Pediatric advanced life support

PALS Basics - The First Few Seconds

• Initial Impression (First 60s): Use the Pediatric Assessment Triangle (PAT) to assess severity.

  • Appearance: Tone, Interactiveness, Consolability, Look/Gaze, Speech/Cry (📌 TICLS).
  • Work of Breathing: Rate, retractions, abnormal sounds.
  • Circulation to Skin: Pallor, mottling, cyanosis.

• Immediate Sequence:

⭐ If pulse is <60/min with poor perfusion despite oxygenation & ventilation, START chest compressions.

Bradycardia & Tachycardia - When the Heart Skips

• Bradycardia (HR <60/min): Primarily caused by hypoxia. Always manage Airway & Breathing first.

  • If HR remains <60/min with poor perfusion despite oxygenation & ventilation, start chest compressions.
  • Epinephrine IV/IO: 0.01 mg/kg.
  • Atropine IV/IO: 0.02 mg/kg (for ↑ vagal tone).

• Tachycardia: Differentiate by QRS duration.

• Key Doses:
  • Adenosine (SVT): 0.1 mg/kg (1st dose), then 0.2 mg/kg.
  • Synchronized Cardioversion: 0.5-1 J/kg, then 2 J/kg.

⭐ The most common cause of pediatric bradycardia is hypoxia. Unlike adults, it is rarely a primary cardiac event.

Pulseless Arrest - Code Blue, Tiny Human

• CPR: High-quality compressions (100-120/min, depth ⅓ AP diameter) & ventilation.
• Shock (VF/pVT): Start at $2$ J/kg, may escalate up to $10$ J/kg.
• Epinephrine: $0.01$ mg/kg IV/IO (0.1 mL/kg of 1:10,000) q 3-5 min.
• Amiodarone: $5$ mg/kg bolus for refractory VF/pVT.
• Reversible Causes: Address H’s & T’s (Hypoxia, Hypovolemia, etc.).

⭐ In children, pulseless arrest is most commonly caused by respiratory failure or shock (asphyxial arrest). Asystole/PEA are the most frequent initial rhythms.

PALS Pharmacology - The Potion Cabinet

• Epinephrine (Adrenaline): 0.01 mg/kg IV/IO for cardiac arrest. For bradycardia, anaphylaxis.
• Amiodarone: 5 mg/kg IV/IO bolus for shock-refractory VF/pVT.
• Lidocaine: 1 mg/kg IV/IO as an alternative to amiodarone.
• Adenosine: 0.1 mg/kg rapid IV push (1st dose); 0.2 mg/kg (2nd dose) for SVT.
• Glucose: 0.5-1 g/kg IV for hypoglycemia (use D10W/D25W).

⭐ For endotracheal administration, the epinephrine dose is much higher: 0.1 mg/kg (using the 1:1000 concentration).

Post-ROSC Care - After the Storm

• Optimize Ventilation/Oxygenation: Maintain SpO₂ 94-99%; avoid hyperoxia. Target normocapnia (ETCO₂ 35-45 mmHg).
• Hemodynamic Support: Maintain systolic BP >5th percentile for age. Give crystalloid boluses (10-20 mL/kg); start vasopressors (epinephrine/norepinephrine) if needed.
• Neurological Care: Treat seizures promptly. Initiate Targeted Temperature Management (TTM) for comatose patients (32-36°C for 24 hrs).
• Monitoring: Continuous ECG, BP, SpO₂, ETCO₂, temperature. Monitor and correct glucose and electrolyte abnormalities.

⭐ Actively prevent and treat fever (>37.5°C) in all post-arrest patients, as hyperthermia is linked to worse neurological outcomes.

High-Yield Points - ⚡ Biggest Takeaways

• PALS prioritizes the C-A-B (Compressions-Airway-Breathing) sequence.
• Deliver high-quality chest compressions at 100-120/min to a depth of at least ⅓ the AP diameter of the chest.
• The compression-to-ventilation ratio is 30:2 for a single rescuer and 15:2 for two rescuers.
• For shockable rhythms (VF/pVT), the initial defibrillation dose is 2-4 J/kg; subsequent doses can be increased up to 10 J/kg.
• The standard Epinephrine dose (IV/IO) is 0.01 mg/kg.
• Consider Amiodarone or Lidocaine for refractory VF/pVT.
• Always identify and treat the reversible causes (the H’s and T’s).