If you are already a PALS provider and are confident in your knowledge and skills, familiarize yourself with the topics and content in the PALS provider manual, most notably the updated guidelines. The topics and content may be new for you. Since any part of it could be on the exam, you will need to be prepared. You should be very comfortable with the PALS algorithms before you attempt the certification exam. If it has been more than two years since you had PALS certification, you will want to determine which areas you may have forgotten since your last certification.
For most people, this will be the medication doses or the algorithms. Once you have refreshed your memory, you may be ready to take the PALS recertification examination. Shock i. Many different disease processes and traumatic events can cause cardiac arrest, but in an emergency, it is important to be able to rapidly consider and eliminate or treat the most typical causes of cardiac arrest. To facilitate remembering the main, reversible causes of cardiac arrest, they can be organized as the Hs and the Ts.
Fluid resuscitation in PALS depends on the weight of the child and the severity of the situation. While dehydration and shock are separate entities, the symptoms of dehydration can help the provider to assess the level of fluid deficit and to track the effects of fluid resuscitation. In the current guidelines, the clinician must fully evaluate the child with febrile illness since aggressive fluid resuscitation with isotonic crystalloid solution may not be indicated.
The child is still in a delicate condition. All major organ systems should be assessed and supported. Maintenance fluids should be given. If the child has been resuscitated in the community or at a hospital without pediatric intensive care facilities, arrange to have the child moved to an appropriate pediatric hospital. Bradycardia is a common cause of hypoxemia and respiratory failure in infants and children.
Bradycardia is a slower than normal heart rate. A heart rate less than 60 beats per minute in a child under 11 years old is worrisome for cardiac arrest unless congenital bradycardia is present. In fact, pulseless bradycardia defines cardiac arrest. Tachycardia is a faster than normal heart rate. Pulseless tachycardia is cardiac arrest. It is important to determine if the tachycardia is narrow complex or wide complex. This should be considered possible ventricular tachycardia.
If the child is not hemodynamically stable then provide cardioversion immediately. Again, it is important to determine if the tachycardia is narrow complex or wide complex. The most commonly used system for correlating tools to the size of a child is the Broselow Pediatric Emergency Tape System.
The medication cart or crash cart is stocked using the color coding system. Basic airways do not require specialist training; however, some proficiency is needed for oropharyngeal and nasopharyngeal airway placement. ACLS in the hospital will be performed by several providers. These individuals must provide coordinated, organized care. Providers must organize themselves rapidly and efficiently. Resuscitation demands mutual respect, knowledge sharing, and constructive criticism, after the code.
When performing a resuscitation, the Team Leader and Team Members should assort themselves around the patient so they can be maximally effective and have sufficient room to perform the tasks of their role.
There are four main types of atrioventricular block: first degree, second degree type I, second degree type II, and third degree heart block. Second degree heart block Mobitz type I is also known as the Wenckebach phenomenon.
Heart block is important because it can cause hemodynamic instability and can evolve into cardiac arrest. The PR interval is a consistent size, but longer or larger than it should be in first degree heart block. Complete dissociation between P waves and the QRS complex. No atrial impulses reach the ventricle. Pulseless electrical activity or PEA is a cardiac rhythm that does not create a palpable pulse is even though it should.
A PEA rhythm can be almost any rhythm except ventricular fibrillation incl. It represents a lack of electrical activity in the heart. It is critically important not to confuse true asystole with disconnected leads or an inappropriate gain setting on an in-hospital defibrillator.
Asystole may also masquerade as a very fine ventricular fibrillation. If the ECG device is optimized and is functioning properly, a flatline rhythm is diagnosed as asystole. Note that asystole is also the rhythm one would expect from a person who has died. Consider halting PALS efforts in people who have had prolonged asystole.
It is inappropriate to provide a shock to pulseless electrical activity or asystole. Cardiac function can only be recovered in PEA or asystole through the administration of medications. This energy may come in the form of an automated external defibrillator AED defibrillator paddles, or defibrillator pads.
VFib and VTach are treated with unsynchronized cardioversion, since there is no way for the defibrillator to decipher the disordered waveform. In fact, it is important not to provide synchronized shock for these rhythms. Ventricular fibrillation is recognized by a disordered waveform, appearing as rapid peaks and valleys as shown in this ECG rhythm strip:. Ventricular tachycardia may provide waveform similar to any other tachycardia; however, the biggest difference in cardiac arrest is that the patient will not have a pulse and, consequently, will be unconscious and unresponsive.
Two examples of ventricular tachycardia are shown in this ECG rhythm strips. The first is narrow complex tachycardia and the second is wide complex tachycardia:. Atrial fibrillation is the most common arrhythmia. It is diagnosed by electrocardiogram, specifically the RR intervals follow no repetitive pattern. Some leads may show P waves while most leads do not. Atrial contraction rates may exceed bpm. The ventricular rate often range is between to bpm.
Atrial flutter is a cardiac arrhythmia that generates rapid, regular atrial depolarizations at a rate of about bpm. This often translates to a regular ventricular rate of bpm, but may be far less if there is a or conduction. By electrocardiogram, or atrial flutter is recognized by a sawtooth pattern sometimes called F waves.
Narrow QRS complex tachycardias include several different tachyarrhythmias. One of the more common narrow complex tachycardias is supraventricular tachycardia, shown below. The heart rate can exceed bpm in infants and bpm in children. Wide complex tachycardias are difficult to distinguish from ventricular tachycardia. Ventricular tachycardia leading to cardiac arrest should be treated using the ventricular tachycardia algorithm. A wide complex tachycardia in a conscious child should be treated using the tachycardia algorithm.
Tissue perfusion will dictate which algorithm to use. Updates to PALS in As we learn more about resuscitation science and medicine, physicians and researchers realize what works best and what works fastest in a critical, life-saving situation.
Updates to the PALS Guidelines Intervention Guideline Guideline Volume for children with febrile illness Restrictive volumes of isotonic crystalloids Aggressive volume resuscitation Atropine for emergency tracheal intubation Controversial for neonates; no minimum dose Routine premedication prior to intubation Arterial blood pressure monitoring If in place, may be useful to adjust CPR No guideline Amiodarone and Lidocaine Acceptable for shock-refractory VFib or Pulseless VTach No guideline Therapeutic hypothermia Fever should be avoided after ROSC but use of therapeutic hypothermia is controversial Therapeutic hypothermia should be used Blood Pressure Fluids and vasoactive agents to maintain systolic blood pressure above the 5 th percentile for age No guideline Compressions to per minute At least per minute.
First Impression The first step is to determine if the child is in imminent danger of death, specifically cardiac arrest or respiratory failure. The provider will evaluate, identify, and intervene as many times as necessary until the child either stabilizes or her condition worsens, requiring CPR and other lifesaving measures.
The evaluate phase of the sequence includes Primary Assessment, Secondary Assessment, and Diagnostic Tests that are helpful in pediatric life support situations. If the child airway is open, you may move onto the next step. However, if the airway is likely to become compromised, you may consider a basic or advanced airway. Often, in unresponsive patient or in someone who has a decreased level of consciousness, the airway will be partially obstructed.
This instruction does not come from a foreign object, but rather from the tissues in the upper airway. You can improve a partially obstructed airway by performing a head tilt and chin lift. If there is suspected trauma to the cervical spine, use a jaw thrust instead. A blocked airway would usually requires a basic or advanced airway. Secondary Assessment and Diagnostic Tests When a child is experiencing an acutely life-threatening event, such as cardiopulmonary failure, it is appropriate to treat the child with CPR and the appropriate arrest algorithm.
When a child is ill but does not likely have a life-threatening condition, you may proceed to the Secondary Assessment. Last dose? How much? New foods? Not patent in respiratory failure.
Breath Sounds Cough, hoarseness, stridor Wheezing Diminished breath sounds, grunting, crackles Unchanged Heart Rate Increased in respiratory distress Decompensates rapidly to bradycardia as respiratory failure ensues Skin Color and Temperature Pale, cool, and clammy in respiratory distress Decompensates rapidly to cyanosis as respiratory failure ensues Varies Level of Consciousness Agitation in respiratory distress Decompensates rapidly to decreased mentation, lethargy, and LOC as respiratory failure ensues Respiratory Rate and Effort Increased in respiratory distress Decompensates rapidly in respiratory failure Varies.
Cardiac Arrest Cardiac arrest occurs when the heart does not supply blood to the tissues. Ventricular Fibrillation and Pulseless Ventricular Tachycardia Ventricular fibrillation and pulseless ventricular tachycardia are shockable rhythms. Epinephrine 0. If the patient regains consciousness, move to ROSC algorithm.
After 2 min. Remember, chest compressions are a means of artificial circulation, which should deliver the epinephrine to the heart. Without chest compressions, epinephrine is not likely to be effective. Chest compressions should be continued while epinephrine is administered. Rhythm checks every 2 min. Look for and treat reversible causes Hs and Ts. If the patient regains circulation, move to ROSC algorithm. Rapid Differential Diagnosis of Cardiac Arrest Many different disease processes and traumatic events can cause cardiac arrest, but in an emergency, it is important to be able to rapidly consider and eliminate or treat the most typical causes of cardiac arrest.
Altered mental status, later. You can detect spontaneous circulation by feeling a palpable pulse at the carotid or femoral artery in children and the brachial artery in infants up to 1 year. The patient is at risk for reentering cardiac arrest at any time. Therefore, the patient should be moved to an intensive care unit. Does the person need an advanced airway? If so, it should be placed. Also, apply quantitative waveform capnography, if available. Is the patient in shock?
If not, monitor and move to supportive measures. If shock is present, determine if it is hypotensive or normotensive. Identify and treat causes Hs and Ts. Fluid resuscitation according to cause of shock. Consider vasopressors. Hypotensive Shock Epinephrine IV 0. Postresuscitation Management The child is still in a delicate condition. Bradycardia Bradycardia is a common cause of hypoxemia and respiratory failure in infants and children.
Obtain intravenous or intraosseous access. Obtain a 12 lead ECG and provide supplemental oxygen. If the above interventions help, continue to support the patient and consult an expert regarding additional management. If the heart rate is still less than 60 bpm despite the above interventions, begin to treat with CPR.
May repeat every minutes. Atropine can be given at a dose of 0. Min Dose: 0. Max Dose: 0. Consider transvenous or transthoracic pacing if available. You may need to move to the cardiac arrest algorithm if the bradycardia persists despite interventions.
Tachycardia Tachycardia is a faster than normal heart rate. If the tachycardia is causing a decreased level of consciousness, hypotension or shock, or significant chest pain, move directly to synchronized cardioversion. If the tachycardia is not causing a decreased level of consciousness,hypotension or shock, or significant chest pain, you may attempt vagal maneuvers, first. Cooperative children can participate in a Valsalva maneuver by blowing through a narrow straw Carotid sinus massage may be effective in older children.
Tachycardia is a slower than normal heart rate. A vagal maneuvers for an infant or small child is to place ice on the face for 15 to 20 seconds Ocular pressure may injure the child and should be avoided If vagal maneuvers fail, you may use Adenosine: 0. Tachycardia with Pulse and Poor Perfusion It is important to determine if the tachycardia is narrow complex or wide complex.
If the wide QRS complex has a regular rhythm, then you can supply synchronized cardioversion at J. If the wide QRS complex is irregular, this is ventricular tachycardia and should be treated with unsynchronized cardioversion i.
Narrow complex tachycardia may be sinus tachycardia or supraventricular tachycardia. Sinus tachycardia has many causes; the precise cause should be identified and treated. Supraventricular tachycardia can be treated with 0.
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