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Pediatric Advanced Life Support


Cardiac Arrest Survival
Since the start of using CPR in the 1980s, in-
hospital survival for children and infants has
increased from 9% to 27%
Out-of-hospital arrests has not improved much from
6% for infants and 9% for children
It is essential to teach more people who to treat
cardiac arrest in children, and give it as quickly as
possible to improve outcomes
Difference in Cause
Adults often have a primary cardiac cause for
cardiac arrest, but in children and infants, the
majority of the causes are due to respiratory
failure and shock
Treat hypoxemia, hypotension, and acidosis to
prevent bradycardia and arrest!
Ventricular fibrillation (VF) and ventricular
tachycardia (VT) are the primary causes of
arrhythmia arrests in children (5-15%)
Age Definition
Defined as 1 to 8 years old
Defined as < 1 year old
Defined as first few hours to days of life
Review of Basic CPR (BLS)
2010 updated
Check for responsiveness and respirations
Call for help
Check for pulses in less than 10 seconds
Give 30 compressions (within 10 sec.)
Rate of at least 100/min
Depth of at least 1/3 of the chest
Open airway and give 2 breaths
Continue compressions (30:2)
Review of Basic CPR (BLS)
2010 updated
Have AED available (with a pediatric dose-
attenuator if possible) for children
For infants, a manual defibrillator is preferred,
although AED can be used if necessary
2 to 4 J/kg initially, max of 10 J/kg
Pediatric Assessment
General Assessment
Appearance, Work of breathing, Circulation
Primary Assessment
Airway, Breathing, Circulation, Disability, Exposure
Secondary Assessment
SAMPLE history, focused exam, glucose test
Tertiary Assessment
Laboratory studies, X-rays, etc as needed
Pediatric Assessment
Separate illness by respiratory versus circulatory
Determine severity of illness
Determine if there is a combination of illness
(respiratory and circulatory)

If at any time there is respiratory failure or distress,

or circulatory shock, activate emergency response
Possible Interventions
Support ABCs (CPR as needed)
100% O2
Assisted ventilation (bag mask or intubate)
Cardiac or respiratory monitoring
IV or IO (intraosseous) access
Fluid resuscitation
Laboratory studies (including glucose)
Administer drugs or cardioversion
Size of Endotracheal Tubes
Use cuffed ETT after age 8
ETT size: (age/4) + 4 (uncuffed)
(age/4) +3.5 if using cuffed tube instead
Check for air leak of < 20-25 cm H20
Preterm infant: 2.5
Term infant 3-3.5
Normal Vital Signs
Age Heart Rate Respiratory Systolic BP
< 1 year 85-180 30-40 70-90

1-2 100-150 25-35 80-95

2-5 60-140 25-30 80-100

5-12 60-120 20-25 90-110

Used primarily for volume replacement and
medication delivery.
Primarily Crystalloids in the Pre-hospital arena
Large volumes may be needed, especially in septic
Normal Saline: Good for Fluid Boluses,
compatible with blood products, most drugs.
0.9% NaCl has an osmolarity of 308 mOsm/liter,
slightly greater than that of plasma
Lactated Ringers: Good for fluid boluses but is
mildly hypo-osmolar when compared to plasma
D5W: Mainly for Hypoglycemia in the stable pt
or for infants.
Dextrose containing solutions should not be
used for boluses
IV access and Meds : Basic
In the critical pediatric Pt, Time to establish access
should be kept to a minimum.
A General rule is 3 sticks in 90 seconds
Do not delay drugs to await IV access, give ET if
If traditional access is unlikely, proceed to
alternative means (intraosseous (IO) in the child
under 6)
Endotracheal (ET) Drugs
Lipid soluble drugs can be given
2-2.5 times standard IV dose (except for
Should be diluted to a volume of 3-5 ml
Should be hyperventilated after
A use a 5 fr catheter to deliver the med depending
on size of ETT, then flush with 3-5 ml after
Can give: NAVEL (narcan, atropine, valium,
epinephrine, lidocaine)
Common PALS Drugs
Drips Resuscitation Drugs
Epi Epi
Dopamine Atropine

Lidocaine Sodium Bicarb

Alpha and beta adrenergic effects
2 standard concentration 1:1000 and 1:10,000
Used in PALS in your unresponsive rhythms
(asystole, PEA, refractory bradycardia),
anaphylaxis, asthma, shock
IV Dose 0.01 mg/kg of 1:10,000 q 3-5 min (max
1 mg)
SQ or IM for asthma or anaphylaxis: 0.01 mg/kg
1:1000 q 15 min
ETT 0.1 mg/kg of 1:1000 q 3-5 min
May or may not be truly effective in small children
in arrest/asystole
Good for vagus suppression during intubation
0.02 mg/kg dose, maximum 0.5 mg
Minimum dose (no matter weight) is 0.1 mg to
avoid refractory bradycardia
Remember that most bradycardia in children are
hypoxic related
Sodium Bicarbonate
Used to treat metabolic acidosis during
Poor perfusion and ventilation are largest
contributors to acidosis
Used after adequate ventilation has been restored
0.1 mEq/kg IV/IO, repeated at 0.5 mEq/kg every 10
Half strength is used for infants younger than 3
Calcium is indicated in hypocalcaemia,
hypermagnesemia, and calcium channel blocker
CaCl is considered more reliable and predictable in
its metabolization, thus it is used more often than
Ca gluconate in the critically ill
Calcium gluconate dose and volume should be
approx. 3 times that of CaCl
1st dose should be 20 mg/kg (0.2 ml/kg) given
Narcotic antagonist
Rapid onset, lasts about 30-45 minute
< 5 years: 0.1 mg/kg
>5 years of age: up to 2 mg (use adult dosing)
Infusion: 0.004-0.16 mg/hour for total reversal
Should be used with caution in newborns from
addicted mothers as it may cause withdrawal
Indicated for VF/pulse less VT and post defibrillation
arrhythmic suppressant
Used in Tachycardia algorithm for WIDE complex
Dose: 1 mg/kg max 3 mg/kg
If successful, proceed to infusion
Critically ill children (infants may rapidly deplete
their glycogen stores, especially during
cardiopulmonary distress)
Glucose is especially important to the neonatal
All pediatric patients in distress should have their
BG (blood glucose) checked
Dose 1.0 gm/kg IV/IO, max concentration of 25%
(D25) used. A 10 % concentration may be advisable
for neonates (D10)
Vasopressor of choice for pre hospital use
Dose dependant:
2-5 mcg/kg/min increases renal blood flow
5-10 mcg/kg/min causes beta adrenergic effects
10-20 mcg/kg/min both alpha and beta effects
Greater than 20 mcg/kg/min not routinely
recommended; mimics norepinephrine
Used in shock without hypovolemia or after it has
been treated
Antiarrhythmic (Class III) for SVT, VT, VF
Dose: 5 mg/kg IV/IO load (bolus if unstable)
May repeat as needed to max daily dose of 15
Contraindicated in 2nd and 3rd degree AV block
Specific Arrhythmia
In pediatrics they are divided into 3 main
First check if there is a pulse. If no pulse, go to PEA
If there is a pulses, check rate. If slow go to
bradycardia; if fast, go to tachycardia


essential to keep up your skills, so when you need
them in an emergency you are ready!
There are constant advances in medicine,
including treatment of cardiac arrest. Keep up
with the literature and recommendations.
As recommendations change, we will include
them in the material to reflect the latest
information available.