PEDIATRIC ADVANCED

LIFE SUPPORT
Course Package

Name:
Pediatric Advanced Life Support
Provider Course

Welcome!
Thank you for choosing Iridia Medical for your Pediatric Advanced Life Support (PALS) training.
Since 1998, Iridia Medical has taken the lead in PALS programs in British Columbia, delivering
PALS courses across the province to thousands of health professionals.

The PALS course aims to prepare health care professionals, within their scope of practice, to direct
or participate in the management of an infant or child with respiratory compromise, circulatory
compromise or cardiac arrest. The purpose of this course is to improve patient outcomes by
providing health care professionals knowledge and skills to improve the quality of care provided
to critically ill or injured children.

The PALS cases presented during the course require you to be constantly thinking and analyzing.
This course will enable you to strengthen existing skills as well as increase knowledge, confidence
and expertise when dealing with pediatric medical emergencies.

At the completion of this course you will receive a PALS completion card valid for 2 years, and
you will have the confidence to use the following important concepts:

1. Basic Life Support (BLS) survey

2. High-quality cardiopulmonary resuscitation (CPR)
3. Pediatric assessment
4. Management of respiratory emergencies
5. Management of cardio-circulatory emergencies, including electrical disturbances
6. Effective resuscitation team dynamics
7. Immediate post-cardiac arrest care

Please wear loose, comfortable clothing. You will be practicing skills that require working on your
hands and knees, bending, standing, and lifting. If you have physical conditions that might prevent
you from participating in the course, please advise the instructor when you arrive. The instructor
will work to accommodate your needs within the stated course completion requirements.

If you are unable to attend the course on this date, please view Our Withdrawal & Transfer Policies
section, and contact us as soon as possible.

Our office is open Monday to Friday, 8:00-5:00. Feel free to contact us with any questions.

Thank you for choosing Iridia Medical. We hope you enjoy the course!
Contents

About Us
Our Story p2

Our Services p3

Our Withdrawal & Transfer Policies p4

Parking, restaurants & accommodation p5

Course Information and Tools

PALS Precourse Preparation p6 - 7

PALS Agenda p8 - 9

Reading
Emergency Cardiovascular Care 2011 - Pediatric Algorithms p11 - 26

Notes p27 - 34
Our Story

In 1998, a British Columbia company suffered the tragic loss of two employees on its worksite
due to Sudden Cardiac Arrest (SCA). Post incident, the company learned that the only treatment
for SCA was the timely delivery of a shock from a defibrillator. Although local ambulances carried
Automated External Defibrillators (AEDs) as standard issue, the worksites distance from the
nearby town meant they would arrive too late to be effective. The only option was to position an
AED onsite. Sadly, efforts to secure such a device were thwarted by regulations that didnt permit
the use of AEDs by non-medical personnel.

That same year, an emergency room physician heard about the companys plight and was moved
to act. He saw the life-saving potential of having AEDs broadly available in workplaces, airports,
community facilities, etc. In response, he founded a company and became a distributor for AEDs
outside of the medical community. That doctor was Dr. Allan Holmes, and the company was
Global Medical Services.

In 2013, Global Medical Services became Iridia Medical, and identifying emerging needs and
responding to them has defined Iridias way of doing business. Embracing this philosophy, Iridia
Medical has grown to offer a broad cross-section of products and services to clients around the
world. Iridia is:

the second largest non-hospital AED distributor in Canada

the leading provider of cardiac care education in British Columbia
the biggest supplier of paramedics to oil and gas operators in BC, and
a recognized name in both health and emergency preparedness consulting.

Our values reflect our desire to remain on the cutting edge of finding needs and meeting them in
innovative ways, providing exceptional, client-focused service, and being a responsible employer
and business. We fully anticipate that as our company grows, well continue to see needs and fill
them to fulfill our vision.

On this journey, Iridia has gone from having one employee (Dr. Holmes himself) to more than 20
office staff, a dozen consultants, and over 100 paramedics. In the process, the company has been
identified as one of the Fastest Growing Companies in British Columbia and has been awarded
the Profit 500 in 2013.

To learn more about Iridia Medical and our rebrand journey visit,
www.iridiamedical.com/iridia-is-born.htm

Page 2
Our Services

Iridia Medical specializes in providing innovative, practical solutions to enhance the delivery
and quality of healthcare for populations across Canada. Our services are separated into four
primary areas:

Medical Education & Training

We have overseen the training and certification of over four thousand
lay rescuers in the use of AEDs, and over three thousand medical
professionals via our advanced training programs, such as Advanced
Cardiac Life Support (ACLS) and Pediatric Advanced Life Support
(PALS).

Medical Consulting
Iridia Medical has influenced healthcare delivery and provided
emergency preparedness guidance for public and private sector
organizations across North America. Our clients include health
authorities, public healthcare facilities, EMS providers, private surgery
and diagnostic imaging facilities, and police and fire departments.

Paramedic Services
Iridia Medical is one of western Canadas top paramedic service
providers. Our comprehensive programs have created a new industry
standard for care in remote and/or high-risk work sites and encompass
everything from the paramedic teams and equipment, a whole medical
unit to telemedicine-supported medical direction.

Automated External Defibrillator Programs

As the founder of BCs first public access automated external
defibrillator (AED) program, Iridia Medical is passionate about
promoting easy access to life-saving tools. We distribute top-of-the-
line AEDs and provide training, support, and medical direction services
to ensure that every client receives full value from their unit.
Our Withdrawal & Transfer Policies

Participant requests for transfers, withdrawals, or refunds must be made in writing to Iridia
Medical prior to the start of the course.

Please email your written notification to registration@iridiamedical.com.

Withdrawals:

If notice of withdrawal is given more than 14 days prior to the registered course date, the
participant will receive a full refund less a 25% administration fee.
If notice of withdrawal is given less than 14 days prior to the registered course date, the
entire tuition or class fee will be non-refundable.

Transfers:

If notice of transfer is given more than 30 days prior to the registered course date, no
transfer fee will be charged.
If notice of transfer is given from 14-30 days prior to the registered course date a transfer
fee of 15% of the total fees will be applied.
Unfortunately due to our commitment to our instructors, we are unable to accept transfers
less than 14 days prior to the registered course date.
Transfer fees are applicable for each transfer.

Cancellations:

Iridia Medical reserves the right to cancel a class and refund registration fees due to
insufficient registration or other circumstances beyond our control.
Iridia Medical will provide participants two weeks notice of cancellation prior to the course
date.

Books:

All book sales are final.

Page 4
Parking, Restaurants &
Accommodation

Is your course held at Iridias Learning Studio? We have mapped out for you our office location,
and recommended parking, restaurants and accommodation around the Iridia Medical office.

Parking: Restaurants:
Iridia Medical, 1644 W 3rd Avenue 1 Subway & Starbucks
Metered street parking is available 2 Chronic Taco
with 2 hour time limit 3 Blondies Caf
4 Beaucoup Caf
The DPS, 1530 Mariners Walk 5 Caf Bica
P1 (North side of W 2nd Ave, between 6 Creek Slice Pizza
Fir St and the main entrance to and many more along W 4th Ave
Granville Island. Covered & secure.) and on Granville Island!
Cost: $18 / 6 hours
Accommodation:
Marks Work Warehouse, Best Western Plus Downtown
P2 1885 W 4th Ave and Cypress St 718 Drake Street Vancouver
(In after 6am out by 6pm. Phone: 604-669-9888
Uncovered.) www.bestwesterndowntown.com
Cost: $10 / daytime
*To receive a discount on your room, advise the Best
Western Plus Downtown front desk you are a student
with Iridia Medical.
PALS Precourse Preparation

Your success in this course depends on adequate precourse preparation. To best prepare and
achieve the objectives of the course, please allow at least eight (8) hours to review the following
PALS resources - also available at www.iridiamedical.com.

Mandatory:
Pediatric Advanced Life Support Provider Manual
This is the required study guide for the course. This book applies new PALS concepts to
realistic situations and includes sections on all of the skill and knowledge requirements.
Also included, is a precourse checklist and a quick reference pocket guide.

Handbook of Emergency Cardiovascular Care for Healthcare Providers

Highly recommended by our Instructors as a real-life reference tool, this pocket sized,
detailed manual can be used at any time during the course and on the job.

Recommended:
Emergency Cardiovascular Care 2011 Essentials for Health Professionals in Hospital -
Pediatric Algorithms
This summary document, included with your course package, provides an organized guide
for responding to pediatric emergencies. This identifies the core concepts of the course,
while the PALS Provider Manuals provide reference material for the algorithms.

Highlights of the 2010 American Heart Association Guidelines for CPR and ECC

PALS Written Precourse Self-Assessment

The following cases will be reviewed during the course, which will assist you in gaining the
knowledge and develop the ability to:

1. Use a systematic approach, recognize and initiate early management of peri-arrest

conditions that may result in cardiac arrest or complicate resuscitation outcome.

2. Demonstrate proficiency in providing BLS care.

3. Recognize and manage respiratory emergencies.

4. Recognize and manage arrhythmias or cardiac arrest until return of spontaneous circulation,
termination of resuscitation, or transfer of care, including immediate post-arrest care.

5. Demonstrate proper use and knowledge of indications for use of medications and vascular
access devices.

6. Demonstrate effective communication as a member or leader of a resuscitation team and

recognize the impact of team dynamics on overall team performance.

Page 6
To successfully complete the course, you must:

Demonstrate competency in BLS knowledge and skills. You will be tested on Bag-Mask
Ventilation and CPR/AED skills.

Demonstrate competency in ACLS knowledge and skills through your performance during
case scenarios.

Pass the closed-book, 50 question multiple-choice exam, with a minimum score of 84%.

In the incident you are unsuccessful in demonstrating BLS/ACLS practical knowledge and skills
during a testable case scenario or do not achieve 84% on the written exam, you will be offered a
second attempt at the end of the course.

If either the second attempts are unsuccessful, arrangements can be made with Iridia Medical to
participate in further training courses and to repeat the evaluation process.
PALS Agenda - Day 1

The Pediatric Advanced Life Support Course is two (2) days. Day 1 is approximately
7 hours and 55 mins with breaks in total.

Course Starts - 8:30am

Welcome & Course Introductions

Lessons 1-2 - 8:35am

PALS Course/PALS Science Overview

Lessons 3-6 - 8:55am

BLS Practice and Competency Testing
Management of Respiratory Emergencies
10min break
Rhythm Disturbances/Electrical Therapy
Vascular Access

11:55pm - 30min lunch

Lesson 7-9A, B, C - 12.25pm

Resuscitation Team Concept,
Pediatric Assessment, and Learning Stations

1:15pm - 10min break

Lessons 9D - 1:25pm
Respiratory Cases 1-4: Core Case Discussion &
Simulations

Lessons 9D - 3:25pm
Shock Cases 5 & 6: Core Case Discussion & Simulations
Day 1 Ends - 4:25pm

Page 8 Large group Divided groups

 PALS Agenda - Day 2

Day 2 is approximately 7 hours and 30 mins with breaks in total.

Welcome & Refreshments - 8:30am

Lesson 9E - 8:35am
Shock Cases 7 & 8: Core Case Discussion & Simulations

Lesson 9F - 9:35am
Cardiac Cases 9 & 10: Core Case Discussion & Simulations

10:35am - 10min break

Lesson 9F - 10:45am
Cardiac Cases 11 & 12: Core Case Discussion & Simulations

Lesson 10 - 11:45am
Putting It All Together

12:45pm - 30min lunch

Lesson 11-12 - 1:15pm

Course Summary/Testing Details - Written Exam

Lesson 13-14 - 2:05pm

PALS Core Case Test 1/Cardiac Cases 9-12
PALS Core Case Test 2/Respiratory Cases 1-4/Shock Cases 5-8

Remediation & Course Evaluations - 3:55pm

Course Ends - 4:00pm

Large group Divided groups

Empowering People to Save Lives
Reading

EMERGENCY
CARDIOVASCULAR
CARE 2011
Essentials for Health
Professionals in Hospital
Enabling Peace of Mind
 Emergency Cardiovascular Care 2011
Essentials for Health Professionals in Hospital

Pediatric Care

Introduction

Healthcare Provider CPR

Pediatric Basic Life Support
Pediatric Cardiac Arrest
Pediatric Unstable Bradycardia
Pediatric Unstable Tachycardia

Electrical Therapies
Pediatric Vital Signs
Abbreviations Glossary
References

Produced by: Tracy Barill RN Michael Dare RN

SkillStat Learning Inc. Dare Consulting Services

Reviewed by: Darin Abbey RN Sheila Finamore RN

Thora Barnes RN Allan Holmes MD
Aaron Davison MD Angela Robson RN

Published: May 2011, British Columbia, Canada

This document can be downloaded freely from bcecc.ca

Emergency Cardiovascular Care 2011: Essentials for Health Professionals in Hospital was developed for education purposes. It is available at
www.bcecc.ca. Feedback is welcome (ecc2011@bcecc.ca). This work is licensed under the Creative Commons Attribution-NonCommercial-
NoDerivs 3.0 Unported License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/3.0/.
 Introduction

On October 18, 2010 the International Liaison Committee On Resuscitation released a major 5 year update to the CPR and
Emergency Cardiovascular Care Guidelines. The American Heart Association (AHA) and the European Resuscitation Council
(ERC) in turn released unique interpretations of this release.

This version was produced the executive summary and reference documents of the AHA and the ERC. This
summary of 2010 emergency cardiovascular care guidelines combines recent resuscitation science, suggested procedures and
guiding principles into an organized approach to in-hospital pediatric emergency cardiovascular care. We hope that a solid
understanding and long term concept adoption of the latest in emergency pediatric care science is enhanced with this supplement.

The algorithms included here are not intended to replace established AHA | ERC guidelines or sound medical judgement.
Resuscitation science is dynamic, with frequent updates. Find the 2010 guidelines in detail, executive summaries and updates online.

(http://www.ilcor.org/en/home/)
(http://guidelines.ecc.org)
(http://www.cprguidelines.eu/2010/)

Much thanks to the reviewers of this document. Their significant investment of time and their many suggestions are added to this
document. Despite great effort invested in this document, an error free result rarely occurs despite several reviews and edits. Please
direct any suggestions or questions to ecc2011@bcecc.ca

A 36 month period of evidence evaluation by 356 resuscitation experts from 29 countries coordinated through the
International Liaison Committee on Resuscitation (ILCOR) culminated with a significant 5-year update release of
(CoSTR) in October 2010. The
American Heart Association (AHA) in turn released the
. The European Resuscitation Council published .

The Heart and Stroke Foundation of Canada (HSFC), a founding member of ILCOR, has co-released the 2010
Guidelines for CPR and ECC. The HSFC sets the Canadian Guidelines for CPR, defibrillation and other aspects of
emergency cardiovascular care in Canada. These guidelines represent the best current understanding of resuscitation
science applied to those imminently at risk for a cardiac arrest, in a cardiac arrest and in the first hours post-arrest.

Change in basic life support sequence of steps from ABC (airway, breathing, chest compression) to CAB (chest
compressions, airway, breathing) for adults and pediatric patients (not newborns) to reduce the time to start
chest compressions
The reduced importance of pulse checks for pediatrics and adults; healthcare providers often cannot find a pulse
quickly or reliably in those who are hemodynamically compromised; limit pulse checks to no longer than 10
seconds
Together with an absence of pulse, abnormal gasps and/or brief seizure activity may also indicate a cardiac
arrest
Continued strong emphasis on high quality CPR with minimum interruptions in chest compressions
Emphasis to limit interruptions in chest compressions before defibrillations to no longer than 5 seconds (chest
compression interruption of even 5-10 seconds before defibrillation is associated with reduced success); chest
compressions should continue while monitor-defibrillator is charging
Use of waveform capnography (end tidal carbon dioxide PETCO2) to continuously monitor tracheal tube
placement, to assess the quality of CPR, and indicate the return of spontaneous circulation

(continued on reverse page)

For educational purposes only

Barill/Dare 2
 Overview of Emergency Cardiovascular Care 2011

Continued emphasis on deferring early tracheal intubation unless done by highly skilled practitioners with interruption of
chest compressions not to exceed 10 seconds; alternatives include advanced supraglottic airways (i.e. laryngeal mask
airway, King Laryngeal Tube) or the use of an oropharyngeal airway with a bag-valve-mask
Strong emphasis on coordinated post-cardiac arrest care with the inclusion of a comprehensive post
resuscitation protocol
Continued emphasis on effective resuscitation team dynamics and team leadership

The 2010 Guidelines for CPR and ECC reinforce the critical time constraints before, during and after a cardiac arrest. The
hemodynamically unstable patient can progress to full cardiac arrest in seconds to minutes. For the arrested patient, seconds
determine success. Consider the following:

For every minute into a cardiac arrest, opportunity for a successful resuscitation is reduced by about 10% - 1% for every 6
seconds
Brain damage can occur after only 180 seconds into a cardiac arrest
Coronary perfusion reaches 30% of normal after about 9 seconds of quality CPR and falls to ineffective levels after only a
2-3 second interruption
Odds for a successful defibrillation diminish after interruptions in compressions of more than 5 seconds

To help ensure a rapid effective response, algorithms are provided to highlight relevant concepts and actions of the most likely
pediatric emergencies facing in-hospital health care providers. Quality of performance of the team leader and the team members in
providing timely, effective care is a major determinant in a successful outcome. Remaining current in resuscitation knowledge and
skills helps to ensure this level of performance.

This booklet includes the essential treatment algorithms for the resuscitation of Infants and Children. Core principles for every
algorithm are included to provide quick reference and draw attention to time-sensitive actions that optimize successful outcomes.
Rapid reference sheets for electrical therapy, pediatric vitals, references and an abbreviation dictionary round out this package.

This document is freely available to be downloaded and copied for learning and teaching. Any changes to this document,
alternative packaging or its inclusion into commercial products require the written permission of the authors.

The past six months has seen the release of guidelines that likely represents the best ECC science in 50 years. We hope that this
booklet will help hospital-based healthcare professionals learn, adopt and share these guidelines to the ultimate benefit of their
patients.

Barill/Dare 3
 Healthcare Provider CPR Skills Summary
Adult: Adolescent and Older Child: 1 year to Adolescent Infant: Under 1 year
Unresponsive
Recognition No breathing or only gasping
No definite pulse palpated within 10 seconds
CPR Sequence CA-B
Lone Rescuer: 2 fingers placed just below
Heel of hand placed on centre of the chest Heel of hand placed on centre of the chest
Compressions the nipple line
on lower half of sternum; second hand on lower half of sternum
Landmark Two Rescuers: 2 thumbs placed just below
placed over first Optional: second hand placed over first
the nipple line with hands encircling chest
Compression At least 100/minute
Rate Change compressors every 2 minutes
Compression
At least 5 cm (2 inches) At least 1/3 the anterior-posterior diameter
Depth
Chest Wall Recoil Allow full recoil between compressions
Airway Head tilt chin lift (jaw thrust if trauma is suspected)
Compression to
30:2 for single rescuer
Ventilation Ratio 30:2
(without 1 or 2 rescuers
15:2 for two rescuers
advanced airway)
Rescue Breaths 1 breath every 5-6 seconds 1 breath every 3 seconds
Rescue Breaths 1 breath every 6-8 seconds (8-10 breaths/minute)
with advanced Breaths delivered asynchronously with chest compressions
airway About 1 second per breath with visible chest rise
5 back blows followed by 5 chest
FBAO - Abdominal thrusts until effective or person is unresponsive (chest thrusts for those who are
compressions until effective or infant
Responsive pregnant or in wheelchair back of wheelchair placed against solid surface)
becomes unresponsive
FBAO -
30 compressions open airway remove foreign body only if seen - 2 attempts to ventilate Repeat until ventilation is successful
Unresponsive
Use AED when available
Use AED as soon as possible
AED If no access to a pediatric attenuated AED, use adult AED
Use adult pads (8-12 cm in diameter)
If pads are too large consider an anterior- posterior pad position

Abbreviations: AED, automated external defibrillator; CPR, cardiopulmonary resuscitation; FBAO, foreign body airway obstruction
Note: ERC and Red Cross recommendation for FBAO responsive is 5 back blows alternating with 5 abdominal thrusts.

4 For educational purposes only

 Pediatric Basic Life Support for Healthcare Providers

If a lone rescuer and

collapse known to be
Give 1 breath every 3 seconds
activate emergency If pulse remains < 60 bpm with
response and poor perfusion after ventilations
: Definite
pulse
add chest compressions
Max 10 seconds
Continue to frequently monitor
pulse and signs of life while
No pulse or unsure? giving rescue breaths

After 2 min, activate emergency response and get AED/

defibrillator if not already done

for 2 minutes, follow prompts of

Not
Shockable AED to reassess rhythm
Shockable
for 2 min Continue until ALS arrives or signs
of life occur

After assessing no pulse or unsure begin with Cardiac arrest in pediatrics most often due to a
compressions then open airway and give 2 breaths respiratory crisis or shock state
(CAB) Maximize time on chest (CPR)
Push (1/3 anterior posterior chest diameter), Deliver quality CPR
(100-120/min) & allow for on Do not over ventilate rate or volume
horizontal hard surface
Compression interruption < 5 sec
With 2 person CPR but without advanced airway, For Infant/Child defibrillation use following priority
deliver 15:2 compressions to ventilations for method chosen:
With 2 person CPR with an advanced airway, one manual defibrillator (2J/kg, then 4J/kg)
rescuer provides continuous compressions while the pediatric attenuated AED
second rescuer delivers breaths once every 6-8 seconds Adult AED
Change chest compressor every 2 min If pad size is an issue (too large) use an anterior-
posterior pad placement

For educational purposes only

Barill/Dare 5
 Pediatric Cardiac Arrest Algorithm

Activate Emergency Response

Begin CPR
Attach Monitor-Defibrillator

Shockable
ASYSTOLE/PEA No Yes VF/VT
rhythm?

CPR for 2 min Shock

IV/IO Access CPR for 2 min
Epinephrine
Consider advanced airway

IV/IO Access
Rapid Identification and Treatment of Most
Likely Cause

History, Physical Exam & Investigations No VF / VT?

Hypovolemia Tension Pneumothorax
Hypoxia Tamponade
Hyper/Hypo K+/H+ Toxins Yes
Hypothermia Thrombosis- PE / MI
Shock
CPR for 2 min
Epinephrine
Consider Advanced Airway

ROSC ? VF / VT?
Post-Cardiac
Yes
Arrest Algorithm
No Yes
No
VF / VT? Shock
CPR for 2 min
Amiodarone
No Yes

PEA: an ominous event combining a

Push (> 1/3 anterior-posterior chest
diameter), (100+/min) & allow for
Compression interruption < 10 sec
Without advanced airway, must
coordinate breaths and compressions
Change chest compressor every 2 min
Waveform capnography to assess CPR
quality - goal PETCO2 > 10mmHg
First shock 2 J/kg, second shock 4 J/kg,
subsequent shocks > 4 J/kg
Max energy 10 J/kg or adult dose
Epinephrine IV/IO 0.01 mg/kg q3-5 min
Amiodarone IV/IO 5 mg/kg, may repeat
up to 2 times for refractory VF/VT
Continuous CPR with supraglottic
advanced airway or ETT tube and
Waveform capnography to confirm
advanced airway placement
Sustained breathing
Skeletal muscle movement
PETCO2 > 35 mm Hg
Pulse & BP
Pediatric cardiac arrest is most often
due to a respiratory crisis (asphyxial
arrest) or shock state
Do not over ventilate rate or
volume
typically life sustaining rhythm with no
signs of life
PEA is not a shockable rhythm
Core concepts of algorithm applicable to pt
trending towards PEA but still alive
With evidence of heart wall motion and/or
narrow QRS complex: exhaust all treatable
causes
A focused head to toe physical exam is
crucial.
Investigations must provide near
immediate results to be of value i.e. FAST
echocardiography
Attempts to treat unconfirmed causes can
be undertaken even if only to rule out a
cause
If Asystole witnessed and pt was just in a
perfusing rhythm or if P waves present
then consider transcutaneous pacing (TCP)

For educational purposes only

Barill/Dare 6
 Unstable Pediatric Bradycardia

Altered level of consciousness

Hypotension
SOB/slow breathing/pulmonary congestion
Signs of shock

onitor continuous ECG, oximetry, blood pressure

xygen - maintain SpO2 > 94 %
ital signs - initial full set including glucose
V/IO - ensure vascular access
CG 12 lead ECG

Monitor & Observe

No
Expert consultation

Yes

No

Yes

Atropine: if increased vagal tone or

primary heart block
Consider transcutaneous/transvenous
pacing

Quality CPR Medications (IV/IO) Waveform capnography to confirm

Push (1/3 anterior-posterior
chest diameter),
(100+/min) & allow for
horizontal hard surface
Compression interruption < 10 sec
Without advanced airway, 15:2
compressions to ventilations
Change compressor every 2 min
Waveform capnography to assess
CPR quality - goal PETCO2 >
10mmHg
Epinephrine 0.01 mg/kg IV/IO q3-5
min, if no IV/IO may give 0.1 mg/kg
on via endotracheal tube
Atropine 0.02 mg/kg IV/IO, may
repeat x 1, minimum dose 0.1 mg,
maximum single dose 0.5 mg
Advanced Airway
Continuous CPR with supraglottic
advanced airway or ETT tube and
breaths once every 6-8 seconds
advanced airway placement
Core Principles
The most common cause of
bradycardias in the pediatric
population is a hypoxic insult.
Oxygenate/ventilate is the treatment
of choice
Pacing may be indicated when other
steps/meds have failed, especially for
sinus node dysfunction or complete
heart block

For educational purposes only

Barill/Dare 7
 Unstable Pediatric Tachycardia

Altered level of consciousness

Hypotension
SOB, pulmonary congestion
Signs of shock

onitor continuous ECG, oximetry, blood pressure

xygen - maintain SpO2 > 94 %
ital signs - initial full set including glucose
V/IO - ensure vascular access
CG 12 lead ECG

No Yes
(QRS < 0.09 seconds

Most likely Ventricular Most likely a

Tachycardia(VT) Supraventricular
Tachycardia (SVT)
Hx and known
Hx of paroxysmal cause for ST
HR change P-waves
P waves absent or Constant PR
No Patient is Unstable? Yes
abnormal interval, variable R-
Fixed HR over time R interval
Infants HR > 220 Ifants HR usually <
If monomorphic and Children HR > 180 200 bpm
regular consider Immediate Cardioversion Children HR usually
Adenosine (If known < 180 bpm
WPW then do not give,
get a expert consult)

Consider: Consider:
Expert Consult Vagal Maneuvers Identify and treat
If Unsucessful
Amiodarone or Adenosine IV/IO underlying cause
Procainamide Cardioversion

Adenosine IV/IO Sedation as needed

1st Dose: 0.1 mg/kg to max 6 mg
rapid push with rapid flush of
10-20 ml NS
2nd Dose: 0.2 mg/kg to max 12
mg rapid push with rapid flush
of 10-20 ml NS
Amiodarone 5 mg/kg over 20-60 min
Procainamide 15 mg/kg over 30-60
min
First shock: 0.5-1.0 J/kg
Subsequent shock if unsuccessful at
2.0 J/kg
In infants and young children apply
crushed ice in bag/glove to face
In older children valsalva maneuver or
carotid sinus massage may be used

For educational purposes only

Barill/Dare 8
 Rapid Reference: Electrical Therapies

Defibrillation is the delivery of significant electrical energy through the heart over about 10 milliseconds with the goal of taking a
critical mass of myocardial cells and depolarizing them into a brief moment of asystole. This asystolic pause allows cells with
automaticity to again dominate the heart in a normal organized rhythm pattern. Synchronized cardioversion is similar to
defibrillation except that the delivery of the energy is timed to the intrinsic rhythm of the patient to avoid shocking during a
relative refractory period of the cardiac cycle. Shocks during this period can produce VF.

Monophasic waveforms deliver the energy of the shock in one direction (one polarity). Very few manufactures
worldwide make this type of defibrillator anymore but some are still in use. Biphasic waveforms deliver a current that reverses
direction during the few milliseconds of the shock as the polarity of the pads/paddles changes. Biphasic waveforms have been
shown to be superior to monophasic waveforms in implanted defibrillators and significantly less myocardial current density is
required with biphasic waveforms

Pediatric: Monophasic and biphasic. First defibrillation 2-4 Joules/kg, subsequent shocks
should be at least 4 Joules/kg. Higher energies can be considered but do not exceed 10 Joules/kg or the recommended
maximum adult energy for the brand of defibrillator

Pediatric Cardioversion: start at 0.5-1 Joules/kg escalating with subsequent attempts to 2 Joules/kg

1. Turn on monitor/defibrillator
2. Set lead switch to pads/paddles or lead I, II, or III if leads have been connected
3. Choose energy (most brands of defibrillators come on set to charge at the first defibrillation energy for an adult) for
defibrillation or synchronized cardioversion.
4. Place defib pads/paddles on patient
For pediatric patients, use appropriate pad sizes to age/weight; an anterior-posterior placement is common
Attempt to keep paddles/pads 1-3 inches away from implanted devices such as ICDs and pacemakers .
5. If performing synchronized cardioversion, ensure standard leads are connected; set synch button to on and ensure that the
rhythm is being appropriately flagged on the R wave. Give sedation as appropriate for the situation
6. Announce that you are charging. Press the charge button on the machine or if using manual paddles the button on the apex
paddle.
7. Warn three times that you are about to shock and visually check that no one is in electrical contact with the patient (direct
contact, through liquids, or through metal)
8. Press shock button on machine or two buttons on paddles simultaneously. Note: for Synchronized cardioversion press shock
button(s) down until shock occurs. The defibrillator is calculating when to shock and this can be very quick or may take several
seconds. Also be sure to re-synch for any subsequent cardioversion attempts as most machines have the synch button turn off after
each attempt.
9. For cardiac arrest situations continue CPR if possible as machine is charged and resume with compressions immediately after
the shock to minimize CPR time off chest.

(continued on reverse page)

For educational purposes only
Barill/Dare 9
 Rapid Reference: Electrical Therapies

(Continued from previous page)

Transcutaneous pacing (TCP) is a highly effective emergency method of pacing for severe symptomatic bradycardias. Other
methods for increasing heart rate like the use of atropine, dopamine, or epinephrine may also be attempted depending on
situational factors and what rhythm the patient is in. This non-targeted method of pacing is unique in that it will also pace skeletal
muscle, gut muscle and the diaphragm at the currents needed to capture the myocardium electrically. This can mean significant
discomfort for the patient and the need for procedural sedation. The current levels needed to get capture are very high in
comparison to other methods of pacing and the aberrancy of the route of conduction from the pads leads to QRS complexes that
are very wide and bizarre resembling large PVCs. These observations are all normal and are expected.

1. Position pads on patient for pacing as indicated by the manufacturer. This is usually an anterior-posterior position. Look for a
indicator on the pads to show if one pad is specific to the apical position.
2. Ensure standard leads are also connected to the patient
3. Turn pacer on
4. While most TCP will come on default in demand (synchronous) mode, verify that it is not set in non-demand (asynchronous)
mode. This mode is rarely used unless there is a situation where artifact is mistakenly being sensed as intrinsic ECG complexes.
5. Set pacer demand rate to a heart rate appropriate to the childs age and physiological demands (see typical heart rates on page 10
of this package)
6. Set current by titrating the mA upwards until you have consistent electrical capture as indicated by seeing pacer spikes followed
by a new QRS morphology. Buffer the capture current (threshold) by increasing the mA by approximately another 10%.
7. Check for mechanical capture (paced rhythm produces cardiac output) by assessing distal pulses (at sites where skeletal muscles
are not contracting surrounding the vessel), level of consciousness, vital signs and other signs/symptoms of improved infusion.
8. Proceed to give analgesia and sedation as needed to keep patient comfortable.
9. Arrange transvenous or permanent pacemaker placement as needed.

For educational purposes only

Barill/Dare 10
 Rapid Reference: Pediatric Vitals Signs
and Equipment Sizes
2010 Guidelines for CPR and Emergency Cardiovascular Care

Age HR SBP RR Wt ETT Blade Chest Tube NG/Foley Arterial Line

(kg) (mm) (Fr) (Fr) (gauge)
Prem 160 55 30-60 <1 2.5 0 8 5 24
Prem 160 60 30-60 1-2 3.0 0 8-10 5 24
Prem 160 62 30-60 2-3 3.0 0-1 10 5 24
Newborn 150 65 30-60 3.5 3.5 0-1 10-12 5-6 24
6m 140 95 30-60 7 4.0 1 12-16 6 22
1y 125 95 24-40 10 4.0 1 16-20 8 22
2-3y 110 100 24-40 12-14 4.5 1.5-2.0 16-20 8 22
4-6y 100 100 22-34 16-20 5.0 1.5-2.0 20-28 10 22
6-8y 90 105 18-30 22-27 5.5-6.0 2.0 24-32 10 22
10-12y 80 115 18-30 30-40 6.0-6.5 2.0-3.0 28-32 10-12 22
16y 75 115 12-16 >50 6.5-7.0 2.0-3.0 32-40 >12 20

Weight LMA Size Central Line

(kg)
Internal Jugular Subclavian Femoral
Diameter Length Diameter Length Diameter Length
(Fr) (cm) (Fr) (cm) (Fr) (cm)
<5.0 1 4 5 4 8 4 8
5-10 1.5 4-5 5-8 4-5 8-12 4-5 8-12
10-20 2 5 8 5 12 5 12
20-30 2.5 5 8 5 12 5 12
30-50 3 5 8 5 12 5 12
50-70 4 7 16 7 16 7 16
70-100 5 7-9 16 7-9 16 7-9 16
>100 6 7-9 16 7-9 16 7-9 16

Chart data from Robert M. Kliegman, ., editors,
, 18th edition (Philadelphia: Saunders Elsevier, 2007), 389

For educational purposes only

Barill/Dare 11
 Abbreviations Glossary
Emergency Cardiovascular Care 2011

abx antibiotic LLUD left lateral uterine displacement

ACE angiotensin converting enzyme LMA laryngeal mask airway
ACLS advanced cardiac life support MAP mean arterial pressure = (2 DBP + SBP)/3
ACS acute coronary syndrome LLUD left lateral uterine displacement
AED automated external defibrillator MgSO4 magnesium sulphate
AF atrial fibrillation MI myocardial infarction
AFl atrial flutter mm Hg millimetres of mercury
AHA American Heart Association MOVIE Monitor Oxygen if required Vital Signs including
glucose IV 12 lead ECG
ALS advanced life support
MVO2 mixed venous oxygen saturation
AMI acute myocardial infarction
NPO nothing by mouth
APLS advanced pediatric life support
NS normal 0.9% saline
ASAP as soon as possible
NSTEMI non-ST elevation myocardial infarction
BB beta blocker
NTG nitroglycerin
BP blood pressure
o PALS pediatric advanced life support
C degrees Celsius
PCI percutaneous coronary intervention
CAB chest compressions airway - breathing
PE pulmonary embolus
CABG coronary artery bypass graft
PEA pulseless electrical activity
CCB calcium channel blocker
PETCO2 end-tidal carbon dioxide
CCR cardiocerebral resuscitation
PPV positive pressure ventilations
CPAP continuous positive airway pressure
Pt patient
CPR cardiopulmonary resuscitation
ROSC return of spontaneous circulation
CVP central venous pressure
rt-PA recombinant tissue plasminogen activator
DBP diastolic blood pressure
s+s signs and symptoms
DIC disseminated intravascular coagulation
SBP systolic blood pressure
ECC emergency cardiovascular care
SIRS systemic inflammatory response syndrome
ED emergency department
SOB shortness of breath
Epi Epinephrine
SpO2 oxygen saturation as measured by a pulse-oximeter
ERC European Resuscitation Council
STEMI ST-elevation myocardial infarction
ETT endotracheal intubation
SVT supraventricular tachycardia
FAST Focused Assessment with Sonography for Trauma
TEE transesophageal echocardiography
FBAO foreign body airway obstruction
TCP transcutaneous pacing
HR heart rate
TIA transient ischemic attack
HSFC Heart and Stroke Foundation of Canada
TIMI Thrombolysis in Myocardial Infarction risk score
Hx history
UA unstable angina
IABP intra-aortic balloon pump
VF ventricular tachycardia
ILCOR International Liaison Committee on Resuscitation
VS vital signs (TPR, BP, SpO2, glucose)
IO intraosseous
VT ventricular tachycardia
ITH induced therapeutic hypothermia
WBC white blood cell
IV intravenous
WPW Wolff Parkinson White pre-excitation syndrome
J Joules
Barill/Dare 12
 References

1. American Heart Association. Out-of-Hospital (Sudden) Cardiac Arrest Statistics. (2009). Retrieved from http://
www.americanheart.org/downloadable/heart/1236978541670OUT_OF_HOSP.pdf

2. Barill, T. & Dare, M. (2006). Managing Cardiac Emergencies. North Vancouver, BC: SkillStat Press.

3. BC Stroke Strategy. A proposed algorithm for identifying patients with acute cerebrovascular syndrome.
(December, 2010). Retrieved from http://www.bcstrokestrategy.ca/documents/BCACVSAlgorithmFinal.pdf .

4. BC Stroke Strategy. Evaluation of TIA Rapid Assessment Clinics. (December, 2010). Retrieved from http://
www.bcstrokestrategy.ca/documents/EvaluationofTIAClinicsFinal.pdf .

5. Cairns, J.A., Connolly, S., McMurtry, S. et al. (2011). Canadian Cardiovascular Society Atrial Fibrillation
Guidelines 2010: Prevention of stroke and systemic thromboembolism in atrial fibrillation and flutter.
, 27, 74-90.

6. Desbiens, Norman A. (2008). Simplifying the Diagnosis and Management of Pulseless Electrical Activity in
Adults: A Qualitative Review. . 36(2), 391-396.

7. Ewy, Gordon A. (2005). Cardiocerebral Resuscitation: The new Cardiopulmonary Resuscitation. Circulation, 111,
2134-2142.

8. Gausche-Hill, M., Fuchs, S. & Yamamoto, L. (Eds.). (2004). .

Toronto: Jones and Bartlett Publishers.

9. Hazinski, Mary F. & Field, John M. (Eds.). (2010). 2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. , 122 (Suppl. 3).

10. Heart and Stroke Foundation of BC and Yukon. . (November

2010). Retrieved from http://www.bcstrokestrategy.ca/documents/ProvincialStrokeActionPlanAppendixA.pdf

11. Hommers, Clare. (2010). Oxygen therapy post-cardiac arrest? The Goldilocks principle?. , 81,
1605-1606.

12. Kory, P., Weiner, J., Mathew, J. et al. (2011). European Resuscitation Council Guidelines for Resuscitation 2010.
, 82(1), 15-20.

13. Kushner, F., Hand, M., King, S.B. et al. (2009). 2009 ACC/AHA guidelines for the management of patients with
ST-elevation myocardial infarction and ACC/AHA/SCAI guidelines on percutaneous coronary intervention.
, 54, 2205-2241.

14. Levy M.M., Fink M.P., Marshall J.C. et al. (2003). 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis
Definitions Conference. . 31(4),1250-6.

15. Lindsay, P., Bayley, M., Hellings, C. et al. (2008). Canadian best practice recommendations for stroke care
(updated 2008). , 179(Suppl. 12), S1-S25.

16. Meaney, P., Nadkarni, V., Kern, K. et al. (2010). Rhythms and outcomes of adult in-hospital cardiac arrest.
, 38(1), 101-108.

17. Nolan, J.P., Hazinski, M.F., Billi, J.E. et al. (2010). 2010 International Consensus on Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations . ,
81(Supplement e).

18. Nolan, J.P., Soar, J., Deakin, C.D. et al. (2010). European Resuscitation Council Guidelines for Resuscitation
2010. , 81(10).

Barill/Dare 13
 References

19. Nolan, J.P., Neumar, R.W., Adrie, C. et al. (2008). Post-cardiac arrest syndrome: Epidemiology,
pathophysiology, treatment, prognostication. A Scientific Statement from the International Liaison Committee on
Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on
Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the
Council on Clinical Cardiology; the Council on Stroke et al. , 79(9), 350-379.

20. Parkash, R., Verma, A. & Tang, A.S.L. (2010). Persistent atrial fibrillation: current approach and controversies.
, 25m 1-7.

21. Pinto, D.S., Kirtane, A.J., Nallamothu, B.K. et al. (2006). Hospital Delays in Reperfusion for ST-Elevation
Myocardial Infarction: Implications when selecting a reperfusion strategy. , 114, 2019-2025.

22. Ralston, M. & Hazinski, M.F. & Schexnayder, S. et al. (2007).

. Dallas, TX: American Heart Association.

23. Ralston, M. & Hazinski, M.F. & Zaritsky, A. et al. (2006). . Dallas, TX:
American Heart Association.

24. Rothwell, P., Giles, M., Chandratheva, A. et al. Effect of urgent treatment of transient ischaemic attack and minor
stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. ,
370, 1432-42.

25. Sandroni, C., Nolan, J., Cavallaro, F. & Antonelli, M. (2007). In-hospital cardiac arrest: incidence, prognosis and
possible measures to improve survival. , 33, 237-245.

26. Smith, Stephen W. & Whitwam, W. (2006). Acute Coronary Syndromes.

, 24, 53-89.

27. Stiell, Ian G., Macle, Laurent et al. (2011). Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010:
Management of Recent-Onset Atrial Fibrillation and Flutter in the Emergency Department.
, 27, 38-46.

28. Van de Werf, F.J. (2006). Fine-tuning the selection of a reperfusion strategy. , 114, 2002-2003.

29. Wann, S., Curtis, A., January, C. et al. (2011). 2011 ACCF/AHA/HRS Focused update on the management of
patients with atrial fibrillation (Updating the 2006 Guideline): A Report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines. , 123, 104-123.

30. Wijesinghe, M., Perrin, K., Ranchord, A. et al. (2008). Routine use of oxygen in the treatment of myocardial
infarction: systematic review. , 95, 198-202.

31. Wright, R.S., Anderson, J.L., Adams, C.D. et al. (2011). 2011 ACCF/AHA Focused Update incorporated into the
ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial
infarction. , 57 (Suppl. E), e215-e367.

Barill/Dare 14
Notes
Notes

Page 28
Notes

Page 30
Notes

Page 32
Notes

Page 34
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