PALS Study Guide

New Updated 2015 AHA Guidelines

Training You Can Trust
ACLS - BLS - CPR - PALS - First Aid
And More!
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Course Overview
This study guide is an outline of content that will be taught
in the American Heart Associaon PALS (Pediatric
Advanced Life Support) Course. It is intended to
summarize important content, but since all PALS content
cannot possibly be absorbed in a class given every two
years, it should be the desire of every Healthcare Provider
to connuously study in order to provide Excellent &
Compassionate Care to both the Pediatric Pa(ent as well
as providing support to the parents.

This guide does not replace the Pediatric Advanced Life Support Provider Manual which can be purchased
or borrowed. Therefore it is only intended as a supplemental guide to help you study for your class and
even more so as a refresher in-between cer(fica(on classes to keep your skills sharp. An addi(onal
resource highly recommend is the AHA Updated ECC Handbook .

We hope you find value in this study guide. Good luck!

Heart Savers Training LLC Team

Course Agenda:
Heart Savers Training, LLC (HST) believes that learning should be non-stressful, educa(onal, prac(cal, and ‘fun.’
That makes us unique in our presenta(on and teaching style. If you have the opportunity to a0end one of our
classes, we hope that you experience ‘why,’ so many Healthcare Professionals enjoy our classes and our teaching
style. Rather than us trying to tell you, just come experience it for yourself.
Below you will find only the ‘dull’ skeletal outline of the items that will be covered. Since no class is exactly ‘the
same’ as the one before it, HST will cover all the material in the order that best suits your class needs as well as in
providing you, your class, and your team a posi(ve, educa(onal experience. Hope to see you there!
• Welcome &Introduc(on Wri0en Exam
• The PALS Overview Pediatric Mega Code Check offs
• BLS Review
* Required Pre-Test *
• PALS Algorithms
The American Heart Associa(on now requires that you take a Pre-Test prior
• Skills Sta(ons & Evalua(ons [IO, Air- to coming to class. Simply print out the completed cer(ficate and bring it
way, Dysrhythmias] with you. If you have trouble prin(ng it out, take a screen shot, either with
your computer or phone, and email a copy to us.
• Simula(on Base Scenarios
The Pre-Test is now required for both the 2-Day Inial and 1-Day Recert
Class. The Pre-Test can be found at h6p://heart.org/eccstudent [A
password is required and can be found in the PALS Provider Manual]

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 2015 AHA PALS Science
Pediatric Resuscita(on Updates
“Pediatric care is constantly advancing and improving”

• CAB
• Compressions
• For Infants and Prepubescent children, you are to depress the depth of the chest at least one
third the AP diameter of the chest and allow for complete recoil
• Infants = 1 1/2 inches or 4 cm
• Children = 2 inches or 5 cm
• Important: Compressions are important, however, some data states that it is possible
to compress too deeply. According to current BLS guidelines, the maximum depth of
compression is 2.4 inches or 6 cm , which according to The American Heart Association
should be followed in an ‘average size’ adolescent.
• Compression Rate is the same as with adults, for both infants, children, and adolescents at
100 to 120 compressions per minute
• Minimizing Chest Compressions: When performing CPR, chest compression
interruptions should be minimal. We should never stop compressing for longer than 10
seconds. Therefore, any treatments, such as: Intubation, establishing an IV, giving
ventilations, etc., should be done while compressions are going on.

• Fluid Resuscitation
• The American Heart Association advises that Rapid Identification and Intervention of SHOCK is
an essential component of all pediatric resuscitation.
• They go on to state that the cornerstone of the treatment of both HYYPOVOLEMIC and SEPTIC
Shock has been the EARLY and RAPID administration of Isotonic Crystalloids [Normal Saline /
Lactated Ringers], which of course should be based on an individualized plan based of each patient
from findings of frequent clinical assessments before, during, and after the fluid therapy has been
given.

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 2015 AHA PALS Science
Pediatric Resuscita(on Updates
“Pediatric care is constantly advancing and improving”

• Atropine
• The administration of Atropine use to be recommended to be given to children before endotracheal
intubation.
• When Atropine is used, the new recommended dosage is 0.02 mg/kg, with no minimum dose, as a
premedication prior to intubation
• Important Note: However, new studies seem to contradict whether Atropine actually even
prevents Bradycardia and other arrhythmias. Also, at the time that this PALS Study Guide was
written, there is no currently no evidence to support the routine administration of Atropine as a
premedication in emergency intubations..

• Invasive Hemodynamic Monitoring During CPR

• The American Heart Association encourages, if already in place, the use of invasive
hemodynamic monitoring devices and their measurements to guide high quality CPR, by high
level emergency providers .

• Lidocaine vs. Amiodarone

• PALS now differs in the guidelines for use of anti-arrhythmias in the treatment of Refractory VF or
Pulseless VT, from previous therapies and for that of adults in ACLS.
• Note: In previous guidelines, Amiodarone was once the preferred drug of choice over
Lidocaine in the treatment of shock-refractory VF or Pulseless VT in children
• Recent studies have now shown that neither Lidocaine or Amiodarone has been associated with
improved survival to hospital discharge
• New Guidelines now allow for the Healthcare Provider to chose either drug for shock-refractory
cardiac arrest arrhythmias.

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 2015 AHA PALS Science
Pediatric Resuscita(on Updates
“Pediatric care is constantly advancing and improving”

• Using Vasopressors for Resuscitation

• In cardiac arrest, Epinephrine should be given, which has been shown to have improved ROSC, and
survival to hospital admission in adults, but is not shown to improve survival to hospital dis-
charge
• Interestingly, in Pediatric Studies, the administration of Epinephrine during cardiac arrest has been
noted to have too many variables to determine the effectiveness of the Epinephrine, and more study
and data is needed.

• ECPR [Extra-Corporeal Cardiopulmonary Resuscitation]

• Children who have underlying cardiac conditions and experience in-hospital cardiac arrest, ECPR
may be considered for patients who are unresponsive to conventional CPR
• This procedure needs to be performed only in hospitals where the necessary expertise, equipment,
and respective protocols are already in place.

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 2015 AHA PALS Science
Pediatric Resuscita(on Updates
“Pediatric care is constantly advancing and improving”

• Targeted Temperature Management

• Formerly known as: Hypothermia Protocol, or in hospitals as
‘Code Cool’ or ‘Artic Sun’, etc..
• For children who are comatose in the first several days after in-
hospital or out-of-hospital cardiac arrest temperature should be
monitored continuously and fever treated aggressively!
• For comatose children who achieve ROSC, in out-of-hospital
cardiac arrest, providers should maintain either:

5 days of Normothermia [36 C to 37.5 C (96.8 F to 99.5 F)]

or
2 days of Hypothermia [32 C to 34 C (89.6 F to 93.2 F)]
3 days of Normothermia [36 C to 37.6 C (98.6 F to 99.5 F)]

• For comatose children who achieve ROSC, in-hospital cardiac arrest, there is insufficient data to
recommend Hypothermia over Normothermia.

• Post-Cardiac Arrest Fluids and Inotropes

• Healthcare providers should use Inotropes and Vasopressors to maintain a systolic blood pressure
above the 5th percentile for the child’s age.
• In order to maintain this, healthcare providers should use Intra-arterial blood pressure monitoring,
when possible, in order to assess blood pressure and identify hypotension.
• Recent studies have shown that children who experience post-ROSC hypotension have a worse

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 2015 AHA PALS Science
Pediatric Resuscita(on Updates
“Pediatric care is constantly advancing and improving”

• Post-Cardiac Arrest: PaO2 and PaCO2

• Post resuscitation also includes managing the patient’s oxygen
• Healthcare providers may need to titrate oxygen administration to achieve Normoxemia [an
oxygen saturation of 94% or above].
• Oxygen in children should be targeted for an oxyhemoglobin saturation of 94% to 99%.
• The Goal: To avoid Hypoxemia which is essential, by achieving the appropriate oxygen
saturation, which is found to be essential in improving survival to pediatric intensive care unit
discharge.
• Ventilations for post-ROSC should target an arterial partial pressure of carbon dioxide
[PaCO2] that is appropriate for the age of the patient, while also avoiding Hypercapnia [CO2 re-
tention] and Hypocapnia [a deficiency of CO2]
• Studies show that in adults, Hypocapnia have worse results.

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 Crical Concepts -
The BLS Survey
• Compress the chest hard and
Why high quality CPR? Rarely do children go into fast between 100-120 min.
cardiac arrest in and of itself, unless it is congenital in nature.
• Allow complete chest recoil
Usually when a child goes into cardiac arrest, it is because of
aDer each compression
something else ‘causing’ it. Fixing the underlying cause is
essenal. However, THE best thing that can be possibly done for • Minimize interrup(ons in
a child / infant in cardiac arrest is GOOD, HIGH QUALITY CPR. compressions (no more than
10 seconds)
CPR is known to keep a li0le blood flow to the heart and brain,
while wai(ng for the AED or defibrillator. It also is known to • Switch providers every two
lengthen the V-fib window – TIME is brain and heart. minutes to prevent fa(gue

• Avoid excessive ven(la(ons

C-A-B
Assess Assessment Techniques & Acons

• CHILD: Tap and shout, “Hey, hey, are you okay?”

1 Check Responsiveness
• INFANT: Tap the baby’s foot—”Baby, baby, are you okay?”

Acvate the Emergency • Acvate or send someone to acvate the emergency response system [911/RRT/
MET/CAT] and get an AED, if one is available.
2 Response System / Get
• Note: If no one responds to your call for help, you must perform two minutes of
AED CPR / Rescue Breathing before you can personally acvate the EMS/RRT system

• CHILD: Check for a Carod pulse for 5 - 10 seconds

• INFANT: Check for a Brachial Pulse for 5 to 10 seconds
• While checking a pulse, also check to see if the infant/child is breathing. If there is
no pulse, the heart rate is < 60, or you are not sure if there is a pulse, start CPR
(30:2) beginning with chest compressions [CAB] unl further help arrives

3 Circulaon
• Compress the center of the chest (lower half of the sternum) hard and fast
between 100-120 compressions per minute at a depth of:
• CHILD: 2 Inches - Use one or two hands
• INFANT: 1 1/2 inches or 1/3 the diameter of the AP - Use two fingers
• When a second rescuer is present, use 15:2 rao and the thumb encircling method
for compressions.
• If there is a pulse, start rescue breathing at 1 breath every 3-5 seconds for an

• If no pulse, check for a shockable rhythm with an AED/defibrillator

4 Defibrillaon • Provide shocks at 2 joules/kg, repeang at 2 - 4 joules/kg, then at 4 joules/kg, up to
and no greater than 10 joules/kg following immediately with high quality CPR

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 In each step of the Pediatric Pa(ent assessments, we are
to use the Evaluate-Idenfy-Intervene sequence
when caring for a seriously ill or injured child to be alert
to life-threatening problems

1. Evaluate
• Evaluate the child to gather informaon about the child’s
condion and status
• Primary Assessment
• Secondary Assessment
• Diagnosc Tests

3. Intervene
• With the appropriate acons, treat and
‘Fix’ the problem BEFORE moving onto the
next step
• Then REPEAT the Process which is ongoing
2. Idenfy
• Determine if there are any problems or
significant findings by type and severity
• Especially if they are Life-Threatening

Three Disnct Assessments

PALS and ACLS now follow the same 3 stages of Paent Assessment. Children
are not ‘li0le adults.’ And since a child can COMPENSATE much faster than an
adult we have to also realize that they can also DECOMPENSATE faster, too.
Therefore, in dealing with the Pediatric Pa(ent there are three (3) SEPARATE
assessments, each one dis(nct, and important. They are:

• The Inial Assessment

• The Primary Assessment
• The Secondary Assessment

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The Inial Assessment

NOTE: What is their:

• Only one (1) of these • Level of Consciousness

has to be ‘off’ • Unresponsive
• If the paent has no • Degree of Interac(vity
pulse, and is not
breathing, begin CPR.
Appearance • Muscle Tone
• Verbal Response or Cry

Do you noce:
How is the pa(ent perfusing? • Apneic
• Pale • Tripod or Sniffing Posion
• Mo0led / Gray • Retracons
• Cyano(c • Audible/Unusual Breath Sounds

Circulaon Work of
to Skin Breathing

APPEARANCE: Inial Assessment of the pediatric pa(ent begins when you first lay eyes on
them from ‘across the room’.
Whether that is when you walk into the pa(ent’s room observing them from the doorway, or they
are being brought to you, coming down the hall, or as a Paramedic when you first see them as you
enter a home/classroom, on a ball field, etc.
When your eyes first see the child you are assessing these three immediate things that will let you
know if this pa(ent is in a possible Life-Threatening Condion.

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The PALS Systemac Approach connues...

You are now at the paent’s side performing what is known as the
PRIMARY ASSESSMENT. The previous Assessment was to determine if
(1) Your pa(ent was in a possible life-threatening condi(on, and (2) If you
The Primary Assessment
were going to need addi(onal help. Now, you will see if you can iden(fy
any life-threatening problems, with immediately beginning any
appropriate interven(ons before going to the next one. It is the A, B, C, D,
&E

A. Airway • Is the Airway: Is the airway: Clear, Maintainable [Patent], or Not

Maintainable

B. Breathing • Respiratory Rate and Pa6ern

∗ Normal - Regular [Is it normal for their Age]; Irregular, Is it too
Fast or too Slow; Apnea

• Respiratory Effort:
∗ Normal or Abnormal [Does it occur on Inspira(on / Expira(on?]
AGE BREATHS PER ∗ Signs of Increased effort:
∗ Nasal flaring
Infant ( < 1 year 30 to 60
∗ Head bobbing: Caused by the use of neck muscles to
Toddler (1 - 3 24 to 60 assist breathing, it indicates that the child has increased
risk for deteriora(on. Most frequently seen in infants
and can be a sign of respiratory distress
Preschooler (4 - 22 to 34
∗ Seesaw Respira(ons

School Age (6 - 18 to 30 ∗ Inadequate [Apnea, Weak cry or cough]

• Chest Expansion and Air Movement

Adolescent (13 - 12 to 16 ∗ Normal / Increased / Unequal / Prolonged: inspira(on /
Expira(on

• Abnormal Lung and Airway Sounds

∗ Stridor [Upper] Wheezing [Lower] Snoring
Grun(ng
∗ Barking Cough Hoarseness Gurgling
∗ Crackles Unequal

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The PALS Systemac Approach connues...

Connues…
The Primary Assessment

• Oxygen Saturaon by Pulse Oximetry

B. Breathing ∗ Note: Pulse oximetry normally gives an accurate es(mate of
hemoglobin oxygen satura(on in the blood. BUT does NOT provide
[Connued]
evidence of OXYGEN DELIVERY or CARBON DIOXIDE elimina(on
∗ Normal Oxygen satura(on ( 94% > )
∗ Hypoxemia ( < 94% )
∗ Important: Be sure to include PECO2 - to determine
adequate PERFUSION of the pa(ent

• Auscultate ALL lung fields

∗ Front of the chest

Important Note: ∗ Just to the LeD and Right of the Sternum

A consistent respiratory rate of less ∗ Under each Axilla

than 10 or more than 60 breaths/
min in a child of any age is abnormal
and suggests the presence of a
potenally serious problem.
∗ Both sides of the Back
∗ Ask:
∗ Is the Air Movement: Normal or Abnormal / Decreased
∗ Compare breath sounds on:
∗ The LeD and Right

∗ The Front and Back

∗ Listen for Abnormal Sounds
∗Determine if air movement is

∗ Normal
∗ Decreased

Important Note:
Determine if the child / infant is either in Respiratory Distress or Respiratory Failure

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The PALS Systemac Approach connues...
Note:
B. Breathing
• Respiratory DISTRESS may progress RAPIDLY to
[Connued]
Respiratory FAILURE

Signs of Respiratory DISTRESS:

• Children usually have an increased Pulse Rate
[Tachycardia]
• Tachypneic
• Increased respiratory effort [e.g., nasal flaring, retrac-
ons, head bobbing]
• Inadequate respiratory effort [e.g., hypovenlaon or
bradypnea]
• Abnormal airway sounds [e.g., stridor, wheezing,
grunng]
• Pale, cool skin
• Changes in level of consciousness

Signs of Respiratory FAILURE:

• Decreased Level of Consciousness
• Stupor, coma (late)

• Very Rapid or Inadequate respiratory rate

• Marked tachypnea (early)

• Bradypnea, apnea (late)

• Increased, decreased, or no respiratory effort
• Poor or absent distal air movement

• Significantly increased or Inadequate [decreased]

Respiratory Effort
• Low Oxygen saturaon (via a Pulse Oximeter) despite
high-flow oxygen that is being delivered to the child
• Cyanosis
• Abnormal heart rate
• Tachycardia (early)

• Bradycardia (late) - Ominous sign

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The PALS Systemac Approach connues...

Connues…
The Primary Assessment

• To determine CIRCULATION, check the:

C. Circulaon • Heart Rate and Rhythm
∗ Normal
∗ Fast [Tachycardia]
∗ Slow [Bradycardia]
∗ These can be affected by:
Important Note: ∗ Anxiety Pain
If the Heart Rate is < 60 bpm with ∗ Fever Agita(on
signs of Poor Perfusion despite
• Pulses
adequate oxygenaon and
venlaon, start CPR immediately ∗ Central [Normal, Weak, Absent]

∗ Peripheral [Normal, Weak, Absent]

• Capillary Refill Time

∗ Normal: < 2 seconds
Capillary Refill: ∗ Delayed: > 2 seconds
• Normal capillary refill me is 2
• Skin Color and Temperature
seconds or less
• Delayed capillary refill is not ∗ Pallor Mo0ling Cyanosis
always abnormal ∗ Warm Skin Cool Skin
• However, any notaon of
capillary refill me >2 seconds
needs to be noted and the • [Connued on Page 15]
underlying cause determined
and addressed as soon as possi-
ble

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The PALS Systemac Approach connues...

Connues…
The Primary Assessment

• To determine CIRCULATION, check the:

C. Circulaon • Heart Rate and Rhythm
[Connued] ∗ Normal
∗ Fast [Tachycardia]
∗ Slow [Bradycardia]
∗ These can be affected by:
∗ Anxiety Pain
∗ Fever Agita(on

• Pulses
∗ Central [Normal, Weak, Absent]

∗ Peripheral [Normal, Weak, Absent]

• Capillary Refill Time

∗ Normal: < 2 seconds
∗ Delayed: > 2 seconds

• Skin Color and Temperature

∗ Pallor Mo0ling
∗ Warm Skin Cool Skin
∗ Cyanosis
∗ Skin Nail beds
∗ Mucous membranes
∗ Compare temperature of Trunk with Extremi(es

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The PALS Systemac Approach connues...
• To determine CIRCULATION, check the:

The Primary Assessment • Blood Pressure

• Note:
• The Cuff should extend to cover at least 50 to 70% of
the upper arm, from the axilla to the antecubital fossa
• The bladder in the cuff should also not cover more than
C. Circulaon 40% of the mid-upper arm circumference
[Connued] • A cuff that is too LARGE will give falsely LOW values
• A cuff that is too SMALL will give falsely HIGH values
• If the Systolic Blood Pressure is NORMAL or ABNORMAL
for children aged 1 to 10 years of age, based on the
following formula [based on the new 2015
Standards]

HYPOTENSION by Systolic Blood Pressure and Age:

Infants ( O - 28 days) Systolic < 60
Children ( 1 to 10 years) = < 70 mm Hg + (2 x age in years)
Children > 10 years = < 90

• Normal Blood Pressures would be starng at these parameters and greater

• For a more in-depth lisng of Blood Pressures per age, see page 53 of the PALS
Provider Manual

Automated Blood Pressure Cuffs may provide inaccurate HIGH readings when the child is in
SHOCK. Therefore, if the child is in SHOCK, an ATERIAL CATHETER/LINE is inserted to enable
accurate monitoring of the child’s intra-arterial pressure. The readings obtained should be
very accurate if the system has been set up properly and the catheter is patent

*** Children can be in SHOCK and sll have a NORMAL Blood Pressure ***
Hypotension is a very LATE SIGN of SHOCK and should be MONITORED CLOSELY due to rapid
deterioraon

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The PALS Systemac Approach Connues...

Connues…
The Primary Assessment

D. Disability • AVPU Pediatric Response Scale is used to assess the child’s

Level of Responsiveness
∗ A Alert
• Decreased level of conscious-
∗ V Responds to Voice
ness
∗ P Responds to Pain [Example: Sternal Rub]
• Loss of muscular tone
∗ U Unresponsive
• Generalized seizures
• Pupils: Here we are checking of:
• Pupil dilaon / constricon /
unequal • Size
• Symmetry
• Reacon to Light
∗ Note: Unequal pupils may suggest a very serious problem:
∗ Increase intracranial pressure [Head Injury]

∗ Eye Injury
∗ Possible inges(on of Drugs/Toxins
∗ Note:
∗ Normally, pupils rapidly CONSTRICT in response to light
∗ When you shine a light into one eye, the other eye should
normally constrict also [consensual constricon]
∗ Slow, or Low constric(on may indicate increased intra-
cranial pressure
∗ If one or both pupils are dilated, par(cularly if they don’t
react to light, the child may have a severe and life-
threatening increase in intracranial pressure and require
immediate evalua(on and treatment

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The PALS Systemac Approach Connues...

Connues…
The Primary Assessment

D. Disability ∗ Blood Glucose

∗ Note: For any:
∗ Seriously INJURED child
∗ SERIOUS ILL child
∗ Or any child with a noted DECREASED LEVEL
OF CONSCIOUSNESS
∗ A Blood Glucose should be obtained
as soon as possible to assess for
either:
∗ Hypoglycemia
∗ Hyperglycemia

∗ Neonates: Blood glucose concentra(on off at

least 45 milligrams per deciliter

∗ Infants and Older Children: Blood glucose

concentra(on of at least 60 milligrams per deciliter

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The PALS Systemac Approach Connues...
The Primary Assessment
E. Exposure
Addional Thoughts:
• Undress the seriously ill or
injured child as necessary to
perform a focused physical
examinaon
• Maintain cervical spine
precauon when turning
any child with a suspected
neck or spine injury.
• Look for evidence of trauma
such as bleeding, burns, or
unusual markings that sug-
gest non accidental
trauma
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Connues…
• Note:
• When performing the Exposure part of the Primary Assess-
ment, do a complete ‘head-to-toe’ VISUAL EXAM of the Skin
and Body.
• Important: Be sure to include the BACK and PERINEAL AREA
• Temperature
∗ Normal
Note:
∗ High
• Infecons are usually associated with
∗ Low Fever
• Skin • Serious infecons, especially in Infants
∗ Injury and immunocompromised children, may
cause HYPOTHERMIA
∗ Discolora(on
∗ PURPURA: Leaking blood into the skin, joints, intes(nes,
or organs can be caused by:
∗ Trauma
∗ Underlying Disease
∗ Medica(on Side Effects
∗ PETECHIAE: Non-blanching purple discolora(ons in the
skin caused by bleeding from capillaries and small vessels
∗ Trauma
∗ Bleeding
∗ Burns
∗ Other types of Injury
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The PALS Systemac Approach Connues...
The Secondary Survey
This helps you obtain vital informaon
in a Systemac Approach with each
paent
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The Secondary Survey involves further treatment of the
Pediatric Paent in the following areas:
• S. A. M. P. L. E. [To be covered in class]
• Management of:
• Respiratory Emergencies
• Shock Emergencies
• Cardiac Emergencies
• Head-To-Toe Exam
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 Management of Respiratory Emergencies

There 4 Types of Respiratory Problems

1. Upper Airway obstrucon:

• Increased respiratory rate and effort
• Retrac(ons - Occur in children with in-
creased chest wall compliance and nega-
(ve intrathoracic pressure
• Nasal Flaring
• ODen Characterized by:
• Inspiratory Stridor Hoarseness Drooling
• Barking Cough Snoring Gurgling Sounds
• Note: Older children will oDen posi(on themselves in a way to make their breathing
easier. Allow them to remain in a posion of comfort.

• Treatments:
♦ Croup: Modified oxygen
Nebulized (Racemic) epinephrine
Cor(costeroids
♦ Anaphylaxis: IM epinephrine or auto injector
Nebulized (Racemic) epinephrine
An(histamines
Cor(costeroids
♦ Foreign body: By allowing posi(on of comfort
Specialty consulta(on

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2. Lower Airway obstrucon:
• Asthma and Bronchioli(s are common causes.
• Air movement may decreased
• Exhala(on may be prolonged
• Expiratory wheezes [may be prolonged]

• Treatments:
• Bronchioli!s: Nasal suc(oning and Bronchodilator
♦ Asthma: Nebulized DuoNeb or Albuterol Cor(costeroids
IM Epi Magnesium Drip
Terbutaline/Xopenex Solu-Medrol

3. Lung Tissue (Parenchymal) disease:

• Causes:
• Pneumonia [Infec(ous / Chemical or Aspira(on]
• Pneumoni(s
• Respiratory Syncy(al Virus (RSV)
• Pulmonary Edema [Cardiogenic / Noncardiogenic or ARDS]
• Symptoms:
• Demonstrates increased respiratory RATE and EFFORT
• This may include:
• GRUNTING
• DECREASED AIR MOVEMENT
• CRACKLES

• Treatments:
♦ An(bio(cs Albuterol / Duoneb
♦ Tylenol for Fever Ven(lator Support if needed
♦ Non-Invasive / PEEP Vasoac(ve Agent
♦ Diure(c

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4. Disordered control of Breathing:
• Can be caused from Brain Injury or Drug Overdose
• Note: Clinical Signs & Symptoms can be NORMAL
• Can also be characterized by:
• IRREGULAR BREATHING PATTERN
• RESPIRATORY RATE is oDen SLOW
• Breathing may be SHALLOW, with INADEQUATE Respiratory Effort
• Air movement may be NORMAL or DECREASED
• May also have: POOR MUSCLE TONE and/or ALTERED MENTAL STATE causing upper air-
way obstruc(on
• Increase ICP, Poisoning/overdose, and neuromuscular disease are common causes
• Irregular breathing pa0ern (“funny breathing”)

• Treatments:
♦ Increased ICP: Avoid: Hypoxemia
Hypercarbia
Hyperthermia
♦ Poisoning/Overdose: An(dote
Call poison control center
♦ Neuromuscular disease: Consider non-invasive or invasive Ven(lator support.

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Breathing Difficulty Locaon of Retracon Descripon

Mild to Moderate Subcostal Retrac(on of the Abdomen

just below the ribcage

Substernal Retrac(on of the Abdomen at

the bo0om of the breast bone

Intercostal Retrac(on between the ribs

Severe Supraclavicular Retrac(on in the Neck just
above the collar bone
Suprasternal Retrac(on in the Chest just
above the breast bone
Sternal Retrac(on of the Sternum
toward the spine

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• The proper use of the correct Airway Device will depend on the severity, need, and condion of the child
or infant
• Oxygen devices vary in the amount of oxygen they provide and concentraon that is delivered
• Oxygen concentraon delivery is determined by four factors:
• Child’s Size
• Oxygen Flow Rate
• Respiratory Rate
• Breathing Volume

Provide oxygen:
• The LOWER the oxygen flow, the LOWER the inspired oxygen concentraon that is delivered
♦ Room air has 21% oxygen
♦ Low flow Oxygen (<10 L/min) pa(ent inspiratory flow exceeds 02 flow
♦ Nasal Cannula: (1 to 4 liters) = increases oxygen by 4% for each liter
♦ Face Mask
♦ Without reservoirs increases oxygen by 10% for each liter not recommended to give
more than 40 to 60% without reservoir
♦ Delivered at a minimum of 6 liters per minute, no higher than 10 liters per minute
• The HIGHER the oxygen flow, the HIGHER the inspired oxygen concentraon that is delivered
♦ High flow oxygen systems
♦ >10 min, usually at 15 lpm) O2 flow exceeds pa(ent inspiratory flow
♦ Tightly sealed against the face
♦ 1-way Valve (that allows exhala(on, but no entrainment of room air)
♦ Has a Reservoir Bag
♦ Nonrebreather Mask

♦ [NRB or Face Mask with reservoir ] = ability to provide 100% oxygen

♦ Delivered at 10 to 15 liters per minute (preferably 15 lpm)
♦ The reservoir bag should always be at least par(ally inflated

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♦ High-Flow Nasal Cannula
♦ Used commonly with the inpa(ent in ICU se[ngs
♦ The flow can be adjusted from 4 liters in Infants to 40 liters in adolescents
♦ The flow can also be (trated to provide addi(onal inspiratory and expiratory pressures which
may improve the pa(ent’s work of breathing
♦ These systems deliver a combina(on of both room air and oxygen
♦ They also allow healthcare providers to (trate the oxygen concentra(on based on the pa(ent’s
needs and satura(ons
♦ Posive Pressure Devices
♦ Bag Mask
• Understanding and knowing how to use a Bag Valve Mask Device (BVM) will be THE most
important Life-Saving skill that you can perform
• Using a BVM with an oxygen concentra(on reservoir can deliver an oxygen concentra(on of
nearly 100%
• Requires a flow rate of at least 10 liters per minute, preferably higher
• Note: The BVM cannot deliver ‘blow by’ oxygen to a pa(ent. NO oxygen is released
from the bag un(l the bag is depressed
• When performed correctly, BVM ven(la(on can be as effec(ve as delivering ven(la(on
through and endotracheal tube (ET Tube) for short periods of (mes
• There are two types:
◊ Flow – inflang Bags Requires compressed gas source, but can deliver free-flow
oxygen at 100%
◊ Self – inflang No compressed gas source is required, unable to deliver free-
flow oxygen, needs a reservoir to deliver 100% oxygen
• When using a BVM, two other intervenons MUST be implemented:
• SUCTIONING
• Never suc(on longer than 10 seconds i
• Suc(oning is only performed ‘coming out’ of the airway, never ‘going in’

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• SUCTIONING [connued]
• There are various hard and soD suc(oning (p devices
• COMPLICATIONS from Suc(oning:

• Hypoxia Vomi(ng
• Vagal S(mula(on SoD Tissue Injury
• Bradycardia Gagging
• Agita(on
• During suc(oning, always monitor the child or infants:
• Heart Rate
• Oxygen Satura(on
• Clinical Appearance
• INSERTING AN ORAL AIRWAY
• Also known as an OPA or Oral Pharyngeal Airway
• Use only with an Unconscious pa(ent with NO gag reflex
• It keeps the tongue from obstruc(ng the tracheal opening / glo[s
• Choose correct size by measuring from the corner of the mouth to the angle of the
jaw.
• Too LARGE: It will BLOCK the airway
• Too SMALL: It can cause the TONGUE to obstruct the airway
• Insert while using a tongue depressor to hold the tongue on the floor of the mouth
and follow the anatomical structure of the oropharynx for inser(on.
• DO NOT put the airway in upside down / towards the roof of the mouth and twist it
180 degrees - it can cause serious damage to the child’s / infant’s mouth
• It is s(ll necessary to keep the head and neck in the sniffing posi(on aDer the oral
pharyngeal airway is in place
• Again, DO NOT use this device with Conscious Children as it can cause Vomi(ng and
Gagging

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 *

• Nasopharyngeal Airway
• Can be used on a Semi - conscious pa(ent
• Choose size based upon the diameter of the nostril (a 12F or 3mm will generally fit a full term infant)
• For proper length, measure from the nose to the ear
• DO NOT use in a pa(ent with a possible head injury [especially a Basal Skull Fracture]

Important:
• When a BVM alone is not effecve in providing adequate oxygen venlaon, then
an ADVANCED AIRWAY may need to be inserted
• Reasons for Inseron of an Advanced Airway include:
• Difficulty in providing effecve Bag-Mask venlaon
• Actual or potenal airway compromise
• Protecon of the Airway
• Advantages of an Advanced Airway
• Reduces the risk of possible Aspiraon and Gastric Insufflaon
• Elimates the need to interrupt chest compressions during CPR

• Endotracheal Tube – usually the ideal airway in both pre-hospital and hospitalized paents
• The E.T. tube is placed using a laryngoscope, looking for the triangular vocal cords, and placing the E.T.
tube through them.
• Determine the proper uncuffed size by age / (divided by) 4, then + (add) 4

• Example age 2 / 4 + 4 = 4.5 size)

• Determine proper cuff size by age / (divided by) 4 then + (add) 3.5—Note: cuffed tubes should not be
inflated to a pressure of >20 cm H2O)
• Intuba(on a0empts should be limited to 30 seconds [‘If you need to take a breath, so does your pa(ent.’]

♦If bradycardia develops or the clinical condi(on of the child being intubated deteriorates, interrupt the
intuba(on a0empt to provide bag-mask ven(la(on with 100% oxygen.

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 *

• Endotracheal Tube [connued]

• Complica(ons of ET Tube Placement
• Trauma to the oropharynx
• Incorrect placement into the esophagus or bronchus

• Confirming E.T. Tube placement:

• THE best way to indicate proper E.T. Tube placement is with CAPNOGRAPHY

• Auscultation of the lungs in all four quadrants to determine equal and bilateral breath sounds, all fields
• Auscultation of the gastric area should produce no gurgling sounds which would indicate intubation of the
esophageal area
• Mist in the tube, though an indicator, is no longer considered a reliable confirmation of proper tube
placement
• Visualization of the cords as the E.T. Tube passes through them
• X-Ray of the chest to confirm placement
• Confirmation with CO2 detector color change device after six ventilations or Esophageal Detector, though
still used in some places, is no longer a very good or reliable indicator to confirm proper placement
(though still used by many hospitals). However, If it used, do not use an esophageal detector on children
less than 20Kg.

Capnography
The importance of Capnography, and all it entails for the Pediatric Paent will be covered more in-
depth in class. Capnography is the standard of care in the AHA 2015 Guidelines for both ACLS & PALS.
You can find further available informaon for study located under the Resource Secon on our website
as a Free Download at:

www.4CPR.org

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• If deterioration in respiratory status occurs in an intubated child, use the DOPE mnemonic to
determine the problem

D. O. P. E.
• D – Displacement – especially without cuffs, E.T. tubes in children can become easily dis-
placed. Correct placement should be confirmed each and every time a child is moved.

• O – Obstruction – E.T. tubes in children can be very small and easily become occluded
• P – Pneumothorax – If breath sounds are diminished on one side, the patient may have a
pneumothorax. Other signs indicating a pneumothorax include: tracheal deviation (though a
later sign), O2 saturation remains low, tachycardia and tachypnea are present. Perform an I
mmediate needle decompression followed by chest/thoracotomy tube placement.

• E – Equipment – always check to make sure that the equipment is functioning properly. If
equipment failure does occur, simply bag the patient with a BVM with supplemental oxygen.

• Laryngeal Mask Airway (LMA) / AirQ [In many loca(ons, the AirQ is replacing the old LMA]

• It is inserted without visualizing the vocals

• Used as a rescue device when ET Tube intuba(on cannot be accomplished successfully

• Other Airway Devices

• Combitube
• King LT

• Final Thoughts on Airway Devices:

• Always Maintain the arterial oxyhemoglobin saturation at a minimum of >94%.
• You should never HYPERVENTILATE the pediatric patient
• 100% is no longer the goal for arterial oxyhemoglobin.
• An Oxyhemoglobin saturation of 100% is generally an indication to wean the FiO2

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• If deterioration in respiratory status occurs in an intubated child, use the DOPE mnemonic to
determine the problem

D. O. P. E.
• D – Displacement – especially without cuffs, E.T. tubes in children can become easily displaced.
Correct placement should be confirmed each and every time a child is moved.

• O – Obstruction – E.T. tubes in children can be very small and easily become occluded
• P – Pneumothorax – If breath sounds are diminished on one side, the patient may have a
pneumothorax. Other signs indicating a pneumothorax include: tracheal deviation (though a
later sign), O2 saturation remains low, tachycardia and tachypnea are present. Perform an I
mmediate needle decompression followed by chest/thoracotomy tube placement.

• E – Equipment – always check to make sure that the equipment is functioning properly. If
equipment failure does occur, simply bag the patient with a BVM with supplemental oxygen.

• Laryngeal Mask Airway (LMA) / AirQ [In many loca(ons, the AirQ is replacing the old LMA]

• It is inserted without visualizing the vocals

• Used as a rescue device when ET Tube intuba(on cannot be accomplished successfully

• Other Airway Devices

• Combitube
• King LT

• Final Thoughts on Airway Devices:

• Always Maintain the arterial oxyhemoglobin saturation at a minimum of >94%.
• You should never HYPERVENTILATE the pediatric patient
• 100% is no longer the goal for arterial oxyhemoglobin.
• An Oxyhemoglobin saturation of 100% is generally an indication to wean the FiO2

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31
 PEDIATRIC SHOCK
• SHOCK is a CRITICAL, LIFE-THREATENING Medical Condi(on
• Shock is a condi(on of CIRCULATORY FAILURE that results from inadequate delivery of oxygen and other
nutrients to the (ssues to meet their demands.
• Shock is oDen, but is not always characterized by inadequate peripheral and end-organ perfusion.
• The defini(on of shock does not depend on blood pressure measurements, but shock can occur with a
normal, increased, or decreased systolic blood pressure and cardiac output
• In Shock, the cardiac output is inadequate to meet the (ssue oxygen needs.
• Shock is progressive, so that that child or infant in shock requires urgent medical care to avoid the end
result of cardiac arrest.
• Because shock is progressive, the child and infant in shock will deteriorate, and may deteriorate rapidly.
• We must remember:
• A child can compensate rapidly in shock, but can also decompensate even more rapidly
• A child that appears ‘normal’ may actually be in a compensatory moment, and on the verge of
‘crashing.’ That is why a child and infant, especially in shock, must be constantly reevaluated.
• As healthcare providers we MUST be able to iden(fy the TYPES, SIGNS, and SYMPTOMS of each shock
and know how to treat them, as soon as possible.

Shock can be categorized into 4 Basic Types:

• Hypovolemic Shock
• Distribuve Shock
• Cardiogenic Shock
• Obstrucve Shock

Note: The earlier we recognize shock, establish priories, and

start treatment, the be6er the child’s chance of a good outcome.
In the treatment of shock, the goal is to improve O2 delivery. This
will help prevent end-organ injury and stop the progression of
cardiopulmonary failure and cardiac arrest.

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 PEDIATRIC SHOCK
• Hypovolemic Shock
• THE most common cause of shock in children worldwide.
• Result of VOLUME LOSS that is usually due to:
• VOMITING
• DIARRHEA
• INADEQUATE FLUID INTAKE
• OSMOTIC DIURESIS (e.g., DKA),
• THIRD SPACE LOSSES (fluid leaking into the (ssues)
• LARGE BURNS
• HEMORRHAGE (internal and external)
• SIGNS of Hypovolemic Shock:
• TACHYCARDIA
• POOR PERFUSION
• LEVEL OF CONSCIOUSNESS may be normal, at first, but will decrease as shock progresses
• BLOOD PRESSURE
• In the beginning of shock may be HIGH due to the release of catecholamines
• As shock progresses, the blood pressure will FALL

• IMPORTANT *
If HYPOTENSION is present, there must be IMMEDIATE TREATMENT to prevent CARDIAC ARREST

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 PEDIATRIC SHOCK

• Distribuve Shock
• Is characterized by inadequate distribu(on of blood flow to some (ssue beds but too much blood
flow to others
• It is typically associated with VASODILATION and some CAPILLARY LEAD, as well as DECREASED
HEART FUNCTION
• Signs and Symptoms of Distribu(ve Shock is more variable than that of Hypovolemic Shock
• SIGNS of Distribu(ve Shock:
• TACHYCARDIA
• POOR PERFUSION
• WARM, FLUSHED SKIN
• BRISK CAPILLARY REFILL Note: Sepc Shock may occur over Hours

• The most COMMON FORM of Distribuve Shock is: SEPTIC Shock

• This usually results from a Systemic Infec(on
• A severe infec(on can release TOXINS into the body that can cause small blood vessels to DILATE
and LEAK FLUID into the surrounding (ssues
• Sep(c Shock is usually PRECEDED by SIGNS and SYMPTOMS of:
• FEVER
• PETECHIAL or PURPURIC RASH

SEPTIC SHOCK
NOTE: In sepc shock the adrenal glands are especially prone to microvascular thrombosis and hemor-
rhage. Because adrenal glands PRODUCE CORTISOL, an important hormone in the body’s stress
response, children with sepsis may develop absolute or relave adrenal insufficiency. Adrenal
insufficiency contributes to low SVR and myocardial dysfuncon in sepc shock.

Therefore… as a roune drug for use in sepc shock

since it may SUPRESS CORTISOL PRODUCTION a\er a SINGLE DOSE. Rather, consider
administraon of stress dose Hydrocorsone (2mg/kg; maximum dose 100 mg).

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 PEDIATRIC SHOCK

• Another form of Distribuve Shock is: ANAPHYLAXTIC Shock

• Anaphylaxis is usually the result of a Severe ALLERGIC REACTION
• The allergen can cuase the release of chemicals within the body that makes the small blood
vessels DILATE and then leak fluid into the (ssues, just like Sep(c Shock
• Anaphylac(c Shock can DEVELOP VERY FAST, oDen within just MINUTES

• Another form of Distribuve Shock is: NEUROGENIC Shock

• As a result of Head injury and/or Spinal injury)

• Cardiogenic Shock
• Results from inadequate (ssue perfusion caused by poor myocardial func(on.

• Common causes of cardiogenic shock are:

• MYOCARDITIS (inflamma(on of the heart muscle)

• CONGENITAL HEART DISEASE

• CARDIOMYOPATHY (an inherited or acquired abnormality of pumping func(ons)

• SEPSIS

• POISONING

• DRUG TOXICITY

• ARRHYTHMIAS

• MYOCARDIAL INJURY (e.g., trauma)

• With Cardiogenic Shock, children usually have marked TACHYCARDIA accompanied by a very high
systemic vascular resistance and severe vasoconstric(on, and decreased cardiac output

• Pulmonary conges(on may develop, causing Respiratory Distress

• Intravascular volume may be normal or high unless the child has had Poor Oral Intake

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 PEDIATRIC SHOCK

• Obstrucve Shock:
• Cardiac Output is impaired by physical obstruc(on to blood flow in or out of the heart

• Obstruc(ons can by caused by:

• AIR

• FLUID

• BLOOD CLOTS

• Examples: Tension Pneumothorax / Cardiac Tamponade

• MASSIVE PULMONARY EMBOLIS

• CONGENITAL HEART DEFECTS Cause severe obstruc(on to:

• PULMONARY

• AORTIC

• SYSTEMIC BLOOD FLOW

• Many of the lesions of Obstruc(ve Shock are call LESIONS that depend on a func(onal ductus
arteriosus for pulmonary or systemic blood flow. Once the ductus starts to close aDer birth,
infants can deteriorate rapidly.

• Because cardiac output is impared in both HYPVOLEMIC and OBSTRUCTIVE Shock, it can be
difficult dis(nguish between the two.

• Once the child or infant has been determined to having one of the Four Types of Shock,
it is ESSENTIAL that we determine the SEVERITY of either being COMPENSATED
[Adequate Blood Pressure] or HYPOTENSIVE [Inadequate Blood Pressure]
• Children/Infants in Compensated Shock may have either a NORMAL or HIGH Systolic
Blood Pressure due to the ‘Flight-or-Flight’ Response. This compensatory mechanism
produces Systemic Vasoconstricon that inially maintains the Blood Pressure.
• Shock with a LOW Systolic Blood Pressure is called HYPOTENSIVE Shock. LOW Blood
Pressure is defined as a Blood Pressure less than the fi\h percenle for the age. Hypo-
tension occurs with the compensatory mechanisms have failed. Hypotensive Shock in
children is an ominous finding, and it requires IMMEDIATE INTERVENTION!

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 PEDIATRIC SHOCK

Recognion of Shock

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 PEDIATRIC SHOCK

For Monitoring of Shock Paents:

• Place pa(ent on CARDIAC MONITOR
• Measure PULSE OXIMETRY
• Take FREQUENT BLOOD PRESSURES
• Obtain RAPID VASCULAR ACCESS for the administra(on of FLUID and DRUG Therapy
• If in Compensated Shock: PERIPHERAL VENOUS access is preferred
• If in UNCOMPENSATED Shock: Establish IO / INTRAOSSEOUS access
• IV / IO Fluid Therapy is indicated for the treatment of Shock
• Note: The primary goal of fluid resuscita(on in Shock it to RESTOR ADEQUATE BLOOD FLOW to the
(ssues.
• The RATE and amount of VOLUME of fluid to be infused will be determined by the child’s
CONDITION
• The RATE of fluid delivery will be affected by the SIZE and LENGTH of the Catheter

• Fluid Boluses:
• HYPOVOLEMIC, DISTRIBUTIVE, and OBSTRUCTIVE Shock: Give fluid boluses RAPIDLY
• 20 cc/kg of an Isotonic Crystalloid over 5 to 10 minutes
• CARDIOGENIC SHOCK: Give fluid boluses in SMALLER doses and MORE SLOWLY
• 5 to 10 cc/kg of an Isotonic Crystalloid over 10 to 20 minutes
• Monitor carefully the HEMODYNAMIC and RESPIRATORY Parameters during fluid infusion, and as
REPEAT as needed

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 PEDIATRIC SHOCK
• Always assess the pa(ent aDer each bolus given
• AUSCULTATE the lungs and Listen for:
• CRACKLES
• RESPIRATORY DISTRESS
• Feel for HEPATOMEGALY [an enlarged Liver]

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Determining The Underlying Causes...
In contrast with cardiac arrest in adults, cardiopulmonary arrest in infants
and children is rarely sudden and is more oDen caused by the progression
of respiratory distress/failure, or shock than by primary cardiac arrhythmias.

* Therefore, Oxygen is the number one treatment of most pediatric condions *

Differenal Diagnosis – The H’s and T’s

It is not enough to ‘just treat’ the pediatric pa(ent. As Healthcare Professionals, we must
also determine what is the underlying cause - what put the pa(ent into their current situ-
a(on to begin with. Unless the cause of an arrhythmia, shock, or respiratory problem is
determined, we will be fu(le in our care of the pa(ent.

Example: An Healthcare Professional can give a child in PEA all the Epinephrine in
the world, but if we don’t determine what caused the problem to begin with
[hypovolemia, severe asthma a0ack, etc.] then we are was(ng our (me. We must de-
termine, treat, and correct it the problem that put the child there or they will not be
helped.

H’s and T’s

• Hypovolemia • Toxins
• Hypoxia • Tamponade, Cardiac
• Hydrogen Ion (acidosis) • Tension Pneumothorax
• Hypo/Hyperkalemia • Thrombosis, Coronary
• Hypothermia • Thrombosis, Pulmonary
• Hypoglycemia

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40
 The Pediatric Heart
• Signs of Instability with Arrhythmia in Children / Infants
• Respiratory Distress or Failure
• Shock with poor end-organ perfusion with or without Hypotension
• Irritability or a decreased level of consciousness
• Chest pain or vague felling of discomfort
• Sudden collapse
• The Most Common Pediatric Arrhythmias are:
• SINUS BRACYCARDIA
• The most serious cause is SEVERE HYPOXIA
• Ini(al treatment is the use of Bag Mask ven(la(on with 100% Oxygen
• If the Bradycardia persists, and the heart rate is less than 60 beats per minute, with poor
perfusion, begin CPR
• Consider Epinephrine or Atropine
• ATRIOVENTRICULAR (AV) BLOCK
• A delay in the conduc(on of the electrical impulse through the heart caused by the AV
node.
• Many AV blocks require no treatment, while some may result in a very low ventricular rate
and can worsen to cardiopulmonary compromise
• These AV blocks require a PACEMAKER
• SINUS TACHYCARDIA
• Is a rapid heart rate that develops when high cardiac output is needed, such as with:
• FEVER
• EXCITEMENT
• EXERCISE
• The presence of Sinus Tachycardia should prompt a search to iden(fy the underlying cause
of the tachycardia
• Some causes may be SIGNIFICANT or even LIFE THREATENING requiring urgent
interven(on, while others may be fairly benign and require no interven(on or only require
ongoing monitoring
• SUPRAVENTRICULAR TACHYCARDIA (SVT)
• This is THE MOST COMMON arrhythmia in children
• SVT is an abrupt increase in the heart rate that does not vary with ac(vity
• This ISN’T a life-threatening problem for most children
• However, emergency treatment is to be considered only if episodes are:
• PROLONGED
• FREQUENT
• CAUSE CARDIORESPIRATORY COMPROMISE
• VENTRICULAR TACHYCARDIA (VT)
• VT is uncommon but poten(ally FATAL condi(on that requires prompt a0en(on
• VT may also cause CARDIAC ARREST, which requires CPR and IMMEDIATE DEFIBRILLATION
for survival
• VT may result from serious heart disease but occasionally occurs in children with other-
wise normal hearts

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 The Pediatric Heart

Bradycardia
Bradycardia is an heart rate that is slow in comparison with a normal heart rate range for the child’s age and
level of ac(vity. Bradycardia is also an ominous sign of impending cardiac arrest in infants and children,
especially if it is associated with hypotension or evidenced by poor perfusion.

If, despite adequate oxygena(on and ven(la(on, the heart rate is < 60/min in an infant or a
child with signs of poor perfusion, begin CPR!
PEA - Pulseless Electrical Ac(vity is simply any Rhythm yet WITHOUT a pulse. Start CPR!

Blocks

First Degree
Block

Second Degree
Block
Type 1

Second Degree
Block
Type 2

Third Degree /
Complete
Block

*** For a more thorough understanding of Cardiac Rhythm Strips, please download our free ACLS Study Guide ***

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43
 Tachycardia

Tachycardia is an heart rate that is fast in comparison with a normal heart rate range for the child’s age and
level of ac(vity.
Sinus Tachycardia is also a normal response to a child with stress or fever
Tachycardias are fast abnormal rhythms origina(ng either in the Atria or the Ventricles of the heart. Tachycar-
dias can be tolerated without symptoms for a variable period of (me. However, tachyarrhythmias can also
cause acute hemodynamic compromise such as shock or deteriora(on to cardiac arrest.
Tachyarrhythmia’s signs and symptoms can include: respiratory distress or failure. Signs of shock (poor end-
organ perfusion) with our without hypotension, Altered mental status (e.g., decreased level of consciousness);
and or sudden collapse with rapid, weak pulses.

Sinus Tachycardia
Sinus tachycardia occurs when the SA node is firing at a rate that is faster than normal for a person’s age.
The rate is generally 101 to 150 bmp. The key to sinus tachycardia is that all components of a normal
ECG are present, P wave, QRS complexes, and T wave. Sinus tachycardia generally starts and stops
gradually. There is oDen a cause such as pain, fever, or agita(on that can be iden(fied and treated.

Supraventricular Tachycardia (SVT)

Supraventricular Tachycardia (SVT) includes any rhythm that begins above the bundle branches. This includes Rhythm
that begins in the SA node, atrial (ssue, or the AV junc(on. Since the rhythms arise from above the bundle branches,
they are characterized by narrow QRS complexes.
Supraventricular tachycardia rate runs from 180 to 250+ [some books list SVT star(ng at 150]. The rhythm is regular
with usually no dis(nguishable P waves due to their fast rate, and fall within the preceding T waves.

• Treatment:
• Try Vagal maneuvers

• Adenosine 0.1mg/kg (maximum dose of 6mg), 2nd dose 0.2mg/kg (maximum dose of 12 mg) RAPID IVP
(2 syringe technique) followed with an immediate 10 - 20 cc flush of Normal Saline

• Synchronized Cardioversion 0.5 - 1.0 joules/kg Increase joules accordingly if unsuccessful

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Ventricular Tachycardia

The queson to ask is, “Is it…”

• Stable vs Unstable
• Pulse vs No Pulse

Ventricular Tachycardia (VT) is a wide - complex arrhythmia generated within the ventricles.

When VT with pulses is present, the ventricular rate may vary from normal to > 200/min. Rapid ventricular
rates compromise ventricular filling, stroke volume and cardiac output and may deteriorate into pulseless VT
or ventricular fibrilla(on.
Most children who develop VT have an underlying heart disease (or have had surgery for heart
disease), long QT syndrome, or Myocardis / Cardiomyopathy. They may have a family history of a
sudden death, unexplained death in a child or young adult, sugges(ng cardiomyopathy or an inherited
cardiac ion “channelopathy.” Other causes of VT in children include: Electrolyte imbalances / disturbances
(e.g., hyperkalemia, hypocalcemia, hypomagnesaemia) and drug toxicity (e.g., tricyclic an(depressants,
cocaine, methamphetamines).

• WIDE QRS (VT with pulse)

• Amiodarone 5mg/kg IV over 20 to 60 minutes
• Or Procainamide 15mg/kg IV over 30 to 60 minutes

• May need synchronized Cardioversion

• WIDE QRS (torsades de points)

• Magnesium load with 25 – 50 mg/kg over 10 minutes
• UNSTABLE (WITH PULSE) = SYNCRONIZED CARDIOVERSION

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How To Synchronize Cardiovert... Overview
• Defibrilla(on is a NON-SYNCHRONIZED
Knowing how your equipment works, AHEAD OF TIME, is
delivery of energy during any phase of
definitely ESSENTIAL! Be familiar with how to operate the
Cardiac Monitor / Defibrillator in the area in which you work. the cardiac cycle
There is a DEFINITE DIFFERENCE between DEFIBRILLATION / • Cardioversion is the delivery of energy
UNSYNCHRONIZED CARDIOVERSION and SYNCHRONIZED
that is SYNCHRONIZED to the large
CARDIOVERSION
R waves or QRS complex

Steps for cardioversion:

1. Consider seda(on
2. Turn on Defibrillator
3. A0ach monitor leads to pa(ent
4. Press “SYNC” mode bu0on

5. Look for markers on R wave indica(ng sync mode

6. Select appropriate energy level
7. Posi(on appropriate pads or paddles
8. Press the charge bu0on – announce that you are doing ‘
this
9. Clear: I’m clear, you’re clear – includes making sure that
the oxygen is away from the pa(ent. Everybody’s clear
10. Press and hold down the shock bu0on and wait for shock
discharge (this may take a few seconds while the machine
looks for R waves and determines where the sync the
shock”
11. Analyze the rhythm again and confirm a pulse. If s(ll in
tachycardia, increase the joules and try again as per
protocol

Note: On many cardiac monitors you must reset the sync mode a\er each synchronized
cardioversion because most defibrillators default back to unsynchronized mode.
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 Ventricular Fibrillaon

When Ventricular Fibrillaon (VF) is present, the heart has no discernable organized rhythm and no coordinated
contrac(ons. Simply, electrical ac(vity is CHAOTIC. The heart is quivering and is unable to pump any blood. There-
fore, pulses are not palpable. VF may be preceded by either what appears to be a mini-seizure, or a brief period of VT
on the cardiac monitor.
Both VF and Pulseless VT algorithms are the same

Course Ventricular Fibrillaon

Fine Ventricular Fibrillaon

Pulseless Arrest includes:

1. Ventricular Fibrilla(on and pulseless ventricular tachycardia [Shockable]
2 Asystole and pulseless electrical ac(vi(es [NOT Shockable]
When shockable, (V-fib and pulseless VT) defibrilla(on can be performed using either monophasic or biphasic
technology. Biphasic, is the newer and be0er technology

First shock is at 2 J/kg, subsequent shocks are 4 J/kg max 10 J/kg not to exceed an adult dose

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It is our hope that this PALS Study Guide provided for you by Heart Savers Training, LLC will (1) be0er prepare you for the PALS 2-
Day or PALS 1-Day Recert Class, and (2) help you to con(nue to fine tune your skills in providing THE BEST Compassionate
and Excellent Professional Care that you possibly can for the Pediatric pa(ent. Also, we ask that you con(nue checking back
frequently on our website as we are constantly adding new materials to be0er equip you in your pa(ent care. Remember, You
CAN make a posive difference in someone else’s life. If you have any ques(ons, please don’t hesitate to contact us.
Hope to see you in class!

Note: All cardiac strips used in this PALS Study Guide are provided for by Heart Savers Training, LLC via our Cardiac Moni-
tors and Arrhythmia Devices

Note: All pictures used in this PALS Study Guide are owned by, and have been purchased by one of the founders of our com-
pany from Shu6erstock via www.shu6erstock.com - Use by anyone else is strictly prohibited

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