This document provides guidance on pediatric advanced life support (PALS). It discusses respiratory and circulatory failure, which often lead to cardiac arrest in children. Asphyxial cardiac arrest caused by lack of oxygen is more common than primary cardiac issues. Shock is also a common precursor and progresses from compensated to decompensated states. Foreign body airway obstruction, drowning, and hypothermia/hyperthermia are covered. The document provides detailed guidance on airway management, ventilation, vascular access, defibrillation, and the management of arrhythmias like tachycardia and bradycardia in a pediatric setting.

1. PEDIATRIC
ADVANCED
LIFE SUPPORT
DR. DEEPASHREE PAUL

2. PEDIATRIC
ADVANCED LIFE
SUPPORT
“Assessment and maintenance of pulmonary and circulatory
function in the period before, during and after an instance of
cardiopulmonary arrest in a seriously ill or injured child, by a
system of critical care procedures and facilities.”
AHA 2014
Timely intervention in seriously ill or injured children is the key to
preventing progression toward cardiac arrest and to saving lives.

3. INTRODUCTION
In contrast to adults, cardiac arrest in infants and children
does not usually result from a primary cardiac cause. More
often it is the terminal result of progressive respiratory
failure or shock, also called an asphyxial arrest. Asphyxia
begins with a variable period of systemic hypoxemia,
hypercapnea, and acidosis, progresses to bradycardia and
hypotension, and culminates with cardiac arrest.

4. BASIC
CONSIDERATIONS FOR
PALS
Paediatric advanced life support (PALS) usually takes place
in the setting of an organized response in an advanced
healthcare environment.
In these circumstances, multiple responders are rapidly
mobilized and are capable of simultaneous coordinated
action.

5. ASPHYXIAL CARDIAC
ARREST
Cardiac arrest caused by asphyxiation (lack of oxygen in
blood)
Carbon dioxide accumulates in the lungs while oxygen in the
lungs is depleted resulting in cardiac arrest.
Causes: drowning, choking, airway obstruction, sepsis,
shock

6. ASPHYXIAL CARDIAC
ARREST
“One large pediatric study demonstrated that CPR with chest
compression and mouth-to-mouth rescue breathing is more
effective than compression alone when the arrest was from a
noncardiac etiology.”
“Ventilations are more important during resuscitation from
asphysia-induced arrest, than during resuscitation from VF
or pulseless VT.”

7. SHOCK
Shock results from inadequate blood flow and oxygen delivery to meet
tissue metabolic demands.
The most common type of shock in children is hypovolemic,
including shock due to hemorrhage.
Distributive, cardiogenic, and obstructive shock occur less frequently.
Shock progresses over a continuum of severity, from a compensated to
a decompensated state.
Compensatory mechanisms include tachycardia and increased
systemic vascular resistance (vasoconstriction) in an effort to maintain
cardiac output and perfusion pressure respectively.
Decompensation occurs when compensatory mechanisms fail and
results in hypotensive shock.

8. Typical signs of compensated shock include
● Tachycardia
● Cool and pale distal extremities
● Prolonged (2 seconds) capillary refill (despite warm
ambient temperature)
● Weak peripheral pulses compared with central pulses
● Normal systolic blood pressure
As compensatory mechanisms fail, signs of inadequate
end-organ perfusion develop. In addition to the above, these
signs include
● Depressed mental status
● Decreased urine output
● Metabolic acidosis
● Tachypnea
● Weak central pulses
● Deterioration in color

9. ● Tachycardia is a common sign of shock, but it can also result
from other causes, such as pain, anxiety, and fever.
● Pulses are weak in hypovolemic and cardiogenic shock, but
may be bounding in anaphylactic, neurogenic, and septic shock.
● Blood pressure may be normal in a child with compensated
shock but may decline rapidly when the child decompensates.
Like the other signs, hypotension must be interpreted within the
context of the entire clinical picture.

10. HYPO/HYPERTHERMI
A
Potential complications of hypothermia include diminished cardiac output,
arrhythmia, pancreatitis, coagulopathy, thrombocytopenia,
hypophosphatemia, hypovolemia from cold diuresis, hypokalemia, and
hypomagnesemia.
● Monitor temperature continuously, if possible, and treat fever (38°C)
aggressively with antipyretics and cooling devices because fever adversely
influences recovery from ischemic brain injury
● Treat post ischemic seizures aggressively; search for a correctable
metabolic cause such as hypoglycemia or electrolyte imbalance.
● Avoid rewarming from 32 to 34°C faster than 0.5°C per 2 hours unless the
patient requires rapid rewarming for clinical reasons.

11. FOREIGN-BODY AIRWAY
OBSTRUCTION
90% of childhood deaths from foreign body aspiration occur
in children < 5 years of age; 65% are infants.
Balloons, small objects, foods (hot dogs, round candies,
nuts and grapes) are the most common causes of foreign-
body airway obstruction

12. FBAO
If FBAO is mild, do not interfere.
• Allow the victim to clear the airway by coughing.
If the FBAO is severe (victim unable to make a sound) you
must act the relieve the obstruction.

13. FBAO
For a child perform subdiaphragmatic abdominal thrusts
until the object is expelled or the victim becomes
unresponsive.
For an infant, deliver repeated cycles of 5 back blows
followed by 5 chest compressions until the object is
expelled or the victim becomes unresponsive.

14. FBAO –
UNRESPONSIVE
Start Chest Compression
After 30 chest compressions open airway
If you see a foreign body remove it
DO NOT perform a blind finger sweep
Give 2 breaths
Followed by 30 chest compressions

15. DROWNING
Outcomes after drowning is determined by the duration of
submersion, the water temperature, and how promptly and
effectively CPR is provided.

16. PEDIATRIC CARDIAC
ARREST
Pediatric cardiopulmonary arrest results when respiratory
failure or shock is not identified and treated in the early
stages.
Early recognition and intervention prevents deterioration to
cardiopulmonary arrest and probable death.

17. CARDIAC ARREST
Pediatric cardiac arrest is:
• Uncommon
• Rarely sudden cardiac arrest caused by primary cardiac
arrhythmias.
• Most often asphyxial, resulting from the progression of
respiratory failure or shock or both.

18. RESPIRATORY
FAILURE
A respiratory rate of less than 10 or greater than 60 is an
ominous sign of impending respiratory failure in children.

19. RESPIRATORY
FAILURE
Respiratory failure is characterized by inadequate ventilation,
insufficient oxygenation, or both. Anticipate respiratory failure
if any of the following signs is present:
● An increased respiratory rate, particularly with signs of
distress (eg, increased respiratory effort including nasal
flaring, retractions, seesaw breathing, or grunting)
● An inadequate respiratory rate, effort, or chest excursion
(eg, diminished breath sounds or gasping), especially if
mental status is depressed
● Cyanosis with abnormal breathing despite supplementary
Oxygen.

20. BREATHING
Breathing is assessed to determine the child’s ability to
oxygenate.
Assessment:
• Respiratory rate
• Respiratory effort
• Breath sounds
• Skin color

21. BREATHING CHILD
If child is breathing, put in recovery position, call emergency
response system, return quickly and re-assess child’s
condition
Turn child on-side (recovery position)

22. INADEQUATE
BREATHING WITH
PULSE
If pulse > 60 per minutes but there is inadequate breathing
give rescue breathing at a rate of about 12 to 20 breathes per
minute.
Reassess pulse about every 2 minutes
• Carotid or femoral for child
• Brachial for infant

23. UNRESPONSIVE AND
NOT BREATHING
If the child is unresponsive and not breathing (or only
gasping) begin CPR.
Start with high-quality chest compression. (30 chest
compressions)
After one cycle 2 minutes check for pulses
Call for help when able

24. AIRWAY
Airway must be clear and patent for successful ventilation.
• Position
• Suction
• Administration of oxygen
• Bag-mask ventilation
• Note: suctioning is helpful if secretions, blood or debris is
present. Use with caution if upper airway swelling is edema
(eg. croup, epiglottitis)

25. BAG-VALVE-MASK

26. LMA –LARYNGEAL MASK
AIRWAY

27. UNCUFFED ET TUBES

28. CUFFED ET TUBE

29. ET TUBE

30. RAPID SEQUENCE
INTUBATION (RSI)
To facilitate emergency intubation and reduce the incidence
of complications, skilled, experienced providers may use
sedatives, neuromuscular blocking agents, and other
medications to rapidly sedate and neuromuscularly block the
pediatric patient.
Use RSI only if you are trained, and have experience using
these medications and are proficient in the evaluation and
management of the pediatric airway.
If you use RSI you must have a secondary plan to manage
the airway in the event that you cannot achieve intubation.

31. CRICOID PRESSURE
DURING INTUBATION
There is insufficient evidence to recommend routine cricoid
pressure application to prevent aspiration during
endotracheal intubation in children.
Do not continue cricoid pressure if it interferes with
ventilation or the speed or ease of intubation.

32. END-TIDAL CO2
(PETCO2)
Continuous capnography or capnometry monitoring, if
available, may be beneficial during CPR, to help guide
therapy, especially the effectiveness of chest compressions
If the PETCO2 is consistently 10 to 15 mm Hg, focus efforts
on improving chest compressions and make sure that the
victim does not receive excessive ventilation.

33. VENOUS ACCESS
Peripheral IV access is acceptable during resuscitation if it can
be placed rapidly, but placement may be difficult in a critically ill
child.
Although a central venous catheter can provide more secure
long-term access, its placement requires training and
experience, and the procedure can be time consuming.
Therefore central venous access is not recommended as the
initial route of vascular access during an emergency.
If both central and peripheral accesses are available, administer
medications into the central circulation since some medications
(eg, adenosine) are more effective when administered closer to
the heart, and others (eg, calcium, amiodarone, procainamide,
sympathomimetics) may be irritating when infused into a
peripheral vein.

34. VASCULAR ACCESS
Vascular access is essential for administering medications
and drawing blood samples. Obtaining peripheral venous
access can be challenging in infants and children during an
emergency; intraosseous (IO) access can be quickly
established with minimal complications by providers with
varied levels of training.

35. VASCULAR ACCESS –
NEW GUIDELINES
New guidelines: in children who are six years or younger
after 90 seconds or 3 attempts at peripheral intravenous
access – Intraosseous vascular access in the proximal tibia
or distal femur should be initiated.

36. INTRAOSSEOUS
ACCESS

38. INTRAOSSEOUS (IO) ACCESS
IO access is a rapid, safe, effective, and acceptable route for
vascular access in children and it is useful as the initial vascular
access in cases of cardiac arrest.
All intravenous medications can be administered
intraosseously, including epinephrine, adenosine, fluids,
blood products and catecholamines.
Onset of action and drug levels for most drugs are comparable
to venous administration.

39. ENDOTRACHEAL
TUBE INTUBATION
New guidelines:
• Secondary confirmation of tracheal tube placement.
• Use of end-tidal carbon dioxide monitor or colorimetric device

40. ENDOTRACHEAL DRUG
ADMINISTRATION
Vascular access (IO or IV) is the preferred method for drug
delivery during CPR, but if it is not possible, lipid-soluble
drugs, such as lidocaine, epinephrine, atropine, and
naloxone
(mnemonic “LEAN”) can be administered via an endotracheal
tube.
However, the effects may not be uniform with tracheal as
compared with intravenous administration.

41. NEUROLOGIC
SYSTEM
A primary goal of resuscitation is to preserve brain function. Limit the
risk of secondary neuronal injury by adhering to the following
precautions:
● Do not routinely provide excessive ventilation or hyperventilation. It
has no benefit and may impair neurologic outcome by adversely
affecting cardiac output and cerebral perfusion. Intentional brief
hyperventilation may be used as temporizing rescue therapy in response
to signs of impending cerebral herniation (eg, sudden rise in measured
intracranial pressure, dilated pupil not responsive to light, bradycardia,
hypertension).
● Therapeutic hypothermia (32°C to 34°C) may be considered for children
who remain comatose after resuscitation from cardiac arrest.

42. CIRCULATION
Circulation reflects perfusion.
Shock is a physiologic state where delivery of oxygen and
substrates are inadequate to meet tissue metabolic needs.

43. CIRCULATION
ASSESSMENT
Heart rate (most accurate assessment)
Blood pressure
End organ profusion
• Urine output (1-2 mL / kg / hour)
• Muscle tone
• Level of consciousness

44. CIRCULATORY
ASSESSMENT
Heart rate is the most sensitive parameter for determining
perfusion and oxygenation in children.
• Heart rate needs to be at least 60 beats per minute to
provide adequate perfusion.
• Heart rate greater than 140 beats per minute at rest
needs to be evaluated.

45. BLOOD PRESSURE
25% of blood volume must be lost before a drop in blood
pressure occurs.
Minimal changes in blood pressure in children may indicate
shock.

46. BLOOD PRESSURE
GUIDELINES
Hypotension is defined as systolic blood pressure
Neonates: < 60 mm Hg
Infants: <70 mm Hg
Child (1 to 10): < 70 mm Hg
Child (>10): < 90 mm Hg

47. IV SOLUTIONS
Crystalloid solution for fluid loss (hypovolemia)
• Normal saline 20ml/kg bolus over 20 minutes
• Ringers Lactate
Blood loss:
Colloid: 5% albumin
Blood
Fresh-frozen plasma

48. GASTRIC
DECOMPRESSION
Gastric decompression with a nasogastric or oral gastric
tube is necessary to ensure maximum ventilation.
• Air trapped in stomach can put pressure on the diaphragm
impeding adequate ventilation.
• Undigested food can lead to aspiration.

49. ELECTROCARDIOGRAPHY
Monitor cardiac rhythm as soon as possible so both normal
and abnormal cardiac rhythms are identified and followed.
Continuous monitoring is helpful in tracking responses to
treatment and changes in clinical condition.

50. ARRHYTHMIAS
Bradycardia with pulse
Tachycardia with pulses and adequate perfusion
Pulseless arrest
• VF/VT
• Asystole

51. DEFIBRILLATORS
Defibrillators are either manual or automated (AED),
with monophasic or biphasic waveforms.
AEDs in institutions caring for children at risk for
arrhythmias and cardiac arrest (eg, hospitals, EDs) must
be capable of recognizing pediatric cardiac rhythms and
should ideally have a method of adjusting the energy
level for children.

52. DEFIBRILLATION
“Children with sudden witnessed collapse (eg, a child
collapsing during an athletic event) are likely to VF or
pulseless VT and need immediate CPR and rapid
defibrillation. “
VF and pulseless VT are referred to as “shockable rhythms”
because they respond to electric shocks.
VT – ventricular tachycardia
VF – ventricular fibrillation

53. DEFIBRILLATION
DOSING
The recommended first energy dose for defibrillation is 2
J/kg.
If second dose is required, it should be doubled to 4 J/kg.
AED with pediatric attenuator is preferred for children < 8
years of age.

54. DEFIBRILLATION
SEQUENCE
Turn AED on
Follow the AED prompts
End CPR cycle (for analysis and shock)
Resume chest compressions immediately after the shock.
Minimize interruptions in chest compressions.
State CLEAR when giving the shock and have visual / verbal
communication with any other rescue personal

55. DEFIBRILLATOR
GUIDELINES
AHA recommends that automatic external defibrillation be
use in children with sudden collapse or presumed cardiac
arrest who are older than 8 years of age or more than 25 kg
and are 50 inches tall.
Electrical energy is delivered by a fixed amount range 150 to
200. (2-4J/kg)

56. TACHYCARDIA WITH
PULSES
Supraventricular tachycardia
History: vague, non-specific, history of abrupt rate change
P waves absent or normal
HR not variable with activity
Infants: rate > 220/min
Children: rate > 180/min

57. BRADYCARDIA WITH
POOR PERFUSION
•If pulse is less than 60 per minutes
and there are signs of poor perfusion
• Pallor
• Mottling
• cyanosis
despite support of oxygenation and ventilation – start
CHEST COMPRESSION

58. BRADYCARDIA
The most common dysrhythmia in the pediatric population.
Etiology is usually hypoxemia
Initial management: ventilation and oxygenation.
If this does not work IV or IO epinephrine 0.01 mg / kg
(1:10,000)
ET tube (not recommended) 0.1 mg / kg
Search for and treat possible contributing factors

59. PULSELESS ARREST
Ventricular fibrillation / ventricular tachycardia
Asystole

60. PULSELESS ARREST
● As soon as the child is found to be unresponsive with no
breathing, call for help, send for a defibrillator, and start CPR
(with supplementary oxygen if available). Attach ECG monitor or
AED pads as soon as available. Throughout resuscitation,
emphasis should be placed on provision of high-quality CPR
● While CPR is being given, determine the child’s cardiac
rhythm from the ECG or, if you are using an AED, the device will
tell you whether the rhythm is “shockable” (eg VF or rapid VT)
or “not shockable” (eg, asystole or PEA). It may be necessary to
temporarily interrupt chest compressions to determine the
child’s rhythm. Asystole and bradycardia with a wide QRS are
most common in asphyxial arrest.
VF and PEA are less common but VF is more likely to be present
in older children with sudden witnessed arrest.

61. MANAGEMENT
Consider vagal maneuvers
Establish vascular access
Adenosine
• First dose 0.1 mg/kg IV (maximum of 6 mg)
• Second dose 0.2 mg/kg IV (maximum of 12 mg)
Synchronized cardioversion: 0.5 to 1 J / kg

62. ASYSTOLE
No Rhythm
No rate
No P wave
No QRS comples

63. PULSELESS ARREST –
ASYSTOLE
CAB: Start CPR
Give oxygen when available
Attach monitor / defibrillator
Check rhythm / check pulse
If asystole give epinephrine 0.01 mg / kg of 1:10,000
Resume CPR may repeat epinephrine every 3-5 minutes until
shockable rhythm is seen

64. PULSELESS ARREST –
VF AND VT
Start CAB
Give oxygen
Attach monitor / defibrillator
Check rhythm: VF / VT
Give one shock at 2 J/kg
If still VF / VT
Give 1 shock at 4 J/kg
Give Epinephrine 0.01 mg/kg of 1:10,000
Consider: amiodarone at 5 mg / kg

65. NEW GUIDELINE
EPINEPHRINE
Still remains primary drug for treating patients for
cardiopulmonary arrest, escalating doses are de-emphasized.
Neurologic outcomes are worse with high-dose epinephrine.

66. PALS DRUGS

67. If CPR is in progress, stop chest compressions briefly,
administer the medications, and follow with a flush of at least
5 mL of normal saline and 5 consecutive positive-pressure
ventilations. Optimal endotracheal doses of medications are
unknown; in general expert consensus recommends
doubling or tripling the dose of lidocaine, atropine or
naloxone given via the ETT. For epinephrine, a dose ten
times the intravenous dose (0.1 mg/kg or 0.1 mL/kg of 1:1000
concentration) is recommended

68. EPINEPHRINE
Action: increase heart rate, peripheral vascular resistance
and cardiac output; during CPR increase myocardial and
cerebral blood flow.
Dosing: 0.01 mg / kg 1: 10,0000

69. AMIODARONE
Used in atrial and ventricular antiarrhythmic
Action: slows AV nodal and ventricular conduction, increase the
QT interval and may cause vasodilation.
Dosing: IV/IO: 5 mg / kg bolus
Used in pulseless arrest

70. ADENOSINE
Drug of choice of symptomatic SVT
Action: blocks AV node conduction for a few seconds to
interrupt AV node re-entry
Dosing
• First dose: 0.1 mg/kg max 6 mg
• Second dose: 0.2 mg/kg max 12 mg
• Used in tachycardia with pulses after synchronized
cardioversion

71. GLUCOSE
10% to 25% strength
Action: increases glucose in hypoglycemia
Dosing: 0.5 – 1 g/kg

72. NALOXONE
Opiate antagonist
Action: reverses respiratory depression effects of narcotics
Dosing: IV/IO
• 0.1 mg/kg < 5 years
• 0.2 mg/kg > 5 years

73. SODIUM
BICARBONATE
pH buffer for prolonged arrest, hyperkalemia
Action: increases blood pH helping to correct metabolic
acidosis

74. DOBUTAMINE
Therapeutic classification: inotropic
Pharmacologic classification: adrenergic
Action: increases force of contraction and heart rate; causes
mild peripheral dilation; may be used to treat shock
Dosing: IV/IO: 2-20 mcg/kg/min infusion

75. DOPAMINE
Therapeutic classification: inonotropic
May be used to treat shock; effects are dose dependent
Increases force of contraction and cardiac output, increases
peripheral vascular resistance, BP and cardiac output
Dosing: IV/IO infusion: 2-20 mcg/kg/min

76. POST-
RESUSCITATION
CARE
Re-assessment of status is ongoing.
Laboratory and radiologic information is obtained.
Etiology of respiratory failure or shock is determined.
Transfer to facility where child can get maximum care.

77. REFERENCES
 Duncan BW, Ibrahim AE, Hraska V, del Nido PJ, Laussen PC, Wessel DL, Mayer JE,
Jr., Bower LK, Jonas RA. Use of rapid-deployment extracorporeal membrane
oxygenation for the resuscitation of pediatric patients with heart disease after
cardiac arrest. J Thorac Cardiovasc Surg. 1998;116:305–311.
 Hoskote A, Bohn D, Gruenwald C, Edgell D, Cai S, Adatia I, Van Arsdell G.
Extracorporeal life support after staged palliation of a functional single ventricle:
subsequent morbidity and survival. J Thorac Cardiovasc Surg. 2006;131:1114 –
1121.
 Ibrahim AE, Duncan BW, Blume ED, Jonas RA. Long-term follow-up of pediatric
cardiac patients requiring mechanical circulatory support. Ann Thorac Surg.
2000;69:186 –192.
 Prodhan P, Fiser RT, Dyamenahalli U, Gossett J, Imamura M, Jaquiss RD, Bhutta
AT. Outcomes after extracorporeal cardiopulmonary resuscitation (ECPR) following
refractory pediatric cardiac arrest in the intensive care unit. Resuscitation.
2009;80:1124 –1129.
 Pediatric Advanced Life Support2010,2014 American Heart Association Guidelines
for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

78. THANK YOU