PALS

PALS Cardiac Arrest

 

 

 

 

 

 

 

 

 

 

 

PALS Cardiac Arrest

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

 

PALS Bradycardia

1. Bradycardia is diagnosed by manual testing or heart rate monitor – Normal heart rates change with age/size.

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?

8. If hypotensive,

• Administer epinephrine 0.01 mg/kg
• Repeat every 3-5 minutes as needed
• Consider atropine 0.02 mg/kg (min dose = 0.1 mg; max dose = 0.5 mg); Repeat one time if needed
• Consider external pacemaker

 

PALS Tachycardia (Initial)

1. Tachycardia is diagnosed by manual testing or heart rate monitor– Normal heart rates vary with age/size.

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

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

 

PALS Tachycardia (Poor Perfusion)

1. Tachycardia is diagnosed by manual testing or heart rate monitor and the child has poor perfusion – Normal heart rates vary with age/size.

2. Consider possible causes but do not delay treatment

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

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
  • Consider vagal maneuvers
  • 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 or procainamide
  • Consider cardioversion at 0.5 to 1 Joule/kg
  • Second cardioversion dose at 2 Joules/kg

Wide QRS Complex

4. Is the child compromised?

Unstable – Provide immediate synchronized cardioversion

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

 

PALS Tachycardia (Adequate Perfusion) – Wide QRS

1. Tachycardia is diagnosed by manual testing or heart rate monitor and the child has adequate perfusion – Normal heart rates vary with age/size.

2. Consider possible causes but do not delay treatment

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

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!)
  • Consider amiodarone (5 mg/kg IV over 20 to 60 minutes) OR procainamide (15 mg/kg IV over 30 to 60 minutes)
  • 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 2nd dose
  • Consider cardioversion at 0.5 to 1 Joule/kg
  • Second cardioversion dose at 2 Joules/kg
  • Consult pediatric cardiologist
  • Search for and treat reversible causes

 

PALS Tachycardia (Adequate Perfusion) – Narrow QRS

1. Tachycardia is diagnosed by manual testing or heart rate monitor and the child has adequate perfusion – Normal heart rates vary with age/size.

2. Consider possible causes but do not delay treatment

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

Determine rhythm

• Sinus tachycardia – Determine cause and treat
• Supraventricular tachycardia
  • Consider vagal maneuvers
  • 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 2nd dose
  • Consider amiodarone or procainamide
  • Consider cardioversion at 0.5 to 1 Joule/kg
  • Second cardioversion dose at 2 Joules/kg
  • Consult pediatric cardiologist
  • Continue to search for treatable causes of tachycardia and treat promptly