PALS - By Dr Rajesh G Konnur Professor Kurji College of Nursing Patna Bihar

2. WORKSHOP ON

4. SESSION-I
Introductory aspects
Of
Pediatric Advanced Life Support
Presenter- Ms. Suwarna Surendran

5. COMPONENTS OF PALS
A. Basic Life Support
B. Advanced Life Support
1.Use of adjunctive equipment and special techniques
to establish and maintain effective oxygenation,
ventilation and perfusion
2. Clinical and ECG monitoring with arrhythmia
detection and management.

6. CONT..
3. Establishment and maintenance of vascular access.
4. Therapies or emergency treatment of patient with cardiac and
respiratory arrest, trauma, shock ,respiratory failure and
other pre-arrest condition.

8. DEFINITION
A system of critical care procedures and facilities ,such as the
intensive care nursery, for the basic and advanced treatment of
seriously ill or injured infants and children. It includes the
neonatal resuscitation program as recommended by the American
Academy of pediatrics and the American Heart Association.
(https://medical.dictionary.the free dictionary.com)

11. Paediatric Advanced Life Support (PALS) refers to the assessment
and support of pulmonary and circulatory functions in the period
before an arrest and during and after an arrest.

12. Ultimate goal of PALS is to save a life, from threatening clinical
events.

13. THE RESUSCITATION TEAM
The American Heart Association guidelines for Paediatric Advanced
Life Support highlights the importance of effective team dynamics
during resuscitation. In the community, the first rescuer on the scene
may be performing CPR alone; where as a paediatric arrest event in
a hospital may bring dozens of people to the patient’s room. It is
important to quickly and efficiently organize team members to
effectively participate in Paediatric Advanced Life Support (PALS).

14. TEAM MEMBERS
TEAM LEADER TEAM MEMBER
Organizes the group Understand their role
Monitors performances Be willing, able and skilled to
perform the role
Able to perform all skills Understand the PALS sequence
Directs all team members Committed to the team’s
success
Provides feedback on group
performances after the resuscitation
efforts

15. A. BASIC LIFE SUPPORT (BLS)
 BLS is the life support method used when there is limited access
to advanced interventions.
 In general, BLS is performed until the emergency medical
services (EMS) arrives.
 BLS utilizes CPR & cardiac defibrillation when an Automated
External Defibrillator is available.
 In every setting, high quality CPR is the foundation of both BLS
and PALS.

16. DIFFERENCES IN BLS FOR INFANTS & CHILDREN
INFANTS (0-12 MONTHS) CHILDREN (1YEAR TO PUBERTY)
•For children and infants , if two rescuers are available to do CPR, the compression to
breath ratio is 15:2. if only one rescuer is available, the ratio is 30:2 for all age group.
Check for infant’s pulse using the
brachial artery on the inside of the upper
arm between the infant’s elbow and
shoulder
Check for child’s using the carotid artery
on the side of the neck or femoral pulse on
the inner thigh in the crease between the
leg and groin
Perform compressions on the infant
using two fingers
Perform compressions on a child using
one or two handed chest compressions
depending on the size of the child
Compression depth should be one third
of the chest depth, for most infants, this is
about 1.5 inches
Compression depth should be one third
of the chest depth, for most children, this is
about two inches
•If you are the only person at the scene and find an unresponsive infant or child, reforms
CPR for 2 minutes before you call EMS or go for an AED.

18. INITIAL DIAGNOSIS AND TREATMENT
BREATHING
CIRCULATION DISABILITY EXPOSUREAIRWAY

19. AIRWAY
Assess the airway and make a determination between
one of three possibilities.
Is the airway open? This means open &
obstructed
If yes proceed to B
Can the airway be
kept open manually?
Jaw lift/ chin thrust
Nasopharyngeal or
oropharyngeal airway
In an advanced airway
required?
Endotracheal
intubation
Chricothyrotomy, if
necessary

20. BREATHING
If the child or infant is not breathing effectively. It is a life –
threatening event and should be treated as respiratory arrest.
Is breathing too fast or too
slow?
Tachypnoea has an extensive
differential diagnosis
Bradypnoe can be sign of
impending respiratory arrest
Is there increased respiratory
effort?
Signs of increase respiratory
effort including nasal flaring,
rapid breathing, cest retractions,
abdominal breathing, stridor,
grunting, wheezing & crackles
In an advanced airway required? Endotracheal intubation
Chrichothyrotomy if necessary

21. CIRCULATION
The assessment of circulation includes:
1. The colour and temperature of the skin and
mucous membranes.
2. Capillary refill.

22. THE NORMAL HEART RATE AND BLOOD PRESSURE IN
PAEDIATRICS ARE:
AGE NORMAL
HEART
RATE
(AWAKE)
NORMAL
HEART
RATE
(ASLEEP)
NORMAL
BLOOD
PRESSURE
(SYSTOLIC)
NORMAL
BLOOD
PRESSURE
(DIASTOLIC)
HYPOTENS
ION BLOOD
PRESSURE
(SYSTOLIC)
Neonate 85-190 80-160 60-75 30-45 <60
1 month 85-190 80-160 70-95 35-55 <70
2 months 85-190 80-160 70-95 40-60 <70
3 months 100-190 75-160 80-100 45-65 <70
6 months 100-190 75-160 85-105 45-70 <70
1 year 100-190 75-160 85-105 40-60 <72
2 years 100-140 60-90 85-105 40-65 <74
Child(2-10
years
60-140 60-90 95-115 55-75 <70+(agex2)
Adolescent
over 10
years
60-100 50-90 110-130 65-85 <90

23. THE NORMAL HEART RATE AND BLOOD
PRESSURE IN PAEDIATRICS ARE:
AGE NORMAL
HEART
RATE
(AWAKE)
NORMAL
HEART
RATE
(ASLEEP
)
NORMAL
BLOOD
PRESSU
RE
(SYSTOLI
C)
NORMAL
BLOOD
PRESSU
RE
(DIASTO
LIC)
HYPOTE
NSION
BLOOD
PRESSU
RE
(SYSTOLI
C)
Neonate 85-190 80-160 60-75 30-45 <60
1 month 85-190 80-160 70-95 35-55 <70
2 months 85-190 80-160 70-95 40-60 <70
3 months 100-190 75-160 80-100 45-65 <70
6 months 100-190 75-160 85-105 45-70 <70
1 year 100-190 75-160 85-105 40-60 <72
2 years 100-140 60-90 85-105 40-65 <74

24. DISABILITY
In PALS ,disability refers to performing rapid neurological
assessment.
The level of consciousness can be determined on a four
level scale.
Pupilary response to light is also a fast and useful way to
assess neurological function.

25. Awake
Response to voice
May be sleepy , but still
interactive
Can only be aroused by
talking or yelling
Responds to pain Can only be aroused by
inducing pain
Unresponsive Cannot get the patient to
respond

26. Neurologic assessments in the AVPV (alert, voice , pain,
unresponsive) response scale and the glassgow coma
scale (GES)
COMPONENTS OF GLASSGOW COMA SCALE:
 Eye opening
 Verbal response
 Motor response

27. GLASGOW COMA SCALE FOR CHILDREN AND
INFANTS
AREA ASSESSED INFANTS CHILDREN SCORE
EYE OPENING
Open
spontaneously
Open in
response to verbal
stimuli
Open in
response to pain
only
No response
Open
spontaneously
Open in
response to verbal
stimuli
Open in
response to pain
only
No response
4
3
2
1

28. AREA ASSESSED INFANTS CHILDREN SCORE
VERBAL
RESPONSE
Coos and
babbles
Irritable cries
Rising response
to pain
Moans in
response to pain
No response
Oriented or
Confused
Innapropriate
words
Incomprehensive
words or nonspecific
sounds
No response
5
4
3
2
1

29. AREA ASSESSED INFANTS CHILDREN SCORE
MOTOR
RESPONSE
Moves
spontaneously and
purposefully
Withdraws to
touch
Withdraws in
response to pain
Responds to pain
with decorticate
posturing
(abnormal flexion)
Responds to pain
with decerebrate
posturing
(abnormal
extension)
No response
Obey command
Localizes painful
stimulus
Withdraws in response to
pain
Responds to pain with
flexion
Responds to pain with
extension
No response
6
5
4
3
2
1

30. EXPOSURE
It includes:
1. To look for signs o trauma, burns, fractures and
any other obvious sign.
2. Skin temperature and colour.
3. Look for more subtle signs such as petechiae or
bruising.

31. SECONDARY DIAGNOSIS AND TREATMENT
Once ABCDE method have done move on to performing a
more thorough survey .It includes:
1. A focused history
 Individual
 Family and any witness
 History should also follow the acronym SPAM(Signs and
symptoms, Past medical history, Allergies,Medications)

32. SIGNS AND SYMPTOMS
I. Evaluate recent events related to current problem
 Preceeding illness , dangerous activity.
2. Examine patient from head to toe for the
followings:
 Consciousness ,delirium
 Agitation,anxiety,depression
 Fever
 Breathing
 Appetite
 Nausea/vomiting
 Diarrhoea

33. PAST MEDICAL HISTORY
 Complicated birth history
 Hospitalizations
 Surgeries
Allergies
 Any drug or enviornmental allergies
 Any exposure to allergens or toxins
Medications
 What medication is the child taking
 Could she have taken any inappropriate medication
or substance?

34. 2.Physical examination
3.Portable chest X-ray
LIFE THREATENING ISSUES
If at any time determines that the child or infant is experiencing
a life – threatening emergency, function support breathing
and cardiovascular function immediately by providing high
– quality CPR.

35. RESUSCITATION TOOLS
Understanding that resuscitation tools available is an
essential component of PALS.These adjuncts are
broken down into sub catogories:
1) Medical devices
2) Pharmacological tools
A medical device is an instrument used to diagnose
,treat or facilitate care.
Pharmacological tools are the medications used to
treat the common challenges experienced during
a paediatric emergency.

36. 1. MEDICAL DEVICES
INTRAOSSEOUS ACCESS
 A quick useful means to administer fluids and medications
in emergency situations when intravenous access cannot
be performed quickly or efficiently.
 Any medication that can be given through a vein can be
administered into the bone marrow without dose
adjustment.
 Contraindications include bone fracture , history of bony
malformation and insertion site infection.

38. BAG- MASK VENTILATION
 It is an important intervention in PALS
 Proper use requires proper fit
 Use a clear mask
 Types of bag masks are self – inflating and flow – inflating
 A self- inflating bag mask should be the first choice in
resuscitations
 Flow inflating bag masks require more training and experience
to operate properly as the provider must manage gas flow
,suitable mask seal , individuals neck position and proper tidal
volume.
 The minimum size bag should be 450 ml for infants and
young/small children. Older children may require a 1000 ml
volume bag

39. PROPER POSITION
 In the absence of neck injury ,tilt the forehead back
and lift the chin.
TIGHT SEAL
 Use the ‘E-C clamp’ which is the letters E and C
formed by the fingers and thumb over the mask.
VENTILATE
 Squeeze the bag over one second until the chest
rises.
 Do not over ventilate

40. ENTOTRACHEAL INTUBATION
ET intubation is used when the airway cannot be
maintained,when bag mask ventilation is inadequate or
ineffective or when a definitive airway is necessary.

41. BASIC AIRWAY ADJUNCTS
OROPHARYNGEAL AIRWAY
 It is a J – shaped device that fits over the tongue to hold
the soft hypo pharyngeal structures and the tongue away
from the posterior wall of the pharynx.
 It is used in persons who are at risk for developing airway
obstruction from the tongue/from relaxed upper airway
muscle.
 It should not be used in a conscious /semiconscious
person because it can stimulate gagging and vomiting.

42. NASOPHARYNGEAL AIRWAY
 The nasopharyngeal airway is a soft rubber or plastic
uncuffed tube that provides a conduit for airflow between
the nares and the pharynx.It is used as an alternative to
an oropharyngeal airway in persons who need a basic
airway management adjunct.
 It may be used in conscious or semiconscious persons.
 The nasopharyngeal airway is indicated when insertion of
an oropharyngeal airway is technically difficult or
dangerous.

43. SUCTIONING
 It is an essential component of maintaining a patent
airway. Providers should suction the airway immediately if
there are copious secretions , blood or vomit.
 To avoid hypoxemia follow suctioning attempts with a short
period of 100%oxygen administration.

44. AUTOMATED EXTERNAL DEFIBRILLATOR
(AED)
 It is both sophisticated and easy to use,providing life
saving power in user friendly device.
 The purpose of defibrillation is to reset the electrical
system of the heart,allowing a normal rhythm a chance to
return
CRITERIA FOR AUTOMATED DEFIBRILLATOR USE:-
 No response after shaking and shouting
 No breathing or ineffective breathing
 No carotid artery pulse detected

46. 2010 AHA GUIDELINES FOR DEFIBRILLATION
Initial dose should be 2to4J/kg (4J /kg for refractory VF)
2010 AHA GUIDELINES FOR AED USE
For 1 to 8 years old ,an AED with a pediatric dose to
attenuator system should be use dif available. For infants
under one year, mannual defibrillation is preferred.If
neither pediatric dose attenuator nor mannual defibrillator
is available ,a standard adult AED may be used.

47. 2.PHARMACOLOGICAL TOOLS
DRUG MAIN PALS USE PEDIATRIC DOSE(IV/10) NOTES
ADENOSINE Supraventricular
tachycardia
1st dose: 0.1mg/kg
(max dose=6mg)
2ns dose:0.2mg/kg
(max dose=12 mg)
Rapid iv/ bolus (NO ET)
flush with saline.
Monitor ECG
AMIODARONE Tacharrhythmia 5mg/kg over 20-60 mts Very long half life.
Monitor ECG & BP
ATROPINE BRADYCARDIA 0.02MG/KG
ET: 0.03MG/KG
Repeat once if needed.
(max. Single dose 0.5mg)
Also used to treat specific
toxins (eg.OP poisioning)
EPINEPHRINE Cardiac arrest or
shock
Iv/io:0.01 mg/kg
(1:10000)(max dose-1 mg)
ET: 0.1mg/kg
(1:1000)
(max dose 2.5mg
Multiple uses
Multiple routes
Repeat every 3 to 5 minutes
if needed
GLUCOSE Hypoglycemia o.5-1gm/kg Newborn- 5-10,l/kg
Infants/children
2-4ml/kgD25W
AD-1-2ML/KG

48. DRUG MAIN PALS USE PEDIATRIC DOSE(IV/10) NOTES
LIDOCAINE Tachy-arrythmia Initial:1mg/kg
Infusion:20-
50mg/kg/mimute
(max dose100mg)
et-2-3mg
MAGNESIUM
SULPHATE
Torceds de points
refractoryasthma
20-50mg/kg over 10-
20 minutes
(max dose 2 gms)
May run faster for
torsades
MITRINONE Cardiogenic shock Initial: 50 mg /kg over
10 to 60 mts
Maintain:0.5 to 0.75
mg/kg/mt
Longer infusion
time &euvolumia
will reduce risk of
hypotension

49. DRUG MAIN PALS USE PEDIATRIC
DOSE(IV/10)
NOTES
NALAXONE Opoid reversal Less than 5
yrs/under
20kg:0.1mg/kg
Over 5
yrs/20kg:2mg IV Q
2-3MTS PRN
PROCAINAMIDE Tachyarrythmia 15mg/kg over30 to
60 minutes
Do not give with
amiadarone.
Monitor ECG &BP
SODIUM
BICARBONATE
Metabolic acidosis 1meq / kg slow
bolus (max.dose
50 meq)
Monitor ABG&ECG
After adequte
ventilation

51. RESPIRATORY DISTRESS & FAILURE
DEFINITION
Respiratory distress is a condition in which pulmonary activity is
insufficient to bring oxygen and to remove carbon dioxide from
the blood.
 The two main actions involved in breathing are ventilation and
oxygenation

52. VENTILATION
Is the airway clear? Are the muscles of the
chest functioning?
Is the rate of breathing
sufficient?
Eg. an obstructed
airway prevents gas
flow.
Eg. chest muscle fatigue can
occur.
Eg. CNS depression can
slow/stop breathing.

53. OXYGENATION
Is oxygen available? Is lung blood flow
adequate?
Can gases cross the
pulmonary
vasculature?
Ex. High attitudes
have low oxygen.
Ex. Vascular shunts
may not send blood
to lungs.
Ex. Pulmonary edema
or pneumonia.

54. DIFFERENCE BETWEEN
RESPIRATORY DISTRESS &
RESPIRATORY FAILURE

55. variable
cyanotic
Fail to respond
bradycardia
Abnormal soundds
No effort
Slow breathing
Possibly obstructed
variable
RESPIRATORY
DISTRESS
pale
Agitated
tachycardia
Clear sounds
Increased effort
tachypnoea
Open without support
RESPIRATORY FAILURE
AIRWAY
RESPIRATORY RATE
RESPIRATORY EFFORT
LUNG SOUNDS
HEART RATE
RESPONSIVENESS
APPEARANCE / CAPILLARY
BEDS

56. CAUSES
Respiratory distress or failure generally falls into one
of four broad categories.
 Upper airway
 Lower airway
 Lung tissue disease
 Central nervous system issues

57. CAUSES
UPPER AIRWAY LOWER
AIRWAY
LUNG
TISSUE
DISEASE
CNS
ISSUES
Croup(swelling) bronchiolitis pneumonia overdose
Foreign body asthma pneumonitis Head
trauma
Retropharynge
al abscess
Pulmonary
edema
anaphylaxis

58. RESPONDING TO RESPIRATORY
DISTRESS & FAILURE
INITIAL MANAGEMENT
AIRWAY Open and
support the
airway
suction Consider
advanced airway
BREATHING Monitor oxygen
stats
Supplemental
oxygen
nebulizers
CIRCULATION Monitor vitals Establish
vascular access

59. CROUP MANAGEMENT
O
.
O
.
.
O
TRACHEOSTOMY
DEXAMETHASONE
INTUBATE
NEBULIZER
OXYGEN

60. CARDIAC ARREST
DEFINITION
Cardiac arrest is defined as the condition of blood circulation
resulting from absent or ineffective cardiac mechanical
activity. The cessation of blood circulation of untreated will
quickly lead to death resulting from organ and tissue
ischemia.
( ncbi.n/m.nih.gov.)

61. RECOGNIZING CARDIAC ARREST
 Cardiac arrest in pediatrics is more commonly the
consequence of respiratory failure or shock.
 Cardiac arrest can often be avoided if respiratory failure
or shock is successfully managed.
 Less than10% of the time , cardiac arrest is the
consequence of ventricular arrhythmia and occurs
suddenly.
 It may be possible to identify a reversible cause of
cardiac arrest and treat it quickly.

62. REVERSIBLE CAUSES OF CARDIAC
ARREST
THE H’S THE T’S
hypovolemia Tension pneumothorax
Hypoxia Tamponade
h+ (acidosis) Toxins
Hypo or hyperkalemia Thrombosis(coronary)
Hypoglycemia Thrombosis (pulmonary)
hypothermia Trauma (unrecognized)

63. RECOGNIZE CARDIOPULMONARY
FAILURE
AIRWAY May or may not be patent
BREATHING Slow breathing
Ineffective breathing
CIRCULATION Bradycardia and hypotension
Slow capillary refill
Weak central pulses(carotid)
No peripheral pulses(radial)
Skin mottling/cyanosis/coolness
DISABILITY Decreased level of consciousness
EXPOSURE Bleeding?
Hypothermia?
Trauma?

64. RECOGNIZE ARREST RHYTHMS
ASYSTOLE
PULSELESS ELECTRICAL ACTIVITY (PEA)
VENTRICULAR FIBRILLATION (VFIB)
PULSELESS VENTRICULAR TACHYCARDIA (VTACH)

65. RESPONDING TO CARDIAC ARREST
 The first management step in cardiac arrest is to
begin high – quality CPR.

66. CPR QUALITY
 Rate at least 100 to 120 compression per minute.
 Compression depth : one–third diameter of chest
(1.5 inches in infants and two inches in children)
 Minimize interruptions
 Do not over ventilate
 Rotate compressor every two minutes.
 If no advanced airway,8 to 10 breaths per minute
with continuous chest compressions.

67. SHOCK ENERGY
 First shock :2J/kg
 Second shock :4Jkg
 Subsequent shocks :> 4J/kg
 Maximum dose of the shock :10J/kg or adult dose.

68. RETURNS OF SPONTANEOUS
CIRCULATION
 Returns of pulse and blood pressure.
 Spontaneous arterial pressure waves with intra –
arterial monitoring.

69. ADVANCED AIRWAY
 Supraglottic advanced airway or ET intubation.
 Wave form capnography to confirm and monitor ET
tube placement.
 Once advanced airway in place ,give one breath
every 6 to 8 seconds (8 to 10 breaths per minute)

70. DRUG THERAPY
 Epinephrine IV/IO dose:0.01 mg /kg (repeat every 3
to 5 minutes; if no IV/IO access, may give
endotracheal dose of 0.1 mg /kg)
 Amiodarone IV/IO dose : 5 mg / kg bolus during
cardiac arrest (may repeat up to two times for
refractory VF / pulseless VT)

71. POST RESUSCITATION CARE
 Maintenance of temperature.
 Close monitoring of vital signs, including SPO2.
 Continuous monitoring for apnoea.
 Administer O2, inotropes & anti-convulsants if
needed.
 Laboratory investigations
 Anticipate & manage complications.

72. ROLE OF NURSE
- AS A CAREGIVER
1. Maintains airway patency with use of airway adjuncts as
required (suction , high flow oxygen).
2. Assist with intubation and securing of ETT.
3. Inserts gastric tube and facilitates gastric decompression
post intubation as required.
4. Prepare and administer IV fluids.
5. Document medications administerd.
6. Continously monitor pulse oxymetry.
7. Monitor CVP.
8. Maintain urine output
9. Elevate head of bed if blood pressure can sustain cerebral
perfusion.
10. Monitor vital signs.

73. -AS A HEALTH EDUCATOR
1. Provides health education regarding PALS.
2. Helps to develop skills in pediatric critical care
nursing.
3. Acts as resource person in promoting health.

74. - AS A RESEARCHER
1. Nurse plays an important role in nursing research.
Research in PALS helps to find treatment &
improve patient care in hospital & community
settings.
2. It helps to improve quality of nursing care in
critical care setup.