Pals Life Saver

PALSStudyGuide
TheAmericanHeartAssociationreleasednewresuscitationscienceandtreatmentguidelineson
October19,2010.
Pleasereadthebelowinformationcarefully
ThisletteristoconfirmyourregistrationintheAmericanHeartAssociationPediatricAdvanced
LifeSupport(PALS)course.
Pleaseplantobeontime.Allclassesstartat9:00amsharp.Ifyouaremorethan15minutes
late,youmaybeturnedawayasrequiredbytheAmericanHeartAssociation(AHA).Students
areexpectedtoattendandparticipateintheentirecourse.
BepreparedtopassthepediatricCPRwithAEDskillstest.Pleasenotethatwedonotrenew
yourBLScardbasedonthisCPRtest,whichisarequirementofthePALScourseitself.However
youcanhoweverpurchaseandcompletetheAHAOnlineeLearningBLSforHealthCare
ProviderProgramthroughourwebsitepriortothePALScourse.WewillverifyyourskillsinBLS
CPRandissueaPALSandBLSforHealthCareProvidercertificateattheendofthecourse.
AllPALSrenewal/recertification(1day)participantsMUSTbringtheircurrentAmericanHeart
AssociationissuedPALScardtoclass.Therearenoexceptionsforexpiredcards.Ifyouforget
yourcardyouwillbeabletoparticipateinthecoursebutwillnotbeissuedyourcarduntilyou
showproofofyourcurrentAHAPALSCard.Refundswillnotbegivenifyouattempttotakethe
PALSrenewal/recertificationcoursewithanexpiredcertification.
PALScertificationcardsandContinuingEducationUnits(CEUs)willbeissuedattheendof
class.
HOWTOGETREADY
ThePALSCourseisdesignedtoteachyouthelifesavingskillsrequiredtobebothateam
memberandateamleaderineitheraninhospitaloranoutofhospitalsetting.ThePALS
Coursecoversextensivematerialinashorttime,youwillneedtostudyandprepareforthe
coursebeforehand.
ThePALSCourseDOESNOTteachCPR,ECGrhythmidentification,pharmacology,orPALS
algorithms.
Thecourseformatrequiresallstudentstobefullypreparedpriortocomingtoclass.Ifyoudo
notreviewCPR,learnandunderstandECGsorthepharmacologyinformationinthePre
courseSelfAssessment,itisunlikelythatyoucansuccessfullycompletethePALSCourse.
www.lifesavercpr.net(209)4992249LifeSaverCPR@hotmail.com
PRECOURSEREQUIREMENTS
Youshouldprepareforthecoursebydoingthefollowing:
1. CompletetheprecoursepreparationchecklistthatcamewithyourPALSProvider
Manual.(ALLSTUDENTSMUSTHAVETHECURRENTAHAPALSMANUALPRIORTO
ATTENDINGCLASS)Bringthechecklistwithyoutothecourse.
2. ReviewthePALSCourseAgenda.
3. ReviewandunderstandtheinformationinyourPALSProviderManual.
4. TheresuscitationscenariosrequirethatyourBLSskillsandknowledgearecurrent.
ReviewandunderstandallBLS2010guidelines.YouwillbetestedonpediatricCPRand
AEDskillsatthebeginningofthePALSProviderCourse.Youmustknowthisinadvance,
sinceyouwillnotbetaughthowtodoCPRorhowtouseanAEDduringthecourse.
5. GototheAHAPALSWebsiteatwww.heart.org/eccstudentandenterthecode
PALSPROVIDER.(studentsareexpectedtoknowhowtoperformBLSCPR,useanAED,
readandinterpretECGs,andallPALSPharmacologypriortothecourse.YOUWILLNOT
BETAUGHTTHISINFORMATIONINCLASS)
6. PrintyourPALSPrecourseCompletionCertificatewithtestscoreandbringitwithyou
toclass.
7. TestyourknowledgeandrecognitionofECGrhythmsonthewebsite
http://www.skillstat.com/ECG_Sim_demo.html
8. Visitmydownloadpageatwww.lifesavercpr.net/downloadstoseeallofthePALS
CourseMaterialandSkillsCheckOffSheetsusedduringthecourse.
WHATTOBRINGANDWHATTOWEAR
BringyourPALSProviderManualtotheclass.Youwillneeditduringeachlessoninthecourse.
YoumaywishtopurchasetheAHAs2010HandbookofEmergencyCardiovascularCarefor
HealthcareProviders(optional),whichyoumaybringtothecoursetouseasareferenceguide
duringsomeofthestationsinthecourse.
Pleasewearloose,comfortableclothingtoclass.Youwillbepracticingskillsthatrequireyouto
workonyourhandsandknees,andthecourserequiresbending,standing,andlifting.Ifyou
haveanyphysicalconditionthatmightpreventyoufromengagingintheseactivities,pleasetell
aninstructor.Theinstructormaybeabletoadjusttheequipmentifyouhaveback,knee,orhip
problems.
RESCHEDULEPOLICY
Norefundswillbeissued.Allregistrationsarefinal.
Youmayrescheduleyourcoursebycallingusatleast7businessdayspriortoyourscheduled
coursedate.Youwillbechargedareschedulingfeeof$50.00
Weunderstandthatemergenciesdocomeup.Ifyouhavetocancellessthan7daysbefore
theclassyouwillbechargedareschedulingfeeof50%ofthecoursecost.
Ifyoucancelwithin24hoursordonotattendyourscheduledclass,youwillforfeitallclass
tuition.
Coursesmustberescheduledandattendedwithin40daysfromtheoriginalstartdate.No
additionalreschedulingrequestswillbehonored.
REQUIREMENTSFORSUCCSESSFULCOMPLETIONOFPALSCOURSE:
RequiredTestsandSkillCheckOffSheets
CompletedPALSPretestisrequiredforadmissiontothecourse.
SuccessfullycompletethePediatricCPRandAEDSkillsCheckOffTestSheet
SuccessfullycompletetheRespiratoryCoreCaseSkillsCheckOffTestSheet
SuccessfullycompletetheShockCoreCaseSkillsCheckOffTestSheet
SuccessfullycompletetheCardiacCoreCaseSkillsCheckOffTestSheet
Score84%orbetteronthemultiplechoicePALSposttest.
YoumaybeallowedtouseyourPALSProviderManual&notes.
Skillstobeperformed:
1. UsethePALSrapidcardiopulmonaryassessment
2. DemonstrateeffectiveinfantandchildCPR
3. UseanAEDonachild
4. Providesafedefibrillationwithamanualdefibrillator
5. Maintainanopenairway
6. Confirmationeffectiveventilation
7. Addressvascularaccess
8. Staterhythmappropriatedrugs,route,anddose
9. Understandtheconsiderationofreversiblecauses
Youwillneedtoknow:
1. PediatricCPRandAED(foundationforPALS)
2. Arrhythmias(identify):
a. SinusRhythm(SR)
b. SinusBradycardia(SB)
c. SinusTachycardia(ST)
d. SupraventricularTachycardia(SVT)
e. VentricularTachycardia(VT)
f. VentricularFibrillation(VF)
g. PulselessElectricalActivity(PEA)
h. Asystole
3. NormalRespiratoryRate(PALSProviderManualp.13)
Age
Rate
Infant
30to60
Toddler
24to40
Preschooler
22to34
Schoolagedchild
18to30
Adolescent
12to16
4. NormalHeartRate(HR)(PALSProviderManualp.18)
AGE
AwakeRateSleepingRate
Newbornto3months
85to205
80to160
3monthsto2years
100to190
75to160
2to10years
60to140
60to90
Morethan10years
60to100
50to90
5. HypotensionbySystolicBloodPressure(SBP)(PALSProviderManualp.74)
AGE
SystolicBloodPressure
TermNeonates(0to28days)
Lessthan60
Infants(1to12months)
Lessthan70
th
Children1to10years(5 BPpercentile) Lessthan70+(ageinyearsX2)
Childrenlessthan10years
Lessthan90
6. ModifiedGlasgowComaScale
ACT
CHILD
EYEOPENING
Spontaneous
ToSpeech
ToPain
None
VerbalResponse Orientated,Appropriate
Confused
Inappropriatewords
Incomprehensiblesounds
None
MotorResponse ObeysCommands
Localizespainfulstimulus
INFANT
SCORE
Spontaneous
4
ToSpeech
3
ToPain
2
None
1
CoosandBabbles
5
Irritable,Cries
4
Criesinresponsetopain
3
Moansinresponsetopain
2
None
1
MovesSpontaneously
6
Withdraws in response to
5
touch
Withdrawsinresponseto Withdraws in response to
4
pain
pain
Flexion in response to Abnormal flexion posture
3
pain
topain
Extension in response to Abnormal
extension
2
pain
posturetopain
None
None
1
HELPFULSTUDENTINFORMATION:
RAPIDCARDIOPULMONARYASSESSMENTANDALGORITHMS
Thisisasystematicheadtotoeassessmentusedtoidentifypediatricpatientsincardiac
andrespiratorydistressandfailure,shock,andpulselessarrest.
Algorithmsaremenusthatguideyouthroughrecommendedtreatmentinterventions.
KnowthefollowingassessmentbecauseitbeginsallPALScasescenarios.The
informationyougatherduringtheassessmentwilldeterminewhichalgorithmyou
chooseforthepatientstreatment.
Aftereachinterventionyouwillreassessthepatientagainusingtheheadtotoeassessment.
GeneralAppearance:
1. Levelofconsciousness:
a. A=awake
b. V=respondstoverbal
c. P=respondstopain
d. U=unresponsive
2. SkinTone:
a. Warm,pink,anddrytocool,pale/cyanotic,diaphoretic
3. Muscletone:
a. Goodtoflaccid
AssessABCs:
(Stopandgiveimmediatesupportwhenneeded,andthencontinuewithassessment)
1. Airway
a. Openandholdwithheadtiltchinlift
2. Breathing
a. Presentorabsent
b. Rate=normal,slow,fast
c. Pattern=regular,irregular,gasping
d. Depth=normal,shallow,deep
e. Sound=stridor,grunting,wheezing
f. Exertion=nasalflaring,sternalretractions,accessorymuscleuse
3. Circulation
a. Centralpulse=presentorabsent
b. Rate=normal,slow,fast
c. Rhythm=regularorirregular
d. QRS=narroworwide
Perfusion:
1. Centralpulseversusperipheralpulsestrength:equalorunequal
2. Skincolor,patternandtemperature:normalorabnormal
3. Capillaryrefill:normalorabnormal(greaterthan2seconds)
4. Liveredgepalpatedatthecostalmargin:normalordry
a. belowcostalmargin(fluidoverload)
Check:
1. SystolicBloodPressure(normalorcompensated):acceptableforageorhypotensive
2. Urineoutput:normal=
a. InfantsandChildren=12cc/kg/hr.
b. Adolescents=30cc/hr.
Classifythephysiologicstatus:
1. Stable:needslittlesupport;reassessfrequently
2. Unstable:needsimmediatesupportandintervention
3. Respiratorydistress:increasedrate,effortandnoiseofbreathing;requiresmuchenergy
4. Respiratoryfailure:sloworabsentrate,weakornoeffortandisveryquiet
SHOCK:
1. Compensatedshock:
a. SBPisacceptablebutperfusionispoor:centralvs.peripheralpulsestrengthis
unequal;peripheralcolorispoorandskiniscool,capillaryrefillisprolonged
2. Decompensatedshock:
a. Systolichypotensionwithpoororabsentpulses,poorcolor,weakcompensatory
effort
3. ApplyAppropriateShockTreatmentAlgorithm:
a. BradycardiawithaPulse
b. TachycardiawithAdequatePerfusion
c. TachycardiawithPoorPerfusion
d. PulselessArrest:VF/VT
e. Asystole/PEA
ADVANCEDAIRWAY
AcuffedoruncuffedEndotrachealTube(ET)maybeusedonInfantsandchildren.
(PALSProviderManualp.87)
1. Toestimatetubesize:
a. Uncuffed:(Ageinyears4)+4Example:(4years4)=1+4=5
b. Cuffed:(Ageinyears4)+3Example:(4years4)=1+3=4
Immediatelyconfirmtubeplacementbyclinicalassessmentandadevice:
Clinicalassessment:
1. Lookforbilateralchestrise.
2. Lookforwatervaporinthetube(thisishelpfulbutnotdefinitive).
3. Listenforbreathsoundsoverstomachandthe4lungfields(leftandrightanteriorand
midaxillary).
Devices:
1. EndTidalCO2Detector(ETD):ifweight>2kg
a. AttachbetweentheETTandBVM
i. Litmuspapercentershouldchangecolorwitheachinhalationandeach
exhalation.
ii. Originalcoloroninhalation=O2isbeinginhaled:expected.
iii. Colorchangeonexhalation=Tubeisintrachea.
iv. Originalcoloronexhalation=Litmuspaperiswet:replaceETD.
2. EsophagealDetector(EDD):ifweight>20kgandinaperfusingrhythm(Resembles
turkeybaster)
a. CompressthebulbandattachtoendofETT:
i. Bulbinflatesquickly=Tubeisinthetrachea.
ii. Bulbinflatespoorly=Tubeisintheesophagus.
*Norecommendationforitsuseincardiacarrest.
DeviceFailure:
1. Whensuddendeteriorationofanintubatedpatientoccurs,immediatelycheck:
b. Displaced:ETtubeisnotintracheaorhasmovedintoabronchus(rightmain
stemmostcommon)
c. Obstruction:Considersecretionsorkinkingofthetube
d. Pneumothorax:Considerchesttrauma,barotrauma,ornoncompliantlung
disease
e. Equipment:Checkoxygensource,BVM,andventilator
MEDICATIONS
DuringArrest:
1. Epinephrine:catecholamine
a. Increasesheartrate,peripheralvascularresistanceandcardiacoutput;
duringCPRincreasesmyocardialandcerebralbloodflow.
b. Dosage:
i. IV/IO:0.01mg/kgof1:10000solution(equals0.1mL/kgofthe
1:10000solution);repeatq.35min
Antiarrhythmic:
1. Amiodarone:atrialandventricularantiarrhythmic
a. SlowsAVnodalandventricularconduction,increasestheQTintervalandmay
causevasodilation.
b. Dosage:
i. VF/PVT:IV/IO:5mg/kgbolus
ii. PerfusingVT:IV/IO:5mg/kgover2060min
iii. PerfusingSVT:IV/IO:5mg/kgover2060min
iv. Max:15mg/kgper24hours
Caution:hypotension,Torsade;halflifeisupto40days
2. Lidocaine:ventricularantiarrhythmictoconsiderwhenAmiodaroneisunavailable
a. Decreasesventricularautomaticity,conductionandrepolarization.
b. Dosage:
i. VF/PVT:IV/IO:1mg/kgbolusq.515min
ii. PerfusingVT:IV/IO:1mg/kgbolusq.515min
iii. Infusion:2050mcg/kg/min
c. Caution:neurologicaltoxicityseizures
3. Magnesium:ventricularantiarrhythmicforTorsadeandhypomagnesemia
a. Dosage:
i. IV/IO:2550mg/kgover1020min;givefasterinTorsade
ii. Max:2gm
b. Caution:hypotension,bradycardia
4. Procainamide:atrialandventricularantiarrhythmictoconsiderforperfusingrhythms
a. Dosage:
i. PerfusingrecurrentVT:IV/IO:15mg/kginfusedover3060min
ii. RecurrentSVT:IV/IO:15mg/kginfusedover3060min
b. Caution:hypotension;useitwithextremecautionwithAmiodaroneasitcan
causeAVblock
IncreaseHeartRate:
1. Epinephrine:Drugofchoiceforpediatricbradycardiaafteroxygenandventilation
a. Doseisthesameaslistedabove.
2. Atropine:Vagolytictoconsiderafteroxygen,ventilationandepinephrine
a. BlocksvagalinputthereforeincreasesSAnodeactivityandimprovesAV
conduction.
b. Dosage:
i. IV/IO:0.02mg/kg;maydoubleamountforseconddose
ii. Childmax:1mg
iii. Adolescentmax:2mg
c. Caution:Donotgivelessthan0.1mg,ormayworsenthebradycardia
DecreaseHeartRate:
1. Adenosine:DrugofchoiceforsymptomaticSVT
a. ForinjectiontechniqueBlocksAVnodeconductionforafewsecondsto
interruptAVnodereentry.
b. Dosage:
i. IV/IO:firstdose:0.1mg/kgmax:6mg
ii. 2nddose:0.2mg/kgmax:12mg
c. Caution:transientAVblockorasystole;hasveryshorthalflife
IncreaseBloodPressure:
1. Dobutamine:Syntheticcatecholamine
a. Increasesforceofcontractionandheartrate;causesmildperipheraldilation;
maybeusedtotreatshock.
b. Dosage:
i. IV/IOinfusion:220mcg/kg/mininfusion
c. Caution:Tachycardia
2. Dopamine:Catecholamine
a. Maybeusedtotreatshock;effectsaredosedependent.
i. Lowdose:increasesforceofcontractionandcardiacoutput.
ii. Moderate:increasesperipheralvascularresistance,BPandcardiac
output.
iii. Highdose:higherincreaseinperipheralvascularresistance,BP,cardiac
workandoxygendemand.
b. Dosage:
i. V/IOinfusion:220mcg/kg/min
c. Caution:tachycardia
Miscellaneous:
1. Glucose:
a. Increasesbloodglucoseinhypoglycemia
b. Preventshypoglycemiawheninsulinisusedtotreathyperkalemia.
c. Dosage:
i. IV/IO:0.51g/kg;thisequals:24mL/kgofD25or510mL/kgofD10or
1020mL/kgofD5
d. Caution:maxrecommended:shouldnotexceedD25%;hyperglycemiamay
worsenneurologicaloutcome.
2. Naloxone:Opiateantagonist
a. Reversesrespiratorydepressioneffectsofnarcotics.
b. Dosage:
i. <5yrsor20kg:IV/IO:0.1mg/kg
ii. >5yrsor20kg:IV/IO:upto2mg
c. Caution:halflifeisusuallylessthanthehalflifeofnarcotic,sorepeatdosingis
oftenrequired.
3. Sodiumbicarbonate:PHbufferforprolongedarrest,hyperkalemia,tricyclicoverdose:
a. IncreasesbloodpHhelpingtocorrectmetabolicacidosis.
b. Dosage:
i. IV/IO:1mEq/kgslowbolus;giveonlyaftereffectiveventilationis
established
c. Caution:causesotherdrugstoprecipitatesoflushIVtubingbeforeandafter.
PALSCourseAgenda(InitialCourse)
Day 1
8:00-8:10
8:10-8:15
8:15-8:30
Welcome, Introductions, and Course Administration

Lesson 1: PALS Course Overview
Lesson 2: Overview of PALS Science
Lesson 3
Lesson 4
BLS Practice and Competency
Management of Respiratory
Divide class into 2 groups
Testing
Emergencies
8:30-9:30
Group 1
Group 2
9:30-9:40
Break
Break
9:40-10:40
Group 2
Group 1
Lesson 5
Lesson 6
Rhythm Disturbances/
Vascular Access
Electrical Therapy
10:40-11:10
Group 2
Group 1
11:10-11:40
Group 1
Group 2
11:40-12:30
Lunch
Lunch
One large group
12:30-1:00 Lesson 7: Resuscitation Team Concept
1:00-1:10 Lesson 8: Overview of Pediatric Assessment
1:10-1:20 Lesson 9A-C: Overview of Learning Stations
1:20-1:40 Lesson 9D: Core Case Discussion: Respiratory Cases 1 and 2
1:40-1:50 Break
Lesson 9D
Lesson 9D
Core Case Simulations
Respiratory Cases 1 and 2
1:50-2:30
Group 1
Group 2
One large group
2:30-2:50 Lesson 9D: Core Case Discussion: Respiratory Cases 3 and 4
Lesson 9D
Lesson 9D
2:50-3:30
Group 1
Group 2
One large group
3:30-3:50 Lesson 9E: Core Case Discussion: Shock Cases 5 and 6
Lesson 9E
Lesson 9E
Shock Cases 5 and 6
Shock Cases 5 and 6
3:50-4:30
Group 1
Group 2
4:30 End of Day 1
PALSCourseAgenda(Recertification/RenewalCourse)
8:00-8:10
8:10-8:15
8:15-8:30
Welcome, Introductions, and Course Administration

Lesson 1: PALS Update Course Overview
Lesson 2: Overview of PALS Science
Lesson 3
Lesson 3
BLS Practice and Competency BLS Practice and Competency
Testing
Testing
8:30-9:30
Group 1
Group 2
9:30-9:40 Break
(Lessons 4, 5, and 6 are optional and are not included in this agenda)
One large group
9:40-10:10 Lesson 7: Resuscitation Team Concept
10:10-10:30 Lesson 8: Coping With Death
10:30-10:40 Lesson 9: Overview of Pediatric Assessment
Lesson 10
Lesson 10
Putting It All Together
Putting It All Together
10:40-11:40
Group 1
Group 2
One large group
11:40-11:45 Lesson 11: Course Summary and Testing Details
11:45-12:30 Lunch
One large group
12:30-1:30 Lesson 12: Written Exam
Lesson 14
Lesson 13
PALS Core Case Test 2
PALS Core Case Test 1
Respiratory Cases 1-4
Cardiac Cases 9-12
Shock Cases 5-8
1:15-2:15
Group 1
Group 2
2:15-3:15
Group 2
Group 1
3:15 Course Ends
3:15 Remediation

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Welcome, Introductions, and Course Administration

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