Systematic approach to the seriously ill or injured (PALS)
SYSTEMATIC APPROACH TO THE
SERIOUSLY ILL OR INJURED CHILD
ADVANCED LIFE SUPPORT
• First quick “from the doorway” observation.
• This initial visual and auditory observation of
the child’s consciousness, breathing and color
is accomplished within seconds of
encountering the child.
Consciousness Level of Consciousness
(eg. Unresponsive, irritable, alert)
Breathing Increased work of breathing, absent or
decreased respiratory effort, or abnormal
sounds heard without auscultation
color Abnormal skin color, such as cyanosis,
pallor or mottling
• Use the evaluate-identify – intervene sequence.
• Always be alert to a life-threatening problem.
• If any point , identify a life-threatening problem,
immediately activate emergency response.
A rapid, hands-on ABCDE approach to evaluate respiratory ,
cardiac and neurologic function; this step includes
assessment of vital signs and pulse oxymetry
A focused medical history and a focused physical
laboratory, radiological and other advanced tests that help
to identify the child’s physiologic condition and diagnosis
On the basis of identification of child’s problem, intervene with
• Positioning the child to maintain a patent airway
• Activating emergency respone
• Starting CPR
obtaining the code cart and monitor
• Placing the child on a cardiac monitor and pulse oximeter
• Support ventilation
• Starting medications and fluids
Primary assessement uses an ABCDE model:
To assess upper airway patency:
• Look for movement of chest or abdomen
• Listen for air movement and breath sounds
Decide if UA is clear , maintainable or not
Signs suggest UA obstruction:
• Increase inspiratory effort with retraction
• Abnormal inspiratory sounds
• Episodes where no airway or breath sounds are
present despite respiratory effort
Clear Airway is open and unobstructed for normal breathing
Maintainable Airway is obstructed but can be maintainable by simple
measures (eg head tilt-chin lift)
Airway is obstructed but cannot be maintainable without
advanced intervention (eg intubation)
• Allow the child to assume a position of comfort or position
the child to improve airway patency
• Use head tilt-chin lift or jaw thrust to open the airway:
- If cervical spine injury suspect, open airway by using a jaw
thrust without neck extension. If this maneuver does not
open the airway, use head tilt-chin lift without neck
• Avoid overextending the head/neck in infants because this
may occlude the airway.
• Suction the nose and oropharynx.
• Perform foreign- body airway obstruction releif tech if suspect
that child has aspirated foreign body:
- <1 yr old, a combination of 5 back blows and 5 chest thrusts
- >1 yr old, providers should give a series of 5 abdominal
thrusts (Heimlich maneuver)
• Use airway adjuncts (NPA or OPA) to keep the tongue from
falling back and obstructing the airway.
• Endotracheal intubation or placement of a laryngeal
• Application of continuous positive airway pressure
(CPAP) or noninvasive ventilation
• Removal of a FB; whis intervention may require
Assessment of breathing includes:
• Respiratory rate
• Respiratory effort
• Chest expasion and air movement
• Lung and airway sound
• O2 saturation by pulse oxymetry
Normal respiratory rate
Age Breaths / min
Infants (< 1 year) 30 – 60
Toddler (1-3 yrs) 24-40
Preschooler (4-5 yrs) 22-34
School age (6-12 yrs) 18-30
Adolescent (13-18 yrs) 12-16
Abnormal respiratory rate
• First sign of respiratory distress in infants.
• Quite tachypnea- tachypnea without signs of increased
• Possible caused are resp muscle fatigue, central nervous
system injury or infection, hypothermia or medication that
depress resp drive.
• Cessation of breathing for 20 secs or cessation for less than
20 secs if accompanied by bradycardia, cynosis or pallor.
• Increase respiratory effort results from
conditions that increase resistance to airflow
or that cause lungs to be stiffer and difficult to
Signs of increase respiratory effort include.
• Nasal flaring
• Head bobbing or seesaw raspirations
• Dilatation of nostrils with each inhalation.
• Most common in infant and younger children
• Inward movement of the chest wall or tissues, neck or
sternum during inspiration.
Head bobbing or seesaw respiration:
Indicate increased risk of deterioration
- Head bobbing- caused by use of neck muscles to assist
• Most frequently seen in infants and sign of respiratory
- Seesaw respiration- chest retract and abdomen expand
Breathing difficulty Location of retraction Description
Mild to moderate subcostal Retraction of abdomen just
Substernal Retraction of abdomen at
the bottom of breast bone
intercostal Retraction between ribs
Severe Supraclavicular Retraction in the neck just
above the collar bone
Suprasternal Retraction in the chest just
above breast bone
sternal Retraction of sternum
toward the spine
Chest expansion and Air movement
• Evaluate magnitude of chest wall expansion
and air movement to assess adequecy of the
child’s tidal volume.
• Normal tidal volume- 5-7 ml/kg
• Tidal volume is difficult to measure unless a
child is mech ventilated, so clinical assessment
Chest wall expansion:
• Chest expansion during inspiration should be
• Decreased or asymmetric chest expansion may result
from in adequate effort, airway obstruction,
atelectasis, pneumothorax, hemothorax, PE, mucosal
plug or FB aspiration.
• Auscultation for air movement is critical.
• Listen for the intensity of breath sounds and quality of
air movement, particularly in the distal lung fields.
• Decreased chest excrusion or air movement
accompanies poor resp effort.
• Diminished distal air entry suggests air flow obstruction
or lung tissue disease.
Lung and airway sounds
- coarse, usually higher pitched breathing sound
typically heard on inspiration.
- Sign of upper airway obstruction
- Indicate – obstruction is critical and requires
Causes: FBAO, Croup , laryngomalacia, tumor or
cyst, upper airway edema
- Typically a short, low pitched sound heard during
- Misinterpreted as soft cry
- Sign of lung tissue disease resulting from small
airway collapse or alvelolar collapse.
- Indicate progression of RD to RF.
- Causes: pneumonia, ARDS, Pulmonary contusion.
- Bubbling sound heard during inspiration or
- Results from upper airway obstruction d/t airway
secretions, vomting or blood.
- High pitched or low pitched whistling sound heard
most often during expiration.
- Indicate lower airway obstruction.
- Causes: Bronchiolitis and Asthma
• Crackles/ Rales:
- Sharp creckling inspiratory sounds.
- Dry crackles: atelectasis and interstitial lung
- Moist crackles: indicate accumulation of alveolar
Oxygen saturation by pulse oxymetry
• Monitor the % of HB that is saturated with
• Interpret pulse oxymetry readings in
conjuction with clinical assessment and other
• Pulse oxymeter does not accurately recognize
methemoglobin or carboxyHB.
Circulation assessed by evaluation of
• Heart rate and rhythm
• Capillary refill time
• Skin color and temp
• Blood pressure
Heart rate and rhythm
Age Awake rate mean
New bon to 3
3 month to 2 yrs 100-190 130
2 yrs to 10 yrs 60-140 80
> 10 yrs 60-100 75
Bradycardia: heart rate slower than normal for
- Most common cause- hypoxia
- If bradycardia associated with poor perfusion
immediately support ventilation wth B&M and
administer supplementry O2..
Tachycardia: heart rate faster than normal for
• Evaluation of pulses is critical to assessment of
systemic perfusion in an ill or injured child.
• Palpate both central and peripheral pulses.
Central pulses: Brachial (In infants) , Carotid (older
children) , femoral , axillary
Peripheral: radial, dorsalis pedis , post. tibial.
• Weak central pulses are worrisome and indicate need
for very rapid intervention to prevent cardiac arrest.
• Beat to beat fluctuation in pulse volume may occur in
children with arrythemias.
Capillary refill time
• Time takes for blood to return to tissue
blanched by pressure.
• Increase as skin perfusion decrease.
• Prolonged CFT indicate low cardiac out put.
• Normal CFT <= 2
• To evaluate CFT lift extremity slightly above
the level of the heart, press on the skin and
rapidly release the pressure.
Skin color and Temperature
• Mucous membrane, nail beds, palms and
soles should be pink.
• When perfusion deteriorates and O2 delivery
to tissue becomes inadequate the hands and
feet are typically affected 1st.
• They may become cool , pale, dusky or
• If perfusion become worst skin over the trunk
and extremities may under go similar changes.
- Decreased blood supply to the skin (cold, stress,
- Decreased skin pigmentation
- Irregular or patchy discoloration of the skin.
- Serious condition such as hypoxemia, hypovolemia
or shock, may cause intense vasoconstriction from
an irregular supply of oxygenated blood to the skin,
leading to mottling.
- Peripheral cyanosis: bluish discoloration of hands
and feet. Seen in shock , CCF , PVD
- Central cyanosis: bluish discoloration of lips and
other mucous membranes.
- Causes :- low ambient O2 tension
-ventilator/ persion imbalance
• Cuff bladder should cover about 40% of the
mid upper arm circumference.
• BP cuff should extend at least 50-75% of the
length of the upper arm.
Age Systolic blood pressure
(0- 28 days)
< 70 + (age in yrs x 2 )
Children > 10 yrs < 90
• Disability assessment is a quick evaluation of
• Clinical signs of brain perfusion are imp indicators of
circulatory function in the ill or injured patient.
• Signs include level of consciousness, muscle tone and
• Signs of inadequate O2 delivery to the brain correlate
with the severity and duration of cerebral hypoxia.
• Standard evaluations include
- AVPU pediatric response scale
- Pupil response to light
• Mild head injury- GCS score 13-15
• moderate head injury- GCS score 9-12
• Mild head injury- GCS score 3-8
Pupils response to light
• Indicator of brainstem function.
• If the pupils fail to constrict in response to
direct light, suspect brain stem injury.
• Irregularities in pupil size or response to light
may occur as result of ocular trauma or ICP.
Assess and record size of pupils , equality of
pupil size , constriction pupil to light.
• Undress the seriously ill and injured child as
necessary to perform a focused physical
• Maintain cervical spine precaution when turning
any child with suspected neck or spine injury.
• Assess core temperature and maintain temp.
• Look any trauma such as bleeding , burns and
unusual marking that suggest nonaccidental
• Look for petechiae and purpura s/o septic shock
• Focused history
• Focused physical examination
• Focused history: to identify imp aspects of the child’s
- Signs and symptoms: breathing difficulty, decrease level
of consciousness, agitation, anxiety, fever, decrease oral
intake, diarrhea, vomiting , bleeding , fatigue, time
course of symptoms
- Allergies: medication, foods , latex
- Medications: name of drug, duration, last dose
- Past medical history: Health history (premature birth),
Significant underlying medical problem, Past surgeries ,
- Last meal: time and nature of last intake of lipid or food
- Events: event leading to current illness or injury,
hazards at scene , treatment during interval from onset
of disease or injury until evaluation, estimated time of
- Measures Pao2 and paco2 dissolved in blood
Pao2 Adequacy of O2 tension in arterial
Paco2 Adequacy of ventilation
Diagnosis ABG result
Hypoxemia Low pao2
Hypercarbia High paco2
Acidosis PH < 7.35
Alkalosis PH >7.45
• Hemoglobin concentration:
- Determine O2 carrying capacity of blood.
• Central Venous Oxygen Saturation:
- Venous blood gases may provide a useful indicator of
changes in balance between O2 delivery to the tissues
and tissue O2 consumption.
- Normal SvO2 is about 70 – 75%, assuming arterial O2
saturation is 100%.
• Arterial lactate:
- concentration of lactate reflect the balance between
lactate production and use.
- Good prognostic indicator.
- With the treatment of shock lactate concentration
- Lack of response to therapy is more predictive of poor
outcome than the initial elevated lactate concentration.
• Central Venous Pressure monitoring:
- Central venous pressure can be monitor through a
central venous catheter.
- Measurement of CVP may provide helpful
information to guide fluid and vasoactive therapy.
• Invasive arterial Pressure monitoring:
- Require arterial catheter , monitoring line ,
transducer and monitoring system.
- Enable cont evaluation and display of the SBP and
- Arterial waveform pattern may provide information
about SVR and visual indication of compromised
cardiac out put.
- Useful in respiratory illness- airway obstruction,
lung tissue disease, barotraumas, pleural disease.
- Evaluation of circulatory abnormality to assess
heart size and presence or absence of CCF.
- To assess for cardiac arrhythmias.
- Noninvasive cardiac imaging
- Cardiac chamber size, ventricular wall thickness,
ventricular wall motion, valve configuration,
pericardial space, estimated ventricular pressure etc
• Peak expiratory flow rate:
- Represents the maximum flow rate generated
during forced expiration.
- Decreases in the presence of airway obstruction.