1. The document provides an overview of Pediatric Advanced Life Support (PALS) including normal vital signs, basic life support, high quality CPR, the pediatric systematic approach, the pediatric assessment triangle, primary and secondary surveys, post-resuscitation care, pediatric trauma key points, and Covid-19 resuscitation updates. 2. It reviews algorithms for the pediatric systematic approach, cardiac arrest, bradycardia, tachycardia, and return of spontaneous circulation. 3. Guidelines are provided for assessment, emergency management, ventilation, circulation, neurologic goals, and personal protective equipment for Covid-19 patients.

1. PALS MODULE 1
PALS OVERVIEW

2. Outline
• Normal Vital Signs
• BLS
• High quality CPR
• Pediatric Systemic Approach
• Pediatric Assessment Triangle
• Primary Survey
• Secondary Survey
• Post-resuscitation Care
• Pediatric Trauma Key Points
• Covid-19 Resuscitation Updates
• Algorithms

3. Normal Vital Signs For Age
AGE Heart Rate BP RR
Premature 120-170 55-75/35-45 40-70
0-3 months 100-150 65-85/45-55 35-55
3-6 months 90-120 70-90/50-65 30-45
6-12 months 80-120 80-100/55-65 25-40
1-3 yr 70-110 90-105/55-70 20-30
3-6 yr 65-110 95-110/60-75 20-25
6-12 yr 60-95 100-120/60-75 14-22
> 12 yr 55-85 110-135/65-85 12-18
PALS Provider Handbook 2016

4. Normal Values For Age
Age Normal urine output
Infants and young children 1.5 to 2 mL/kg/hour
Older children and adolescents 1 mL/kg/hour
Normal urine output in well-hydrated infants, young children, older children, and adolescents:
PALS Provider Handbook 2016
Hypoglycemia
Newborn < 45mg/dL
Child < 60mg/dL
Blood glucose test

5. Pediatric Glasgow Coma Scale
UpToDate

6. Recognition of Cardiac Arrest
• Unresponsiveness
• No breathing or only gasping
• No pulse (assess for no more than 10
seconds)
START CPR!

7. Cardiac Arrest
Age Depth
Rate and
Compression Ratio
Technique Landmark
Infant
1/3 AP diameter
of chest
At least 100
30:2 Single-R
15:2 Two-R
Thaler or
2-finger
Technique
Just below the
nipple line
1 year to Puberty
1/3 AP diameter
of chest
At least 100
30:2 Single-R
15:2 Two-R
2 hands
Between the
nipples, above
xiphoid
PALS Provider Handbook 2016

8. Cardiac Arrest
PALS Provider Handbook 2016
Component Recommendations
CHILDREN INFANTS
Recognition Unresponsiveness, No breathing or gasping, No Pulse
(10 second check)
CPR sequence C-A-B
Compression rate 100-120min
Compression depth At least 1/3 AP diameter
About 2 inches (5cm)
At least 1/3 AP diameter
About 1 ½ inches (4 cm)
Chest wall recoil Allow complete recoil between compressions
Compression
interruptions
Minimize interruption to less than 10 seconds

9. Cardiac Arrest
PALS Provider Handbook 2016
Component Recommendations
CHILDREN INFANTS
Airway Head tilt-chin lift
(suspected trauma: jaw thrust)
Ventilations with
advanced airway
1 breath every 6 seconds
(10 breaths per minute)
Asynchronous with chest compressions
Deliver each breath over 1 second with
visible chest rise

10. CPR for Infants
Source: https://youtu.be/XJQF-qUWOLA

11. CPR for Children
Source: https://youtu.be/c7Q1s7ppSwc

12. Pediatric Assessment Triangle (PAT)
• Represents the initial visual and auditory
assessment of the seriously ill or injured child
• Accomplished within the first seconds of
patient contact
• Purpose: to identify life-threatening conditions
PALS Provider Handbook 2016

13. Pediatric Assessment Triangle (PAT)
Appearance Indicator of overall physiologic status, including degree of interactivity,
muscle tone and verbal response
Uses TICLS (Tone, Interactiveness, Consolability, Look/Gaze,
Speech/Cry)
Breathing
(work of
breathing)
Determines Increased work of breathing by assessing the patient’s
position (tripod or sniffing position), work of breathing and adventitial
breath sounds
Circulation (Color) Evaluates child circulatory status based on general color
Abnormal skin color, cyanosis, pallor or mottling, petechiae or purpura
PALS Provider Handbook 2016

14. Pediatric Systematic Approach
Evaluate
Identify
Intervene
PALS Provider Handbook 2016

15. Pediatric Systematic Approach
Source: https://youtu.be/pi9SeSY8Xg8

16. Pediatric Systematic Approach
Evaluation Description
Primary survey Rapid hands on ABCDE approach to evaluate
respiratory, cardiac and neurologic function (vital signs
and pulse oximetry)
Secondary survey Focused medical history and focused physical exam
(SAMPLE)
Diagnostic tests Labs, radiographs to identify the physiologic condition
and diagnosis
PALS Provider Handbook 2016

17. Evaluate (primary survey)
• A – airway
• B – breathing
• C – circulation
• D – disability
• E – exposure
PALS Provider Handbook 2016

18. Evaluate (secondary survey)
• Focused history
• S – signs and symptoms
• A – allergies
• M – medications
• P – past medical history
• L – last meal
• E – events surrounding
• Focused physical examination
PALS Provider Handbook 2016

19. If at any part of this sequence you find that a patient
has a life-threatening condition, correction of that
condition takes precedence over completing the
elements of the assessment.

20. Identify
Type Severity
Respiratory Upper airway
Lower airway
Lung tissue disease
Disordered control of breathing
Respiratory distress
Respiratory failure
Circulatory Hypovolemic shock
Distributive shock
Cardiogenic shock
Obstructive shock
Compensated shock
Hypotensive shock
Cardiopulmonary failure
Cardiac arrest
PALS Provider Handbook 2016

21. Intervene
• Positioning the child to maintain patent
airway
• Activate emergency response
• Start CPR
• Obtain code cart and monitors
• Place monitors/leads
• O2 administration
• Support ventilation
• Start meds and fluids
PALS Provider Handbook 2016

22. Always perform REASSESSMENT to evaluate the
response to treatment and to track the progression
of identified physiologic and anatomic problems.

23. Post-resuscitation Care
• Goals of therapy
• Respiratory
• Cardiovascular
• Neurologic

24. Goals of Therapy
• Optimize and stabilize airway, oxygenation,
ventilation, and cardiopulmonary function
• Emphasis on restoring and maintaining vital
organ perfusion and function
• Prevent secondary organ injury
• Identify and treat the cause of acute illness
• Minimize the risk of deterioration
PALS Provider Handbook 2016

25. Respiratory
• Continue to monitor and support the child’s
airway, oxygenation, and ventilation
• Maintain adequate oxygenation (generally an
O2 saturation ≥94% but <100%) to reduce the
risk of reperfusion injury
PALS Provider Handbook 2016

26. Cardiovascular
• Restore and maintain intravascular volume
(preload)
• Treat myocardial dysfunction
• Control arrhythmias
• Maintain normal blood pressure and adequate
systemic perfusion
• Consider therapies to reduce metabolic
demand
PALS Provider Handbook 2016

27. Neurologic
• Maintain adequate brain perfusion
• Maintain normoglycemia
• Provide targeted temperature
managementTreat increased intracranial
pressure
• Treat seizures; search for and treat cause
PALS Provider Handbook 2016

28. Pediatric Trauma Key Points
• Assessment
• Emergency room management

29. Assessment
• Will still follow PALS Systemic Approach
Algorithm
• Reassessment continues throughout
stabilization period
APLS 2004

30. Emergency room management
• Spine stabilization must be maintained with all
airway maneuvers
• Breathing and immediate life-threatening chest
injuries must be addressed
• External and/or internal hemorrhage control is
important
• Traumatic brain injury can be assessed using
AVPU or GCS
• All clothing must be removed to completely
assess but make sure normothermia is
maintained
APLS 2004

31. Cervical Spine Immobilization
Uptodate

32. Covid-19 Updates
• Basic Life Support
• Pediatric Advanced Life Support

33. Covid-19 Resuscitation Updates
BASIC LIFE SUPPORT
• Lay bystanders should protect themselves as
far as feasible and avoid actions with a high
risk of transmission
• PPE must be donned
• Rescue breathing using bag-mask with filter
and tight seal
BLS for Suspected or
Confirmed Covid-19
2020

34. Covid-19 Resuscitation Updates
PEDIATRIC ADVANCED LIFE SUPPORT
• Healthcare providers should use PPE when
treating a critically ill child who has
confirmed or suspected COVID-19
• Limit personnel attending the code
• Prioritize intubation; Chest compressions
must be stopped while intubating patient
• Connect to ventilator with filter as much as
possible
PALS for Suspected or
Confirmed Covid-19
2020

35. Always don Personal Protective Equipment (PPE)
when treating a suspected or confirmed Covid-19
patient.

36. Algorithms
• Basic Life Support
• Pediatric Advanced Life Support
• Systematic approach
• Cardiac arrest
• Bradycardia
• Tachycardia
• Return of spontaneous circulation

37. Pediatric Covid-19 Basic Life Support
Algorithm
BLS for Suspected or Confirmed Covid-19 2020

38. Pediatric Covid-19 Basic Life Support
Algorithm
BLS for Suspected or Confirmed Covid-19 2020

39. Pediatric Systemic Approach Algorithm
PALS Provider Handbook 2016

40. Pediatric Systemic Approach Algorithm
PALS Provider Handbook 2016

41. Pediatric Covid-19 Cardiac Arrest
Algorithm
PALS for Suspected or Confirmed Covid-19 2020

42. Pediatric Covid-19 Cardiac Arrest
Algorithm
PALS for Suspected or Confirmed Covid-19 2020

43. Pediatric Bradycardia With a Pulse and
Poor Perfusion Algorithm
PALS Provider Handbook 2016

44. Pediatric Bradycardia With a Pulse and
Poor Perfusion Algorithm
PALS Provider Handbook 2016

45. Pediatric Tachycardia With a Pulse and
Poor Perfusion Algorithm
PALS Provider Handbook 2016

46. Pediatric Tachycardia With a Pulse and
Poor Perfusion Algorithm
PALS Provider Handbook 2016

47. Management of Shock After ROSC
PALS Provider Handbook 2016

48. Management of Shock After ROSC
PALS Provider Handbook 2016

49. 1. Chameides L, Samson RA, Schexnayder SM, Hazinski MF (Eds). Pediatric Advanced
Life Support Provider Manual. USA: American Heart Association; 2016.
2. Chameides L, Samson RA, Schexnayder SM, Hazinski MF (Eds). Basic Life Support
Provider Manual. USA: American Heart Association; 2016.
3. Fuchs S, Yamamoto L. APLS: The pediatric emergency medicine resource. Elk
Grove Village, Ill.: American Academy of Pediatrics; 2012.
4. Evaluation and acute management of cervical spine injuries in children and
adolescents. Uptodate. https://www.uptodate.com/contents/evaluation-and-
acute-management-of-cervical-spine-injuries-in-children-and-
adolescents?search=pediatric%20cervical%20spine&source=search_result&selected
Title=1~150&usage_type=default&display_rank=1#H2634661051. Published Sep 9,
2019. Accessed August 20, 2020.
5. BLS Healthcare Provider Pediatric Cardiac Arrest Algorithm for the Single Rescuer
for Suspected or Confirmed COVID-19 Patients. American Heart Association.
https://cpr.heart.org/-/media/cpr-files/resources/covid-19-resources-for-cpr-
training/english/algorithmbls_adult_cacovid_200406.pdf?la=en. Published April
2020. Accessed August 15, 2020.
6. Pediatric Cardiac Arrest Algorithm for Suspected or Confirmed COVID-19 Patients.
American Heart Association. https://cpr.heart.org/-/media/cpr-
files/resources/covid-19-resources-for-cpr-
training/english/algorithmpals_cacovid_200406.pdf?la=en. Published April 2020.
Accessed August 15, 2020.