Pediatric Advanced Life Support
Agenda
DAY 1
 Course introductions and
overview
 Review new 2011 updates
 BLS primary survey video
 PALS secondary survey video
 CPR and AED practice, ETCO2
monitoring (group 1)
 Airway devices and intubation
(group 2)
 Bradycardia station (group 1)
 Asystole/PEA station (group2)
 Patient assessment Video
 Respiratory emergencies (group
1)
 VF/VT station (group 2)
DAY 2
 Tachycardias
 Shocks
 Lead II rhythm review
 Team resuscitation concept
video
 Algorithm review
 Mega-code review/practice
Testing and Megacode
 Remediation
Introduction
 PALS is designed to give the learner the ability to assess and
quickly respond to pediatric emergencies including
respiratory arrest and cardiac arrest.
 The course is two days and encompasses a written exam and
a core scenario that must be passed with at least an 84%.
First hour of class we will be going over a pre-test.
PALS Over View: AHA guidelines
Purpose of PALS
 Acquire the ability to recognize an infant or child whom requires advanced life support
 Learn to apply the “Assess, Categorize, Decide and Act” model of assessment
 Learn the importance and technique for quality and effective CPR and advanced life
support
 Learn effective team coordination and team member roles in resuscitation
Key Points of Importance of PALS
 The first step in cardiac arrest is prevention
 If cardiac arrest does occur, effective high quality CPR is the most important aspect in
successful resuscitation
 Studies show that poor skills by healthcare workers lead to increased incidences of death
and brain death
 All PALS students must perform effective and quality CPR throughout the course
 WATCH PALS INTRODUCTION ON VIDEO
*NEW 2011 CPR UPDATE CHANGES:
BLS
 If there's a palpable pulse >60, but the patient shows inadequate
breathing, give rescue breaths at a rate of 12–20
breaths/minute (one breath every three to five seconds) using
the higher rate for younger children
 If the pulse is <60 and there are signs of poor perfusion (pallor,
mottling, cyanosis) despite support of oxygenation and
ventilation, begin chest compressions. Beginning CPR prior
to full cardiac arrest results in improved survival.
 Place less emphasis on the pulse check. For an unresponsive and
non-breathing child, begin CPR if a pulse cannot be detected
within 10 seconds
*NEW 2011 CPR UPDATE CHANGES:
BLS
 Initiate CPR with chest compressions rather than rescue breaths (CAB
rather than ABC). Asphyxial cardiac arrest is more common in
infants and children, and ventilations are extremely important in
pediatric resuscitation. The CAB sequence for infants and children is to
simplify training. Therefore, start CPR with chest compressions
immediately, while a second rescuer prepares to provide ventilation
 Compress at a rate of at least 100/min. After each compression,
allow the chest to recoil completely
 Depth of compressions is at least one-third (1/3) the
anterior-posterior diameter of the chest or approximately 1½
inches (4 cm) in infants and 2 inches (5 cm) in children. Note:
Inadequate compression depth and incomplete recoil is common even
among trained providers.
*NEW 2011 CPR UPDATE CHANGES:
BLS
 For the lone rescuer, a compression-ventilation ratio of
30:2 is recommended. For two rescuers, a ratio of 15:2 is
recommended.
 Oropharyngeal and nasopharyngeal airways help maintain an open
airway. Make sure to select the correct size.
 Deliver ventilations with as short a pause in compressions as
possible. If an advanced airway is in place, compressions should be
delivered without pauses for ventilation. Ventilations should
be delivered at a rate of eight to 10 breaths/minute
(every six to seven seconds) without interrupting
compressions. Avoid excessive ventilation
*NEW 2011 CPR UPDATE CHANGES:
Defibrillation

Follow package directions for placement of defibrillator pads. Place manual electrodes over the
right side of upper chest and the apex of the heart (to left of nipple over left lower ribs). There is no
advantage in an anterior-posterior position of the paddles.

Paddle size: Use the largest electrodes that will fit on the childʼs chest without touching, leaving
about 3 cm between electrodes. “Adult” size (8–10 cm) electrodes should be used for children >10
kg (approximately one year). “Infant” size should be used for infants <10 kg.

An initial dose of 2 to 4 J/kg is acceptable. For refractory VF, itʼs reasonable to increase the
dose to 4 J/kg. Higher energy levels may be considered, not to exceed 10 J/kg or the adult
maximum dose

If an AED with an attenuator is not available, use an AED with standard electrodes

In infants <1 year, a manual defibrillator is preferred. If not available, an AED with
an attenuator may be used. An AED without a dose attenuator may be used if neither
a manual defibrillator nor a dose attenuator is available
Broselow Tape
*NEW 2011 CPR UPDATE CHANGES:
PALS
 The PALS cardiac arrest algorithm is simplified and organized
around two-minute periods of uninterrupted CPR.
 Exhaled CO2 detection is recommended as confirmation
of tracheal tube position with a perfusing rhythm in all
settings and during intra- or inter-hospital transport.
Capnography/capnometry, used for confirming proper
endotracheal tube position, may also be useful to assess and
optimize the quality of chest compressions during CPR
 It may also spare the rescuer from interrupting chest
compressions for a pulse check because an abrupt and
sustained rise in PetCO2 is observed just prior to clinical
identification of ROSC.
*NEW 2011 CPR UPDATE CHANGES:
PALS
 Upon ROSC, titrate inspired oxygen (when oximetry is available) to
maintain an arterial oxyhemoglobin saturation >94% but <100% to
limit the risk of hyperoxemia.
 Bradycardia with pulse and poor perfusion: epinephrine,
atropine and pacing may be used.
 Tachycardia with pulse and poor perfusion: > Narrow complex
(QRS <0.09) SVT: Attempt vagal stimulation. Adenosine is the drug of
choice. If hemodynamically unstable or adenosine are ineffective,
perform synch cardioversion, starting at a dose of 0.5 to 1 J/kg,
increasing to 2 J/kg. > Wide complex (QRS>0.09) tachycardia,
hemodynamically stable: Adenosine may be considered if the rhythm is
regular and monomorphic and is useful to differentiate SVT from VT.
Consider cardioversion using energy described for SVT. Expert
consultation is strongly recommended prior to administration of
amiodarone or procainamide. If hemodynamically unstable,
cardioversion is recommended.
SVT
 Stable: Vagals first, then Adenosine 0.1, 0.2mg/kg, Then
cardiovert as last resort 0.5-1J/kg
 Unstable: Cardiovert
VT with pulse:
Stable: Adenosine .1, .2, Amiodarone 5mg/kg over 60 min,
then cardioversion if needed.
Unstable: Cardioversion
VT/VF: no pulse , defib ASAP, CPR, Epi, after third shock
Amiodarone
*NEW 2011 CPR UPDATE CHANGES:
PALS
 Routine calcium administration is not recommended for pediatric cardiopulmonary
arrest in the absence of documented hypocalcemia, calcium channel blocker overdose,
hypermagnesemia or hyperkalemia.
 Etomidate has been shown to facilitate endotracheal intubation in infants and children
with minimal hemodynamic effect but is not recommended for routine use in pediatric
patients with evidence of septic shock.

Although there have been no published results of prospective randomized pediatric trials
of therapeutic hypothermia, based on adult evidence, therapeutic hypothermia (to 32–
34°C) may be beneficial for adolescents who remain comatose after resuscitation from
sudden, witnessed, out-of-hospital VF cardiac arrest. Therapeutic hypothermia (to 32–
34°C) may also be considered for infants and children who remain comatose after
resuscitation from cardiac arrest.
 Whenever possible, provide family members with the option of being present during
resuscitation of an infant or child.
CPR Practice and Competency Testing
 Single person resuscitation (30:2 ratio, 100 compressions a
minute, 2 minute cycles)
 Two person resuscitation (15:2 ratio)
 Use of Bag/Mask (remember, always bag a patient whom
becomes distressed and cyanotic on the ventilatior)
CPR Practice and Competency Testing
 Compression techniques (one hand method, two hand, two
finger or encircling thumb technique)
Watch video on CPR practice, we will be
practicing CPR soon
Overview of PALS CPR
 High Quality CPR
 Compression rate of at least 100 per minute
 Push hard and fast
 Compression depth 1/3 AP diameter of the chest, 1 ½ inches in
infants and 2 inches in pediatrics
 Allow proper chest recoil after each compression to allow for proper
cardiac output
 Minimize interruptions for continuous brain and organ perfusion
 Avoid excessive ventilation to prevent impendence of venous return
back to the heart and gastric insufflation
Overview of PALS CPR
AED
 Paddle size: Use the largest electrodes that will fit on the childʼs chest
without touching, leaving about 3 cm between electrodes. “Adult” size
(8–10 cm) electrodes should be used for children >10 kg
(approximately one year). “Infant” size should be used for infants <10
kg.
 If an AED with an attenuator is not available, use an AED with
standard electrodes
 In infants <1 year, a manual defibrillator is preferred. If not
available, an AED with an attenuator may be used. An AED
without a dose attenuator may be used if neither a manual
defibrillator nor a dose attenuator is available
Airway Management
 Upper airway obstruction:
 Note presence of stridor (typically inspiratory)
 Note cough (seal like, dull, muffled)
 Note Conciousness
 Note breath sounds (decreased?), note HR (typically tachycardic)
 Note color, retractions, grunting, tachypnea and WOB
 If in distress causing compromise: open airway and determine if an advanced
airway is needed. Support ventilations and begin CPR as needed
 Possible causes: Croup, Epiglotitis, Apiration, inhaled toxins, anaphylaxis
 Administer nebulized epinephrine/racemic for moderate stridor/barking
cough
 Treat underlying problem: airway, cool mist, racemic epinephrine, decadron,
steroids
Airway Management
Lower Airway Obstruction
 Note presence of Wheezing (typically expiratory), prolonged
expiratory phase and airtrapping
 Note decreased aeration in lungs, desaturation
 Note color (cyanosis is a late sign)
 Causes: Asthma, Pneumonia, Bronchiolitis, aspiration that has
migrated passed trachea (unilateral wheezing)
 Treat with bronchodilators, bronchial hygein and
bronchoscopy
Advanced Airways
 Airway problems in the pediatric population is especially
critical as it typically is the precipitating cause of pediatric
arrest
Advanced Airways
 Cuffed ETT now considered as safe or more safe than a non
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cuffed for small children
Verify placement with exhaled CO2 detector (turns yellow
for correct placement); check chest rise, breath sounds then
CXR
Exhaled CO2 may not be detected in prolonged arrest
May use a EDD
USE DOPE mnemonic when determining deterioration of an
intubated patient; D: displacement of ETT, O: obstruction of
the tube; P: pneumothorax; E: equipment failure
Support of Ventilation
The method of advanced airway support (endotracheal
intubation versus laryngeal mask versus bag-mask) provided to
the patient should be selected on the basis of the training and
skill level of providers in a given advanced life support (ALS)
system and on the arrest characteristics and circumstances (eg,
transport time and perhaps the cause of the arrest).
Split up into two groups
 Group 1.
 Group 2.
 CPR practice
 Intubation practice
 Bag and mask practice
 LMA overview
 AED practice
 Oxygen management
20 minutes per group then
switch
Airway Management
Watch Airway Management Video
Rapid Sequence Intubation
 To facilitate emergency intubation and reduce the incidence
of complications, skilled, experienced providers may use
sedatives, neuromuscular blocking agents, and other
medications to rapidly sedate and paralyze the victim. Use
RSI only if you are trained and have experience using these
medications and are proficient in the evaluation and
management of the pediatric airway. If you use RSI you must
have a secondary plan to manage the airway in the event that
you cannot achieve intubation.
Airway Management
CuffedVersus Uncuffed Tubes
 In the in-hospital setting a cuffed endotracheal tube is as safe as an uncuffed tube for infants beyond
the newborn period and in children.In certain circumstances (eg, poor lung compliance, high
airway resistance, or a large glottic air leak) a cuffed tube may be preferable provided that attention
is paid to endotracheal tube size, position, and cuff inflation pressure
Disordered control of breathing
 Occurs often after a head injury or as a result of aneurysm or infection in brain. Normal rhythmic
breathing is altered, requires protection of airway with artificial airways.
Endotracheal Tube Size
 Length-based resuscitation tapes are helpful and more accurate than age-based formula estimates of
endotracheal tube size for children up to approximately 35 kg, even for children with short stature.
 In preparation for intubation with either a cuffed or an uncuffed endotracheal tube, confirm that
tubes with an internal diameter (ID) 0.5 mm smaller and 0.5 mm larger than the estimated size are
available. During intubation, if the endotracheal tube meets resistance, place a tube 0.5 mm smaller
instead. Following intubation, if there is a large glottic air leak that interferes with oxygenation or
ventilation, consider replacing the tube with one that is 0.5 mm larger, or place a cuffed tube of the
same size if an uncuffed tube was used originally. Note that replacement of a functional
endotracheal tube is associated with risk; the procedure should be undertaken in an appropriate
setting by experienced personnel.
Airway Management
 If an uncuffed endotracheal tube is used for emergency intubation,
it is reasonable to select a
 3.5-mm ID tube for infants up to one year of age and a
 4.0-mm ID tube for patients between 1 and 2 years of age.
 After age 2, uncuffed endotracheal tube size can be estimated by the
 following formula:
 If a cuffed tube is used for emergency intubation of an infant less than
1 year of age, it is reasonable to select a 3.0 mm ID tube. For children
between 1 and 2 years of age, it is reasonable to use a cuffed
endotracheal tube with an internal diameter of 3.5 mm After age 2 it
is reasonable to estimate tube size with the following formula
Respiratory Compromise
 Be vigilant for signs of respiratory compromise. Often, symptoms
of shock or cardiac distress are treated without regard to
respiratory status, but in many cases a cardiac dysrhythmia or
compensated shock can be completely resolved by aggressive
oxygenation.
 Whenever a pediatric patient’s heart rate is too slow, or is slowing,
the first and primary treatment is to give assisted ventilations if the
child’s airway is not maintained or their work of breathing is not
effective.
 For pediatric patients with any symptoms, always provide oxygen,
the exact flow rate depending on patient needs. Stable patients
with a cardiac dysrhythmia but no respiratory distress can receive
low-flow oxygen (up to 4 L/min.) via nasal cannula. Unstable
cardiac patients, patients in shock (compensated or hypovolemic),
or patients with respiratory distress should receive oxygen via
non-rebreather mask, if they tolerate it. Patients in respiratory
failure should receive assisted ventilations via bag-mask valve.
Respiratory Compromise
 It is critical that students correctly categorize the degree of
respiratory compromise and provide appropriate
oxygenation.
 In Respiratory Distress, the patient will have an increased
respiratory rate and effort. Be alert for patient position, nasal
flaring, retractions, and accessory muscle use. Skin color may
be normal or pale, and the patient may exhibit the beginnings
of an Altered Level of Consciousness (ALOC). Adventitious
breath sounds may or may not be present. Any patient in
respiratory distress should receive high-flow oxygen via nonrebreather mask, if they tolerate it.
Respiratory Compromise
 In Respiratory Failure, the patient may have an increase in
respiratory effort with increased or decreased respiratory rate. Be
alert for patient position, nasal flaring, retractions, and accessory
muscle use. Head bobbing, decreased respiratory effort, “seesaw”
respiratory pattern, shallow respirations, cyanosis, difficulty
speaking, and poor air movement (diminished or absent breath
sounds) are signs of respiratory failure. For any child in respiratory
failure or severe respiratory distress, you should consider the
following interventions: AssistedVentilations (provide ventilations via
Bag-valve Mask); Advanced Airway (consider Endotracheal
Intubation); or MechanicalVentilations (such as CPAP or BiPAP).
When providing assisted ventilations, students should remember
that hyperventilation (ventilating too often, too rapidly, or with
too much volume) will diminish the effectiveness of
circulation.
Exhaled or End-Tidal CO2 Monitoring
 When available, exhaled CO2 detection (capnography or
colorimetry) is recommended as confirmation of tracheal tube
position for neonates, infants, and children with a perfusing
cardiac rhythm in all settings (eg, prehospital, emergency
department [ED], ICU, ward, operating room) and during
intrahospital or interhospital transport.
 Remember that a color change or the presence of a capnography
waveform confirms tube position in the airway but does not rule
out right mainstem bronchus intubation. During cardiac arrest, if
exhaled CO2 is not detected, confirm tube position with direct
laryngoscopy because the absence of CO2 may reflect very low
pulmonary blood flow rather than tube misplacement.
Exhaled or End-Tidal CO2 Monitoring
 Confirmation of endotracheal tube position by colorimetric end-
tidal CO2 detector may be altered by the following:
 If the detector is contaminated with gastric contents or acidic drugs
(eg, endotracheally administered epinephrine), a consistent color
rather than a breath-to-breath color change may be seen.
 An intravenous (IV) bolus of epinephrine may transiently reduce
pulmonary blood flow and exhaled CO2 below the limits of
detection.
 Severe airway obstruction (eg, status asthmaticus) and pulmonary
edema may impair CO2 elimination below the limits of detection.
 A large glottic air leak may reduce exhaled tidal volume through the
tube and dilute CO2 concentration.
Capnography-Show video
Oxygen
 Ventilate with 100% oxygen during CPR because there is
insufficient information on the optimal inspired oxygen
concentration once the circulation is restored, monitor
systemic oxygen saturation.
 Titrate oxygen administration to maintain the
oxyhemoglobin saturation ≥94%-99%
If resuscitation efforts are unsuccessful, note possible causes for the
arrest: 6 H’s and 5 T’s
H’s
1.
 2.
 3.
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4.
5.
 6.
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Hypovolemia (look for signs of fluid/blood loss. Give fluid blolus’s and reassess)
Hypoxia (confirm chest rise and bilateral breath sounds with ventilation, check o2 source)
Hydrogen Ion Acidosis (Resp acidosis; provide adequate ventilation but do not
hyperventilate, metabolic acidosis; give sodium bicarb)
Hyper/Hypokalemia (for hyper give calcium chloride 10 ml of 10% over 5 minutes, for
hypo give potassium or magnesium 5ml of 50% solution)
Hyper/hypothermia
Hypo/hyperglycemia (check glucose with Accu-check)
T’s
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1.
2.
 3.
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4.
 5.
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Tablets (Drug OD); find antidote or reverse drug, poison control. Always ask the
family for metabolic or toxic causes during resuscitation
Tamponade (look for chest trauma, malignancy, central line insertion, JVD)
Tension Pneumothorax- desreased BS, deviated trachea, high peak pressures or difficult to
bag, chest tube with needle decompression OVER THE THIRD RIB AT THE
MIDCLAVICULAR LINE
Thrombosis- give thrombolytics for suspected embolus
Trauma- inspect body completely, remove clothing, secure airway, control bleeding and
give volume with isotonic crystalloids and blood products
Arrhythmia Review
Ventricular Tachycardia without Pulse and
Ventricular Fibrillation
PulselessV-Tach
 VT- series of wide bizarre QRS that produce little to no
cardiac output; rate above 100
 Requires immediate defibrillation with 2J/kg followed by
immediate CPR
 If after 2 minutes still in VT or VF, shock again at 4J/kg
 Establish IV and give Epinephrine 0.01mg/kg
Ventricular Tachycardia without Pulse and
Ventricular Fibrillation
V-Fib
 Chaotic; no defined rhythm, never a HR/pulse
 Requires immediate defibrillation with 2J/kg followed by
immediate CPR
 If after 2 minutes still in VT or VF, shock again at 4J/kg
 Establish IV and give Epinephrine 0.01mg/kg
 Both of these arrhythmias will require emergent
CPR, Defibrillation and Drugs!
Bradycardia
 Bradycardia occurs when the heart beats slower than 60 beats per minute; occurs as a
result of heart block or increased vagal tone.
What do you do:
 Support ABC’s as necessary
 Give Oxygen
 Attach Monitor and prepare defibrillator
 Determine if bradycardia is causing cardiopulmonary compromise
 IF YES: Perform CPR if despite oxygenation and ventilation with bagging; the heart rate remains
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below 60/min with poor perfusion
If bradycardia persists when rhythm is checked after 2 minutes; Give EPINEPHRINE and repeat
every 3-5 minutes as necessary
If patient has increased vagal tone (Physiological causes of increased vagal tone include bradycardia
seen in athletes; pathologic causes include MI, toxic or environmental exposure, electrolyte disorders,
infection, sleep apnea, drug effects, hypoglycemia, hypothryroidism, and increased intracranial
pressure) or primary AV BLOCK; give ATROPINE first dose 0.02 mg/kg, may repeat
(minimum dose is 0.1mg to maximum total dose of 1 mg)
Consider pacing if drugs fail
Watch for asystole and ne prepared to perform CPR
 If bradycardia is not causing any compromise; monitor patient, supply oxygen and aquire
expert consultation. Also note possible causes H’s and T’s.
Transcutaneous Pacing
 Not commonly performed with pediatrics, however it is
utilized to supplement a failing conduction system associated
with high degree blocks or severe unresponsive bradycardia
Pediatric Pulseless Arrest Algorithm
BLS: Initiate CPR 30:2 or 15:2 ratios; avoid hyperventilation (CAB)
Bag/mask ventilate with 100% oxygen
Attach monitor and prepare defibrillator
Check rhythm once on monitor after 2 minute cycle of CPR. Determine if the
rhythm is shockable (VT, VF) or not; also a IV/IO should be established and an
advanced airway should be considered
 If shockable (VT, VF)
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 Give 1 shock: manual start with 2 J/Kg; AED
 Resume CPR immediately after shock
 Give 5 cycles (approximately 2 minutes) and then check rhythm again and determine if its
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shockable or not
If it is shockable continue CPR while defibrillator is charging and administer second shock
with 4 J/Kg then resume CPR
Give epinephrine at this time IV/IO 0.01 mg/kg (1:10,000 soln) or ETT; repeat every 35 minutes
Keep checking rhythm after every 2 minutes to determine if it is shockable or not, if after
3 shocks VF or VT remain, consider antiarrythmics;
AMIODARONE 5 mg/kg IV/IO or LIDOCAIN 1 mg/kg IV/IO’ consider
Magnesium 2.5-5 mg/Kg IV/IO max dose 2g for Torsades de Pointes. If
rhythm continues the same; consider H’s and T’s
ASYSTOLE
ASYSTOLE
Algorithm: Pulseless Arrest – Not Shockable (Course Guide, page 39)
Remember: DEAD:
• Determine whether to initiate resuscitative efforts.
• Epinephrine 0.01 mg/kg (1:10,000 solution) q 3-5 min IV/IO. Give
as soon as possible after resuming CPR, circulate with chest
compressions.
 • Aggressive oxygenation – use compression: ventilation ratio of 15:2
consider advanced airway. Avoid hyperventilation – do not ventilate too
often, too quickly, or with too much volume.
 • Differential Diagnosis or Discontinue resuscitation – Are they still
dead? Consider the 6 H’s and 5 T’s (see above) – check blood glucose;
check
 core temperature; consider Naloxone; etc.
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PULSELESS ELECTRICAL ACTIVITY
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Algorithm: Pulseless Arrest – Not Shockable
Remember: PEA:
• Possible causes (consider the 6 H’s and 5 T’s).
• Epinephrine 0.01 mg/kg IV/IO q 3-5 minutes. Give as soon as possible after resuming CPR,
circulate with chest compressions.
• Aggressive oxygenation – use compression: ventilation ratio of 15:2 consider an advanced airway.
Avoid hyperventilation – do not ventilate too quickly, too often, or with too much volume. Note: In
PEA, the electrical system of the heart is functioning, but there is a problem with the pump, pipes, or
volume – a mechanical part of the system is not working.You can use the 6 H’s and 5 T’s to
remember the most common reversible causes of PEA:
Hypovolemia Toxins
Hypoxia Tamponade, cardiac
Hydrogen Ion (acidosis) Tension Pneumothorax
Hypo-/Hyperkalemia Thrombosis (coronary or pulmonary)
Hypoglycemia Trauma
Hypothermia
PEA will have the
appearance of a sinus
rhythm, however no
pulse is present!
Tachycardia with Pulse and Adequate
Perfusion
 Assess and support ABC’s as needed
 Provide Oxygen, do not rely on SpO2 monitor, may be unreliable (mask, nasal
cannula…)
 Attach monitor, prepare defibrillator
 Evaluate/Obtain a 12 lead EKG
 On EKG if QRS is normal (0.08 to 0.12 seconds)
 Probable sinus tachycardia
 Compatible with history consistent with known cause (fever, pain, fear…)
 P waves present/normal
 Variable R-R with consistent PR
 Infants: rate usually <220/min; children rate usually <180/min
 Treat causes (this will return rate to normal)
Tachycardia with Pulse and Adequate
Perfusion
 On EKG if QRS is narrow (less than 0.08 seconds)
 Probable Supraventricular tachycardia
 Compatible history (vague, non specific, abrupt rate changes)
 P waves abnsent/abnormal
 HR not variable with activity
 Infants rate >220/min, children rate > 180/min
 Treatment: consider vagal maneuvers first (if patient is stable), ideal vagal= ice to face in
infants, establish IV and consider ADENSOSINE 0.1 mg/kg IV (maximum first dose 6
mg). Use rapid bolus technique. If patient is unstable and has no IV, cardiovert
immediately.
Tachycardia with Pulse and Adequate
Perfusion
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On EKG if QRS is wide (greater than 0.12 seconds)
Possible Ventricular tachycardia
Consider expert consultation
Search and treat possible causes
Consider pharmacologic cardioversion with: Amiodarone 5 mg/kg IV over
20-60 minutes or Procainamide 15 mg/kg over 30-60 minutes (both will
slow ventricular conduction and improve contractility, thus increasing cardiac
output)
Do not administer Amiodarone and Procainamide together
May attempt Adenosine if not already administered
Consider electrical cardioversion for unstable patients or if medications fail
Cardiovert with 0.5 to 1 J/kg (may increase to 2 J/kg if initial dose
is ineffective)
Sedate prior to cardioversion
Obtain 12 lead EKG
Pediatric Tachycardia with Pulses with
Poor Perfusion
 Same as previous slide; except DO NOT DELAY
CARDIOVERSION FOR IV access and consider
possible causes H’s and T’s
Cardioversion verse Defribillation
 Cardioversion: 0.5 to 1 J/kg with sync mode on (may
increase to 2 J/kg if 1st shock unsuccessful) use sedation with
analgesia when possible
 For unstable SVT, VT, A-Fib, A-Flutter not controlled by
Adenosine or Vagal Manuvers. Cardiovert if vascular access is
not established (Do not delay cardioversion to establish IV/IO)
 Defibrillation: 2-4 J/kg, increase Joules, unsynchronized,
for VT/VF, perform immediate CPR after shock, assess
rhythm every 2 minutes; epinephrine should be given in
conjunction every 3-5 minutes, 0.01 mg/kg
Split up into two groups
 Group 1:
 Group 2:
 Review pulseless arrest
 Review defibrillation,
algorithm and drug
management, review
VF/VT algorithm, Review
Bradycardia and
tachycardia algorithm
cardioversion and T.C.P on
defibrillator
Medications and administration
 Preferred route IV/IO because ETT route is unreliable in
dosing and absorption
 Prolonged use of Epinephrine with increasing does no longer
done
Watch IO insertion video
Medications
Adenosine
 0.1 mg/kg (up to 6 mg)
 0.2 mg/kg for second dose
 Rapid IV push, max single dose 12 mg.
 For SVT (after vagal manuevars)
Amiodarone
 5 mg/kg rapid IV/IO
 Max 15 mg/kg/day for refractory pulselessVT/VF
Medications
Atropine Sulfate
 0.02 mg/kg IV/IO/TT
 Min dose 0.1 mg, max single dose 0.5 mg, 1 mg adolescent,
may double second dose. For bradycardia after epinephrine
Epinephrine
 0.01 mg/kg (1:10,000) IV/IO
 0.1 mg/kg (1:1000) ETT
 Repeat every 3-5 minutes during CPR
 Consider a higher dose (0.1mg/kg) for special conditions,
given for VT/VF, aystole, PEA, bradycardia
Medications
Glucose
 0.5-1 g/kg IV/IO max dose 2-4 mL/kg of 25% soln
 5%= 10-20 mL/kg, 10%= 5-10 mLkg, 25%= 2-4 ml/kg in
large vein
Dobutamine
 2-20 ug/kg/min
 Titrate to desired effect
Dopamine
 2-20 ug/kg/min
 Presser effects at higher doses>15 ug/kg/min
Medications
Lidocain
 1 mg/kg
 IV/IO/TT (with TT dilute with NS to a volume of 3-5 ml and follow with
positive pressure ventilations. Given as a alternative to Amiodarone
Magnesium Sulfate
 25-50 mg/kg IV/IO over 10-20 min
 Max dose 2 g, given for Torsades De Pointes
Naloxone
 If <5 yr old or 20 kg: 0.1 mg/kg
 If >5 yr old or 20 kg, 2 mg
 Titrate to desired effect, for barbituate overdose
Sodium Bicarb
 1 mEq/kg per dose
 Infuse slowly and only if ventilation is adequate
Management of Shock
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 6.
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Give Oxygen
Monitor Pulse Ox
ECG monitor
Blood Pressure
IV/IO access
BLS as indicated
Bedside Glucose
Management of Shock
Shock results from inadequate blood flow and oxygen delivery to meet tissue metabolic demands.
Shock progresses over a continuum of severity, from a compensated to a decompensated state.
Attempts to compensate include tachycardia and increased systemic vascular resistance
(vasoconstriction) in an effort to maintain cardiac output and blood pressure. Although
decompensation can occur rapidly, it is usually preceded by a period of inadequate end-organ
perfusion. Signs of compensated shock include:
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Tachycardia
Cool extremities
Prolonged capillary refill (despite warm ambient temperature)
Weak peripheral pulses compared with central pulses
Normal blood pressure.
As compensatory mechanisms fail, signs of inadequate end-organ perfusion develop. In addition to
the above, these signs include
Depressed mental status
Decreased urine output
Metabolic acidosis
Tachypnea
Weak central pulses
Management of Shock
 Signs of decompensated shock include the signs listed above plus
hypotension. In the absence of blood pressure measurement,
decompensated shock is indicated by the nondetectable distal pulses
with weak central pulses in an infant or child with other signs and
symptoms consistent with inadequate tissue oxygen delivery.
 The most common cause of shock is hypovolemia, one form of which is
hemorrhagic shock. Distributive and cardiogenic shock are seen less
often. Learn to integrate the signs of shock because no single sign
confirms the diagnosis. For example:
 Capillary refill time alone is not a good indicator of circulatory volume,
but a capillary refill time of >2 seconds is a useful indicator of
moderate dehydration when combined with a decreased urine output,
absent tears, dry mucous membranes, and a generally ill appearance. It
is influenced by ambient temperature, lighting, site, and age.
Management of Shock
 Tachycardia also results from other causes (eg, pain, anxiety,
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fever).
Pulses may be bounding in anaphylactic, neurogenic, and septic
shock.
In compensated shock, blood pressure remains normal; it is low in
decompensated shock. Hypotension is a systolic blood pressure less
than the 5th percentile of normal for age, namely:
● <60 mm Hg in term neonates (0 to 28 days)
● <70 mm Hg in infants (1 month to 12 months)
● <70 mm Hg + (2 x age in years) in children 1 to 10 years
● <90 mm Hg in children >10 years of age
Management of Shock
Management of Shock
Hypovolemic Shock
 Signs and Symptoms of Shock: Pale/cool/clammy skin,
increased HR, BP either low (decompesated) or normal
(compensated), obtunded
 Non-Hemmorrhagic: 20 ml/kg NS or LR bolus, repeat as
needed. Consider Colloid after 3rd NS/LR bolus
 Hemmorrhagic: Control bleeding; 20 ml/Kg NS/LR bolus,
repeat 2 or 3 times as needed and transfuse PRBCs as
indicated
 Causes in PALS:
 Dehydration from illness
 Trauma from accidents
 Diarrhea, vomiting
Management of Shock
Septic Shock
 Common with sustained infection, chronic disease, immune compromised and
cancer patients on chemotherapy
 Altered mental status and perfusion
 Give O2 and support ventilation as needed
 Establish IV/IO
 Obtain ABG, Lactate, Glucose, Calcium, Cultures and CBC
 BLS as needed
 Push 20 ml/kg boluses of isotonic fluid up to 3, 4 or more blouses based on patient response
 Correct hypoglycemia and hypocalcemia as needed
 Administer Antibiotics STAT
 Consider Vasopressor drip to maintain BP and stress dose hydrocortisonse (used to treat
shock)
 If patient responds to fluid with normal BP send to ICU to monitor
 If patient does not respond: Begin vasoactive drugs; establish A-line for BP monitoring,
Central line for fluid delivery; administer Dopamine for renal perfusion; administer
Norepinephrine (Levophed) for blood pressure
 Evaluate SVO2 (goal greater than 70%, obtained from PA line)
 If SVO2 is less than 70% consider MILRINONE or NITROPRUSSIDE
Management of Shock
Neurogenic Shock (Head injury that disrupts BP regulation)
 Give 20 ml/Kg NS/LR bolus repeat PRN
 Give Vasopressor
Cardiogenic Shock
 Follow PALS algorithms for bradycardia and tachycardia
 Other such as Cardiomyopathy, Myocarditis, CHD or poisoning give 510 ml/kg NS/LR bolus, repeat PRN, give Vasoactive infusion and
consider expert consultation
Obstructive Shock
 Tension Pneumothorax: Needle decompression and chest tube
 Ductal Dependent: Prostaglandin Ei, and cardiologist consultation
 Cardiac Tamponade: Pericardiocentesis and 20 ml/kg bolus NS
 Pulmonary Embolism: 20 ml/kg bolus, thrombolytics and
anticoagulants
Pediatric Assessment
 The AHA utilizes a specific assessment protocol known as
“Assess – Categorize –Decide – Act” model: Assess the
patient; Categorize the nature and severity of their illness;
Decide on the appropriate actions; and Act.
 Once you have completed this process, begin again by
reassessing the patient, always seeking additional information
that will help in determining the nature of the illness or
treatment of the patient.
Pediatric Assessment
Assess
 Categorize illness as a respiratory, circulatory or a
combination problem Assess severity of problem
Respiratory
 Upper vs. Lower airway obstruction
 Lung tissue disease
 Disordered control of breathing (head injury)
 Severity: respiratory distress, impending or failure
Pediatric Assessment
Circulatory (arrhythmia or shock)
 SHOCK: give repeated boluses of isotonic crystalloid (NS or LR)
of 20 ml/kg for HYPOTENSION associated with shock
 Give NS or LR as initial fluids for volume replacement
 Isotonic Colloid given only after crytalloid is give
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Hypovolemic: loss of blood, dehydration, vomiting, diarrhea
Obstructive: neurological impairment affecting skeletal muscles
Distributive/Septic: infection migrating to major organs
Cardiogenic: multiple areas of ischemic damage to the heart leading to
poor output.
 GIVE VASOACTIVE DRUGS SUCH AS MILRINONE for
compensated shock. Give medium does of Dopamine for
uncompensated shock with boluses of fluid, avoid epinephrine as it
increases myocardium O2 demand making ischemia worse
Pediatric Assessment
 *Severity: Compensated (normotensive, normal systolic BP but will
have a decreased level of consciouness, cool extremities, delayed
capillary refill and faint distal pulses) or hypotensive (results in increased
HR, low BP, and weak pulses)
General Assessment
 Inspection (what you see: WOB, appearance, color, edema, alertness…)
Primary Assessment
 Circulation, Airway, breathing, Disability, Exposure
 This is hands on assessment (vitals, Spo2, neuro status such as a patient
whom responds to painful stimulus by grabbing your hand if pinched but
otherwise does not respond verbally, temperature and bleeding…)
Pediatric Assessment
 Secondary Assessment
 Focus on history (SAMPLE)
 Signs and symptoms
 Allergies
 Medications
 Past Hx
 Last Meal consumed
 Events leading to present problem
 This is a thorough head to toe examination
Tertiary Assessment
 Lab studies, CXR, EKG, ABG…know when to obtain each. Example: know
when to obtain a head CT for a MVA patient whom is unresponsive with no
signs of pneumothorax
Pediatric Assessment
 As you provide treatment, you must frequently reassess
your patient (especially after initiating a therapy or
intervention). Then re-categorize the patient based on the
information available to you; what you first categorize
(correctly) as respiratory distress may turn out to be the
result of a life-threatening dysrhythmia, so you would need to
recategorize the problem as cardiac once you identify the
heart rhythm, and then treat the patient appropriately.
Pediatric Assessment
Pediatric Assessment
 • Cardiac: Common life-threatening dysrhythmias include SupraventricularTachycardia
or Bradycardia. Patients in cardiac arrest may be in Ventricular Fibrillation, Pulseless
Ventricular Tachycardia, Asystole, or Pulseless Electrical Activity (PEA), which includes
all other heart rhythms that present without a pulse. In pediatric patients, severely
symptomatic bradycardia may require CPR.
 Respiratory: Respiratory problems can be broadly divided into Upper Airway
Obstruction, Lower Airway Obstruction, Lung Tissue Disease, or Disordered Control of
Breathing (which includes any ineffective respiratory rate, effort, or pattern.
 Shock: Shock (widespread inadequate tissue perfusion) can be Hypovolemic,
Obstructive, Distributive (Septic), or Cardiogenic in nature. If a patient’s General
Appearance indicates that they may be unconscious, you should check for responsiveness.
If the patient is Unresponsive, get help (send someone to call 911 and bring back an
AED, call a code, etc.). The BLS
 Algorithm should then be followed – open the Airway, check for Breathing, and assess
Circulation. If the patient is apneic, rescue breathing started; if the patient is pulseless (or
if a pediatric patient has a heart rate less than 60 with serious signs and symptoms),
rescuers should begin CPR.
Changes to PALS beginning later this
year
 Chest Compressions: Push at a rate of 100 to 120 per minute
 Ventilation during CPR with an advanced airway: 1 breath
every 6 seconds )10 per minte) while continuous chest
compressions are performed
 Fluid Resuscitation: Initial fluid bolus of 20ml/kg is
acceptable however, be cautious with children with febrile
illness in settings with limited access to critical care
resources (ie, vents, inotropic support)
 Atropine for intubation: No evidence support use for ped
bradycardia delivery before intubation
Changes to PALS beginning later this
year
 Antiarrhythmic medications for shock-refractory VF or
pulseless VT : Amiodarone or lidocaine is equally acceptable for
the treatment of shock-refractory ventricular fibrillation (VF) or
pulseless ventricular tachycardia (pVT).
 Targeted temperature management: For children who are
comatose in the first several days after cardiac arrest (in-hospital
or out-of- hospital), temperature should be monitored
continuously and fever should be treated aggressively. For
comatose children resuscitated from OHCA, it is reasonable for
caretakers to maintain either 5 days of normothermia (36°C to
37.5°C) or 2 days of initial continuous hypothermia (32°C to
34°C) followed by 3 days of normothermia. For children
remaining comatose after IHCA, there are insufficient data to
recommend hypothermia over normothermia.
Test Review
 Respiratory distress defined as an increase WOB, tachypnea with or without
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desaturation
Respiratory failure= inadequate oxygenation/ventilation
Lower airway problems= wheezing, prolonged expiratory times
Upper airway problems= inspiratory stridor
Disordered control of breathing = erratic breathing patterns
Administer 20 ml/kg of isotonic crystalloid over 5-10 minutes initially for all
shocks except cardiogenic (10 ml/kg)
Intraosseous lines are ideal for shock patients, they are easy to insert and are
quickly done, unlike peripheral access
Obtain a bedside Glucose after fluid administration for patients in Shock
Needle decompression location for pneumos
Know compensated vs. hypotensive shock, know BP ranges for age groups
For SVT, if unstable = cardioversion 0.5-1 J/kg. If not unstable = Vagals first,
ice to face, then adenosine then shock
Test Review
 SpO2 range for children post ROSC= 94-99%
 Suctioning may cause bradycardia due to vagal stimulation, be prepared to intervene if
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HR does not return to normal
Remember DOPE for distress after intubation
Give IM Epi for anaphylactic/allergic reactions
First drug of choice for pulseless arrest, PEA, VF/VT, bradycardia is Epi 0.01 mg/kg
Defibrillate VF/VT without pulse, first at 2 J/kg then 4 J/kg
CPR = CAB, spend 10 seconds or less palpating a pulse, ratio 30:2 or 15:2, 1/3 a-p
diamteter
Check pulses in infants and small children in the brachial artery
Use an AED on all patients if warranted. If pediatric size pads are not available for an
infant you may use adult pads (anything is better than nothing)
Attach AED as soon as it arrives in a code
Most pediatrics have respiratory failure than leads to cardiac, if a patients breathing
slows, their HR will follow, bag the patient to increase the HR
Know all algorithms
Testing and Megacode
 Mega code and Testing
 Groups of 5 for the mega code, you will rotate through and
then return to the exam