Pediatric Advanced Life Support (PALS)

PALS Study Guide

Welcome to the Randall Childrens Hospital PediNet program and PALS!
This study guide will help you to focus and prioritize your studying for your upcoming Pediatric
Advanced Life Support (PALS) class while making the material clinically applicable. Use the
study guide with your PALS Provider Manual (10/11 date on the back) in hand.

See pages 8 & 9 of the PALS manual as a starting point. Learn to categorize pediatric
emergencies and use the Evaluate-Identify-Intervene strategy.
Read through pages 10 & 11 and think about how you would apply these interventions.

Next, open your AHA PALS Study Card (also dated 2011). You may use this card during
the PALS course for reference (except during the written test), so you will want to review
each of the algorithms carefully as well as the handy drug information and list of
reversible causes of pediatric emergencies (Hs & Ts).

High quality CPR literally saves lives and preserves function. For your PALS class:
o Be prepared to pass the adult/child 1- and 2-rescuer CPR/AED and infant 1- and
2-rescuer CPR skills test. The resuscitation scenarios require that your BLS skills
and knowledge are current.
o Review & understand all BLS 2010 guidelines, especially as they relate to the
pediatric patient. You will find this information in the BLS for Healthcare Providers
manual (also refer to skills checklists in the PALS Provider Manual on pages
234-237). See www.americanheart.org/cpr.

High quality CPR:

Deep and fast compressions (100-120/min) full recoil of the chest; but hands maintain
position. Pediatrics: two rescuers: 15 compressions for 2 breaths.
Minimize interruptions to maintain coronary artery perfusion; 1) Efficient switch of roles every
two minutes to avoid fatigue; 2) prepare for rhythm checks / shock delivery and return to CPR
Carefully administered positive pressure ventilation (PPV) - well positioned airway to minimize
esophageal air, just enough pressure to make the chest rise, time for exhalation do not
hyperventilate. Rescue breaths every three to five seconds; with advanced airway every 6
8 seconds; In CPR: 2 breaths for every 15 compressions.

The following pages of tables describe many of the pediatric emergencies you may
face in your PALS case scenarios AND when giving care to children in trouble.
See the AHA Pediatric Advanced Life Support Provider Manual dated 10/11for more details

Respiratory emergencies
Most pediatric emergencies are caused by or eventually involve respiratory compromise. If
Most pediatric emergencies are caused by or eventually involve respiratory compromise. If
this is not already an area of strength for you, read pages 12 -17 in the PALS Provider Manual
first.
Respiratory distress:
Respiratory failure:

Any increased work of breathing above baseline

Inadequate oxygenation, ventilation or both

Categories of respiratory
distress / failure

Upper airway obstruction

Signs and symptoms:
poor air entry
stridor (usually
inspiratory, might be
biphasic)
retractions
barky cough for croup,
often with fever
usually not tachypneic

Lower airway obstruction

Signs and symptoms:
expiratory wheeze
poor air entry and
prolonged expiratory
phase.

Selected Causes

Initial Treatment
supplemental oxygen for
all (if possible check pulse
oximeter in room air first)

Reference
2011 PALS
Book pages 3767 p. 46, 58
overviews
p. 44, p. 50-51
p. 44, p. 50-52
p. 44, p 51

Nasal obstruction
Foreign body
Croup / tracheitis /
epiglottitis
Anaphylaxis

Nasal suction
Heimlich if obstruction
Racemic epinephrine /
dexamethasone for croup
IM epinephrine

Tonsilar
hypertrophy, tumor
or mass

Nasal airway
Oral airway if unconscious

Asthma / reversible
bronchospasm
Bronchiolitis - may
hear more coarse
BS than wheeze

Albuterol, steroids, oxygen

p. 44, p 53-54

Nasal suction, oxygen, can

try albuterol usually
doesnt help

p. 44, p 53-54

Pneumonia /
aspiration

Oxygen, Continuous
Positive Airway Pressure
(CPAP) if needed
Oxygen, CPAP prn
Oxygen, CPAP prn

p. 44-5, p. 55-6

Benzodiazepime for active

seizure; PPV
Consider antidote; Positive
Pressure Ventilation (PPV)
PPV

P. 45, p. 57

PPV

P. 45, p. 57

p. 44, p. 50,
p. 52
p. 44, p. 51

Wheeze may not be heard until air

exchange is improved

Lung tissue disease

Signs and symptoms:
tachypnea
retractions
rales or crackles
focal decreased breath
sounds

Disordered control of
breathing
Signs and symptoms:
hypoventilation
apnea
erratic breaths

Aspiration
Pulmonary
hemorrhage
Seizure / postictal
Ingestion
Head trauma / child
abuse / tumor /
mass
CNS infection

See the AHA Pediatric Advanced Life Support Provider Manual dated 10/11for more details

p. 44-5, p. 55-6
p. 44-5, p. 55-6

P. 45, p. 57
P. 45, p. 57

Shock
Shock is defined as tissue delivery of oxygen and nutrients inadequate to meet the
bodys metabolic needs. Shock can be characterized as compensated or hypotensive.
Tachycardia is the earliest vital sign abnormality in shock. Delayed capillary refill, cool
extremities, & weak pulses are important signs. Untreated compensated shock will progress to
hypotensive shock. For children 1- 10 yrs of age, systolic blood pressure less than 70 mm Hg
+ (childs age in yrs x 2) is considered hypotensive. Hypotensive shock can quickly
deteriorate into cardiac arrest and therefore deserves aggressive intervention.
All patients in shock require fluid resuscitation and supplemental oxygen. Fluid boluses for
shock are 10 20 ml/kg infused over 5-20 minutes. Serial fluid boluses are infused until
perfusion is improved. Children receiving serial fluid boluses should be watched for evidence
of heart failure including increased work of breathing, rales or enlarging liver. Patients
unresponsive to fluid boluses may require vasopressors. The most aggressive fluid is
required for distributive shock (especially septic shock). Children with myocardial dysfunction
or diabetic ketoacidosis (DKA) need smaller, slower boluses.

Look at pages 83 & 107 in the PALS Manual for 2 quick references
Types of shock
Hypovolemic
Usual fluid bolus
is 20ml/kg over
5-20 min

Distributive

Obstructive

Common causes
Gastroenteritis
Third spacing
Large burns
Hemorrhage
Diabetic ketoacidosis (DKA)
Septic shock
Anaphylactic shock
Neurogenic shock
Tension pneumothorax
Ductal-dependent
congenital heart disease
Cardiac tamponade

Initial intervention
Serial crystalloid fluid boluses

Reference
PALS Book
pgs 69-74;
83; 85-95;
Blood for anemia when available 96-99 107
Smaller, slower boluses for DKA
Aggressive fluid: 60 ml/kg
PALS Book
within the first hour; antibiotics
pgs 69-73;
IM IV Epi; steroids
75-78; 83;
99-103; 107
Needle decompression
PALS Book
Prostaglandin infusion
pgs 69-73;
79-83; 105107

Massive pulmonary embolus

Cardiogenic

Congenital heart disease

Myocarditis
Cardiomyopathy
Arrythmia
Septic shock
Poisoning
Ischemic injury

Careful fluid boluses, consider

pressors with expert
consultation.

See the AHA Pediatric Advanced Life Support Provider Manual dated 10/11for more details

PALS Book
pgs 69-73;
78-79; 83;
103-105;
107

Cardiac rhythm abnormalities - with a pulse:

Rhythm
abnormalities: with
a pulse
Sinus tachycardia
Normal QRS with a p
wave before each QRS;
variable with states of
agitation

Sinus bradycardia
HR less than normal
for age (or < 60 for any
age), but normal p wave,
normal PR interval and
QRS complex
** Can be completely
normal for fit young
person / sleeping, etc.

Common causes

Initial Treatment

Dehydration

Fluid resuscitation (oral

rehydration if safe; IV if
significant hemodynamic
compromise or altered
mental status)
Antipyretic / analgesic /
reassurance

Fever / pain / anxiety

For all causes:

CPR if poor perfusion and HR < 60 despite
oxygenation / ventilation; epinephrine if bradycardia persists
Ingestion / intoxication
Increased intracranial
pressure
Hypoxemia / hypotension /
acidosis / hypothermia
AV node dysfunction
Starvation; eating disorder

Supraventricular
tachycardia (SVT)

Compensated SVT

Rate > 180 bpm kids;

> 220 babies; no
variability; narrow
complex QRS and no P
wave

Decompensated SVT

AV Block
Bradycardia

Normal variant,
Congenital, myocarditis,
infarction, post-surgical,
drug ingestion, hypoxemia,
Electrolyte / metabolic
abnormalities
Monomorphic - congenital
heart disease, postsurgical, infarction; Hs
and Ts
Polymorphic / torsades de
pointe - often drug related

Abnormal or variable
PR interval

Ventricular
tachycardia with a
pulse
Wide complex QRS
(>0.09 sec) - if uniform
QRS morphology, could
be aberrant SVT.

Reference
2011 PALS
Book / Card
Book: pgs 1224; 134-8
Card:
tachycardia
algorithm

Oxygen / PPV
Antidote if available
Critical care consult
(possible hyperventilation)
Oxygen; fluid resuscitation;
warming
Seek expert care
Avoid orthostasis, monitor
rhythm (can deteriorate)
Vagal maneuvers;
adenosine
Adenosine if IV access
(proximal); synchronized
cardioversion if no IV access
and decompensated

Book: p 113-20

Oxygen therapy
Antidote if known drug
exposure
Seek expert care

Book: p 113-20
Card:
bradycardia
algorithm

Consult expert consider

amiodorone / synchronized
cardioversion after sedation

Book: p 121-40
Card:
tachycardia
algorithm

Card:
bradycardia
algorithm see front of card
for normal heart
rates for age
Book: p 121-4;
126-40
Card:
tachycardia
algorithm

Consult expert - Consider

magnesium sulfate

See the AHA Pediatric Advanced Life Support Provider Manual dated 10/11for more details

Cardiac rhythm abnormalities - pulseless arrest:

Pulseless Arrest

Treatment - In addition to
CPR, electricity and meds
think of and treat reversible
causes

Reversible causes

Shockable rhythms
Ventricular Fibrillation
No definable QRS complex
just irregular disorganized
electrical activity

Ventricular Tachycardia
without pulse
Wide complex, nearly identical,
fast QRS complexes without PR
interval (monomorphic) or
polymorphic (torsades)

High Quality CPR

* Defibrillate as soon as
pads on, rhythm identified
and defibrillator charged

First dose 2+ J/kg (round up)

Second dose 4+ J/kg

Third dose 10 J / kg
All doses up to the adult dose

2 minutes between rhythm

checks and shocks
Dont interrupt CPR until

ready to shock
Epinephrine 1:10,000 IV/IO
0.1 ml/kg by rapid push after
second shock (or just before)
Amiodorone if persistent

NON - Shockable rhythms

High Quality CPR;
Asystole
flat line
Pulseless Electrical Activity
(PEA)
QRS complexes, but no pulse

Epinephrine

1:10,000 IV/IO 0.1ml/kg

every 3 5 minutes by rapid
push (NOT shockable
rhythms)

Hs & Ts

Reference
2011 PALS
Book / Card
Book: p. 141167
Card: Cardiac
Arrest Algorithm

Hypovolemia (20ml/kg
NS or LR bolus)
Hypoxia (oxygenate /
vent)
Hydrogen ion (acidosis)
Hypoglycemia (check
CBG)

Hypo-hyperkalemia
Hypothermia (check
temp)
Tension pneumothorax
Tamponade, cardiac
Toxins (history helps)
Thromboxis, pulmonary
Thrombosis, coronary

Book: p. 141167
Card: Cardiac
Arrest Algorithm

** The conditions in the above tables represent the majority of pediatric

emergencies. In the PALS course, you and your team will practice
management of these disease states. Many of these conditions can be
found on your PALS Study card. Use the card during class preparation and
during the class case scenarios.
Go to pages 234-237, 239, 240 and 246-257 of the PALS manual to review
the checklists of expectations for team performance during the case
scenarios. Your instructor will be assessing you based on these checklists.
Review of this study guide, the PALS manual, card and the checklists will
ensure your success in class and prepare you for pediatric emergencies.
See the AHA Pediatric Advanced Life Support Provider Manual dated 10/11for more details