Pediatric Advanced Life Support (PALS): Protocols and Best Practices Sumarized

Pediatric Advanced Life Support (PALS) is more than just a certification; it's a systematic framework designed to give critically ill infants and children the best chance of survival. Unlike adults, children often go into cardiac arrest due to respiratory failure or shock, not primary cardiac events. Therefore, PALS emphasizes early recognition, a structured assessment approach, and timely, specific interventions to prevent full cardiac arrest.

This article explores the core PALS algorithms and essential protocols that guide healthcare professionals during these high-stakes emergencies, reflecting the latest evidence-based guidelines from authoritative bodies like the American Heart Association (AHA).

The Core Philosophy: Evaluate-Identify-Intervene

The PALS approach is built on a continuous cycle of Evaluate-Identify-Intervene. This cycle ensures ongoing assessment and adaptability as a child's condition changes rapidly.

1. Evaluate: Gather data through initial impression (Pediatric Assessment Triangle), primary assessment (ABCDE), secondary assessment, and diagnostics.

2. Identify: Pinpoint the problem as respiratory, circulatory, or both, determining the specific type and severity.

3. Intervene: Implement both general supportive measures (e.g., oxygen, airway positioning) and specific, targeted treatments (e.g., medications, fluid boluses).

Key PALS Protocols and Algorithms

PALS incorporates several key algorithms to manage specific clinical scenarios. Here are the core protocols:

1. The PALS Systematic Approach Algorithm (for a conscious, critically ill child)

This algorithm guides initial assessment and management of a sick or injured child who is not in immediate cardiac arrest.

• Initial Impression: A quick "across the room" assessment of the child's Appearance (is the child interactive?); Breathing (work of breathing, abnormal sounds); and Circulation (skin color) helps determine the severity of the situation within seconds.

• Primary Assessment (ABCDE):

  • Airway: Ensure it is patent. Use head-tilt/chin-lift or jaw thrust maneuvers if necessary.

  • Breathing: Assess respiratory rate and effort. Provide supplemental oxygen or ventilation support as needed.

  • Circulation: Check pulse, capillary refill time, and blood pressure. Support perfusion with fluids or medications if compromised.

  • Disability: Evaluate neurological status using the AVPU scale (Alert, Verbal, Pain, Unresponsive) or Glasgow Coma Scale.

  • Exposure: Conduct a full body check for injuries or rashes while maintaining temperature.

• Secondary Assessment: This involves a focused history using the SAMPLE mnemonic (Signs/Symptoms, Allergies, Medications, Past medical history, Last meal, Events leading to illness/injury) and a thorough physical exam.

• Diagnostic Tests: Order appropriate tests such as ECG, chest X-ray, blood gases, or glucose checks.

2. The Pediatric Cardiac Arrest Algorithm

This is the definitive protocol for a child who is unresponsive with no breathing and no pulse. High-quality CPR is the foundation of this protocol.

Action	Details and Dosages
Confirm Arrest & Start CPR	Shout for help, activate emergency response, check pulse for max 10 seconds. Start C-A-B sequence (Compressions-Airway-Breathing).
CPR Quality	Rate: 100–120 compressions/min. Depth: At least one-third the anterior-posterior (AP) chest diameter (approx. 4 cm for infants, 5 cm for children). Ratio: 15:2 (two-rescuer) or 30:2 (single rescuer).
Rhythm Check (after 2 mins CPR)	Shockable? (VF/pVT): Deliver first shock at 2 J/kg. Immediately resume CPR.
Medication (for shockable or non-shockable rhythms)	Epinephrine: 0.01 mg/kg IV/IO (0.1 mL/kg of 1:10,000 solution) every 3-5 minutes during CPR.
Subsequent Shocks (if shockable)	Second shock: 4 J/kg. Subsequent shocks: ≥4 J/kg (max 10 J/kg or adult dose).
Antiarrhythmics (if refractory VF/pVT)	Amiodarone: 5 mg/kg IV/IO bolus (may repeat up to 2 times). OR Lidocaine: 1 mg/kg IV/IO loading dose.
Identify & Treat Reversible Causes	The "H's and T's" (Hypovolemia, Hypoxia, Hypoglycemia, Hypothermia, Hyperkalemia, etc.; Tamponade, Toxins, Tension pneumothorax, Thrombosis).

3. Pediatric Bradycardia and Tachycardia Algorithms

These algorithms focus on identifying and treating rhythm disturbances before cardiac arrest occurs.

• Bradycardia with poor perfusion: Often treated with oxygenation/ventilation, chest compressions (if pulse < 60 bpm despite support), Epinephrine, and possibly atropine.

• Tachycardia (SVT or VT): May require adenosine or synchronized cardioversion, depending on stability and QRS complex width.

The Importance of Post-Resuscitation Care

Achieving the Return of Spontaneous Circulation (ROSC) is a critical step, but PALS guidelines emphasize comprehensive post-resuscitation care to optimize long-term neurological outcomes.

This involves:

• Optimizing ventilation and oxygenation.

• Managing hemodynamics (blood pressure and perfusion).

• Implementing Targeted Temperature Management (temperature control between 32°C and 37.5°C for at least 36 hours).

• Identifying and treating the underlying cause of the arrest.

Conclusion

Pediatric emergencies are challenging, but the PALS systematic approach and evidence-based algorithms provide a robust roadmap for healthcare providers. By emphasizing early recognition of respiratory distress and shock, high-quality CPR, and effective team communication, PALS dramatically improves survival rates for the youngest, most vulnerable patients.

For healthcare professionals, staying current with guidelines and continuous training is vital to ensure readiness when seconds count. You can find official PALS training and certification information through resources like the American Heart Association.

ABCDE approach

1. Airway Obstruction Protocols

Airway obstruction in a child can rapidly lead to hypoxia and cardiac arrest. Protocols vary significantly based on whether the obstruction is mild or severe, and if the patient is conscious or unconscious.

Conscious Child with Severe Foreign Bod

y Airway Obstruction (FBA0)

If the child cannot cough, speak, or breathe:

• Infants (<1 year): Deliver a sequence of 5 back blows and 5 chest thrusts (similar to compressions but faster and sharper) until the object is expelled or the infant becomes unconscious.

• Children (>1 year): Perform abdominal thrusts (Heimlich maneuver) until the object is expelled or the child becomes unconscious.

• If the child becomes unconscious: Immediately begin CPR starting with chest compressions (CAB sequence). Do not perform blind finger sweeps. Open the airway and look for the object only if you can clearly visualize it and easily reach it.

Airway Management in General Respiratory Distress

Regardless of the cause (croup, asthma, anaphylaxis), the first priority is securing the airway and delivering oxygen.

• Positioning: Allow the child to assume a position of comfort (e.g., sitting up, "sniffing position"). Do not force them to lie flat, as this exacerbates distress.

• Oxygen Delivery: Use the least invasive method possible (blow-by, nasal cannula, face mask) to maintain oxygen saturation >94%.

• Advanced Interventions: If basic measures fail, PALS protocols guide advanced interventions such as non-invasive positive pressure ventilation (NIPPV) or rapid sequence intubation (RSI) if respiratory failure is imminent.

2. Respiratory Distress and Failure Management

PALS differentiates between respiratory distress (increased work of breathing, normal compensation) and respiratory failure (inadequate oxygenation/ventilation).

• Initial Evaluation: Use the Pediatric Assessment Triangle and primary ABCDE survey to classify the problem (e.g., upper airway obstruction, lower airway obstruction, parenchymal disease, restrictive lung disease).

• Treatment Goals: Normalize oxygenation and ventilation using condition-specific therapies.

  • Asthma/Bronchiolitis: Administer albuterol/salbutamol, ipratropium, systemic corticosteroids.

  • Croup: Use humidified oxygen, nebulized epinephrine, and corticosteroids (dexamethasone).

• Escalation: Failure to respond mandates escalation to bag-mask ventilation or intubation.

3. Acute Heart Failure (AHF) Protocols

AHF in children often presents differently than in adults, typically as shock, poor perfusion, or severe respiratory distress due to pulmonary edema.

• Assessment: Look for signs of poor cardiac output: weak pulses, prolonged capillary refill, cool extremities, muffled heart sounds, and hepatomegaly.

• Intervention:

  • Airway/Breathing: Support ventilation; diuretics (furosemide) for pulmonary edema.

  • Circulation: Avoid large, rapid fluid boluses in primary pump failure. Use smaller cautious boluses if signs of hypovolemia coexist.

  • Medications: Initiate inotropes (e.g., milrinone, dopamine, epinephrine infusion) to improve contractility and cardiac output. Consult pediatric cardiology early.

4. Sepsis and Septic Shock Protocols

Sepsis is a time-sensitive emergency that requires immediate, goal-directed therapy within the first hour to prevent multi-organ failure.

• Recognition: Identify fever/hypothermia with signs of poor perfusion (tachycardia, tachypnea, weak pulses, altered mental status).

• The "Sepsis Bundle" (First Hour):

  • Fluid Resuscitation: Administer rapid, aggressive IV/IO fluid boluses (20 mL/kg of isotonic crystalloid) up to 40-60 mL/kg in the first hour. Reassess frequently for fluid overload (rarely a concern in true septic shock without cardiac disease).

  • Broad-Spectrum Antibiotics: Administer appropriate antibiotics within 1 hour of recognition.

  • Vasopressors: If perfusion remains poor after 40–60 mL/kg fluid, start vasoactive medications (e.g., epinephrine or norepinephrine infusions) immediately to maintain adequate blood pressure and perfusion.

  • Glucose Check: Treat hypoglycemia immediately.

5. Neurological Emergencies (Seizures and Status Epilepticus)

Status epilepticus (a seizure lasting >5 minutes, or recurrent seizures without full recovery of consciousness) requires rapid intervention.

• Primary Steps: Ensure safe positioning (side-lying), maintain ABCs, and check blood glucose level.

• Medication Protocol:

  • First Line (Benzodiazepines): Administer Midazolam (IM/IV/IO/buccal/intranasal) or Lorazepam (IV/IO) immediately to stop the seizure.

  • Second Line: If seizures continue, administer a loading dose of an antiepileptic drug like Fosphenytoin or Levetiracetam in consultation with pediatric neurology/ED physicians.

6. Special Circumstances Protocols

PALS protocols adapt for specific, high-risk scenarios:

Drowning

• Priority: Oxygenation First. The primary injury is hypoxia. Secure the airway and begin ventilation/CPR immediately. Do not delay resuscitation to clear the spine unless severe trauma is strongly suspected.

• Hypothermia: Manage core temperature as hypothermia is common. "They aren't dead until they are warm and dead" is an old PALS adage.

Electrocution

• Safety First: Ensure the scene is safe before approaching the patient.

• Assessment: Check for entry and exit burns. PALS follows the standard cardiac arrest algorithm if needed. Defibrillation protocols apply, but note that neurological and muscular injury is common.

Exposure to Toxins/Poisoning

• Immediate Action: Secure ABCs. Contact a Poison Control Center immediately for expert guidance on specific antidotes and treatments. (In the US, call 1-800-222-1222).

• Supportive Care: Management is primarily supportive—treat symptoms like seizures, arrhythmias, or respiratory depression while awaiting toxicologist recommendations. Activated charcoal may be indicated in specific ingestions.