Pediatric Advanced Life Support

I. PALS System Approach Algorithm

Evaluate

Intervene Identify

Initial Impression

Consciousness Level of consciousness

(unresponsive, alert, irritable)
Breathing Increased work of breathing, absent or decreased respiratory effort, stridor

Color Abnormal skin color, cyanosis, pallor or mottling

EVALUATE:
Clinical assessment Description

Primary assessment Rapid hands on ABCDE approach to evaluate respiratory, cardiac and
neurologic function (vital signs and pulse oximetry)
Secondary assessment Focused medical history and focused physical exam
Diagnostic tests Labs, radiographs to identify the physiologic condition and diagnosis

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 A – airway

B – breathing (rate, effort, chest expansion and air movement, breath sounds, O2 sats)

C – circulation (heart rate, rhythm, pulses, CRT, skin color and temp, BP)

D – disability (consciousness, tone, seizures, pupil abnormalities)

E – exposure (hypothermia, significant bleeding, petechiae, purpura consistent with septic shock)

IDENTIFY

Type Severity

Respiratory Upper airway Respiratory distress

Lower airway Respiratory failure
Lung tissue disease
Disordered control of breathing
Circulatory Hypovolemic shock Compensated shock
Distributive shock Hypotensive shock
Cardiogenic shock
Obstructive shock
Cardiopulmonary failure
Cardiac arrest

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INTERVENE

Position the child to maintain patent airway

Activate emergency response

Start CPR

Obtain code cart and monitors

Place monitors/leads

O2 administration

Support ventilation

Start meds and fluids

Determine if the problem is life threatening:

Absent or agonal respiration, respiratory distress, cyanosis, decreased level of consciousness

II. Team Dynamics

Roles of Team Members

 Airway
 Compressor
 Monitor/defibrillator
 Observer/recorder
 IV/IO/Meds
 Team leader

III. Recognition and Management of Respiratory Emergencies

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Signs of Respiratory Problems
Clinical Signs Upper Airway Lower Airway Lung tissue Disordered Control
Obstruction Obstruction Disease of Breathing

A Patency Airway open and Maintanable/ Not Maintanable

B Respiratory Increased Variable

Rate/Effort

Breath Sounds Stridor Wheezing Grunting Normal

Barking cough Prolonged Crackles

Expiratory Phase
Hoarseness Decreased Breath
Sounds

Air Movement Decreased Variable

C Heart Rate Tachycardia (Early) Bradycardia (Late)

Skin Pallor, Cool Skin (Early) Cyanosis (Late)

D Consciousness Anxiety, Agitation (Early) Lethargy Unresponsiveness(Late)

E Temperature Variable

Management Respiratory Emergencies

UPPER AIRWAY OBSTRUCTION

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 Croup Anaphylaxis Aspiration Foreign Body
Nebulized Epinephrine IM epinephrine Allow position of Comfort
Corticosteroids Salbutamol Expert Consult
Antihistamine,Corticosteroid
LOWER AIRWAY OBSTRUCTION
Bronchiolitis Asthma
Nasal Suctioning Salbutamol + Ipratropium
Bronchodilator Trial Corticosteroids
Subcutaneous Epinephrine
Magnesium Sulfate
Terbutaline
LUNG TISSUE DISEASE
Pneumonia/Pneumonitis Pulmonary Edema
Salbutamol Non-invasive/Invasive Ventilatory Support with PEEP
Antibiotics Vasoactive Support
Diuretics
DISORDERED CONTROL OF BREATHING
Increased ICP Poisoning/Overdose Neuromuscular Disease
Avoid Hypoxemia Antidote Noninvasive/Invasive Ventilatory
AvoidHypercarbia Contact Poison Control Support
Avoid Hyperthmia
Equipment

 Self-inflating ventilation bag with face mask

 Facemask

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  Nasal cannula

Positioning

 Ear should be anterior to the shoulder

To Provide

Delivery of effective ventilation

 Open the airway

In the absence of suspected neck trauma:

o Tilt the head back while 2 or 3 fingers are positioned under the angle of the mandible to lift it up and
forward, moving the tongue off the posterior pharynx

o Place the thumb and forefinger in a “C” shape over the mask and exert downward pressure on the mask

o “E-C” clamp technique

 Seal the mask to the face

 Deliver an adequate tidal volume

Parameters of oxygenation and ventilation

 Visible chest rise

 O2 saturation

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  Exhaled CO2
 Heart rate
 Blood pressure
 Distal air entry
 Signs of improvement or deterioration

What to do in case effective ventilation is not achieved?

1. Reposition and open airway

2. Verify mask size and ensure fit
3. Suction airway
4. Check O2 support
5. Check bag mask
6. Treat gastric inflation

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IV. RECOGNITION AND MANAGEMENT OF SHOCK

Compensatory mechanism Area Sign

Increased heart rate heart tachycardia

Increased SVR skin Cold pale, mottled, pale,
diaphoresis
Peripheral circulation Delayed capillary refill time

Pulses Weak pulses, narrow pulse

Increased renal and kidney Oliguria,

splanchnic vascular
Intestine Vomiting, ileus
resistance

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RECOGNITION OF SHOCK
Clinical signs HYPOVOLEMIC DISTRIBUTIVE CARDIOGENIC OBSTRUCTIVE

A Patency AIRWAY OPEN and MAINTANABLE / Not MAINTAINABLE

B Respiratory Rate INCREASED
Respiratory Normal to Increased Labored
effort
Breath sounds Normal Normal(±crackles) Crackles, grunting
C Systolic BP COMPENSATED SHOCK  HYPOTENSIVE SHOCK
Heart Rate INCREASED
Pulse Pressure Narrow Variable Narrow
Peripheral Weak Bounding or Weak Weak
Pulses
Skin Pale, Cool Warm or Cool Pale, Cool
Capillary refill Delayed Variable Delayed
Urine Output Decreased
D Consciousness Irritable Early, Lethargic Late
E Temperature Variable

Management of Shock

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 HYPOVOLEMIC SHOCK

Nonhemorrhagic Hemorrhagic
20ml/kg NS/LR Bolus, repeat as needed Control external bleeding
Consider colloid 20ml/kg NS/LR Bolus, repeat 2-3x as needed, Transfuse pRBC as
indicated
DISTRIBUTIVE SHOCK
Septic Anaphylactic Neurogenic
Septic Shock Algorithm IM epinephrine 20ml/kg NS/LR Bolus, repeat as needed
Fluid boluses (20ml/kg NS/LR) Vasopressor
Salbutamol, Antihistamine, Corticosteroid
Epinephrine Infusion
CARDIOGENIC SHOCK
Bradyarrythmia/Tachyarrythmia Others(CHD,Myocarditis,Cardiomyopathy)
Management Algorithms:Bradycardia, Tachycardia 5- 10ml/kg NS/LR bolus, repeat prn
with Poor perfusion Vasoactive Infusion
Expert Consult
OBSTRUCTIVE SHOCK
Ductal Dependent (LV Tension Pneumothorax Cardiac Tamponade Pulmonary Embolism
outflow Obstruction)

Prostaglandin E1 Needle decompression Pericardiocentesis 20ml/kg NS/LR Bolus, repeat as needed

Expert Consult Tube Thoracostomy 20ml/kg NS/LR bolus Thrombolytics,Anticoagulants
Expert consult

Intraosseous Line

• Simple, quick (can be accomplished in 30 to 60s)

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• Can be safely used to administer all drugs and fluids needed during resuscitation

• Sites:

• Proximal Tibia below growth plate

• Distal Tibia just above medial malleolus

• Distal femur

• Anterior Superior Iliac Spine

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V. RECOGNITION AND MANAGEMENT OF PEDIATRIC CARDIAC ARREST

Cardiopulmonary Failure is a combination of respiratory failure and shock: Inadequate oxygenation, ventilation
and tissue perfusion

EVALUATE:

AIRWAY Possible upper airway obstruction

Bradypnea
BREATHING
Irregular, ineffective respirations

Bradycardia
Delayed CRT
Weak central pulses
CIRCULATIO
Absent peripheral pulses
N
Cool extremities
Mottled or cyanotic skin
Hypotension

DISABILITY Decreased sensorium

EXPOSURE Bleeding, hypo/hyperthermia, etc

Pathways to Cardiac Arrest

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 Hypoxia/Asphyxial Sudden Cardiac Arrest
Most Common in infants, children and adolescents More common in adults
Due to respiratory failure or shock Due to sudden development of VF or pulseless VT

Recognition of Cardiac Arrest

 Unresponsiveness

 No breathing or only gasping

 No pulse (assess for no more than 10 seconds)

Management of Cardiac Arrest

START HIGH-QUALITY CPR, Begin Chest Compressions (C-A-B)

PALS Guidelines, 2010 :

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 Rate and
Age Depth Compression Technique Landmark
Ratio
At least 100 Thaler or
1/3 AP diameter of Just below the
Infant 30:2 Single-R 2-finger
chest nipple line
15:2 Two-R Technique
At least 100 Between the
1/3 AP diameter of
1 year to Puberty 30:2 Single-R 2 hands nipples, above
chest
15:2 Two-R xiphoid
Between the
At least 100
Adult 2 inches (5cm) 2 hands nipples, above
30:2
xiphoid

2015 UPDATES:
Component Recommendations
CHILDREN INFANTS
CPR sequence C-A-B
Compression rate 100-120min
Compression depth At least 1/3 AP diameter At least 1/3 AP diameter
About 2 inches (5cm) About 1 ½ inches (4 cm)
Chest wall recoil Allow complete recoil between compressions
Compression interruptions Minimize interruption to less than 10 seconds

Component Recommendations

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 CHILDREN INFANTS
Airway Head tilt-chin lift
(suspected trauma: jaw thrust)
Ventilations with advanced 1 breath every 6 seconds
airway (10 breaths per minute)
Asynchronous with chest compressions
Deliver each breath over 1 second with visible chest rise

High-Quality CPR:
 Push hard, Push fast (rate of 100-120/min)
 Allow complete chest recoil
 Minimize interruption to less than 10 seconds
 Avoid excessive ventilation
 No advanced airway, 15:2 compression-ventilation ratio; Advanced airway, 1breath every 6 seconds (10
breaths per minute) with continuous chest compressions
 Rotate compressor every 2 minutes

Reversible Causes of Cardiac Arrest

Hypovolemia Tension pneumothorax

Hypoxia Tamponade (cardiac)
Hydrogen ion (acidosis) Toxins
Hyper/hypokalemia Thrombosis, pulmonary
Hypoglycemia Thrombosis, coronary
Hypothermia Trauma

Terminating Resuscitative Efforts

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 No reliable predictors of when to stop resuscitation

 Children who underwent prolonged resuscitation with absence of ROSC after 2 doses of Epinephrine were
unlikely to survive

 Decision to stop resuscitation influenced by the cause of the arrest, available resources, location of
resuscitation, likelihood of any reversible or contributing conditions

VI. Neonatal Resuscitation

Airway Position:
 Put the baby on its back
 Position the head so that it is slightly extended-A folded piece of cloth under the shoulders may help
accomplish this

Bag-Mask Ventilation

1. Select the appropriate mask

2. Reposition the newborn - make sure that the neck is slightly extended
3. Place the mask on the newborn's face, so that it covers the chin, mouth and nose
4. Form a seal between the mask and the infant's face
5. Check the seal by ventilating two or three times and observing for the rise of the chest

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 6. Once a seal is ensured and chest movement is present, ventilate the newborn with a frequency of around 40
breaths per minute
7. “breath…2,3….breath…2,3…..breath…2,3”
8. Hold the head in the correct position to keep the airway open during ventilation and keep a tight seal between
the mask and the face
9. Observe the chest for an easy rise and fall

If the chest is NOT rising, the most probable obstacles are:

 inappropriate head position

 poor seal between the mask and the face

 insufficient ventilation pressure

Chest Compression

 Indicated for a heart rate that is <60 bpm despite adequate ventilation with supplementary oxygen for 30
seconds
 Thumb technique: circling the chest with both hands and using a thumb to compress the sternum
o Advantage: allows better depth control during compressions and it generates higher peak systolic and
coronary perfusion

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  2 finger technique : supporting the infant's back with one hand and using the tips of the middle and index
finger to compress the sternum
o Advantage: used when access to the umbilicus is required
 Compressions should be delivered on the lower third of the sternum to a depth of approximately one third of
the AP diameter of the chest

One ventilation should be interposed after every 3 chest compressions (3:1)

 “1 and 2 and 3 and breath….1 and 2 and 3 and breath…”

 overall rate of 120 compression/ventilation events per minute is recommended

 this equates to 90 compressions and 30 breaths each minute

REFERENCES:

2010 American Heart Association Pediatric Advanced Life Support Provider Manual.

Neonatal Resuscitation Guidelines. Circulation. 2005: 112

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