condition and limit exposure to severe
hypercapnia/hypocapnia.
 Set specific hemodynamic goals during post cardiac arrest care and review daily.
 Monitor with cardiac telemetry.
 Monitor arterial blood pressure (MAP)
Hemodynamic Monitoring
 Monitor serum lactate, urine output and central venous oxygen saturation to help guide therapies.
 Use parenteral fluid bolus with or without inotropes or vasopressors to maintain a systolic blood pressure greater
than the fifth percentile for age and sex.
 Measure and continuously monitor patient’s core temperature.
 Prevent and treat fever immediately after arrest and during rewarming.
 If patient is comatose, apply Targeted Temperature Management (TTM) of 32°C – 34°C, followed by 36 °C – 37.5 °C
Targeted Temperature Management (TTM)
or only TTM at 36 °C – 37.5 °C.
 Prevent shivering.
 Monitor blood pressure and treat hypotension during rewarming.
 If patient has encephalopathy and resources are available, monitor with continuous electroencephalogram.
Neuromonitoring  Manage and treat seizures
 Consider early brain imaging to diagnose treatable causes of Cardiac Arrest.
 Measure blood glucose levels and avoid hypoglycemia.
Electrolytes and Glucose
 Maintain electrolytes within normal ranges to avoid possible life-threatening arrhythmias.
Sedation  Manage and treat with sedatives and anxiolytics
 Always consider multiple modalities (clinical and other) over any single predictive factor.
 Remember that assessments may be modified by TTM or induced hypothermia
Prognosis
 Consider electroencephalogram in conjunction with other factors within the first 7 days after cardiac arrest.
 Consider neuroimaging such as Magnetic Resonance Imaging (MRI)during the first 7 days after cardiac arrest.

Be Prepared for an
Emergency. Be Trained.
Save a Life.