PALS Sequence Algorithm

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1. When evaluating the child’s level of consciousness, breathing and color, note:
 Level of consciousness – Is the child awake and alert, irritable and crying or unresponsive?
 Breathing – Is the child’s respiratory pattern normal for his age, diminished or absent, or extremely labored?
 Color – Is the child’s 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)

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PALS Cardiac Arrest Algorithm

3
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

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PALS Post Arrest Shock Management Algorithm

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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 H’s and the T’s:

 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 child’s 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 36°C to 37.5°C OR

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

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PALS Bradycardia Algorithm

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1. Bradycardia is diagnosed by manual testing or heart rate monitor – Normal heart rates change with age/size.
Age Age Range Normal Heart
Category Rate
Newborn 0-3 months 80-205 per minute
Infant/Young 4 months to 2 75-190 per minute
child years
Child/School 2-10 years 60-140 per minute
Age
Older child/ Over 10 years 50-100 per minute
Adolescent
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?

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PALS Tachycardia Initial Management Algorithm

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1. Tachycardia is diagnosed by manual testing or heart rate monitor– Normal heart rates vary with age/size.
Age Category Age Range Normal Heart
Rate
Newborn 0-3 months 80-205 per minute
Infant/Young 4 months to 2 75-190 per minute
child years
Child/School 2-10 years 60-140 per minute
Age
Older child/ Over 10 years 50-100 per minute
Adolescent
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
For synchronized cardioversion, begin with an electrical dose of 0.5 to 1 J/kg of the child’s body weight. If ineffective, increase the energy level to 2 J/kg. For
defibrillation (cardiac arrest with a shockable rhythm), first shock should be given at 2 J/kg and the second shock should be given at 4 J/kg. Subsequent shocks
may be higher, up to the adult maximum of 10 J/kg body weight.

Stable child – continue assessment

Systolic Abnormally Low

Age Age Diastolic Blood
Blood
Category Range Pressure
Pressure Systolic Pressure
Neonate 1 Day 60-76 30-45 <60
Neonate 4 Days 67-84 35-53 <60
To 1
Infant 73-94 36-56 <70
month
Infant 1-3 months 78-103 44-65 <70
Infant 4-6 months 82-105 46-68 <70
7-12 <70 + (age in years
Infant 67-104 20-60
months x 2)
<70 + (age in years
PreSchool 2-6 years 70-106 25-65
x 2)
10
 <70 + (age in years
School Age 7-14 years 79-115 38-78
x 2)
15-18
Adolescent 93-131 45-85 <90
years

4. Assess the child’s 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 child’s 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

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PALS Tachycardia Poor Perfusion Algorithm

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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/ Over 10 years 50-100 per minute
Adolescent
Systolic
Age Age Diastolic Blood Abnormally Low
Blood
Category Range Pressure Systolic Pressure
Pressure
Neonate 1 Day 60-76 30-45 <60
Neonate 4 Days 67-84 35-53 <60
To 1
Infant 73-94 36-56 <70
month
Infant 1-3 months 78-103 44-65 <70
Infant 4-6 months 82-105 46-68 <70
7-12 <70 + (age in years
Infant 67-104 20-60
months x 2)
<70 + (age in years
PreSchool 2-6 years 70-106 25-65
x 2)
<70 + (age in years
School Age 7-14 years 79-115 38-78
x 2)
15-18
Adolescent 93-131 45-85 <90
years

2. Consider possible causes but do not delay treatment

 Vagal Maneuvers
 Synchronized Cardioversion
 Medications
 Support Airway, Breathing, Circulation

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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
o Consider vagal maneuvers
o Consider adenosine 0.1 mg/kg rapid IV up to 6 mg in first dose
o May repeat adenosine at 0.2 mg/kg up to 12 mg in second dose
o Consider amiodarone or procainamide
o Consider cardioversion at 0.5 to 1 Joule/kg
o Second cardioversion dose at 2 Joules/kg

Wide QRS Complex

4. Is the child compromised?

Unstable – Provide immediate synchronized cardioversion

Cardioversion Rules
QRS narrow and regular 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

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PALS Narrow QRS Tachycardia Adequate Perfusion Algorithm

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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 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

Systolic
Diastolic Blood Abnormally Low
Age Category Age Range Blood
Pressure Systolic Pressure
Pressure
Neonate 1 Day 60-76 30-45 <60
Neonate 4 Days 67-84 35-53 <60
Infant To 1 month 73-94 36-56 <70
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 <70 + (age in years x 2)

PreSchool 2-6 years 70-106 25-65 <70 + (age in years x 2)

School Age 7-14 years 79-115 38-78 <70 + (age in years x 2)

Adolescent 15-18 years 93-131 45-85 <90

2. Consider possible causes but do not delay treatment

 Vagal Maneuvers
 Synchronized Cardioversion
 Medications
 Support Airway, Breathing, Circulation

Determine rhythm
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 Sinus tachycardia – Determine cause and treat
 Supraventricular tachycardia
o Consider vagal maneuvers
o Consider adenosine 0.1 mg/kg rapid IV up to 6 mg in first dose
o May repeat adenosine at 0.2 mg/kg up to 12 mg in 2nd dose
o Consider amiodarone or procainamide
o Consider cardioversion at 0.5 to 1 Joule/kg
o Second cardioversion dose at 2 Joules/kg
o Consult pediatric cardiologist
o Continue to search for treatable causes of tachycardia and treat promptly

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PALS Wide QRS Tachycardia Adequate Perfusion Algorithm

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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 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

Systolic Blood Diastolic Blood Abnormally Low Systolic

Age Category Age Range
Pressure Pressure Pressure
Neonate 1 Day 60-76 30-45 <60
Neonate 4 Days 67-84 35-53 <60
Infant To 1 month 73-94 36-56 <70

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 <70 + (age in years x 2)

PreSchool 2-6 years 70-106 25-65 <70 + (age in years x 2)

School Age 7-14 years 79-115 38-78 <70 + (age in years x 2)

Adolescent 15-18 years 93-131 45-85 <90

2. Consider possible causes but do not delay treatment

 Vagal Maneuvers
 Synchronized Cardioversion
 Medications
 Support Airway, Breathing, Circulation

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Determine rhythm

 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!)
o Consider amiodarone (5 mg/kg IV over 20 to 60 minutes) OR procainamide (15 mg/kg IV over 30 to 60 minutes)
o Consider adenosine 0.1 mg/kg rapid IV up to 6 mg in first dose
o May repeat adenosine at 0.2 mg/kg up to 12 mg in 2nd dose
o Consider cardioversion at 0.5 to 1 Joule/kg
o Second cardioversion dose at 2 Joules/kg
o Consult pediatric cardiologist
o Search for and treat reversible causes

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