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PALS SEQUENCE ALGORITHM

1. When evaluating the childs level of consciousness, breathing and color, note:

Level of consciousness Is the child awake and alert, irritable and crying or
unresponsive?

Breathing Is the childs respiratory pattern normal for his age, diminished or absent, or
extremely labored?

Color Is the childs color normal for his ethnicity, cyanotic or pale, or mottled?

2. Is the child responsive and breathing normally?


No Activate EMS and continue
Yes Continue to Primary Assessment Sequence
3. Check the femoral of brachial pulse. Is it greater than 60 bpm?
No Start high-quality CPR and continue for two minutes
Yes Open airway and ventilate
4. If help is not available, access EMS and secure AED (leave child if necessary)
5. Provide high-quality CPR for a single provider give 30 compressions and 2 breaths for two
minutes before attempting other interventions (Two providers give 15 compressions and 2
breaths)
6. Check rhythm with AED and follow instructions (administer shock as needed)

PALS CARDIAC ARREST ALGORITHM

1. Activate emergency medical services, call a pediatric code blue, obtain AED or defibrillator
2. Is the rhythm shockable?
Rhythm IS shockable (ventricular fibrillation or unstable ventricular tachycardia)
1. Administer shock at 2 Joules/kg
2. Administer high-quality CPR for 2 minutes
3. Check rhythm
If not shockable, move to asystole/PEA rhythm protocol
If shockable, continue
4. Administer shock at 4 Joules/kg
5. Administer epinephrine 0.01 mg/kg IV or 0.1 mg/kg per ETT every 3-5 minutes
6. Administer high-quality CPR for 2 minutes
7. Check rhythm
If not shockable, move to asystole/PEA rhythm protocol
If shockable, continue
8. Administer shock at >4 Joules/kg
9. Administer Amiodarone 5 mg/kg IV (repeat 2 times if needed) or lidocaine 1 mg/kg IV
10. Administer high-quality CPR for 2 minutes
11. Check rhythm
If not shockable, move to asystole/PEA rhythm protocol
If shockable, repeat steps 8-11

Rhythm IS NOT shockable (asystole or pulseless electrical activity)


1. Administer high-quality CPR for 2 minutes

2. Administer Epinephrine 0.01 mg/kg IV or 0.1 mg/kg per ETT every 3-5 minutes
3. Check rhythm
If shockable, move to VF/VT rhythm protocol
If not shockable, continue
4. Administer high-quality CPR for 2 minutes
5. Check rhythm
If shockable, move to VF/VT rhythm protocol
If not shockable, continue
6. Administer Amiodarone 5 mg/kg IV (repeat 2 times if needed)
7. Administer high-quality CPR for 2 minutes
8. Check rhythm
If shockable, move to shockable rhythm protocol
If not shockable, continue CPR and medications

PALS POST ARREST SHOCK MANAGEMENT ALGORITHM

After successful resuscitation, the team must continue to manage the airway, ventilation, and
circulation and perform diagnostic testing. Post-resuscitation measures should include:

Treatment of the underlying causes of the initial injury or illness;

Prevention of further injury; Optimization of body functions

Transport to the next level of care

To meet these goals, rescuers should focus on respiratory, cardiovascular, neurologic, renal,
gastrointestinal, and hematologic systems. Administer oxygen as needed in order to maintain a
blood oxygenation level/saturation greater than 94% (based on pulse oximetry). If the precise
cause of the initial shock symptoms has not yet been identified, consider possible causes of
shock in the pediatric patient.
It is often helpful to remember the Hs and the Ts:

Hypovolemia

Hypoxia

(H+) Acidosis

Hypoglycemia

Hypo/Hyperkalemia

Hypothermia

Tension Pneumothorax

Toxins

Tamponade

Trauma

Thrombosis

Once the cause has been identified, provide definitive treatment as soon as possible. It will
usually also be necessary to provide additional fluid boluses. When needed, give crystalloid for
volume resuscitation. Monitor fluid resuscitation carefully.

Volume resuscitation may not be enough to maintain the childs blood pressure. In these cases,
you may consider adding pressors. One approach is to start with epinephrine, then move to
norepinephrine, then move to dopamine. Alternatively, some rescuers will begin with
dobutamine, then progress to dopamine, then try epinephrine followed by milrinone. The doses
of these cardiovascular agents are based on the size of the patient and then titrated to maintain an
effective blood pressure. These agents require an intensive care unit, an arterial line, and constant
monitoring. Diagnostic tests should be done at the same time as interventions.
For cardiac arrest outside of hospital, start and maintain targeted temperature management:

5 days at 36C to 37.5C OR

2 days at 32C to 34C followed by 3 days at 36C to 37.5C

PALS BRADYCARDIA ALGORITHM

1. Bradycardia is diagnosed by manual testing or heart rate monitor Normal heart rates change
with age/size.
Age Category

Age Range

Normal Heart Rate

Newborn

0-3 months

80-205 per minute

Infant/Young child

4 months to 2 years

75-190 per minute

Child/School Age

2-10 years

60-140 per minute

Older child/ Adolescent

Over 10 years

50-100 per minute

2. Consider possible causes

Hypoxia

Acidosis

Hyperkalemia

Hypothermia

Heart block

Toxins/Overdoses

Trauma

3. and treat immediately

Hypoxia Administer oxygen

Acidosis Treated with increased ventilation; use sodium bicarbonate carefully if needed

Hyperkalemia Restore normal potassium level

Hypothermia Rewarm slowly to avoid over-heating

Heart block Consult pediatric cardiologist for possible administration of atropine,


chronotropic drugs, and external pacemaker

Toxins/Overdoses Supportive care; administer antidote if one is available

Trauma Increase oxygen and ventilation; Avoid increased intracranial pressure by


treating bradycardia aggressively in cases of head trauma

4. Establish airway and support breathing as needed.


5. Monitor heart rate/rhythm and blood pressure

Cardiac Arrest? Go to PALS Cardiac Arrest Algorithm

6. Establish IV/IO Access


7. Hypotension?
Age Category

Age Range
1 Day
4 Days
To 1 month

Systolic Blood
Pressure
60-76
67-84
73-94

Diastolic Blood
Pressure
30-45
35-53
36-56

Abnormally Low
Systolic Pressure
<60
<60
<70

Neonate
Neonate
Infant
Infant

1-3 months

78-103

44-65

<70

Infant

4-6 months

82-105

46-68

<70

Infant

7-12 months

67-104

20-60

PreSchool

2-6 years

70-106

25-65

School Age

7-14 years

79-115

38-78

Adolescent

15-18 years

93-131

45-85

<70 + (age in years x


2)
<70 + (age in years x
2)
<70 + (age in years x
2)
<90

8. If hypotensive,

Administer epinephrine 0.01 mg/kg

Repeat every 3-5 minutes as needed

Consider atropine 0.02 mg/kg (min dose = 0.1 mg; max dose = 0.5 mg); Repeat one time
if needed

Consider external pacemaker

PALS TACHYCARDIA INITIAL MANAGEMENT ALGORITHM

1. Tachycardia is diagnosed by manual testing or heart rate monitor Normal heart rates
vary with age/size.
Age Category
Newborn

Age Range
0-3 months

Normal Heart Rate


80-205 per minute

Infant/Young child

4 months to 2 years

75-190 per minute

Child/School Age

2-10 years

60-140 per minute

Older child/ Adolescent

Over 10 years

50-100 per minute

2. Consider possible causes but do not delay treatment

Vagal Maneuvers

Synchronized Cardioversion

Medications

Support Airway, Breathing, Circulation

3. Is the child stable or unstable?


A child with tachycardia is considered unstable if he or she is hypotensive, has a decreased level
of consciousness, is in shock, or is experiencing ischemic chest pain.
Unstable Child Administer synchronized cardioversion immediately
Cardioversion Rules
QRS narrow and regular
QRS narrow and irregular
QRS wide and regular
QRS wide and irregular

50-100 Joules
120-200 Joules
100 Joules
Turn off the synchronized
mode and defibrillate
immediately

Stable child Continue assessment

Age
Category
Neonate
Neonate
Infant
Infant
Infant
Infant
PreSchool
School
Age
Adolescen
t

Age
Range
1 Day
4 Days
To 1
month
1-3
months
4-6
months
7-12
months
2-6
years
7-14
years
15-18
years

Systolic Blood
Pressure
60-76
67-84
73-94

Diastolic Blood
Pressure
30-45
35-53
36-56

Abnormally Low
Systolic Pressure
<60
<60
<70

78-103

44-65

<70

82-105

46-68

<70

67-104

20-60

70-106

25-65

79-115

38-78

93-131

45-85

<70 + (age in
years x 2)
<70 + (age in
years x 2)
<70 + (age in
years x 2)
<90

4. Assess the childs tissue perfusion


If tissue perfusion is poor, move directly to the PALS Tachycardia Poor Perfusion Algorithm
If tissue perfusion is adequate
5. Measure the width of the childs QRS complex on ECG
If the QRS complex is narrow (QRS 0.09 sec), move to the PALS Narrow QRS Tachycardia
Adequate Perfusion Algorithm
If the QRS complex is wide (QRS >0.09 sec), move to the PALS Wide QRS Tachycardia
Adequate Perfusion Algorithm

PALS TACHYCARDIA POOR PERFUSION ALGORITHM

1. Tachycardia is diagnosed by manual testing or heart rate monitor and the child
has poor perfusion Normal heart rates vary with age/size.
Age Category
Age Range
Normal Heart Rate
Newborn
0-3 months
80-205 per minute
Infant/Young child

4 months to 2 years

75-190 per minute

Child/School Age

2-10 years

60-140 per minute

Older child/ Adolescent

Over 10 years

50-100 per minute

Age Category

Age Range
1 Day
4 Days
To 1 month

Systolic Blood
Pressure
60-76
67-84
73-94

Diastolic Blood
Pressure
30-45
35-53
36-56

Abnormally Low
Systolic Pressure
<60
<60
<70

Neonate
Neonate
Infant
Infant

1-3 months

78-103

44-65

<70

Infant

4-6 months

82-105

46-68

<70

Infant

7-12 months

67-104

20-60

PreSchool

2-6 years

70-106

25-65

School Age

7-14 years

79-115

38-78

Adolescent

15-18 years

93-131

45-85

<70 + (age in years x


2)
<70 + (age in years x
2)
<70 + (age in years x
2)
<90

2. Consider possible causes but do not delay treatment

Vagal Maneuvers

Synchronized Cardioversion

Medications

Support Airway, Breathing, Circulation

3. Is the QRS Complex narrow (0.09 sec) or wide (>0.09 sec)?


Narrow QRS Complex
Determine rhythm

Sinus tachycardia Determine cause and treat

Supraventricular tachycardia

Consider vagal maneuvers

Consider adenosine 0.1 mg/kg rapid IV up to 6 mg in first dose

May repeat adenosine at 0.2 mg/kg up to 12 mg in second dose

Consider amiodarone or procainamide

Consider cardioversion at 0.5 to 1 Joule/kg

Second cardioversion dose at 2 Joules/kg

Wide QRS Complex


4. Is the child compromised?
Unstable Provide immediate synchronized cardioversion
QRS narrow and regular

Cardioversion Rules
50-100 Joules

QRS narrow and irregular

120-200 Joules

QRS wide and regular

100 Joules

QRS wide and irregular

Turn off the synchronized mode and defibrillate


immediately

Stable

Consider adenosine 0.1 mg/kg rapid IV up to 6 mg in first dose

May repeat adenosine at 0.2 mg/kg up to 12 mg in second dose

Consider amiodarone (5 mg/kg IV over 20 to 60 minutes) OR procainamide (15 mg/kg


IV over 30 to 60 minutes)

Consult pediatric cardiologist

PALS NARROW QRS TACHYCARDIA ADEQUATE PERFUSION ALGORITHM


1. Tachycardia is diagnosed by manual testing or heart rate monitor and the child
has adequate perfusion Normal heart rates vary with age/size.

Age Category

Age Range

Normal Heart Rate

Newborn

0-3 months

80-205 per minute

Infant/Young child
Child/School Age
Older child/ Adolescent

4 months to 2 years
2-10 years
Over 10 years

75-190 per minute


60-140 per minute
50-100 per minute

1 Day
4 Days
To 1 month
1-3 months
4-6 months

Systolic Blood
Pressure
60-76
67-84
73-94
78-103
82-105

Diastolic Blood
Pressure
30-45
35-53
36-56
44-65
46-68

Infant

7-12 months

67-104

20-60

PreSchool

2-6 years

70-106

25-65

School Age

7-14 years

79-115

38-78

Adolescent

15-18 years

93-131

45-85

Age Category

Age Range

Neonate
Neonate
Infant
Infant
Infant

Abnormally Low
Systolic Pressure
<60
<60
<70
<70
<70
<70 + (age in years
x 2)
<70 + (age in years
x 2)
<70 + (age in years
x 2)
<90

2. Consider possible causes but do not delay treatment


Vagal Maneuvers
Synchronized Cardioversion
Medications
Support Airway, Breathing, Circulation
Determine rhythm
Sinus tachycardia Determine cause and treat
Supraventricular tachycardia

Consider vagal maneuvers

Consider adenosine 0.1 mg/kg rapid IV up to 6 mg in first dose

May repeat adenosine at 0.2 mg/kg up to 12 mg in 2nd dose

Consider amiodarone or procainamide

Consider cardioversion at 0.5 to 1 Joule/kg

Second cardioversion dose at 2 Joules/kg

Consult pediatric cardiologist

Continue to search for treatable causes of tachycardia and treat promptly

PALS WIDE QRS TACHYCARDIA ADEQUATE PERFUSION ALGORITHM

1. Tachycardia is diagnosed by manual testing or heart rate monitor and the child has adequate
perfusion Normal heart rates vary with age/size.
Age Category
Newborn
Infant/Young child
Child/School Age
Older child/ Adolescent

Age Range
0-3 months
4 months to 2 years
2-10 years
Over 10 years

Normal Heart Rate


80-205 per minute
75-190 per minute
60-140 per minute
50-100 per minute

1 Day
4 Days
To 1 month
1-3 months
4-6 months

Systolic Blood
Pressure
60-76
67-84
73-94
78-103
82-105

Diastolic Blood
Pressure
30-45
35-53
36-56
44-65
46-68

Infant

7-12 months

67-104

20-60

PreSchool

2-6 years

70-106

25-65

School Age

7-14 years

79-115

38-78

Adolescent

15-18 years

93-131

45-85

Age Category

Age Range

Neonate
Neonate
Infant
Infant
Infant

2. Consider possible causes but do not delay treatment


Vagal Maneuvers
Synchronized Cardioversion
Medications
Support Airway, Breathing, Circulation

Determine rhythm

Abnormally Low
Systolic Pressure
<60
<60
<70
<70
<70
<70 + (age in years
x 2)
<70 + (age in years
x 2)
<70 + (age in years
x 2)
<90

Possible SVT with QRS aberrancy Follow PALS Narrow QRS Tachycardia Adequate
Perfusion Algorithm and use the supraventricular rhythm pathway. Continue to reassess
vitals, cardiovascular status, and tissue perfusion. Be prepared to treat for ventricular
tachycardia/ventricular fibrillation.

Ventricular tachycardia (may deteriorate to ventricular fibrillation or unstable or pulseless


ventricular tachycardia!)

Consider amiodarone (5 mg/kg IV over 20 to 60 minutes) OR procainamide (15


mg/kg IV over 30 to 60 minutes)
Consider adenosine 0.1 mg/kg rapid IV up to 6 mg in first dose
May repeat adenosine at 0.2 mg/kg up to 12 mg in 2nd dose
Consider cardioversion at 0.5 to 1 Joule/kg
Second cardioversion dose at 2 Joules/kg
Consult pediatric cardiologist
Search for and treat reversible causes