PALS Recertification

I am in the process of re-certifying for the umpteenth time and I need to publish this before the stupid server times out and wipes out my words again. Times does fly, 2 years in fact, when you’re not having so much fun.

Primary assessment. Secondary assessment. Diagnostic tests. I n t e r v e n e. I d e n t i f y. Evaluate-Identify-Intervene Sequence Pediatric Advanced Life Support 2010.

PALS Systemic Approach AlgorithmI find that I learn better with repetition. This review allows me to review the course material and it just sticks better. There is a systematic approach to assessment of a sick child and by following the algorithm demonstrated to the left, the clinician will not miss anything.






It can’t be stressed the need to evaluate, intervene, and reassess. Never forget ABCDE (Airway, Breathing, Circulation, Disability, Exposure)





In the pediatric patient, halting the march towards respiratory failure and subsequently cardiac arrest, is the ultimate goal to care of this population.











The pre-course assessment identified that I need to do a bit of work with identification and treatment of pediatric arrhythmias. I hope others will find this review helpful and useful.

Reversible causes of cardiac arrestWith such an abysmal survival rate associated with cardiac arrest the whole process of the recognition and correction of those conditions that prevent cardiac arrest his key to the increased survival of the pediatric critically ill patient. Thus the recognition and correction of the six Hs and 6 Ts,

Normal and Asystole

Normal Sinus Rhythm, Ventricular Fibrillation, Asystole
Normal Sinus Rhythm, VF, and Asystole

The most common rhythm in a pediatric patient it is as demonstrated by the first line that is called normal sinus rhythm. To manually estimate the rate on an EkG, count the number of RR intervals between two Tick marks (6 seconds) in the rhythm strip and multiply by 10 to get the bpm.  It is also necessary to recognize the morphology each complex has a normally shaped improper duration of the P-wave QRS complex and T-wave. Again,  it’s important to recognize normal so septal deviations can be recommended and corrected.   However even this normal rhythm can deteriorate  two asystole pulseless electric activity ventricular fibrillation or ventricular tachycardia into cardiac arrest.


Pediatric Cardiac Arrest Algorithm-2015 Update

         Shock, Shock, Shock…Epi, Epi, Epi PALS-Cardiac-Arrest-Algorithm 2015

The foundation of basic and advanced life support in the pediatric population is high-quality CPR.  This last update calls for hands only CPR, and I found it rich when they said that when the rescuer is unskilled, or unwilling or unable to provide rescue breathes, it is appropriate hands only CPR in the sequence demonstrated in the figure.  High-quality CPR is demonstrated when you push hard, push fast, allow full recoil, minimize interruptions ,and avoid excessive ventilation. The immediate goal to prevent death in cardiac arrest is the return of spontaneous circulation(ROSC).   If you happen upon a pediatric patient that is unresponsive and pulseless you assume that they are in cardiac arrest. You are to either activate EMS if it’s in the field or call a rapid response if you’re in the hospital. We are going to assume that I’ll be in the hospital. We locate the AED, place the paddles, and recognize if the waveform is shockable.  If it’s ventricular fibrillation or PEA, I shock at 2 J per kilo and then every subsequent should be 4 J per kilo.  I will perform CPR for two more minutes(I will more than likely be with another rescuer so compression to rescue breathes is 15:2 and for 1 is 30: 2) and then reevaluate the rhythm a repeat the cycle above. If the rhythm is not shockable, we proceed with effective CPR for two minutes, we get IV access or instill epinephrine through the advanced airway. The epinephrine can be repeated every 3 to 5 minutes, review the rhythm if the rhythm switches to a shockable rhythm, then we proceed with the previous steps as demonstrated in that the other part of the algorithm or continue CPR and look for reversible causes of cardiac arrest and correct them. With ROSC, then start post arrest care.


So far we’ve discussed normal sinus rhythm and conditions  the exact opposite asystole and electrical activity but you have no pulse therefore no spontaneous circulation.  This section deals primarily with those rhythms where the heart rate is slower than 60 bpm and can result in hypotension and decrease mental status and other signs of shock.  Cardiac output equals the stroke volume times the heart rate. So any condition that effectively will not allow you to increase the heart rate you can bet that there is going to be a decrease in cardiac output and therefore a decrease in circulation. Congenital abnormalities can do this, cardiomyopathy’s can do this, hypovolemia of sepsis etc. can do this.


If the rhythm is slow and there’s poor perfusion the algorithm calls for effective CPR and if the bradycardia persists you are to give epinephrine 0.1 mg/mL  or 0.1 mL per kg  or atropine at 0.02 mg per kilo maximum dose is 0.5 mg or a minimum dose of 0.1 mg. Atropine at can be used for Mobitz type heart block. And temporary pacing may be necessary. Again you are providing intervention and then reassessing and treating other reversible causes of bradycardia.



In general fast heart rhythms are tolerated well by the pediatric patient.  However in the case of atrial flutter and SVT can be associated with poor growth and congestive heart failure if not recognize and corrected.

Sinus Tachycardia- The QRS complex has a normal morphology but the rate is just fast usually depending on the age can be higher than 120 bpm.  There usually is underlying cause like high temperatures, hypovolemia or other reversible causes.

Supraventricular Tachycardia(SVT) is often viewed as a simple arrhythmia to fix: start with vagal maneuvers, then go with adenosine(Dose: 0.1 mg/kg subsequent dose is 0.2 mg/kg). But those maneuvers don’t work. What are your other options? In SVT consider transfer and if delay, Amiodarone 5 mg/kg infused over 20-60 minutes max dose of 300 mg. Suggest infusing in ICU setting. Procainamide 15 mg/kg over 30 to 60 minutes. Lidocaine or magnesium can also be used. Consider Synchronized Cardioversion. Establish IV access, conscious sedation because shocking anyone hurts, ABCs, and shock. 1st dose is 0.5-1 j/kg then each subsequent dose is 2 J/kg.

Atrial Flutter is a narrow complex tachycardia that can develop in infants with normal hearts. There can be an aberrant reentrant circuit that causes this arrhythmia. Treatment by specialist with synchronized cardioversion and sometimes ablation maybe necessary.


With the topic of pediatric resuscitation so wide and complex(kind of like V Tach) I provided only a review of 1 aspect of this topic. And the old adage use it or lose is right, I would suggest quarterly megacodes or didactic reviews in those community settings in which very sick pediatric patients are not the norm, and the skill set of the clinical staff maybe a bit rusty or non-existent.


I invite you to refer to the American Heart Association’s website on the recognition and treatment of congenital heart disease and also a synopsis of pediatric resuscitation, reviewed UpToDate, and  at the following links.    Recognition and Treatment of Congenital Heart Disease

Recognition and Treatment of Congenital Heart Defects in Newborns

Newborn Screening for Critical Congenital Heart Disease



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