Pediatric Advance Life Support (PALS)

PALS Systematic Approach EVALUATE

COMPONENTS: -Initial Assessment
-Primary Assessment
1. Initial Assessment
-Secondary Assessment
2. Primary Assessment
3. Secondary Assessment
4. Diagnostic Test Intervene Identify

I. Initial Assessment (ABC)

 A-Appearance (level of consciousness and ability to interact)
 B-Breathing
- work of breathing
- Precision
- Audible breath sounds(stridor, grunting, and wheezes)
- Signs of absent or increase of respiratory effort
 C-Circulation (color)
- Look for pallor/paleness/motling
- Cyanosis in the lips or fingernails
- Flushing
- Petechial
Unconcious Patient=BLS Assessment
II. Primary Assessment (ABCDE)
 A-Airway (Open, Maintain & Protect)
- ensure that the airway is opened, maintained, and protected
 B-Breathing (Rate, Pattern, O2 Saturation, Effort, Lung Sounds)
- Review the breathing rate. Is it normal? Fast? Slow? Look at the breathing pattern.
- Review oxygen saturation, and if the saturation is below 94%, start oxygen
- Check the respiratory effort and listen to the lungs and airway sounds .
 C-Circulation (HR, BP, Cap Refill, Central/Peripheral Pulses)
- Evaluate the heart rate and rhythm, blood pressure, capillary refill, which should be below 2
seconds.
- Also, the central and peripheral pulses. Weak central pulses are worrisome and might indicate the
need for rapid intervention to prevent cardiac arrest.
Definition of Hypotension by Systolic Blood Pressure and Age

AGE SYTOLIC BP
Neonate (0-28 days) <60mmHg
Infants (1-12 months) <70mmHg
Children (1-10 years old) ( Age in years X 2 ) + 70
Children (>10 years old) 90mmHg
-Based on the fifth percentile
  D-Disability (AVPU/ GCS, Pupils, Blood Glucose)
- perform a disability assessment to quickly evaluate neurological function
- Perform the evaluation towards the end of the primary assessment and repeat it during the
secondary assessment to monitor for changes in the child's neurological status.
Tools Used to Assess:
a. AVPU (A-Alert, V-Voice, P-Pain, U-Unresponsive)
b. Glasgow Coma Scale (GCS)
- For preverbal or nonverbal children
c. PERRL (P-Pupil, E-Equal, R-Round, R-Reactive, L-Light)
d. Blood Glucose
Definition of Hypoglycemia in Children
i. Newborn: if BG is 50mm/dL or 2.2millimole/L or less
ii. Children: If BG is 60mm/dL or 3.2 millimole/L and below

 E-Exposure (Temperature & Rashes)

RESPIRATORY OR SHOCK OR BOTH?

 RESPIRATORY- Distress or Failure
 Respiratory Classification:
 Upper Airway Obstruction (e.g: foreign body aspiration, anaphylaxis, and croup)
 Lower Airway Obstruction (e.g: asthma or bronchiolitis)
 Lung Tissue Disease (e.g: involves parenchyma or lung tissue cells)
 Disordered Control of breathing (e.g: seizures, central nervous system infection, head injuries)
 SHOCK- Compensated or Hypotensive
- Shock does not require the presence of hypertension, it can be present with normal, increased,
or decreased systolic blood pressure.
 Type of SHOCK:
 Hypovolemic shock: caused by reduced intravascular volume due to things like diarrhea,
vomiting, and bleeding
 Distributive Shock: clinical state characterized by reduced SVR leading to maldistributive
distribution of blood volume and blood flow
 Obstructive Shock: a condition that physically impairs blood flow by limiting venous return
to the heart or limit the pumping of blood from the heart, resulting in decreased cardiac
output.(e,g: pericardial tamponade, tension pneumophorex, massive pulmonary embolism,
and ductal-dependent heart defects)
 Cardiogenic Shock: reduce cardiac output, secondary to abnormal cardiac function or pump
failure, resulting in decreased systolic function and cardiac output. (e.g: congenital heart
disease, myocarditis, arrhythmias, and cardiomyopathy)
 III. Secondary Assessment
Focused Physical Exam
S-Signs and Symptoms
A- Allergies  Repeat vital signs
M- Medications  HEENT(head, ears, eyes, nose, throat)
P- Past Medical History  Chest: Heart & Lungs
L- Last Meal  Abdomen
E- Events leading to an injury or illness
 Back
 Extremities
IV. Diagnostic Assessment  Neurologic Function
 Arterial Blood Gas (ABG)
 Venous Blood Gas (VBG)
 Capillary Blood Gas  Chest x-ray
 Hemoglobin Concentration  ECG
 Central Venous O2 Saturation  Echocardiogram
 Arterial Lactate  Point of Care Ultrasound Sonography
 Peak Expiratory Flow rate (PEFR)
 Central Venous Pressure Monitoring
 Invasive Arterial Pressure Monitoring

PALS Cardiac Arrest Algorithm (VF & pVT)

 In contrast to adult cardiac arrest, cardiac arrest in infants and children usually results from
progressive respiratory failure or shock rather than a primary cardiac cause
 The hypoxic or asphyxia arrest occurs most often in infants and young children especially those
with underlying disease.
 Sudden cardiac arrest from ventricular arrhythmia occurs in about 5 to 15 percent of all pediatric
hospital and out of hospital cardiac arrest
 shockable rhythm like ventricular fibrillation or pulseless ventricular takicari is the presenting
rhythm in only about 14 percent of pediatric cardiac arrest cases it is present in about 27 of
such arrests at some point during the resuscitation

BLS Assessment
 Check for Response (hey! Hey! Hey! Are you ok!)
 Check Breathing/ pulse (5-10 seconds)
 Activate Code Blue/ Call EMS
 Defibrillation
Focus: High Quality CPR and Defibrillation

ASSESS FOR VF/Pulseless VT

1st Shock
 1x2J/kg
 Then resume high-quality CPR(100-120 pushes/min)
 IV/IO access
 Prepare Meds
  High Quality CPR
Persistent VF/Pulseless VT
2nd Shock
 1x4J/kg
 Immediately start with high quality chest compressions
 Give EPINEPHRINE 0.01mg/kg IV (0.1mL/kg of 0.1mg/mL)(Push every 3-5 minutes)
 Consider Advanced Airway
 Waveform Capnography
 Prepare Meds
Persistent VF/Pulseless VT
3rd Shock
 1 x ≥4J/kg
 Maximum 10J/kg or Adult Dose
 Resume high quality CPR
 Prepare next medication either:
-Amioddarone (5mg/kg IV push) or Lidocaine (1mg/kg IV push)

We must consider our Reversible Cause: 5H’s and 5T’s

5 H’s 5 T’s

 Hypoxia  Tension Pneumothorax

 Hydrogen ion (Acidosis)  Thrombosis (Pulmonary)
 Hypothermia  Thrombosis (Coronary)
 Hypokalemia/Hyperkalemia  Tamponade (Cardiac)
 Hypovolemia  Tablets

 Prepare Meds
 High Quality CPR

Persistent VF/Pulseless VT
4th Shock
 1 x ≥4J/kg
 Maximum 10J/kg or Adult Dose
 Resume High-Quality compression again
 Give the next medication the Epinephrine (0.01mg/kg IV), push every 3-5 minutes.
 Prepare next medication
 Then always monitor high-quality CPR
 STOP, switch and analyse

Persistent VF/Pulseless VT
5th Shock
 1 x ≥4J/kg
 Maximum 10J/kg or Adult Dose
 Resume High quality CPR
 Give medications (Amiodarone and Lidocaine)

4 minutes interval between Epinephrine

 4 minutes interval between Amiodarone
PALS Cardiac Arrest Algorithm (A-systole & PEA)
 It is important to identify and treat respiratory distress respiratory failure and shock before
progression to cardiopulmonary failure and cardiac arrest.

As always we start with:

BLS Assessment
 Check for Response (hey! Hey! Hey! Are you ok!)
 Check Breathing/ pulse (5-10 seconds)
 Activate Code Blue/ Call EMS
 Defibrillation
Focus: High Quality CPR
 Once the crash car comes immediately connect the monitor because we want to
hunt for vf or pulseless vt.
 This time we found A-systole, continue CPR.
 Consider flat line protocol to ensure that it is a true A-systole
 Ensure that the device is set up appropriately, check if the leads and pads are
selected and properly attached.
 Then immediately continue with High-quality CPR. (Rate of 100-120 pushes/min)
 Keep in mind during: Single Rescue CPR: Compression to Ventilation ratio should be
30:2, for two or more rescuers its 15:2.
 Get an IV/IO Access (if none, Endotracheo ot ET route is a 3rd option)
 Prepare Medications(Epinephrine 0.01mg/kg IV, push every 3-5 minutes)
 Monitor high-quality CPR
 Consider Advanced Airway
 Waveform Capnography(helps to monitor tube placement and quality of CPR)
After 2 minutes of High-Quality CPR, Stop, switch, and analyse!
Remember the 5H’s and 5T’s

 Prepare Meds
 Monitor High-quality CPR

PALS Bradycardia Algorithm

 The pediatric bradycardia with a pulse algorithm outlines the steps for evaluating and
managing the child who presents with symptomatic bradycardia
 Once you identify bradycardia assess for signs of cardiopulmonary compromise.

If there is NO signs of Cardiopulmonary Compromise:

 Support ABC’s as needed

 Consider Oxygen
 Observe and perform frequent reassessments
 Obtain a 12-lead ECG
 Identify and treat underlying causes
If THERE ARE signs of Cardiopulmonary Compromise such as:

 Acutely altered mental status?

 Signs of shock?
 Hypotension?

Assessment and Support (ABCs)

A: Open, Maintain & Protect Airway
B: Assist Breathing with PPV and O2 prn
B: Monitor oximetry
C: Cardiac Monitor to identify the rhythm
C: Monitor pulse
C: Monitor BP
“START CPR if HR <60bpm despite good Oxygenation and Ventilation”

Get IV/IO access (Entertracheal or ET route as 3rd option)

Prepare Meds
- Epinephrine: indicated for symptomatic bradycardia that persists despite effective
oxygenation and ventilation.(0.01mg/kg IV, push for 3-5min; ET: 0.1mg/kg)
- Atropine: an anticholinergic drug, accelerates sinus or atrial pacemakers and
enhances AV conduction.(0.02mg/kg IV; ET: 0.04 to 0.06mg/kg) may repeat once,
in 5 minutes.
Monitor High-Quality CPR
Consider Transthoracic Pacing or Consider Transvenous Pacing
- As mentioned in the previous slide atropine and pacing are preferred over
epinephrine as the first choice treatment of symptomatic AV blocks due to primary
bradycardia.
- Temporary trans-thoracic or transvenous spacing may be life-saving in selected
cases of bradycardia caused by complete heart blocks or abnormal sinus node
function.
- For example pacing is indicated for AV block after surgical correction of congenital
heart disease.
Reversible Causes:
- Two most common potentially reversible causes of bradycardia are hypoxia and
increase vagal tone.
- Also consider hypothermia and medications.

“Be aware that after Heart Transplantation the patient might not respond to medication like
atropine and early pacing may be indicated in these situations”
PALS Bradycardia Algorithm
 The pediatric tachycardia algorithm outlines the steps for evaluating and managing the
child who presents with tachycardia.

Initial Assessment and Support

Initial Assessment and Support
 Open, Maintain & Protect Airway
 Assist Breathing as necessary
 Monitor oximetry
 Cardiac monitor to identify the
rhythm
 Monitor pulse
 Monitor BP
 12-lead ECG if available
Probable Sinus Tachycardia if:
 P waves present/normal
 Variable RR interval Evaluate rhythm with 12-Lead ECG or
 Infant rate usually <220/min monitor.
 Child rate usually <180/min

Cardiopulmonary Compromise
Search for and  Acutely altered mental status
treat cause  Signs of shock
 Hypotension
Narrow Complex Tachycardia
Unstable Stable
NARROW
(≤ 0.09 sec)
Probable Supraventricular Tachycardia Probable Supraventricular Tachycardia

 P waves absent/abnormal  P waves absent/abnormal

 RR interval not variable  RR interval not variable
 Infant rate usually ≥220/min  Infant rate usually ≥220/min
 Child rate Usually ≥180/min  Child rate Usually ≥180/min
 Hx of abrupt rate change  Hx of abrupt rate change

Probable Supraventricular Tachycardia Consider Vagal Maneuvers

 If IV/IO access is present, give

Adenosine.
 If IV/IO access is not available, or if If IV/IO access is present, give Adenosine
Adenosine is ineffective, perform
Synchronize Cardioversion
 the easiest technique to use in both infants and children is to put eyes to the face apply
a small plastic bag filled with ice and water to the upper half of the face for about 15
to 20 seconds.
Do not occlude the nose and the mouth.
older children that is old enough to follow instructions can perform the valsava
maneuver by blowing through a narrow straw it is important to never use ocular pressure
as it may produce retinal injury.
It is important to monitor and record the ECG continuously before during and after
attempted vagal maneuvers.
If vagal stimulation was not successful and an IV/IO is present give adenosine is the drug
of choice for most common forms of SVT caused by a re-entrant pathway involving the
AV node.
Using a length based resuscitation tape is helpful to get the correct dose for
medications and joule settings based on weight.

Wide Complex Tachycardia

 If the qrs is greater than 0.09 seconds treat it as a possible ventricular tachycardia or VT.
 If the patient is stable and the rhythm is irregular and qrs is monomorphic consider
adenosine.
 Avoid adenosine if the rhythm is irregular as this may result in an unstable rhythm.

Unstable Stable
WIDE
(> 0.09sec)
Possible Ventricular Tachycardia Possible Ventricular Tachycardia

Synchronized Cardioversion If the rhythm is Regular and

QRS Monomorphic,
Expert consultation is advised
consider Adenosine
before additional drug therapies

Expert consultation is
recommended
Consider Medications:
- AMIODARONE (5mg/kg, over 20-60 minutes)
- PROCAINAMIDE (15mg/kg, over 30-60 minutes)
- DO NOT routinely administer Amiodarone and Procainamide together or with other
medications that prolong the QT interval.
- If these initial efforts do not terminate the rapid rhythm re-evaluate the rhythm if not
already administered consider adenosine
*Final Steps and Conclusion
- Re-evaluate rhythm if initial efforts do not terminate rapid rhythm.
- Perform immediate synchronized cardioversion for unstable VT.
- Seek expert consultation as needed.
- Encourage viewers to like, subscribe, and stay tuned for future videos.
 WHAT IS PEDIATRIC DEFIBRILLATION, CARDIOVERSION AND PACING?

Pediatric Defibrillation, Cardioversion, and Pacing

- Highlights the importance of familiarity with defibrillators and crash carts in medical emergencies.
A. Defibrillation
- Defibrillation is the delivery of an electrical shock to depolarize the myocardium.
- Indicated for lethal arrhythmias like ventricular fibrillation (VF) and pulseless ventricular tachycardia
(VT).
*Chance will diminish 7-10 % per min delayed
- American Heart Association recommends specific joule settings for pediatric defibrillation based on
weight.
1st Shock 2J/Kg
2nd Shock 4J/Kg
3rd Shock ≥ 4J/Kg
*not to exceed 10 J/Kg ( Adult dose)
*Crash cart- one of the first items that will grab and bring to the patient's bedside
Defibrillation
 Multi-function pads are commonly used for quick and safe shock delivery without ECG leads.
*anterior-posterior (smaller children)
-the one pad is positioned anteriorly low chest in front of the heart while the second pad is
placed posteriorly behind the heart in between the scapula
*anterior- apex
-one pad is placed below the clavicle while the other is placed on the left side of the chest
below the pectoral muscle
 Defibrillation Paddles
- Ordered as an additional accessory if required
*When patient’s chest is open →internal paddles

 attach the pads as per the pads diagram

(ex: our patient is weighing 25 kilogram we selecting 50 joules)
 press the charge button
 make sure no one is touching the patient
 immediately deliver the shock
 start with high quality chest compressions pushing hard pushing fast at the rate of 100 - 220
pushes per minute
*After every shock = immediate high quality CPR

Other consideration:
 Pre-charge the device 15 sec before the end of each 2-min cycle
 Check for a pulse as placeholder 15 sec before
 Prepare to deliver a shock in 10 seconds or less at two minutes
 Hover over the chest for CPR
A. Cardioversion
-deliver a shock on top of the peak of the R wave or actually a few milliseconds before the peak of
the r wave
*We do not want to shock on the t wave as it can convert the rhythm into ventricular fibrillation
- mostly used on unstable tachyarrhythmias where the patient has a pulse
- Common pediatric rhythms for cardioversion include supraventricular tachycardia (SVT) and stable
ventricular tachycardia.
-less common in pediatrics unless the child has a history of congenital heart disease is atrial fibrillation
and atrial flutter
 Stable patient: has no serious signs or symptoms and has a normal blood pressure → medications
 Unstable patient: → synchronized cardioversion
*synchronized cardioversion can also be used on stable patients if the medication options did not
convert the rhythm
- Joule settings for synchronized cardioversion follow AHA guidelines and are based on the child's
weight.
1. 0.5 J/Kg – ½ half the child’s weight
2. 1J/Kg – the child’s weight
3. 2 J/kg – 2x the child’s weight
- Sedation may be considered, and expert consultation is advised for unstable patients.

Transcutaneous Pacing (TCP)

- TCP delivers electrical energy to stimulate cardiac contraction
-primarily used for bradycardia due to complete heart block or abnormal sinus node function.
*TCP is only a temporary measure until a more permanent solution is available
- Anterior-posterior pad placement is recommended.
- Activation and adjustment of pacing parameters are done while monitoring ECG for pacing spikes
and capture.

EKG/ECG INTERPRETATION

BLOOD FLOW
 Blood flow in the heart starts on the right side.
 Oxygen-depleted blood enters the right atrium and is pumped through the tricuspid valve into
the right ventricle.
 The right ventricle contracts and sends blood through the pulmonic valve into the pulmonary
artery for oxygenation in the lungs.
 Oxygenated blood returns to the left side of the heart through the pulmonary vein.
 The left atrium contracts and sends blood through the mitral valve into the left ventricle.
 The left ventricle contracts and sends blood through the aortic valve into the aorta for
distribution to the body.
 The electrical conduction system stimulates heart contractions by causing depolarization and
repolarization of heart cells.
 Depolarization leads to contraction, while repolarization leads to relaxation of the heart cells.
 Understanding depolarization and repolarization is crucial for interpreting EKGs.
 Depolarization is linked to contraction, and repolarization is linked to relaxation in the heart.

SA NODE
 SA node stands for sinoatrial node in the right atrium
  Known as the pacemaker of the heart, controlling heart rate (60-100 beats per minute)
 Responsible for atrial contraction through atrial depolarization
 Electrical signals travel from SA node through internal pathways to left atrium
 Signal passes through Bachmann's bundle to reach AV node
 AV node stands for atrioventricular node and acts as a gatekeeper
 AV node delays impulses slightly to allow atria to empty before ventricles contract
 Prevents leftover blood in atria before ventricles contract to avoid issues
 Signal then travels to bundle of His for further transmission
VENTRICLE DEPOLARIZATION
 Ventricle depolarization leads to ventricular contraction
 Electrical conduction system includes SA node, bundle of His, bundle branches, and Purkinje
fibers
 SA node to Purkinje fibers forms the PQRST complex on EKG
 Normal sinus rhythm shows all parts measuring and forming perfectly
 Issues in the system can lead to dysrhythmias like atrial flutter, atrial fibrillation, and VTAC
 Animation shows SA node firing, atrial depolarization, AV node activation, ventricular
depolarization, and contraction
 EKG strip paper contains small boxes representing time measurements
 Each small square represents 0.04 seconds, large square contains five small squares (0.20
seconds)
 Analyzing EKG involves measuring parts of the PQRST complex in small squares

P Waves
 3Rs
Regularity
Rate (60-100 bpm)
Resemblance (< 3 squares)
 The P wave and PR segment is an integral part of an electrocardiogram (ECG). It represents
the electrical depolarization of the atria of the heart. It is typically a small positive deflection
from the isoelectric baseline that occurs just before the QRS complex.
T waves
 T waves are characteristically upright and reflect ventricular repolarisation.
QRS COMPLEX
 The QRS complex is the main spike seen in the standard ECG. It is the most obvious part of
the ECG, which is clearly visible.
  The QRS complex represents the depolarization of ventricles. It shows the beginning of
systole and ventricular contraction.
Q-wave
Q wave represents the depolarization of the interventricular septum. It is represented as a
small downward deflection. The P-wave is immediately followed by a Q-wave. Abnormality in
Q-wave indicates the presence of infraction.
R-wave
The Q is followed by R-wave. This wave follows as an upward deflection. The R is then followed
by an S-wave. Large amplitudes of R and S wave indicates left ventricular hypertrophy.
S-wave
R wave is followed by a deflection downwards, represented by S. The point where the QRS
complex joins the ST segment is called the J-point. The J-point can also be defined as the first
point of inflection of the upstroke of the S-wave.
HOW TO READ AN ECG INTERPRETATION
Confirm details
Before beginning ECG interpretation, you should check the following details:
 Confirm the name and date of birth of the patient matches the details on the ECG.
 Check the date and time that the ECG was performed.
 Check the calibration of the ECG (usually 25mm/s and 10mm/1mV).
Heart rate
What is a normal adult heart rate?
Normal: 60-100 bpm
Tachycardia: > 100 bpm
Bradycardia: < 60 bpm

Regular heart rhythm

If a patient has a regular heart rhythm, their heart rate can be calculated using the following
method:

 Count the number of large squares present within one R-R interval.
 Divide 300 by this number to calculate heart rate.
Irregular heart rhythm
If a patient’s heart rhythm is irregular, the first heart rate calculation method doesn’t work (as the
R-R interval differs significantly throughout the ECG). As a result, you need to apply a different
method:
 Count the number of complexes on the rhythm strip (each rhythm strip is typically 10
seconds long).
 Multiply the number of complexes by 6 (giving you the average number of complexes in 1
minute).
Heart rhythm
A patient’s heart rhythm can be regular or irregular.
Irregular rhythms can be either:
*Regularly irregular (i.e. a recurrent pattern of irregularity)
*Irregularly irregular (i.e. completely disorganised)
Mark out several consecutive R-R intervals on a piece of paper, then move them along the rhythm
strip to check if the subsequent intervals are similar.

Cardiac Axis
- Cardiac axis denotes the direction of electrical spread in the heart and is typically from 11 o'clock
to 5 o'clock in a healthy individual.
- Leads I, II, and III are pivotal in determining the cardiac axis.
- Right axis deviation and left axis deviation are discussed, along with associated EKG findings and
clinical implications.

P Waves
- P waves are scrutinized for presence, normalcy, and association with QRS complexes.
- Absence of P waves and irregular rhythms may suggest conditions like atrial fibrillation.
- Various morphologies of P waves indicate different atrial activities, including sawtooth patterns in
flutter and chaotic baseline in fibrillation.

PR Interval
- The PR interval should fall between 120-200 ms, with prolonged intervals indicating atrioventricular
delay, such as first-degree heart block.
- Second-degree heart blocks (type 1 and type 2) and third-degree heart block are discussed,
elucidating their distinctive EKG presentations.

 Tips for remembering types of heart block

To help remember the various types of AV block, it is useful to know the anatomical location of the
block within the conducting system.
First-degree AV block:
 Occurs between the SA node and the AV node (i.e. within the atrium).
Second-degree AV block:
 Mobitz I AV block (Wenckebach) occurs IN the AV node (this is the only piece of conductive
tissue in the heart which exhibits the ability to conduct at different speeds).
 Mobitz II AV block occurs AFTER the AV node in the bundle of His or Purkinje fibres.
Third-degree AV block:
 Occurs at or after the AV node resulting in a complete blockade of distal conduction
Shortened PR interval
If the PR interval is shortened, this can mean one of two things:
 Simply, the P wave originates from somewhere closer to the AV node, so the conduction takes
less time (the SA node is not in a fixed place, and some people’s atria are smaller than others).
 The atrial impulse is getting to the ventricle by a faster shortcut instead of conducting slowly
across the atrial wall. This accessory pathway can be associated with a delta wave

QRS Complex
- QRS complex characteristics, including width, height, and morphology, are crucial in EKG analysis.
- Broad QRS complexes are indicative of bundle branch blocks, with mnemonic aids provided for
identifying left bundle branch block (LBBB) and right bundle branch block (RBBB).
- Q waves, R waves, and S waves are examined for signs of myocardial infarction and ventricular
hypertrophy.
* The width can be described as NARROW (< 0.12 seconds) or BROAD (> 0.12 seconds)

* Height can be described as either SMALL or TALL

 DELTA WAVE
-The mythical ‘delta wave‘ indicates that the ventricles are being activated earlier than
normal from a point distant from the AV node. The early activation then spreads slowly across
the myocardium, causing the QRS complex’s slurred upstroke.

Q WAVES

 Isolated Q waves can be normal.

 A pathological Q wave is > 25% the size of the R wave that follows it or > 2mm in height and >
40ms in width.
 A single Q wave is not a cause for concern – look for Q waves in an entire territory

R AND S WAVES

 Assess the R wave progression across the chest leads (from small in V1 to large in V6).

 The transition from S > R wave to R > S wave should occur in V3 or V4.

J POINT SEGEMNT

The J point is where the S wave joins the ST segment.

This point can be elevated, resulting in the ST segment that follows it being raised (this is known as
“high take-off”).

High take-off (or benign early repolarisation) is a normal variant that causes a lot of angst and
confusion as it LOOKS like ST elevation.

Key points for assessing the J point segment:

 Benign early repolarisation occurs mostly under the age of 50 (over the age of 50, ischaemia is
more common and should be suspected first).

 Typically, the J point is raised with widespread ST elevation in multiple territories making
ischaemia less likely.

 The T waves are also raised (in contrast to a STEMI, where the T wave remains the same size
and the ST segment is raised).

 The ECG abnormalities do not change! During a STEMI, the changes will evolve – in benign
early repolarisation, they will remain the same.

ST Segment and T Waves

- The ST segment represents ventricular repolarization and should ideally be isoelectric.
- ST elevation and depression are analyzed for ischemic changes, with specific criteria outlined for
diagnosing myocardial infarction and ischemia.
- Tall T waves, inverted T waves, biphasic T waves, and U waves are explored in the context of various
cardiac and non-cardiac conditions.
U WAVES
 U waves are not a common finding.
 The U wave is a > 0.5mm deflection after the T wave best seen in V2 or V3.
 These become larger the slower the bradycardia – classically U waves are seen in various
electrolyte imbalances, hypothermia and secondary to antiarrhythmic therapy (such as
digoxin, procainamide or amiodarone).

EKG RHYTHMS

1. Normal Sinus Rhythm (NSR)

- Regular rhythm with a rate of 60-100 beats per minute (bpm).
- P wave preceding each QRS complex, QRS duration normal (0.06-0.10 seconds).
- PR interval within normal limits (0.12-0.20 seconds).

2. Sinus Bradycardia
- Regular rhythm with a rate less than 60 bpm.
- P wave preceding each QRS complex, QRS duration normal.
- PR interval within normal limits.

3. Sinus Tachycardia
- Regular rhythm with a rate greater than 100 bpm.
- P wave preceding each QRS complex, QRS duration normal.
- PR interval within normal limits.

4. Ventricular Fibrillation (VF)

- Chaotic, irregular rhythm with no identifiable waves.
- No effective cardiac output.
- Requires immediate defibrillation.

5. Ventricular Tachycardia (VT)

- Regular or irregular rhythm with a rate greater than 100 bpm.
- Absence of P waves, wide QRS complexes (>0.12 seconds).
- May be sustained (lasting >30 seconds) or nonsustained.

6. Pulseless Electrical Activity (PEA)

- Organized electrical activity without a palpable pulse.
- EKG may show various rhythms (e.g., NSR, bradycardia, tachycardia) but no effective cardiac
contraction.

7. Asystole
- Flatline, absence of electrical activity.
- No pulse, no cardiac output.
 - Requires immediate advanced cardiac life support (ACLS) measures.

8. Atrial Flutter
- Atrial rate typically 250-350 bpm, usually regular.
- Sawtooth appearance of flutter waves (F waves).
- Variable ventricular response depending on AV node conduction.

9. Atrial Fibrillation (AF)

- Irregularly irregular rhythm.
- Absence of distinct P waves, replaced by fibrillatory waves.
- QRS complexes usually normal unless there's conduction abnormality.

10. AV Heart Blocks (Type 1, 2, and 3):

- Type 1 (Wenckebach): Progressive lengthening of PR interval until a QRS complex is dropped.
- Type 2: Constant PR interval with occasional dropped QRS complexes (2:1, 3:1, etc.).
- Type 3 (Complete heart block): No association between P waves and QRS complexes, resulting in
atrial and ventricular rhythms dissociation. Requires immediate intervention.

References:
The Resuscitation Coach. (2021, October 8). Pediatric Advanced Life Support (PALS) Systematic approach

[Video]. YouTube. https://www.youtube.com/watch?v=28TCmtmWBZQ

The Resuscitation Coach. (2021b, October 15). PALS Cardiac Arrest Algorithm 2020 (VF & PVT) [Video].

YouTube. https://www.youtube.com/watch?v=sZoSPtGhpoU

The Resuscitation Coach. (2021c, October 22). Pediatric Advanced Life Support (PALS) Cardiac Arrest

Algorithm (A-Systole & PEA) [Video]. YouTube. https://www.youtube.com/watch?v=-cVacjs-D0w

The Resuscitation Coach. (2021d, October 29). Pediatric Advanced Life Support (PALS) BradyCardia

algorithm [Video]. YouTube. https://www.youtube.com/watch?v=6Vu6PC8fIuo

The Resuscitation Coach. (2021e, November 12). Pediatric Advanced Life Support (PALS) Tachycardia

algorithm [Video]. YouTube. https://www.youtube.com/watch?v=3vwM2XI6sgI

The Resuscitation Coach. (2022, May 7). What is pediatric defibrillation, cardioversion and pacing? [Video].

YouTube. https://www.youtube.com/watch?v=9rHG19S-qUc