2020 Interim Training Materials:

PALS Provider Manual Changes

Purpose
These instructions will help update the current Pediatric Advanced Life Support (PALS) Provider Manual with science
from the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency
Cardiovascular Care.

Provider Manual Changes

Print these materials and give to students to help them know where to change the information in their provider
manual:

1. Pediatric Chains of Survival

2020 Changes
• A new in-hospital cardiac arrest Chain of Survival for pediatrics was added, and it has the sixth link, for recovery.
• A sixth link, recovery, was also added to both of the out-of-hospital Chains of Survival (adult and pediatric).
− The process of recovery from cardiac arrest extends long after the initial hospitalization. Support is needed
during recovery to ensure optimal physical, cognitive, and emotional well-being and return to social and
role functioning. This process should be initiated during the initial hospitalization and continue for as long
as needed.
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• Video discussions

2. Infant Compressions
2020 Changes
• Single rescuer: use 2 fingers, 2 thumbs, or the heel of 1 hand for infants.

− For infants, single rescuers (whether lay rescuers or healthcare providers) should compress the sternum
with 2 fingers or 2 thumbs placed just below the nipple line.
− For infants, if the rescuer is unable to achieve guideline-recommended depths (at least one third the
diameter of the chest), it may be reasonable to use the heel of 1 hand.
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• Part 2: Review of BLS and AED for Infants and Children
− Section: Begin High-Quality CPR, Starting With Chest Compressions (skills checklist and video)
− Section: Chest Compression Technique
− Appendix: Infant CPR Skills Testing Checklist

3. Pediatric Assisted Ventilation Rates

2020 Change
• For infants and children with a pulse who are receiving rescue breathing or who are receiving CPR with an
advanced airway in place, provide 1 breath every 2 to 3 seconds (20-30 breaths per minute).

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• Part 1: Course Overview
− Airway Management Skills Station, videos
• Part 4: Recognition and Management of Cardiac Arrest
− Table 18: Summary of High-Quality CPR Components for BLS Providers
− Pediatric Cardiac Arrest Algorithm–2015 Update

4. Intubation
2020 Change
• It is reasonable to choose a cuffed endotracheal tube (ETT) over uncuffed ETT for intubating infants and
children. When a cuffed ETT is used, attention should be paid to ETT size, position, and cuff inflation pressure
(usually less than 20-25 cm H2O).
• Routine use of cricoid pressure is not recommended during endotracheal intubation of pediatric patients.
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• Part 4: Recognition and Management of Cardiac Arrest
− Table 18: Summary of High-Quality CPR Components for BLS Providers
− Recognition and Management of Cardiac Arrest, section: Insertion of an Advanced Airway During CPR

5. Pediatric Cardiac Arrest Algorithm

2020 Change
• Early epinephrine: modified to emphasize the role of early epinephrine for nonshockable rhythms after starting
CPR; it is reasonable to administer the initial dose of epinephrine within 5 minutes from the start of chest
compressions.

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• Part 2: Review of BLS and AED for Infants and Children
− PALS Pocket Reference Card
• Part 4: Recognition and Management of Cardiac Arrest
− Pediatric Cardiac Arrest Algorithm – 2015 Update, Step 9

6. Septic Shock Treatment

2020 Changes
• Administer fluid—10 mL/kg to 20 mL/kg aliquots—with frequent reassessment.
• It is reasonable to use either epinephrine or norepinephrine as an initial vasoactive infusion; if neither is
available, dopamine can be considered.
− If the patient is still unresponsive to fluids and requiring vasoactive support, it may be reasonable to
consider stress-dose corticosteroids.
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• Part 9: Management of Shock
− Section: Rate and Volume of Fluid Administration
− Pediatric Septic Shock Algorithm
− Management of Shock Flowchart
− PALS Pocket Reference Card
• Appendix
− Various case scenarios, videos
7. Hypoglycemia
2020 Change
• For children with suspected hypoglycemia who are awake but unwilling to swallow oral glucose, it may be
reasonable to apply a slurry of granulated sugar and water under the tongue.

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• Part 9: Management of Shock
− Section: Glucose, Management of Hypoglycemia

8. Additional PALS Updates

2020 Changes
• The Pediatric Cardiac Arrest Algorithm and the Pediatric Bradycardia With a Pulse Algorithm have been updated
to reflect the latest science.
• The single Pediatric Tachycardia With a Pulse Algorithm now covers both narrow-complex and wide-complex
tachycardias in pediatric patients.
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• PALS Pocket Reference Card
• Part 11: Management of Arrythmias