PALS Study Guide

Ages Ages
Infant is considered age _____ Infant is considered < 12 months
Toddler is _____ Toddler is 1 year to 2 years
Preschooler is _____ Preschooler is 2 - 10 years (for PALS)
School Age is _____ School Age is 10+
Adolescent is _____ Adolescent is 13-18yr
Resp Rate Resp Rate
Infant ___________ Infant 30-60
Toddler __________ Toddler 24-30
Preschool ________ Preschool 22-34
School Age _______ School Age 18-30
Adolescent is _____ Adolescent is 12 -20
Heart Rate Heart Rate
Infant ________ Infant 80-205
Toddler _______ Toddler 75-190
Preschool _____ Preschool 69-140
School Age ____ School Age 50-100
Adolescent is _____ Adolescent is 60-100
Hypotension by SBP Hypotension by SBP
<1 month ____ <1 month <60
1 month to 1 years ____ 1 month to 1 years <70
1 - 10 years _____ 1 - 10 years <70 + (2 x age in years)
10 + _____ 10 + <90
Adolescent is _____ <90
Decompensated shock is when the Hypotension + signs of poor perfusion = de-
________________ compensated shock.
Treat Possible Causes
Name the 6 H's and 5 T's 6 Hs 5 Ts
Hypo xia
Hypo volemia
Hypo thermia
Hypo glycemia
Hypo /hyper kalemia
Hydro gen ion (acidosis)
T amponade
T ension pneumothorax
T oxins – poisons, drugs
T hrombosis – coronary (AMI)
– pulmonary (PE)
T rauma
What do you start your assessment with? Start with child’s general appearance:
1st thing is __________ Is the level of consciousness: A= awake V= re-
What does A, V, P, U sponds to verbal P= responds to pain U= unre-
sponsive
2nd thing is ______ Is the overall color: good or bad?
 3rd thing is ______ Is the muscle tone: good or floppy?
Next thing to assess is _____________ Then assess ABCs: (stop and give immediate
If the first part of the assessment treated is support when needed, then continue with as-
needed, what do you do? sessment)
For airway you must do ______ Airway: Open and hold with head tilt-chin lift
For breathing ______ Breathing: Is it present or absent?
Is the rate normal or too slow or too fast?
Check ______, ____, ____, _____, _____ Is the pattern regular or irregular or gasping?
Is the depth normal or shallow or deep?
Is there nasal flaring or sternal retractions or
accessory muscle use?
Is there stridor or grunting or wheezing?
For circulation ______ Circulation:
Check ____, ____, ____, ____ Is central pulse present or absent?
Is the rate normal or too slow or too fast?
Is the rhythm regular or irregular?
Is the QRS narrow or wide?
Next assess _____ Next look at perfusion:
Check _____, Is it _____ Is the central pulse versus peripheral pulse
strength equal or unequal?
Skin for ____, _____, _____ Is skin color, pattern and temperature normal
or abnormal?
Capillary for ____ Is capillary refill normal or abnormal (greater
than 2 seconds)?
Liver edge for ____
If liver edge is at costal margin, this means Is the liver edge palpated at the costal margin
____ (normal or dry)
If it is below it, this means ____ Or below the costal margin (fluid overload)?

Next assess _____ and _____ Is systolic BP acceptable for age (normal or
compensated) or hypotensive?
Normal urine output in an infant and child is Is urine output adequate for: infants and chil-
_____ dren (1– 2cc/kg/hr) or
and in adolescents ______ adolescents (30cc/hr)?

Next check ______ status Physiologic status

Stable is defined as _____ Stable: needs little support; reassess frequently
Unstable is defined as _____ Unstable: needs immediate support and inter-
vention
Resp distress is defined as ____ Respiratory distress: increased rate, effort and
noise of breathing; requires much energy
Resp failure is defined as ____ Respiratory failure: slow or absent rate, weak
or no effort and is very quiet
Compensated shock is defined as _____ Compensated shock: SBP is acceptable but per-
fusion is poor: central vs. peripheral pulse
strength is unequal
 peripheral color is poor and skin is cool
capillary refill is prolonged
Decompensated shock is defined as _____ Decompensated shock: Systolic hypotension
with poor or absent pulses, poor color, weak
compensatory effort.
Next apply _____ Apply the appropriate treatment algorithm:
The four algorithms are ________ • Bradycardia with a Pulse
• Tachycardia with Adequate Perfusion
• Tachycardia with Poor Perfusion
• Pulseless Arrest: VF/VT and Asystole/PEA
ADVANCED AIRWAY ADVANCED AIRWAY
What kind of cuff can be used for the ET? A cuffed or uncuffed Endotracheal Tube (ET)
may be used on Infants and children.
How do you estimate ET size? To estimate tube size: ECC Handbook p. 87
Uncuffed = (Age in years ÷ 4) + 4. Example: (4
Give example of uncuffed for 4 yo. years ÷ 4) = 1 + 4 = 5
Give example of cuffed for 4 yo. Cuffed = (Age in years ÷ 4) + 3. Example: (4
years ÷ 4) = 1 + 3 = 4
What is the first thing to do once the ET is Immediately confirm tube placement by clinic-
placed? al 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 midax-
illary).
• Look for water vapor in the tube (if seen this
is helpful but not definitive).
Assessment? Name 3 things. ►Devices:
Devices are _____ • End-Tidal CO2 Detector (ETD): if weight > 2
kg
Where does it attach? Attaches between the ET and Ambu bag;
give 6 breaths with the Ambu bag:
- Litmus paper center should change color with
What does the color... each inhalation and each exhalation.
Purple mean? A- Purple -- EtCO2 < 0.5%
Tan mean? B- Tan -- EtCO2 0.5-2%
Yellow mean? C- Yellow – EtCO2 >2%
Normal EtCO2 = Normal EtCO2 is >4% hence the device should
turn yellow when endotracheal tube is inserted
in patients with intact circulation. Limitations
of this device
1. It is a useful device to confirm endotracheal
tube placement in patients not in cardiac arrest.
In patients with cardiac arrest, a value of
<0.5% EtCO2, the device is virtually of no use
in confirming the endotracheal tube, because
 the tube could be in the esophagus or that the
circulation is not bringing enough CO2 to the
lungs. In non-arrest patients the device is 100%
sensitive, while it is 69% in patients with cardi-
ac arrest (4).
2. The membrane can turn ‘yellow’ (implies
EtCO2 > 2%) when the device is contaminated
with acidic substances like gastric acid, Lido-
caine-HCl, epinephrine HCl.
3. The device is unable to give a reading if it is
clogged with secretions, or the device broken.
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 esophag-
us.
No recommendation for its use in cardiac
arrest.
If intubated patient suddenly deteriorates, im- ►When sudden deterioration of an intubated
mediately check for 4 things; these are? patient occurs, immediately check:
Displaced = tube is not in trachea or has moved
into a bronchus (right mainstem most common)
Obstruction = consider secretions or kinking of
the tube
Pneumothorax = consider chest trauma or baro-
traumas or non-compliant lung disease

Equipment = check oxygen source and Ambu

bag and ventilator
PALS DRUGS
PALS DRUGS In Arrest:
In arrest Epinephrine: catecholamine ECC Handbook p.
Give _______ 92
Increases heart rate, peripheral vascular resist-
This drug does what 3 things? ance and cardiac output; during CPR increases
myocardial and cerebral blood flow.
During CPR this drug does what 2 things? IV/IO: 0.01 mg/kg of 1:10 000 solution (equals
Give what route and how often? 0.1 mL/kg of the 1:10 000 solution); repeat q.
3–5 min
ET: 0.1 mg/kg of 1:1000 solution (equals 0.1
What's the method for giving ET? mL/kg of the 1:1000 solution); repeat q. 3–5
min
 Antiarrhythmics:
Antiarrhythmics
What are the 4 main antiarrhythmics? Which
can be given ET? Amiodarone: atrial and ventricular antiar-
Amiodarone is given for _____ rhythmic ECC Handbook p. 89
Slows AV nodal and ventricular conduction, in-
Main action is ____ creases the QT interval and may cause vas-
odilation.
VF/PVT: IV/IO: 5 mg/kg bolus
Dose is ____ Perfusing VT: IV/IO: 5 mg/kg over 20-60 min
Given over _____ minutes Perfusing SVT: IV/IO: 5 mg/kg over 20-60 min
Max: 15 mg/kg per 24 hours
Caution: hypotension, Torsade;
Max dose is ____ in 24/h half-life is up to 40 days
Main side effect _____ Lidocaine: ventricular antiarrhythmic to con-
Half life is ____ sider when amiodarone is unavailable ECC
Lidocaine is given for ____ Handbook p. 94
Decreases ventricular automaticity, conduction
and repolarization.
Main action is ____ VF/PVT: IV/IO: 1 mg/kg bolus q. 5-15 min
ET: 2 -3 mg/kg
Dose is ____ Perfusing VT: IV/IO: 1 mg/kg bolus q. 5-15
ET dose is ___ min
Perfusing VT ____ Infusion: 20-50 mcg/kg/min
Caution: neuro toxicity → seizures
Infusion is ___ Magnesium: ventricular antiarrhythmic for Tor-
Main side effect is ____ and ____ sade and hypomagnesemia ECC Handbook p.
Magnesium is given for ____ 94
Shortens ventricular depolarization and repol-
arization (decreases the QT interval).
Main action is ____ IV/IO: 25-50 mg/kg over 10–20 min;
give faster in Torsade
Dose is ____ Max: 2 gm
Does one ever give it faster? When? Caution: hypotension, bradycardia
Max dose is ____ Procainamide: atrial and ventricular antiar-
Caution for ____ and ____ rhythmic to consider for perfusing rhythms
Procainamide is given for ____ ECC Handbook p. 96
Slows conduction speed and prolongs ventricu-
lar de- and repolarization (increases the QT in-
Main action is _____ terval).
Perfusing recurrent VT: IV/IO: 15 mg/kg in-
fused over 30–60 min
Dose for perfusing, recurrent VT is ____ Recurrent SVT: IV/IO: 15 mg/kg infused over
30–60 min
Dose for recurrent SVT is ____ Caution: hypotension; use it with extreme cau-
tion with amiodarone as it can cause AV block
Caution for ____ and ____ or Torsade
Increase heart rate:

To increase heart rate:

Epinephrine is given for ____ Epinephrine: drug of choice for pediatric
bradycardia after oxygen and ventilation ECC
Which is the drug of choice in pediatric brady- Handbook p. 92
cardia? Dose is the same as listed above.

Which can be given ET? Atropine: vagolytic to consider after oxygen,

ventilation and epinephrine ECC Handbook p.
Atropine: 89
Blocks vagal input therefore increases SA node
activity and improves AV conduction.
Main action is _____ IV/IO: 0.02 mg/kg; may double amount for
second dose
Dose is ____ ET: 0.03 mg/kg
Child max: 1 mg
ET dose is ____ Adolescent max: 2 mg
Max in child is ____ Caution: do not give less than 0.1 mg or may
Max in adolescent is ____ worsen the bradycardia
Caution is ____ Decrease heart rate:
Adenosine: drug of choice for symptomatic
To decrease heart rate: SVT See ECC Handbook p. 88 for injection
Drug of choice is ____ technique
Blocks AV node conduction for a few seconds
to interrupt AV node re-entry.
Main action is ____ IV/IO: first dose: 0.1 mg/kg max: 6 mg
second dose: 0.2 mg/kg max: 12 mg
Dose is ____, and the max is ____ Caution: transient AV block or asystole; has
Second dose is ____ and the max is ____ very short half-life
Caution is _____ Increase blood pressure:
Dobutamine: synthetic catecholamine ECC
To increase blood pressure: Handbook p. 92
Dobutamin is given for ____ and is a _____ Increases force of contraction and heart rate;
causes mild peripheral dilation; may be used to
Main action is _____ treat shock.
IV/IO infusion: 2- 20 mcg/kg/min infusion
Caution: tachycardia.
Dose is ____ Dopamine: catecholamine ECC Handbook p.
Caution is ____ 92
Dopamine is given for ____ and is a ____ May be used to treat shock; effects are dose de-
pendent.
It may also be given for ____ Low dose: increases force of contraction and
cardiac output.
A low dose does what? Moderate: increases peripheral vascular resist-
 ance, BP and cardiac output.
A moderate dose does what? High dose: higher increase in peripheral vascu-
lar resistance, BP, cardiac work and oxygen de-
A high dose does what? mand.
IV/IO infusion: 2–20 mcg/kg/min
Caution: tachycardia
The dose range is _____ Miscellaneous:
Caution is _____ Glucose: ECC Handbook p. 93
Miscellaneous: Increases blood glucose in hypoglycemia; pre-
Glucose given for ____ and _____ vents hypoglycemia when insulin is used to
treat hyperkalemia.
IV/IO: 0.5–1 g/kg;
5–10 mL/kg of D10
2–4 mL/kg of D25
1-2 mL/kg of D50
Caution: maximum recommended concentra-
Dose is ____ tion should not exceed D25%; hyperglycemia
If you have D10, this amount would be _____ may worsen neuro outcome
If you have D25, this amount would be _____ Naloxone: opiate antagonist ECC Handbook p.
If you have D50, this amount would be _____ 95
Caution is _____ Reverses respiratory depression effects of nar-
cotics.
< 5 yr or 20 kg: IV/IO: 0.1 mg/kg
Naloxone given for _____ > 5 yr or 20 kg: IV/IO: up to 2 mg
Caution: half-life is usually less than the half-
Action is ______ life of narcotic, so repeat dosing is often re-
quired;
Dose is < 5 yo _____ ET dose can be given but is not preferred;
Dose is > 5 yo _____ can also give IM or SQ.
Caution is _____ Sodium bicarbonate: pH buffer for prolonged
arrest, hyperkalemia, tricyclic overdose: ECC
Handbook p. 97
Main route is ___ but also can be given ____ Increases blood pH helping to correct metabol-
ic acidosis.
Sodium bicarbonate is given for what 3 IV/IO: 1mEq/kg slow bolus; give only after ef-
things? fective ventilation is established
Caution: causes other drugs to precipitate so
Action is _____ flush IV tubing before and after
ET drug administration: distribution is un-
Dose is _____ predictable as is the resulting blood level of the
drug; if there is no IV/IO access,
Caution is _____ Give the drug down the ET and flush with 5
mL NS then give 5 ventilations to disperse the
Can it be given ET? 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
CHILD AND INFANT CPR age).
Give the 4 steps and explain them. 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 compres-
sions 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
AED’s voice prompts.
• Use child pads if victim’s age is 1 – 8 years.
• After the AED shocks or says “no shock ad-
vised”, resume CPR.
• After 5 cycles of CPR, check rhythm/pulse.
Give 3 steps for Child Two-rescuer CPR. 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
Two-rescuer CPR breaths (over 1 second each).
Name and explain the 3 steps. • 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
AED’s voice prompts.
 • Use child pads if victim’s age is 1 – 8 years.
• Continue CPR while attaching the AED until
it says to not touch victim.
lnfant CPR

Infant Two-rescuer CPR 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 CPR Infant Two-rescuer CPR
Name and explain the differences between in- • Same as Two-rescuer Child CPR except use
fant CPR and Child CPR. the 2 thumb-encircling hands technique.
Infant Two-rescuer CPR Infant CPR Give 3 steps for Child Two-rescuer CPR.
Name and explain the differences between Child Two-rescuer CPR
child and infant 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
AED’s voice prompts.
• Use child pads if victim’s age is 1 – 8 years.
• Continue CPR while attaching the AED until
it says to not touch victim.
• Consider the differential for ALOC, which can be remembered by the mne-
monic AEIOU TIPS:
o A – Alcohol/acidosis/ammonia (metabolic disease)
o E – Epilepsy
o I – Infection
o O – Opiates
o U – Uremia
o T – Trauma
o I – Insulin/Hypoglycemia
o P – Poisoning/Psychogenic
o S – Shock/Sepsis

Isotonic Crystalloids 20ml/kg usually over 10-20 minutes repeat as needed

Atropine 0.02 mg/kg
Epinephrine 0.01mg/kg 1:10,000
Amiodarone 5mg/kg in
Lidocaine 1mg/kg
Magnesium 25-50mg/kg
Shock 2J/kg on 1st, then 4J/kg on 2nd
D10W 5-10 ml/kg
D25W 2-4 ml/kg 0.5-1 g/kg
D50W 1-2 ml/kg
Adenosine 0.1 mg/kg
DOPE (Displacement, Obstruction, Pneumothorax, Equipment failure) re ET
Tube