Pediatric Advanced Life Support (PALS): Asystole/Pulseless Electrical Activity (PEA)
PALS: Pediatric Arrest
1. The initial evaluation is as follows: [1, 2, 3, 4]
Activate emergency response system.
Initiate pediatric basic life support (BLS) algorithm.
2. The initial intervention is as follows:
Start high-quality cardiopulmonary resuscitation (CPR).
Administer oxygen if hypoxemic.
Attach monitor/defibrillator.
Monitor blood pressure and oximetry.
3. Check rhythm, as follows:
Shockable rhythm = Ventricular fibrillation or pulseless ventricular tachycardia (VF/VT)
Nonshockable rhythm = Asystole/pulseless electrical activity (PEA)
Shockable Rhythm
1. Initial treatment of VT/VF, as follows:
Defibrillate immediately.
Continue CPR for 2 minutes.
Obtain intravenous (IV)/intraosseous (IO) access.
Consider advanced airway, end-tidal carbon dioxide tension (PETCO 2).
2. Administer vasopressor (epinephrine q3-5min).
3. Check pulse and rhythm every 2 minutes, as follows:
If nonshockable, see Nonshockable Rhythm (below).
If shockable, see Shockable Rhythm (above) and administer amiodarone or lidocaine after second defibrillation attempt.
Rotate chest compressors.
Identify and treat reversible causes.
4. If return of spontaneous circulation (ROSC), see PALS: Post-Cardiac Arrest Care.
Nonshockable Rhythm
1. Initial treatment of asystole/PEA is as follows:
Continue CPR for 2 minutes.
Obtain intravenous (IV)/intraosseous (IO) access.
Consider advanced airway, end-tidal carbon dioxide tension (PETCO 2).
2. Administer vasopressor (epinephrine q3-5min).
3. Check pulse and rhythm every 2 minutes, as follows:
If nonshockable, see Nonshockable Rhythm (above).
If shockable, see Shockable Rhythm (above).
Rotate chest compressors.
Identify and treat reversible causes.
4. If return of spontaneous circulation (ROSC), see PALS: Post-Cardiac Arrest Care.
CPR Quality
See the list below:
Push hard and fast, at least one-third anteroposterior (AP) chest diameter and 100-120 compressions per minute.
Allow complete chest recoil.
Minimize interruptions in compressions.
Avoid excessive ventilation.
Rotate compressor every 2 minutes or if fatigued.
Compression-to-ventilation ratio is 30:2 for a single rescuer, 15:2 for multiple rescuers.
Continuous compressions if advanced airway present, asynchronous ventilation (children) or timed ventilation (infants)
Shock Energy
See the list below:
2 J/kg first shock
4 J/kg second shocks
≥4 J/kg subsequent shocks, maximum 10 J/kg or adult dose
Drug Therapy
See the list below:
Epinephrine 0.01 mg/kg IV/IO q3-5min; use 1:10000 concentration (0.1 mL/kg)
Epinephrine 0.1 mg/kg endotracheal tube (ETT) q3-5min, use 1:1000 concentration (0.1 mL/kg), not preferred route
Amiodarone 5 mg/kg IV/IO, may repeat up to 2 times for refractory VF/VT
Lidocaine 1 mg/kg IV/IO loading dose, 20-50 mcg/kg/min maintenance infusion
Flush medications with fluid after and elevate extremity for 10-20 seconds.
Combining medications is not recommended and may cause harm.
Routine use of sodium bicarbonate is not recommended and may cause harm.
Advanced Airway
See the list below:
Endotracheal tube (ETT) or supraglottic airway (SGA)
Waveform capnography to confirm and monitor ET tube placement
Ventilation every 6 seconds asynchronous with compressions
Stop CPR for no longer than 10 seconds for the placement of an advanced airway.
Return of Spontaneous Circulation
Signs of ROSC are as follows:
Pulse and blood pressure present
Abrupt sustained increase in PETCO 2 (typically >40 mm Hg)
Spontaneous arterial pressure waves with intra-arterial monitoring
Reversible Causes (H’s and T’s)
See the list below:
H's: hypovolemia, hypoxia, H+ (acidosis), hypokalemia, hyperkalemia, hypothermia, hypoglycemia
T's: toxins cardiac, tamponade (cardiac), tension pneumothorax, thrombosis (pulmonary, coronary)
Most Recent Guideline Changes
Changes from the 2010 guidelines include the following:
Simultaneous breathing and pulse check in less than 10 seconds
Administer epinephrine as soon as feasible after the onset of cardiac arrest due to an initial nonshockable rhythm.
Provide opioid overdose education, either alone or coupled with naloxone distribution and training, to persons at risk for opioid overdose.
Changes from the 2010 PALS guidelines include the following:
Amiodarone or lidocaine is equally acceptable for the treatment of shock-refractory VT/VF in children.
There is no evidence to support the routine use of atropine as a premedication to prevent bradycardia in emergency pediatric (age >1 year) intubations.
For septic shock, the initial fluid bolus is 20 mL/kg.
For children who are comatose in the first several days after cardiac arrest, fever should be treated aggressively.
For comatose children resuscitated from out-of-hospital cardiac arrest (OHCA), maintain either 5 days of normothermia or 2 days of initial continuous hypothermia (32˚C-34˚C) followed by 3 days of normothermia.
References
Neumar RW, et al. Part 1: Executive Summary: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3. 132 (18 Suppl 2):S315-67. [Medline].
Atkins DL, et al. Part 11: Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3. 132 (18 Suppl 2):S519-25. [Medline].
de Caen AR, et al. Part 12: Pediatric Advanced Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3. 132 (18 Suppl 2):S526-42. [Medline].
American Heart Association. 2015 Handbook of Emergency Cardiovascular Care for Healthcare Providers. ISBN 978-1-61669-397-8. November 2015
