PALS Interim Study Guide

2006
Bulletin:
New resuscitation science and American Heart Association treatment guidelines were released November 28, 2005!

The new AHA Handbook of Emergency Cardiac Care (ECC) contains these 2005 Guidelines and is required study for this course. The 2006 PALS Provider Manual is not yet available. This interim study guide will provide you with additional study information.

What is required to successfully complete PALS?

Completed PALS Pre-test is required for admission to the course. Score 84% on the multiple-choice post-test. It is a timed test and you may be allowed to use your ECC Handbook. You must be able to demonstrate: the PALS rapid cardiopulmonary assessment effective infant and child CPR using an AED on a child safe defibrillation with a manual defibrillator maintaining an open airway confirmation of effective ventilation addressing vascular access stating rhythm appropriate drugs, route and dose consideration of treatable causes

What happens if I do not do well in the course?

The Course Director or Instructor will first remediate (tutor) you and you may be allowed to continue in the course. If it is decided you need more time to study, you will be placed into the next course.

Where do I start?
CPR/AED: You will be tested with no coaching. If you can not perform these skills well without coaching, you can/may be directed to take the course at another time. Know p. 7 of this study guide well. Arrhythmias: Before you come be sure you can identify: Sinus Rhythm (SR), Sinus Bradycardia (SB), Sinus Tachycardia (ST), Supraventricular Tachycardia (SVT), Ventricular Tachycardia (VT), Ventricular Fibrillation (VF), Torsades de Pointes, Pulseless Electrical Activity (PEA) and Asystole.

You will need to know:

Respiratory Rate
Age Infant Toddler Preschooler School-age child Rate 30 24 22 18 60 40 34 30 Age

Heart Rate
Sleeping 80 75 60 50 Awake 205 190 140 100 < 3 months 3 months - 2 years 2 10 years 10 + years

ECC Handbook p. 74

Hypotension by Systolic Blood Pressure (SBP)

Age < 1 month 1 month 1 year 1 10 years 10 + years
ECC Handbook p. 74

SBP < 60 < 70 < 70 + (2 x age in years) < 90

Hypotension + signs of poor perfusion =

decompensated shock.

Treat Possible Causes

.

6 Hs
Hypo xia Hypo volemia Hypo thermia Hypo glycemia Hypo /hyper kalemia Hydro gen ion (acidosis)

5 Ts
T amponade T ension pneumothorax T oxins poisons, drugs T hrombosis coronary (AMI)
pulmonary (PE)

T rauma

Spacing separations may help as a memory aid.

Rapid Cardiopulmonary Assessment and Algorithms

This is a systematic head-to-toe assessment used to identify infants and children in respiratory distress and failure, shock and pulseless arrest. Algorithms are menus that guide you through recommended treatment interventions.

Know the following assessment because it begins all PALS case scenarios. The information you gather during the assessment will determine which algorithm you choose for the patients treatment. After each intervention you will reassess the patient again using the head-to-toe assessment.

Start with childs general appearance:

Is the level of consciousness: Is the overall color: good Is the muscle tone: good A= awake V= responds to verbal P= responds to pain U= unresponsive or bad? or floppy?

Then assess ABCs: (stop and give immediate support when needed, then continue with assessment) Airway:
Open and hold with head tilt-chin lift Is the rate normal Is the pattern regular Is the depth normal Is there nasal flaring Is there stridor or absent? or too slow or irregular or shallow or sternal retractions or grunting or absent? or too slow or irregular? or wide?

Breathing: Is it present

or too fast? or gasping? or deep? or accessory muscle use? or wheezing?

Circulation: Is central pulse present

Is the rate normal Is the rhythm regular Is the QRS narrow

or too fast?

Next look at perfusion:

Is the central pulse versus peripheral pulse strength equal Is skin color, pattern and temperature normal Is capillary refill normal Is the liver edge palpated at the costal margin (normal or dry) or unequal? or abnormal? or abnormal (greater than 2 seconds)? or below the costal margin (fluid overload)?

And check:
Is systolic BP acceptable for age (normal or compensated) Is urine output adequate for: infants and children (1 2cc/kg/hr) or hypotensive? or adolescents (30cc/hr)?

Now classify the physiologic status:

Stable: Unstable: needs little support; reassess frequently needs immediate support and intervention

Respiratory distress: increased rate, effort and noise of breathing; requires much energy Respiratory failure: slow or absent rate, weak or no effort and is very quiet Compensated shock: SBP is acceptable but perfusion is poor: central vs. peripheral pulse strength is unequal peripheral color is poor and skin is cool capillary refill is prolonged Decompensated shock: Systolic hypotension with poor or absent pulses, poor color, weak compensatory effort.

Apply the appropriate treatment algorithm:

Bradycardia with a Pulse Tachycardia with Adequate Perfusion Tachycardia with Poor Perfusion Pulseless Arrest: VF/VT and Asystole/PEA

Advanced Airway
A cuffed or uncuffed Endotracheal Tube (ET) may be used on Infants and children. To estimate tube size:
ECC Handbook p. 87

Uncuffed = (Age in years Cuffed =

4) + 4. (Age in years 4) + 3.

Example: (4 years Example: (4 years

4) 4)

= 1 +4= 5 = 1 +3= 4

Immediately confirm tube placement by clinical assessment and a device:

Clinical assessment:
Look for bilateral chest rise. Listen for breath sounds over stomach and the 4 lung fields (left and right anterior and midaxillary). Look for water vapor in the tube (if seen this is helpful but not definitive).

Devices:
End-Tidal CO2 Detector (ETD): if weight > 2 kg Attaches between the ET and Ambu bag; give 6 breaths with the Ambu bag: Litmus paper center should change color with each inhalation and each exhalation. Original color on inhalation = Color change on exhalation = Original color on exhalation = Okay CO2!! Oh-OH!! O2 is being inhaled: expected. Tube is in trachea. Litmus paper is wet: replace ETD. Tube is not in trachea: remove ET. Cardiac output is low during CPR.

Esophageal Detector (EDD): if weight > 20 kg and in a perfusing rhythm Resembles a turkey baster: Compress the bulb and attach to end of ET. Bulb inflates quickly! Tube is in the trachea. Bulb inflates poorly? Tube is in the esophagus. No recommendation for its use in cardiac arrest.

When sudden deterioration of an intubated patient occurs, immediately check:

Displaced = tube is not in trachea Obstruction = consider secretions Pneumothorax = consider chest trauma Equipment = check oxygen source
or has moved into a bronchus (right mainstem most common) or kinking of the tube or barotraumas and Ambu bag or non-compliant lung disease and ventilator

PALS Drugs
In Arrest:
Epinephrine: catecholamine
ECC Handbook p. 92

Increases heart rate, peripheral vascular resistance and cardiac output; during CPR increases myocardial and cerebral blood flow. IV/IO: 0.01 mg/kg of 1:10 000 solution (equals 0.1 mL/kg of the 1:10 000 solution); repeat q. 35 min ET: 0.1 mg/kg of 1:1000 solution (equals 0.1 mL/kg of the 1:1000 solution); repeat q. 35 min

Antiarrhythmics:
Amiodarone: atrial and ventricular antiarrhythmic
ECC Handbook p. 89

Slows AV nodal and ventricular conduction, increases the QT interval and may cause vasodilation. VF/PVT: IV/IO: 5 mg/kg bolus Perfusing VT: IV/IO: 5 mg/kg over 20-60 min Perfusing SVT: IV/IO: 5 mg/kg over 20-60 min Max: 15 mg/kg per 24 hours Caution: hypotension, Torsade; half-life is up to 40 days

Lidocaine: ventricular antiarrhythmic to consider when amiodarone is unavailable

Decreases ventricular automaticity, conduction and repolarization. VF/PVT: IV/IO: 1 mg/kg bolus q. 5-15 min ET: 2 -3 mg/kg Perfusing VT: IV/IO: 1 mg/kg bolus q. 5-15 min Infusion: 20-50 mcg/kg/min Caution: neuro toxicity seizures

ECC Handbook p. 94

Magnesium: ventricular antiarrhythmic for Torsade and hypomagnesemia

Shortens ventricular depolarization and repolarization (decreases the QT interval). IV/IO: 25-50 mg/kg over 1020 min; give faster in Torsade Max: 2 gm Caution: hypotension, bradycardia

ECC Handbook p. 94

Procainamide: atrial and ventricular antiarrhythmic to consider for perfusing rhythms

ECC Handbook p. 96

Slows conduction speed and prolongs ventricular de- and repolarization (increases the QT interval). Perfusing recurrent VT: IV/IO: 15 mg/kg infused over 3060 min Recurrent SVT: IV/IO: 15 mg/kg infused over 3060 min Caution: hypotension; use it with extreme caution with amiodarone as it can cause AV block or Torsade

Increase heart rate:

Epinephrine: drug of choice for pediatric bradycardia after oxygen and ventilation Dose is the same as listed above. Atropine: vagolytic to consider after oxygen, ventilation and epinephrine
ECC Handbook p. 92

ECC Handbook p. 89

Blocks vagal input therefore increases SA node activity and improves AV conduction. IV/IO: 0.02 mg/kg; may double amount for second dose ET: 0.03 mg/kg Child max: 1 mg Adolescent max: 2 mg Caution: do not give less than 0.1 mg or may worsen the bradycardia

Decrease heart rate:

Adenosine: drug of choice for symptomatic SVT
See ECC Handbook p. 88 for injection technique Blocks AV node conduction for a few seconds to interrupt AV node re-entry. 0.1 mg/kg max: 6 mg IV/IO: first dose: second dose: 0.2 mg/kg max: 12 mg Caution: transient AV block or asystole; has very short half-life

Increase blood pressure:

Dobutamine: synthetic catecholamine
ECC Handbook p. 92

Increases force of contraction and heart rate; causes mild peripheral dilation; may be used to treat shock. IV/IO infusion: 2- 20 mcg/kg/min infusion Caution: tachycardia

Dopamine: catecholamine

ECC Handbook p. 92

May be used to treat shock; effects are dose dependent. Low dose: increases force of contraction and cardiac output. Moderate: increases peripheral vascular resistance, BP and cardiac output. High dose: higher increase in peripheral vascular resistance, BP, cardiac work and oxygen demand. IV/IO infusion: 220 mcg/kg/min Caution: tachycardia

Miscellaneous:
Glucose:
ECC Handbook p. 93

Increases blood glucose in hypoglycemia; prevents hypoglycemia when insulin is used to treat hyperkalemia. IV/IO: 0.51 g/kg; this equals: 24 mL/kg of D25 or 510 mL/kg of D10 or 1020 mL/kg of D5 Caution: maximum recommended concentration should not exceed D25%; hyperglycemia may worsen neuro outcome

Naloxone: opiate antagonist

ECC Handbook p. 95

Reverses respiratory depression effects of narcotics. < 5 yr or 20 kg: IV/IO: 0.1 mg/kg > 5 yr or 20 kg: IV/IO: up to 2 mg Caution: half-life is usually less than the half-life of narcotic, so repeat dosing is often required; ET dose can be given but is not preferred; can also give IM or SQ.

Sodium bicarbonate: pH buffer for prolonged arrest, hyperkalemia, tricyclic overdose:

Increases blood pH helping to correct metabolic acidosis. IV/IO: 1mEq/kg slow bolus; give only after effective ventilation is established Caution: causes other drugs to precipitate so flush IV tubing before and after

ECC Handbook p. 97

ET drug administration: distribution is unpredictable as is the resulting blood level of the drug; if there is no IV/IO access,
give the drug down the ET and flush with 5 mL NS then give 5 ventilations to disperse the drug.

Child and Infant CPR

Child CPR
1. Tap and ask: Are you OK? Send someone to call 911 and bring an AED (AEDs are approved for children 1- 8 years of age). 2. Open the airway with the head-tilt/chin lift. Assess breathing. If inadequate: give 2 breaths over 1 second each. Each breath should make the chest rise. 3. Check carotid or femoral pulse for no more than 10 seconds. If pulse is felt, give 12-20 breaths per minute (one every 3-5 seconds). If pulse not definitely felt, give 30 compressions in center of chest, between the nipples. Compress 1/3 1/2 depth of chest wall with one or two hands. One cycle of CPR is 30 compressions and 2 breaths. Give 5 cycles of CPR; minimize interruptions (about 2 minutes). 4. When an AED arrives: After 5 cycles of CPR, turn it on and follow AEDs voice prompts. Use child pads if victims age is 1 8 years. After the AED shocks or says no shock advised, resume CPR. After 5 cycles of CPR, check rhythm/pulse.

Child Two-rescuer CPR

1. When using a basic airway: One rescuer gives 15 compressions and pauses. Other rescuer gives 2 breaths during pause. One cycle of CPR is 15 compressions and 2 breaths (over 1 second each). Rescuers change compressor role after every 5 cycles of CPR.

2. When an advanced airway is in place: Give 100 continuous compressions per minute. Give 8-10 breaths per minute (one every 6-8 seconds). 3. When an AED arrives: After 5 cycles of CPR, turn it on and follow AEDs voice prompts. Use child pads if victims age is 1 8 years. Continue CPR while attaching the AED until it says to not touch victim.

Infant CPR
Same as Child CPR except compress sternum with two fingers. There is no recommendation for or against using the AED in infants under 1 year old.

Infant Two-rescuer CPR

Same as Two-rescuer Child CPR except use the 2 thumb-encircling hands technique.

Bradycardia with a Pulse

ECC Handbook p.76

f ABCs: rapid head-to-toe assessment

(refer back to p. 3 of this guide)

f Give oxygen: hypoxia is # 1 cause of bradycardia in infants/children f Attach monitor /defibrillator

Is bradycardia still causing symptoms?

NO

Such as altered level of consciousness, respiratory distress, poor perfusion

YES

f Give oxygen If needed f Observe, reassess f Consider expert consult

f Give oxygen f If HR < 60 with poor perfusion, start CPR

f Give epinephrine: IV/ IO: 0.01 mg/kg of 1:10 000 (0.1 mL/kg) ET: 0.1 mg/kg of 1:1000 (0.1 mL/kg) f Repeat every 3 to 5 minutes at same dose

fConsider atropine: IV/IO: 0.02 mg/kg may repeat minimum dose: 0.1mg max dose, child: 1mg f Consider cardiac pacing

Consider and treat possible causes: 6Hs and 5Ts

Refer back to p. 2 of this study guide.

Tachycardia with Adequate Perfusion

ECC Handbook p.79

f ABCs: rapid head-to-toe assessment f Give oxygen f Attach monitor/defibrillator and identify rhythm

Narrow QRS

Wide QRS

Sinus Tachycardia f Infants: HR < 220 bpm f Children: HR < 180 bpm f History makes sense for HR f HR varies f P waves present and normal

SVT f Infants: HR > 220 bpm f Children: HR > 180 bpm f History is vague, nonspecific f HR does not vary
f HR changes abruptly f P waves absent or abnormal

Ventricular Tachycardia

y Give oxygen if needed y Obtain IV access

y Consider: -amiodarone 5 mg/kg IV over 30-60 min f Give oxygen if needed f Give oxygen if needed f Treat the cause f Consider vagal maneuvers

or
-procainamide 15 mg/kg IV over 30-60 min

or
-lidocaine 1 mg/kg IV bolus

f Obtain IV access f Give adenosine IV SLAM! - first dose: 0.1 mg/kg - repeat dose: 0.2 mg/kg

y Consult pediatric cardiologist y Consider synchronized cardioversion - first dose: 0.5 1J/kg - next dose: 2J/kg y Sedate before cardioversion y Obtain 12-lead ECG

Consider and treat possible causes: 6Hs and 5Ts

Tachycardia with Poor Perfusion

ECC Handbook p.78

f ABCs: rapid head-to-toe assessment f Give oxygen and support as needed f Attach monitor/defibrillator and identify rhythm

Narrow QRS

Wide QRS

Sinus Tachycardia f Infants: HR < 220 bpm f Children: HR < 180 bpm f History makes sense for HR f HR varies f P waves present and normal

SVT f Infants: HR > 220 bpm f Children: HR > 180 bpm f History is vague, nonspecific f HR does not vary
f HR changes abruptly f P waves absent or abnormal

Ventricular Tachycardia

f Give oxygen f Consider vagal maneuvers but do not delay f Give oxygen if needed f Treat the cause f If IV access is present: adenosine IV SLAM! - first dose: 0.1 mg/kg - repeat dose: 0.2 mg/kg

y Synchronized cardioversion:
- first dose: 0.5 1J/kg - next dose: 2J/kg

y Sedate before cardioversion

but do not delay

or
fSynchronized cardioversion: - first dose: 0.5 1J/kg - next dose: 2J/kg fSedate before cardioversion but do not delay

y Expert consultation advised y Consider:

-amiodarone 5 mg/kg IV over 30-60 min

or
-procainamide 15 mg/kg IV over 30-60 min

Consider and treat possible causes: 6Hs and 5Ts

Pulseless Arrest VF and Pulseless VT

ECC Handbook p.77

f ABCs: Give CPR f Give oxygen as soon as available f Attach monitor /defibrillator

Check rhythm: VF/ VT Check pulse: none Resume CPR until defibrillator is charged

y Give 1 shock at 2 J/kg y Resume CPR immediately yGive 5 cycles of CPR

Check rhythm: VF/ VT Check pulse: none Resume CPR until defibrillator is charged

y Give 1 shock at 4 J/kg y Resume CPR immediately f Give epinephrine: IV/ IO: 0.01 mg/kg of 1:10 000 (0.1 mL/kg) ET: 0.1 mg/kg of 1:1000 (0.1 mL/kg) Repeat : every 3-5 min y Give 5 cycles of CPR

Check rhythm: VF/ VT Check pulse: none Resume CPR until defibrillator is charged

y Give 1 shock at 4 J/kg y Resume CPR immediately fConsider: -amiodarone 5 mg/kg IV

or
- lidocaine 1 mg/kg IV

or
-magnesium 25-50 mg/kg IV/IO if Torsade y Give 5 cycles of CPR

Consider and treat possible causes: 6Hs and 5Ts

Pulseless Arrest Asystole and PEA

ECC Handbook p.77

f ABCs: Give CPR f Give oxygen as soon as available f Attach monitor /defibrillator

Check rhythm: Asystole/PEA Check pulse: none Resume CPR immediately

f Give epinephrine: IV/ IO: 0.01 mg/kg of 1:10 000 (0.1 mL/kg) ET: 0.1 mg/kg of 1:1000 (0.1 mL/kg) Repeat : every 3-5 min y Give 5 cycles of CPR

Check rhythm: Asystole/PEA Check pulse: none Resume CPR immediately

Consider and Treat Possible Causes 6 Hs

Hypo xia Hypo volemia Hypo thermia Hypo glycemia Hypo / hyper kalemia Hydro gen ion (acidosis)

5 Ts
T amponade T ension pneumothorax T oxins poisons, drugs T hrombosis coronary (AMI)
pulmonary (PE)

T rauma