PALS notes
SYSTEMATIC APPROACH
The interventions are based on the application of both the BLS and PALS Surveys. The BLS
Survey is designated by 1, 2, 3, 4, while the PALS Survey follows the familiar A, B, C, D.
The American Heart Association (AHA) updated its BLS guidelines in 2015 to incorporate the
following changes:

C – A – B replaces A – B – C. Circulation – Airway – Breathing (the 2020 update
continues to reinforce C – A – B)

Early bystander CPR improves outcome. Chest compressions receive the highest
priority

Perform CPR if the victim is not breathing or if respirations are inadequate. Do
not look, listen and feel

High–Quality CPR is emphasized

Do not lean on the chest wall between compressions

Do not perform cricoid pressure

Pulse checks should take ten (10) seconds or less

Use a manual defibrillator for infants if available
Updates released in 2020 include the following:

Continue rescue breathing or bag-mask ventilation until spontaneous breathing
returns

Higher ventilation rates of at least 30/min in infants (younger than 1 year), and at
least 25/min in children are associated with improved rates of ROSC and survival
in pediatric in-hospital cardiac arrest

IM or intranasal Naloxone can be administered in suspected opioid overdose
scenarios if a pulse is present

Early administration of Epinephrine (within 5 minutes of cardiac arrest) is
recommended

Epinephrine or Norepinephrine can be administered for shock treatment

Dopamine can be used if Epinephrine or Norepinephrine are not available

Consider stress dose corticosteroid administration for fluid-resistant septic
shock patients treated with vasopressors

Evaluation for and treatment of post-arrest seizures is recommended

Nonconvulsive status epileptics after cardiac arrest can be treated after
consultation with experts

Consider blood products for ongoing volume resuscitation in hemorrhagic shock
patients

Initial fluid boluses in septic shock range from 10-20 ml/kg with frequent
reassessment

When invasive blood pressure monitoring is available, diastolic blood pressure
can guide CPR quality assessment

Cricoid pressure is no longer advised as it decreases the success rate of
intubation

If no pulse is present in a suspected opioid overdose, high-quality CPR takes
precedence over Naloxone administration

Pediatric cardiac arrest survivors should be evaluated for rehabilitation and
offered neurologic services for at least the first year after an arrest

Myocarditis poses a high risk of arrest and early consideration to ICU transfer is
indicated

Early consideration of extracorporeal life support, even pre-arrest, for children
with myocarditis or cardiomyopathy

Congenital heart disease is often treated with complex staged surgical
procedures and consultation with a specialist can guide resuscitation

Advanced monitoring including invasive techniques, extracorporeal life support,
anticoagulants, inhaled nitric oxide, and prostacyclin may be considered on a
case-by-case basis

Pulmonary hypertension and acute right heart failure can be treated with inhaled
nitric oxide and prostacyclin therapy

Avoid hypoxia and acidosis by carefully monitoring all pulmonary hypertension
cases

Provide analgesia, sedation, and neuromuscular blockade (paralysis) for
pediatric patients at high risk for hypertensive crises

Oxygen administration and hyperventilation to induce alkalosis can be beneficial
as an initial treatment of pulmonary hypertension

Advanced monitoring and pharmacological intervention are recommended for
congenital heart patients who have undergone partial or complete repair
The first step in any situation is to assess the safety of the scene. This means the safety of both
the victim and the rescuer. The victim must be moved from traffic or water. The scene should
be surveyed for other dangers such as gas, electricity, or other chemicals. The provider must be
aware of the presence of blood and bodily fluids and must take appropriate precautions.
The next action is to determine the degree of consciousness of the victim. It is at times difficult,
even for experienced professionals, to accurately detect a pulse. When in doubt, it is better to
perform CPR than withhold life–saving intervention.
If the victim does not respond, begin the BLS initial assessment and move on to the PALS
assessment. If the victim is conscious, begin the PALS Survey (covered later in the course
material) and complete an initial assessment.
Agonal breathing is ineffective and is common with cardiac arrest. By removing the
interpretation and assessment of breathing, chest compressions can be delivered earlier.
INITIAL ASSESSMENT
The AHA recommends following the A – B – C – D – E approach when performing the initial
assessment. These easy to remember steps flow down a path that provides intervention,
support and determination of potential causes.
A – AIRWAY
An initial glance at the patient often provides substantial clues to their respiratory status. If the
victim is crying or is making loud noises, their airway is patent, and they are spontaneously
breathing.
The first step is to determine if the airway is open. If it is open and unobstructed, then proceed
to the evaluation of B – Breathing.
If the airway is not open, perform the head–tilt/chin–lift maneuver (or jaw thrust if trauma
suspected). Consider inserting a nasopharyngeal airway (NPA), or an oropharyngeal airway (if
unconscious).
At times, an advanced airway may be required or beneficial to manage the airway. Do not let
this delay the assessment of circulation, or the initiation of CPR, when indicated. An airway can
always be managed with a mask or bag–mask device, and an advanced airway intubation can
be performed later.
B – BREATHING
Take a moment to observe the victim, and answer these questions: Is their chest rising? Are
they breathing rapidly and shallowly? Are they only gasping?
C – CIRCULATION
Observation and pulse assessment are key steps in determining the circulatory status. Poor
color or blue appearance imply ineffective circulation. Capillary refill should be less than two (2)
seconds in a normal child. A delay indicates poor perfusion and can be a sign of severe
dehydration as well. Cool skin may be one final abnormal sign.
The pulse and blood pressure vary widely depending on a child’s age – consult the accepted
reference of your employer or institution. An infant’s pulse can vary from 90 beats–per–minute
(bpm) to 190 bpm. The overall clinical picture, combined with the victim’s pulse, is valuable in
determining if the measured heart rate is normal, or is a sign of a clinical problem.
BLOOD PRESSURE IN VARIOUS AGES
Generally Accepted as Hypotension (systolic blood pressure):

< 60 mm Hg in term neonates (0 to 28 days)

< 70 mm Hg in infants [one (1) month to twelve (12) months]

< 70 mm Hg + (2 × age in years) in children one (1) to ten (10) years

< 90 mm Hg in children ≥ ten (10) years of age
A general rule of thumb for children: the lower limit of normal BP = (Age x 2) + 70
D – DISABILITY
Perform a rapid neurological assessment in all pediatric cases. Simply observing the victim’s
behavior provides valuable clues to the neurological status. Determine the level of
consciousness, and check for appropriate pupil size (symmetric) and responsiveness to light.
The AVPU Scale is a simple mnemonic to aid in assessing disability.

A: (Alert) – Interactive, awake, alert

V: (Verbal) – Responds to voice

P: (Pain) – Can only be aroused by applying a painful stimulus

U: (Unresponsive) – Patient does not respond
The Glasgow Coma Scale (GCS) can also be used for pediatric patients and is modified for
infants. This score assigns a point value for eye opening, verbal and motor responses.
From the above numerical values, three (3) is the lowest possible score. Most experts
recommend placing an advanced airway in any patient with a GCS less than eight (8).
E – EXPOSURE
In this step, the patient should be examined for any clues to the cause. Search for trauma or
signs of injury, burns, fractures or scars. Skin color and temperature can also provide valuable
clues. After evaluation, cover the patient as much as the clinical scenario allows to prevent loss
of body heat.
SECONDARY ASSESSMENT – DIAGNOSE AND TREAT
This step allows for a more comprehensive evaluation, including a focused history and a
detailed physical exam. Family, friends, and witnesses can provide valuable clues to the
etiology. Work from head to toe in a systematic manner. Use diagnostic tools, such as finger–
stick glucose, when indicated.
Continue to assess the patient throughout all phases of care. Patients can deteriorate at any
time and prompt intervention is required. Early recognition of a change in condition allows for
intervention and can prevent further deterioration. Assessment is never done until the victim is
stabilized, or care is handed off to a higher–level provider.
Use SPAM to perform a more detailed history:
TEAM CONCEPTS
A successful outcome relies on coordination and teamwork. PALS providers must learn to be
both effective team leaders and to function as a team member when the situation dictates.
Caring for critically ill children adds a significant element of stress and effective communication
is essential.
Successful communication during critical patient care relies on several established concepts:

Closed–Loop Communication

Clear Messages

Clear Roles and Responsibilities

Knowing One's Limitations

Knowledge Sharing

Constructive Intervention

Reevaluation and Summarization

Mutual Respect
Understanding the dynamics and roles of all team members make the PALS provider more
effective and efficient.
TEAM LEADER
The team leader is the captain of the code. He/She coordinates all actions and activities
performed during the arrest situation. They are responsible for simultaneously assessing the
patient and instructing specific interventions to be rapidly carried out.
The team leader also monitors the performance and effectiveness of the various interventions
being carried out – compression rate/depth, the timing of ventilations, and administration of
medications at the proper intervals.
The team leader has a solid understanding of the how and why of PALS and can explain the
rationale behind each intervention/technique.
CLOSED–LOOP COMMUNICATION
The leader should give commands while making eye contact with the person assigned to carry
out a specific task. The team member should give a verbal acknowledgment of the task. No
additional tasks are assigned until a confirmation is received.
CLEAR MESSAGES
Speak in a clear and controlled manner. Yelling or becoming worked up only increases other
team member's stress.
Pediatric codes are emotionally charged events. Take a deep breath and deliver your message
in a clear and controlled tone.
CLEAR ROLES AND RESPONSIBILITIES
Assign specific roles to each team member – chest compressions, ventilations, IV meds,
monitor/defibrillator, recording/charting, etc.
KNOWING ONE'S LIMITATIONS
Understand personal limitations and the limitations of various team members. Do not assign a
bystander to administer IV meds when a nurse is available. Knowing limitations in advance can
allow time to call in backup personnel to help.
KNOWLEDGE SHARING
The team leader should ask for input and the team members should not fear offering
constructive ideas when resuscitation is not going as planned, or when the patient is not
responding as expected.
CONSTRUCTIVE INTERVENTION
Utilize tactful intervention when an action is about to be performed out of sequence or is not
indicated. This is done in a non–threatening manner and can be discussed at the post–arrest
debriefing.
REEVALUATION AND SUMMARIZATION
Care and interventions must be reevaluated and summarized. By doing so, drug errors may be
prevented, and missing interventions can be resolved.
MUTUAL RESPECT
Supporting all team members builds an attitude of trust and teamwork. Treating team
members as equals and appreciating the contributions of each team member based on their
preexisting skill and expertise, is crucial.
ROLES
The team leader can give specific assignments. Often in real-world code situations, the care
team self–assigns roles based on skill and preference. The team leader must be prepared to
reassign roles based on skill level and observation during resuscitation. The team leader will
most often stand at the foot of the bed to observe the actions of the team, patient response(s),
and the monitor(s).
Roles include:

Airway

Compressor

IV/IO meds

Monitor/defibrillator

Observer/recorder
During pediatric arrest situations, family members may be present. Consider assigning a team
member to offer support, comfort, or explanation about what is happening during the
resuscitation. Family members may find being present helps with the understanding and
grieving process.
Debriefing after caring for a cardiac arrest victim is beneficial for the mental health of
caregivers. Family members should also be offered social and psychological support services.
PALS Case: Respiratory Distress & Failure
Case Example: A six–month–old child has been ill with a cough and wheezing. He has been
feeding poorly for several days. After a period of rapid breathing, his breathing slows, and he
becomes unresponsive. The babysitter calls 911 for help.
The majority of cardiac arrest cases are preceded by respiratory difficulties. Prompt recognition
may allow intervention and prevention of deterioration.
Pediatric patients can display different signs of respiratory distress, including stridor, grunting,
nasal flaring, too slow or too rapid breathing, or gasping. Determine if effective breathing is
occurring through observation of both the rate and the depth of respirations.
The initial response is based on the severity. If mild distress is present, support the airway and
assess the oxygen saturation. If oxygen saturation is less than 94%, administer supplemental
oxygen. In an alert child with respiratory distress, begin with the least invasive maneuvers first
to avoid exacerbating the child’s anxiety.
Wheezing or stridor suggests airway inflammation. In such a case, the victim may respond to
nebulized therapy. Racemic epinephrine may be nebulized to relieve the stridor caused by
croup. Bronchodilators (ex: albuterol) can alleviate wheezing.
Monitor vital signs and establish IV access. Pediatric patients can compensate rather well up to
a point. That being said, proactively establishing an IV is beneficial, as decompensation occurs
rapidly.
In cases of respiratory failure, prompt airway support is mandatory. Begin with mask or bag–
mask ventilation. Place airway adjunctsas needed (NPA or OPA) and consider advanced airway
placement. Use 100% oxygen during the initial resuscitation, and suction the airway as needed
to clear mucous, blood, or debris.
The patient’s history can provide valuable clues to the cause and can allow directed
interventions to improve outcomes. For example, relieving obstruction in an unresponsive
choking victim, or administration of epinephrine in an arrest situation due to anaphylaxis.
PALS SURVEY
The PALS Survey in this case focuses on the management of a respiratory arrest scenario.
Assume a pulse is present in this scenario, but in a real-world case, you must closely monitor for
any change in condition and be prepared to initiate chest compressions.
MANAGEMENT OF RESPIRATORY ARREST
PALS utilizes the A – B – C – D approach. Rescuers may provide ventilation with a bag–mask
device or place an advanced airway. The following summarizes the necessary PALS actions
required for Respiratory Arrest:
A – Airway:

Open and maintain a patent airway

Consider advanced airway devices
B – Breathing:

Administer supplemental oxygen as indicated

Assess the adequacy of ventilation and oxygenation

Avoid over-ventilation
C – Circulation:

Assess and monitor the quality of CPR

Attach cardiac monitor and defibrillator pads

Obtain intravenous (IV) or intraosseous (IO) access

Administer appropriate drug therapy

Monitor and manage cardiac rhythm and blood–pressure

Administer fluids if indicated
D – Differential Diagnosis:

Consider underlying cause(s)

Treat any reversible cause
OPENING THE AIRWAY
After assessing the scene for safety, open the airway using the head–tilt, chin–lift maneuver. If
cervical spine trauma is suspected, use the jaw thrust maneuver alone.
If unable to deliver a breath, try repositioning the airway and repeat the attempt.
SUPPLEMENTAL OXYGEN
Supplemental oxygen should be administered to all patients with respiratory difficulties,
respiratory arrest, and cardiac arrest. The goal is an oxygen saturation of at least 94%.
AIRWAY MANAGEMENT
Opening the airway in patients who can still breathe spontaneously allows for effective
respiration. However, if the patient is unconscious, consider placing an oral or nasopharyngeal
airway. This helps maintain the patency of the airway and allows for more effective
ventilation. Do not attempt to place an oral airway in a patient with a preserved gag reflex, as
this can trigger vomiting.
VENTILATION
Ventilation is performed using a mouth–to–mask or a bag–mask device. The mask apparatus
contains a one–way valve that allows for the delivery of oxygen to the patient but prevents
blood, mucus, or vomitus from passing back through the mask.
The proper technique for using a mask involves the C–E hand position technique. The thumb
and index finger form the “C” by securing the mask around the victim’s nose and mouth. The
other three (3) fingers form the “E” and are used to lift and pull the jaw into the mask for a
proper seal. Pushing the mask on the face may collapse the airway.
Each breath is delivered over one (1) second, regardless if using a mouth–mask or bag–mask
device. Avoid over–ventilating the patient. Monitor the chest by observing its rise as the breath
goes in.
Additional features of the mask include a suctioning port, the ability to attach supplementary
oxygen, and the ability to administer nebulized medications. End tidal CO 2 monitors can also be
attached.
The 2020 guidelines have increased the respiratory rate for pediatric resuscitation. Breaths
should be delivered every 2 — 3 seconds, for a total of 20 — 30 breaths per minute in pediatric
cases.
TRAUMA PRECAUTIONS
Use caution when establishing and maintaining an airway in suspected trauma cases. Use the
jaw thrust maneuver alone and avoid hyperextension of the neck. Clues to the possibility of
cervical spine trauma include head and facial trauma, mechanism of injury, and signs of
multiple injuries.
Have someone stabilize the patient’s head by placing their hands on either side of the patient’s
face with their fingers spread. This prevents unnecessary movement of the neck and reduces
the possibility of worsening a cervical spine or spinal cord injury. Rigid cervical collars can make
the placement of an advanced airway more difficult. Once the airway is secure, but before
transport, a rigid spinal mobilization device should be placed.
If the airway cannot be established or maintained by using a jaw thrust alone, ventilation takes
priority. The head–tilt, chin–lift maneuver may be used with caution.
PALS Case: Bradycardia
Case Example: A two–year–old took some heart medication belonging to her grandmother.
She is lethargic and her pulse is 40.
Bradycardia is an abnormally slow heart rate based on the child’s age and clinical situation. By
definition, a heart rate of less than 60 beats per minute (bpm) is considered bradycardic. When
bradycardia produces symptoms and signs of compromised cardiovascular function,
intervention is required.
Older children may tolerate bradycardia without serious signs and symptoms. A thorough
search for the underlying cause can be carried out instead of rushing to treat an asymptomatic
rhythm.
Treatment of bradycardia requires recognition of specific rhythm disturbance. You should be
familiar with the appearance of the following ECG rhythms:

Sinus Bradycardia

First–Degree AV Block

Second–Degree AV Block

o
Type I (Wenckebach Phenomenon / Mobitz I)
o
Type II (Non-Wenckebach / Mobitz II)
Third–Degree AV Block
BRADYCARDIA ALGORITHM
Note: Relative bradycardia is a term based on the specifics of a clinical scenario. For example,
a heart rate of 100 bpm in the setting of massive hemorrhage is relatively bradycardic, even
though one would expect a tachycardic response to hemorrhagic shock.
PACING
Pacing devices deliver an electrical stimulus and cause cardiac contraction. By depolarizing the
heart muscle, Transcutaneous Pacing (TCP) can provide life–saving treatment to the
bradycardic patient.
Pacing is uncomfortable and sedation should be considered. However, do not delay care in any
critical patients to achieve sedation. Consider a benzodiazepine for sedation and a narcotic for
pain control. Keep in mind that these agents can cause hypotension and can exacerbate the
situation.
Indications for TCP:

Unstable bradycardia causing hemodynamic compromise

Bradycardia causing an unstable clinical condition

Bradycardia with symptomatic ventricular escape rhythms

Symptomatic bradycardia, Mobitz Type II and Third–Degree AV Block
Points of Emphasis:

Do not use TCP in severely hypothermic patients

Pacing is not indicated for treating asystole

Pacing causes muscle contraction and prevents assessment of carotid pulse

Consider sedation in conscious patients if it will not delay care or cause
deterioration
STEPS FOR PERFORMING TRANSCUTANEOUS PACING (TCP)
The clinical response determines whether or not the pacing unit requires adjustment. Look for
improvement in signs and symptoms related to the bradycardia. Blood pressure and mental
status should improve once bradycardia is corrected. Most patients show signs of improvement
as the heart rate approaches 60 – 70 bpm.
Adjust the milliampere output until capture occurs – this will be evidenced by QRS complexes
appearing on the monitor just after a pacer spike. As the clinical condition improves, a femoral
pulse should be palpable.
Significant bradycardia can precipitate wide complex rhythms that can deteriorate to VF or VT.
Prompt initiation of pacing can increase heart rate and resolve this issue.
PALS Case: Tachycardia
Case Example: An eight–year–old child has been complaining of palpitations and feeling dizzy.
Past history is unremarkable.
The key decision in treating these patients is to determine whether the tachycardia is causing
clinical instability. In these cases, prompt cardioversion is performed before drug therapy.
In unstable tachycardia, the heart rate is too fast to allow proper filling and output. Common
symptoms include low blood pressure, altered mental status, shock, ischemic chest pain, and
heart failure. Rapid recognition of symptomatic tachycardia, and recognition of serious
symptoms, allow the rescuer to perform a prompt intervention.
MANAGEMENT
Determining the level of consciousness, the presence or absence of a pulse, and overall
perfusion, are the first steps in the management of unstable tachycardia. Be prepared to assist
breathing, administer oxygen, attach a cardiac monitor, measure BP and oxygen saturation,
establish IV/IO access, and obtain a 12–Lead ECG. Various team members often perform these
actions simultaneously.
If any of the above are present, synchronized cardioversion is indicated. Consider sedating the
patient if the clinical situation allows.
PEDIATRIC TACHYCARDIA ALGORITHM
NARROW COMPLEX
Sinus tachycardia is a common cause of increased heart rate and is due to an underlying
process, such as fear, stress, or hypovolemia. Supraventricular tachycardia (SVT) is also a
relatively common cause of tachycardia in children and is often treated with adenosine.
A regular narrow complex tachycardia could be due to SVT. Adenosine may be administered if
an IV has been established. Do not delay cardioversion in unstable patients while waiting for an
IV to be started.
Stable tachycardia can become unstable at any time. In this situation, perform immediate
cardioversion.
MANAGEMENT
The approach is based on whether the rhythm is regular and the width of the QRS.
Adenosine Use:
Adenosine is the first drug used for stable narrow complex tachycardia. It can also be used in
unstable narrow complex tachycardia patients as preparations are made for cardioversion.
Regular monomorphic wide–complex tachycardia can also represent SVT and may respond to
adenosine.
Note: adenosine will not convert atrial fibrillation or flutter but can be used as a diagnostic
maneuver to reveal flutter waves in a rapid narrow complex tachycardia case.
Common side effects of adenosine are chest tightness or heaviness and flushing. The half–life of
adenosine is seconds, so these effects will be shortlived and should not be viewed as allergic
reactions.
Pre–excitation is an abnormal pathway of electrical activity and can be associated with pre–
excitation atrial fibrillation. In this setting, avoid beta–blockers and adenosine, as these can
result in a paradoxical increase in ventricular rate. Consider expert consultation to assist in
treatment decisions.
WIDE COMPLEX
Wide complex in pediatric patients is accepted as a QRS > 0.09 seconds. In general, it is safe to
assume a wide complex rhythm is not a normal baseline, and it represents VT. If a wide
complex tachycardia is causing serious signs or symptoms, perform immediate cardioversion.
Adenosine can be considered if the rhythm is regular and the QRS complexes are
monomorphic.
CARDIOVERSION
Cardioversion is the delivery of a shock to disrupt the abnormal electrical activity in the heart
and to restore normal sinus rhythm. Shocks may be synchronized to the QRS cycle or
unsynchronized. Patients who deteriorate are always treated with unsynchronized
cardioversion.
SYNCHRONIZED CARDIOVERSION
Shock delivery is timed to the cardiac cycle and is delivered on the R wave. Synchronized
cardioversion uses a lower energy setting than defibrillation. Synchronization requires the
analysis of several QRS complexes and may add a delay if the R wave is of low amplitude.
Additionally, a quick look performed by holding the paddles to the chest, instead of using pads,
often DOES NOT allow synchronization, and therefore, does not allow a shock to be delivered.
Note: Biphasic units may allow lower energy settings. Consult manufacturer documentation.
UNSYNCHRONIZED CARDIOVERSION INDICATIONS:

No pulse

Clinical deterioration

Unsure of monomorphic or polymorphic VT
Note: If delivery of unsynchronized shock results in VF, immediately defibrillate.
CARDIOVERSION TECHNIQUE:
1. Sedate patient unless unstable
2. Turn unit ON
3. Attached leads and pads
4. Press the SYNC button
5. Confirm marker on R wave on the monitor screen
6. Adjust gain until marker on each R wave
7. Select appropriate dose based on condition (see Energy Settings above)
8. Loudly announce: “Charging – everyone clear”
9. Press the CHARGE button
10. Clear the patient – ensure no one touching the patient or stretcher
11. Press the SHOCK button
12. Reassess rhythm
13. If Tachycardia persists, increase energy
14. Press the SYNC mode
15. Repeat steps from #5 onward
PALS Case: Shock
Shock results when inadequate tissue perfusion occurs. This can occur for a variety of reasons,
as are discussed below. The body will attempt to compensate for shock by increasing heart rate
and shunting blood away from non–vital organs.
The body may be able to compensate for a period, which is referred to as compensated shock.
Eventually, the mechanism causing shock will overwhelm the body's ability to compensate and
frank shock occurs (decompensated shock).
In 2015, AHA updates clarified the use of IV fluids in the resuscitation of children. Rapid IV fluids
should be administered early on in cases of septic shock. The standard 20 mL/kg IV fluid bolus is
acceptable therapy in cases of shock.
However, in children with severe febrile illness, fluid restriction is advised in settings where
resources are limited. Bolus therapy with IV fluids in settings without mechanical ventilation
and ionotropic support should be undertaken with caution.
Epinephrine and norepinephrine can be considered first-line drug therapy for shock treatment.
Dopamine may be considered when epinephrine and norepinephrine are not available.
HYPOVOLEMIC SHOCK
Case Example: A four–year–old child has been vomiting and has had diarrhea for five (5) days.
His parents have been trying a variety of natural remedies. His heart rate is 150 bpm, the
capillary refill is poor, and he is lethargic.
Hypovolemic shock occurs when the intravascular volume is diminished significantly and blood
pressure decreases. Causes include severe dehydration (vomiting / diarrhea / lack of water) and
blood loss.
The body responds by increasing heart rate and constricting blood vessels, in an attempt to
improve circulation (tissue perfusion).
Treatment is geared towards locating and controlling hemorrhage, replacing intravascular
volume (IV fluids and/or blood products), and maximizing tissue perfusion.
For hypovolemic hypotensive pediatric patients, give a bolus of 20 mL/kg of IV fluids as an initial
approach and repeat as necessary. In cases of hemorrhage, three (3) mL of IV fluids should be
given for every one (1) mL of blood. Consider giving blood when blood pressure fails to improve
after IV fluid therapy has been administered.
Per the 2020 guidelines, blood products can be administered for ongoing volume resuscitation
in the hemorrhagic shock patient.
Search for sources of blood loss, while keeping in mind the bleeding may be internal. Solid
organs, such as the liver, spleen, or kidney, can hemorrhage after trauma. Very small children
can lose a significant amount of blood from head injuries or lacerations. Femur fractures can
also result in a large loss of blood volume into the soft tissues of the leg.
CARDIOGENIC SHOCK
Case Example: A patient has a complex history of congenital heart disease. She has had
several corrective heart surgeries, her skin is cool and clammy, the capillary refill is poor, and
she is lethargic. The chest exam reveals rales bilaterally.
Poor cardiac function is the principal underlying abnormality in cardiogenic shock. The heart
simply cannot pump blood effectively, resulting in hypotension and poor perfusion. Blood often
backflows into the pulmonary vasculature and results in dyspnea. When listening to the chest,
the clinical exam often reveals crackles and rales. The liver may be palpable in the upper right
abdomen. Pulses will be diminished, neck vein distention may occur, and pedal edema can also
be noted.
Treatment of cardiogenic shock is complex and expert consultation is often warranted.
Judicious use of IV fluids, medications to decrease systemic vascular resistance, and inotropic
medications to support cardiac function may all be required.
Complex congenital heart conditions are typically treated with staged surgical procedures. A
variety of interventions, including nitric oxide, prostacyclin, or analogs, may be administered.
DISTRIBUTIVE SHOCK
Case Example: A patient spiked a high fever last night and is now covered with a petechial
rash. He is unresponsive, his respiratory rate is 28, his pulse is 155 bpm and his oxygen
saturation is 88%.
Distributive shock occurs when blood volume and intravascular fluid are abnormally
distributed. The vascular tone is abnormal, and blood is shunted abnormally, resulting in low
blood pressure and poor perfusion.
Types of distributive shock include anaphylactic, septic, and neurogenic. In simple terms, you
can think of the various forms of distributive shock as follows:
Signs and symptoms vary greatly depending on the underlying triggering mechanism. Common
clinical features include tachycardia, increased respiratory rate, and hypotension.
Treatment is directed at the underlying mechanism, but commonly includes IV fluids for all
types of distributive shock. Give a bolus of 20 mL/kg of IV fluid and repeat every 5 – 10 minutes
as needed. Additional therapies are dependent on the underlying cause.
Patients in septic shock require aggressive use of broad–spectrum antibiotics, IV fluids, and
vasopressor medications. In select cases, a stress dose of hydrocortisone can be beneficial.
Epinephrine is the drug of choice for all anaphylactic shock cases. IV fluids, steroids, and
antihistamines are also given to interrupting the flood of substances caused by the inciting
exposure (drug, bee sting, nuts, etc.). Vasopressors may be required if an anaphylactic shock is
not quickly reversed with the initial therapy.
Neurogenic shock results from spinal cord injury and the disruption of sympathetic input. The
loss of nervous system input causes blood vessels to dilate and blood pressure to plummet. The
heart rate often fails to increase and is a clinical clue to this condition. IV fluids and
vasopressors are often used to treat this condition.
OBSTRUCTIVE SHOCK
Case Example: A seven–year–old fell off a roof and is now unresponsive. His neck veins are
distended and crepitance is felt on the chest wall and subcutaneous tissue. His BP is 60 systolic
and his heart rate is 165 bpm.
In obstructive shock, cardiac contractility is normal, but the heart cannot pump effectively due
to a blockage of blood flow. Common causes include cardiac tamponade, congenital heart
problems, massive pulmonary embolus, and tension pneumothorax.
Treatment is dependent on the underlying cause. A tension pneumothorax can be quickly
treated with a needle decompression followed by a chest tube. Cardiac tamponade requires
pericardial drainage. Massive pulmonary embolisms can be treated with fibrinolytic therapy or
other invasive procedures.
PALS Case: Cardiac Arrest
Case Example: You are attending a little league baseball game when one of the players
suddenly collapses. You rush onto the field and find a pulseless apneic child.
Most cardiac arrest cases in children result from respiratory problems and respiratory failure.
Sudden cardiac death can occur due to underlying conditions including hypertrophic
cardiomyopathy, congenital heart problems, and prolonged QT syndrome. A sudden impact to
the chest wall can cause a lethal disruption to the heart rhythm, which often results in sudden
cardiac arrest. This is referred to as commotio cordis.
It is estimated that less than 10% of pediatric cardiac arrest cases are due to primary cardiac
arrhythmias. Arrest rhythms include asystole, pulseless electrical activity (PEA), pulseless VT,
and VF.
Prevention is the key component for pediatric cardiac arrest management. Early detection and
intervention of respiratory distress/failure can often prevent the cardiac arrest from occurring.
Certain conditions, when detected early, can facilitate the prevention or correction of cardiac
arrest. The common reversible causes of cardiac arrest are divided into two groups – the H’s
and the T’s.
Historical clues of PEA include the history preceding cardiac arrest, signs of hypovolemia, and
suspicion of drug overdose or poisoning. Hypovolemia and hypoxia are the most easily
correctable.
The ECG must be evaluated for clues to the underlying cause. A classic example is the
prolongation of the QT interval, which is an inherited syndrome.
An update in 2019 recommended bag-mask ventilation as a reasonable option for airway
management in pediatric cardiac arrest patients in out-of-hospital (OHCA) settings when
compared with other advanced airway interventions (endotracheal intubation or supraglottic
airway).
GENERAL APPROACH
Asystole is the absence of cardiac activity. The heart is not contracting, no electrical activity is
present on the cardiac monitor and blood is not being pumped. A variety of rhythms
deteriorate to asystole, including VT, VF, PEA, and bradycardia.
Before an asystole diagnosis can be made, it must be confirmed in two (2) separate leads, and
the rescuer must make sure the leads and monitor are properly connected. Many refer to this
as "flat line," but this is a generic term that only implies a lack of activity on the monitor. This
can result from true asystole, operator error, or technical problems. Use caution when making a
diagnosis, as fine VF can appear similar to asystole. Subtle variation from the baseline will help
differentiate fine VF from asystole.
The majority of patients suffering asystolic arrest do not survive and the prognosis is universally
poor. Prolonged aggressive resuscitation efforts are futile unless special circumstances, such as
drug overdose or hypothermia, precipitated asystole.
The 2020 guideline updates stress the importance of early epinephrine administration. When
feasible, it should be administered within five minutes of CPR — or less depending on the
clinical scenario.
CARDIAC ARREST ALGORITHM - ASYSTOLE/PEA
Treatment of asystole, as in all algorithms, focuses on high–quality CPR. CPR, along with drug
therapy, is indicated. No shock will be indicated. Epinephrine is the only drug used in the
asystole/PEA algorithm. IV/IO access is established as soon as possible, and the doses are as
follows:

0.01 mg/kg (0.1 ml/kg of 1:10,000 solution) IV/IO

Repeat every 3 – 5 minutes
Drug therapy takes place during compressions. No interruptions in compressions or ventilations
are required.
HOW DEFIBRILLATION WORKS
An AED SHOCK stuns the heart and essentially stops all electrical activity. The normal intrinsic
pacemaker of the heart will hopefully resume functioning. The initial rhythm after cardiac arrest
and SHOCK delivery is typically too slow and does not adequately pump blood. CPR should be
performed for two (2) minutes after a shock is delivered to aid in perfusion. Return of
spontaneous circulation (ROSC) is the term used to describe the phenomenon of the heart
regaining intrinsic rhythm and restoring perfusion (pumping function).
Early defibrillation is the key to survival. Statistics show that for every minute without CPR, the
chance of survival decreases by almost 10% per minute. Immediate CPR after VF arrest
decreases survival probability to around 4% per minute. While CPR does not adequately
circulate blood, it does provide some degree of perfusion.
Always use an AED if:

The patient is unresponsive

The patient is not breathing or is breathing ineffectively

The patient has no pulse present
HOW TO USE AN AED
Become familiar with the AED device used in your facility or clinical setting. Review the
maintenance and troubleshooting information from the manufacturer.
Follow these steps for using an AED:
1. Open the AED case and turn the device ON
2. Expose the victim's chest
3. Attach AED pads to the victim’s chest
4. Do not touch the victim when AED is ANALYZING
5. Before delivering SHOCK, make sure the victim’s chest is clear and no one is
touching the victim
6. Press the SHOCK button
7. Resume CPR for two (2) minutes
8. Repeat cycle: CPR – analyzing – shock if indicated – CPR
The AED may indicate no shock is advised. In this case, resume CPR for another two (2)
minutes. A check electrodes message may indicate the pads are not connected to the AED, or
that contact between the pads and victim is inadequate. Double-check connections but do not
delay compressions.
POINTS OF EMPHASIS

Do not place the pads over a pacemaker or implantable cardioverter defibrillator

Remove the victim from the water and dry the chest before applying pads

Remove any medication patches from the chest

Make sure the pads do not touch each other

Loudly state, “A SHOCK IS GOING TO BE GIVEN – EVERYONE CLEAR”

The patient's muscles will contract when a shock is given

Do not delay compressions while trying to troubleshoot the AED

Atropine is not indicated for routine use before intubation

Amiodarone and Lidocaine are equally acceptable for shock refractory VF & VT

Invasive monitoring can guide resuscitation if already in place before arrest

Extracorporeal CPR can be useful in cases of underlying cardiac conditions when
an arrest occurs in–hospital (IHCA), if resources and expertise are available
Post–Resuscitation Care
The post–resuscitation phase of care occurs after the return of a pulse. This is known as Return
of Spontaneous Circulation, or ROSC. The goals of this phase are supporting oxygenation and
maximizing tissue/organ perfusion.
POST–RESUSCITATION ALGORITHM
RESPIRATORY SYSTEM
Maximize oxygen delivery to the body. Utilize additional tools, such as x–ray, arterial blood gas
analysis, pulse oximetry, and capnography.
Oxygen saturation should be maintained at a level of at least 94%. Avoid prolonged use of
100% oxygen, as this can be toxic to tissues. Advanced airway placement is required for
unconscious patients and patients who are unable to maintain appropriate oxygenation.
CARDIOVASCULAR SYSTEM
The cardiovascular system is supported by carefully monitoring and utilizing interventions that
optimize hemodynamics. IV fluids and vasopressors may be needed to manage blood pressure
and possibly heart rate. Transfusion may be considered when perfusion remains poor, and
when hemoglobin levels are low. Urine output is often a good parameter to monitor.
NEUROLOGICAL SYSTEM
Preservation of neurological function is critical for quality of life afteran arrest. Fever is treated
aggressively. Hypothermia, post–arrest, is tolerated as long as it is not causing complications.
Glucose should be monitored carefully, and it is crucial to take steps to prevent or correct both
hypoglycemia and hyperglycemia.
Cerebral perfusion pressure, which relates to the difference between intracranial and mean
arterial pressure, is an important concept. Ensuring adequate blood flow to the brain and
elevating the head of the bed when feasible are beneficial.
Frequent neurologic assessment monitoring for seizure activity, and invasive blood pressure
monitoring, are all aspects of intensive post–arrest neurological care.
Detection and treatment of seizures after cardiac arrest is critical. Consider consultation for the
treatment of non-status epilepticus in post-arrest survivors. Routine use of EEG monitoring is
recommended for cardiac arrest survivors with neurologic symptoms or encephalopathy.
RENAL SYSTEM
Urine output is a good measure of renal perfusion. The goal for infants and small children is
more than 1 mL/kg/hr. However, large amounts of diluted urine imply diabetes insipidus. In this
situation, steps must be taken to prevent loss of circulatory volume and electrolyte
abnormalities. Indwelling Foley catheters are useful in quantifying urine output.
GASTROINTESTINAL SYSTEM
Critical illness is linked to gastritis and stress-induced ulcers. Monitor for any signs of GI
bleeding. Liver function should be monitored – elevations can be significant, depending on the
period of cardiac arrest before ROSC.
HEMATOLOGIC SYSTEM
Correct anemia when present by giving transfusions of packed red blood cells (pRBC). Monitor
and correct for coagulopathy, including platelet transfusions, when indicated.
SOCIAL DYNAMICS
The social dynamics of a pediatric arrest case are often more emotionally charged than other
situations. In all cases, be prepared to support family needs, and involve social support systems
and specialists immediately.
Key Points After Resuscitation (After ROSC):

Targeted Temperature Management (TTM) can be implemented for comatose
children after ROSC

Inotropes and vasopressors should be used to maintain systolic BP above the 5th
percentile after ROSC

Oxygen should be titrated to keep saturation between 94 – 99%

Care must be taken to avoid hypocapnia or hypercapnia

Fever should be prevented and treated after ROSC

No single factor or variable predicts prognosis

Multiple factors must be considered when predicting outcomes after ROSC
ALS EKG & Rhythm Analysis
INTRODUCTION
Learning to quickly interpret EKGs and Rhythm Strips is an essential skill for all healthcare
professionals. For those new to this art, it can be intimidating. While not designed to be an allencompassing manual, we will provide a framework for easily and quickly identifying the
essentials required for PALS care.
By the end of this section, students will have an appreciation for common life-threatening
patterns and be competent to proceed down the correct arm of the PALS algorithm without
hesitation.
Each section provides examples of the rhythm and cues to its proper identification. Be sure to
study the additional key points for the rhythms to solidify your understanding and knowledge.
BASIC CONCEPTS
The normal flow of electrical activity in the heart is simplified and proceeds in an orderly
process:
A simple framework for rapid EKG or rhythm analysis is provided and is a powerful tool to help
correctly identify rhythms. As you learn and gain confidence, the application of this method will
operate subconsciously.
1. Sinus Rhythm or not?
2. Fast, Normal, or Slow?
3. Regular or Irregular?
4. Narrow Complex or Wide Complex?
STEP 1: SINUS RHYTHM OR NOT?
Sinus rhythm is determined when a P wave precedes every QRS complex consistently. We’ll get
into blocks later, but for now, this is the first step. Identify if a P wave is present. If it maintains
a consistent relationship with the QRS, then chances are good sinus rhythm is present.
STEP 2: FAST, NORMAL, OR SLOW?
The rate allows categorization into bradycardia (< 60 beats/minute), normal (60 — 100
beats/minute), or tachycardia (> 100 beats/minute). As you learn the various PALS algorithms, it
will be much clearer how this simple distinction helps predict which rhythm you are analyzing.
STEP 3: REGULAR OR IRREGULAR?
Regularity is easy to see and manifests as either a regular R-R interval or a variable R-R interval.
Be sure to look at the entire EKG or rhythm strip before making this determination. Irregular
rhythms can be due to atrial fibrillation, aberrant conduction, premature contractions, and a
few others. But for now, categorize it into regular or irregular.
STEP 4: NARROW COMPLEX OR WIDE COMPLEX?
The last step is to determine if the QRS is normal or wide. This will also help to correctly place
the rhythm you are looking at into the proper diagnosis.
If this paradigm is new, resist the temptation to overthink its utility. If you are already an expert
EKG reader, file it away as a simple tool you can share with those struggling to master rhythm
interpretation.
GENERAL GUIDELINES AND DEFINITIONS

P wave is generated by atrial contraction.

PR interval — normal is between 0.12 — 0.2 seconds or about 3 — 5 mm on the
EKG paper.

QRS complex occurs when the ventricles and the rest of the myocardium
depolarizes. A normal QRS is between 0.6 — 0.1 sec. Anything beyond that is
considered wide complex.

T wave represents ventricular repolarization.

R-R interval is the distance between the peaks of two consecutive R waves.
NORMAL HEART RATES
WHAT CAUSES ARRHYTHMIAS?
Determining the precise cause can be challenging or nearly impossible, but a rapid search for
potential or reversible causes is always prudent. This is a shortlist of possibilities.
PALS RHYTHMS YOU MUST KNOW:
NORMAL SINUS RHYTHM
In normal sinus rhythm, a P wave always appears before every QRS complex. The rate is
between 60 — 100 beats/minute. The R-R interval is regular and the QRS narrow.
EKG Rhythm Example:
Normal Sinus Rhythm
We hope you can see from this first example of how applying the four questions can be helpful.
Sinus arrhythmia is a normal variant and not considered pathologic. It occurs due to increased
blood flow during inspiration. The negative intrathoracic pressure results in the increased
venous return into the chest and is subsequently seen as variability in heart rate.
BRADYCARDIA / TACHYCARDIA
Bradycardia is simply defined as a heart rate of < 60 bpm. Sinus tachycardia is a rapid rhythm —
rates can exceed 140 bpm in children, and 180 bpm for infants, though rates often do not
exceed 220 bpm. For school-aged children, sinus tachycardia is commonly considered a heart
rate of over 120 bpm.
The causes are vast and range from benign to pathologic and potentially life-threatening.
Treatment is aimed at the underlying disorder.
EKG Rhythm Example:
Sinus Bradycardia Rhythm
Sinus Tachycardia Rhythm
Ventricular Tachycardia Rhythm
AV BLOCKS
1ST DEGREE AV BLOCK
In this condition, the conduction from the atria to the ventricles is impaired. This produces a
longer PR duration. The delay should be relatively consistent from beat to beat on the EKG.
EKG Rhythm Example:
1st Degree AV Block Rhythm
2ND DEGREE AV BLOCK
In this disturbance, not all of the P waves are conducted through the conduction system. There
are two types of 2nd degree blocks:
In case you are curious, the names Mobitz and Wenckebach are historical for those who
discovered this electrical phenomenon.
2ND DEGREE — WENCKEBACH — MOBITZ TYPE I
In this arrhythmia, the PR interval becomes progressively longer until a QRS is dropped. This
dropped beat will be noted as a P wave that is not followed by a QRS complex. Then the
sequence repeats itself again and again.
EKG Rhythm Example:
2nd Degree AV Block — Wenckebach — Mobitz Type I Rhythm
For those wanting a bit more, this block is generally due to a conduction problem within the AV
node. The PR interval increases progressively until on P wave is not conducted and the QRS
complex does not appear.
2ND DEGREE — NON-WENCKEBACH MOBITZ TYPE II
This block is often due to a block below the AV node. It is similar to Type I with the exception
that the PR interval is not lengthened. Think if this as an all or nothing phenomenon. The
impulse either gets through the AV node and His bundle, or it does not.
On the EKG, look for two or more normal P wave — QRS complexes, followed by a dropped
beat. In general, the ratio of P waves to QRS complexes is constant.
EKG Rhythm Example:
2nd Degree AV Block — Non-Wenckebach — Mobitz Type II Rhythm
Key distinction: In 2nd Degree Non-Wenckebach Mobitz Type II block there is NO progressive
lengthening of the PR interval.
3RD DEGREE — COMPLETE HEART BLOCK
Third-degree heart block is serious business. In this block, no atrial impulses are being
transmitted to the AV node and it is considered a complete heart block.
The ventricles have an inherent conductivity and will continue to contract but at a slower rate.
This is termed an escape rhythm, or idioventricular escape rhythm, and generates a heart rate
of 30 — 45 beats/minute.
The atria and ventricles operate independently of each other and are said to have
disassociated. AV dissociation is noted on the EKG when P waves have no consistent
relationship to QRS complexes. Both the P waves and QRS complexes appear at regular
intervals but have no relation to one another.
EKG Rhythm Example:
3rd Degree AV Block Rhythm
When 3rd degree heart block first occurs, there can be a pause before the intrinsic ventricular
rate begins. If this pause is longer than a few seconds, many patients will faint. This is termed a
Stokes-Adams attack.
SUPRAVENTRICULAR ARRHYTHMIAS
This arrhythmia is produced from above the AV node or within the atria. It can occur for a
variety of reasons due to abnormal electrical pathways, drugs, toxins, ischemia, and advancing
age (as well as others).
The broad definition of supraventricular arrhythmias also includes atrial flutter, atrial
fibrillation, multifocal atrial tachycardia, and AV node reentrant tachycardia (AVNRT).
Note: AVNRT is a more modern term for supraventricular tachycardia or SVT.
AV NODAL REENTRANT TACHYCARDIA (AVNRT)
AVNRT is very common and is abrupt in both onset and offset. Often a premature beat, such as
an atrial premature beat, triggers it to begin. Common symptoms include:

Palpitations

Shortness of breath

Dizziness

Syncope

Irritability

Chest pain

History of abrupt onset and termination
Additional symptoms for infants include:

Poor feeding

Lethargy

Pallor
Congestive Heart Failure (CHF)
AVNRT is completely regular. Remember the four questions at the beginning of this section?
The rate is approximately 180 bpm for children and 220 for infants. P waves can be hard to
identify due to the rapid rate and are often buried in the QRS complexes.

EKG Rhythm Example:
AVNRT Rhythm
ATRIAL FLUTTER
The chaotic atrial impulses in flutter occur at a rapid rate — up to 250 — 350 beats/minute —
and occur regularly. The result is a sawtooth pattern known as flutter waves. The P waves occur
rapidly, and a flat baseline is not seen in atrial flutter.
Atrial flutter is rarely seen beyond the newborn period, except in the setting of underlying
congenital heart disease and after cardiac surgical procedures or interventions.
EKG Rhythm Example:
Atrial Flutter Rhythm
Atrial flutter can be the result of underlying pathophysiology but can also at times be seen in
normal hearts.
The AV node is not able to process all the incoming impulses from the atrial and becomes
refractory. This results in a type of AV block. 2:1 is the most common pattern — meaning for
every two flutter waves, one gets through to the AV node and generates a QRS complex. Other
patterns, such as 3:1 and 4:1, are also possible.
Increasing vagal tone — such as with bearing down or carotid massage — can increase vagal
tone and turn a 2:1 block into a 4:1 block, making it easier to see the tell-tale flutter waves.
ATRIAL FIBRILLATION
In this chaotic rhythm, the AV node is bombarded with hundreds of impulses every minute. The
result is that the AV node can only handle the conduction of a certain amount of impulses and
lets them through at variable intervals. This is evident on the EKG and when feeling the
patient’s pulse, as it will be irregularly irregular.
QRS complexes occur in irregular and unpredictable intervals ranging from a normal (< 100
beats/minute) rate to faster. The faster rates are generally between 120 — 180 beats/minute
and this phenomenon is called atrial fibrillation with rapid ventricular rate.
Atrial fibrillation is mostly seen in children with underlying structural heart disease and in those
who have undergone cardiac surgery.
EKG Rhythm Example:
Atrial Fibrillation Rhythm
A variety of conditions can be responsible including:

Advancing age

Chronic hypertension

Obesity

Mitral valve disease

Alcohol abuse

Coronary artery disease

Metabolic syndrome
Symptoms commonly include:

Palpitations

Weakness

Shortness of breath

Lightheadedness or dizziness

Chest pain
Many elderly are unaware of this condition and fail to notice symptoms.
VENTRICULAR ARRHYTHMIAS
Definition: Any arrhythmia originating below the AV Node
PREMATURE VENTRICULAR CONTRACTIONS
Perhaps the most common of all arrhythmias, many of us have PVCs during the day and are
completely unaware.
The QRS complex is bizarre and wide as the electrical impulse does not follow the normal
pathway. Make sure the QRS complex is at least 0.12 seconds and scan all leads, as it may not
appear wide in every lead.
Isolated PVCs are rarely of consequence but play close attention when ischemia and acute MI is
present, as they may herald the onset of ventricular tachycardia.
Often PVCs occur randomly but they can also present in patterns associated with normal sinus
rhythm alternating with PVCs. This is known as bigeminy (two normal beats and one PVC) or
trigeminy (three normal beats and one PVC).
VENTRICULAR TACHYCARDIA (VT)
Definition: a run of three or more PVCs.
The rate for VT is generally between 100 bpm — well over 200 bpm. It may be very slightly
irregular. If VT lasts longer than 30 seconds, it is considered sustained. VT often produces
hemodynamic collapse and requires emergent intervention to prevent cardiac arrest.
EKG Rhythm Example:
Ventricular Tachycardia (VT) Rhythm
Be on the lookout for this potentially lethal arrhythmia in patients with ischemia or recent
myocardial infarction. Up to 5% of acute MI patients will develop VT within 48 hours and this
risk persists for weeks after myocardial infarction.
VENTRICULAR FIBRILLATION (VF)
This is a fatal arrhythmia if not quickly reversed. The EKG will reveal a rapid chaotic pattern. No
cardiac output is possible, and CPR and defibrillation must be carried out immediately.
VF is the most important shockable rhythm and immediate recognition and action are
demanded.
EKG Rhythm Example:
Ventricular Fibrillation (VF) Rhythm
TORSADES DE POINTES
In patients with underlying QT prolongation, this unique form of VT can occur. Classically, it is
described as a twisting of points as the QRS complexes appear to rotate around a horizontal
axis on the EKG or rhythm strip.
EKG Rhythm Example:
Torsades de Pointes Rhythm
QT prolongation can occur for a variety of reasons:

Genetic mutation

Acute MI

Drug side effects and interactions
Treatment of torsade’s is variable and influenced by potential causes. Options include overdrive
pacing, magnesium infusion, Isoproterenol, or Mexiletine.
ACCELERATED IDIOVENTRICULAR RHYTHM
This regular rhythm occurs during an acute MI or the repercussion process. It is regular and
ranges from 50 -100 beats/minute. A ventricular escape focus is most likely generating this
rhythm and rarely requires treatment. If the rate drops slower than 50 beats/minute, it is
termed idioventricular rhythm.
EKG Rhythm Example:
Accelerated Idioventricular Rhythm
MYOCARDIAL INFARCTION
When the blood supply to the heart is acutely compromised, a myocardial infarction can occur.
During this process, several EKG changes can be noted. It is important to understand that the
changes can evolve, and serial EKGs and monitoring are critical when this condition is
suspected.
Classically, the EKG evolves through three different stages:
1. Acute T wave peaking that progresses to T-wave inversion
2. ST-segment elevation
3. New Q waves appear
Understand that not all three stages are always seen and any one of these changes can be
noted on the EKG without the presence of the others. Practice and repetition are the keys to
mastering EKG interpretation.
Once ST elevation occurs, injury to the myocardium has occurred. This is termed ST-segment
elevation myocardial infarction or STEMI.
Note: Acute MI in the pediatric population is fortunately very rare, but can occur due to
anomalous origin of the left main coronary artery.
EKG Rhythm Example:
ST-segment elevation myocardial infarction (STEMI) Rhythm
When looking for ST elevation, the general rule of thumb is to compare elevation to a baseline
of the T-P segment (the baseline EKG tracing between the T wave and following P wave).
Note: an acute myocardial infarction can also occur without ST elevation and is referred to as
a non-ST segment elevation myocardial infarction (non-STEMI).
ASYSTOLE
The absence of all cardiac activity is called asystole. If immediate intervention is not able to
reverse asystole, death results.
Take a deep breath and evaluate this rhythm systematically. First, check the patient. If they are
awake, asystole is an artifact. Check all equipment and monitors. Make sure all leads are
attached to the patient and connected. Many a nurse has panicked when asystole alarms on
the monitoring equipment only to discover a connection came loose when the patient rolled on
their side in bed.
EKG Rhythm Example:
Asystole Rhythm
PULSELESS ELECTRICAL ACTIVITY (PEA)
This condition is also known as electromechanical dissociation, PEA, and pulseless electrical
activity. In this ominous situation, the EKG or monitor will show a rhythm that should be
perfusing the patient and generating a pulse, but it does not.
EKG Rhythm Example:
Pulseless Electrical Activity (PEA) Rhythm
Immediate intervention is required as well as a quick analysis of potential causes of PEA. A
commonly taught memory technique is H’s & T’s.
The overall clinical picture is important to consider. When BP is too low, a radial pulse will be
difficult to palpate. Check central pulses, such as the carotid or femoral pulse. Also, the
patient's responsiveness is invaluable. If they are awake and talking, they are perfusing their
brain and PEA does not exist. Analyze the clinical scenario and use medical history if available to
help determine reversible causes such as those listed above.
PALS Medications
The PALS provider must be familiar with the commonly used medications for the various
algorithms.