PALS Comprehensive

Cheatsheet Content

### PALS Overview - **PALS:** Pediatric Advanced Life Support - **Goal:** Improve outcomes for critically ill infants and children. - **Key Principles:** Early recognition, effective CPR, systematic approach. #### Normal Pediatric Vital Signs (Approximate) | Age Group | Heart Rate (bpm) | Respiratory Rate (breaths/min) | Systolic BP (mmHg) | | :------------- | :--------------- | :----------------------------- | :----------------- | | **Infant** (0-12 mo) | 100-160 | 30-60 | 70-100 | | **Toddler** (1-3 yr) | 90-150 | 24-40 | 80-110 | | **Preschool** (3-6 yr) | 80-140 | 22-34 | 80-110 | | **School-age** (6-12 yr) | 70-120 | 18-30 | 90-120 | | **Adolescent** (>12 yr) | 60-100 | 12-20 | 90-120 | *Note: These are general ranges. Trends and clinical context are crucial.* ### Systematic Approach 1. **Initial Impression:** (ABCDE) * **A**irway: Patent, maintainable, unmaintainable. * **B**reathing: Rate, effort, lung sounds. * **C**irculation: Heart rate, pulses, skin color, capillary refill. * **D**isability: LOC (AVPU), pupils, glucose. * **E**xposure: Rashes, trauma, temperature. 2. **Primary Assessment:** (ABCDE + Vitals, Pulse Ox, Capnography) * Detailed assessment based on initial impression findings. 3. **Secondary Assessment:** (SAMPLE) * **S**igns & Symptoms * **A**llergies * **M**edications * **P**ast Medical History * **L**ast Meal * **E**vents leading to illness/injury 4. **Diagnostic Tests:** Labs, imaging, etc. ### Respiratory Distress & Failure - **Recognize:** Tachypnea, increased WOB (retractions, nasal flaring), abnormal airway sounds (stridor, wheezing), pallor, anxiety. - **Respiratory Distress:** Increased WOB, adequate oxygenation/ventilation. - **Respiratory Failure:** Inadequate oxygenation/ventilation, compensation exhausted, impending arrest. - **Management:** Position airway, suction, oxygen, ventilatory support (BVM, intubation), medications (bronchodilators, steroids). * **Upper Airway Obstruction:** Croup, foreign body. * **Lower Airway Obstruction:** Asthma, bronchiolitis. * **Lung Tissue Disease:** Pneumonia, ARDS. * **Disordered Control of Breathing:** CNS dysfunction, poisoning. ### Shock - **Recognize:** Tachycardia, poor perfusion (cool extremities, delayed cap refill), hypotension (late sign in children). - **Types of Shock:** * **Hypovolemic:** Dehydration, hemorrhage. * Tx: Fluid boluses (isotonic crystalloids 20 mL/kg over 5-20 min). * **Distributive:** Sepsis, anaphylaxis, neurogenic. * Tx: Fluid boluses, vasopressors (norepinephrine, dopamine), epinephrine for anaphylaxis. * **Cardiogenic:** Myocarditis, congenital heart disease, arrhythmia. * Tx: Cautious fluid boluses, inotropes (dopamine, epinephrine, milrinone), vasodilators. * **Obstructive:** Tension pneumothorax, cardiac tamponade, PE. * Tx: Address underlying cause (needle decompression, pericardiocentesis). - **Management for all shock:** Airway, breathing, oxygen, vascular access, fluid boluses, treat cause. ### Bradycardia - **Definition:** HR too slow for age, causing symptoms (hypotension, altered mental status, poor perfusion). - **Common Causes:** Hypoxia, vagal stimulation, hypothermia, drugs. - **Algorithm:** 1. Assess oxygenation & ventilation. 2. If HR < 60 bpm with poor perfusion despite oxygenation/ventilation: * Start chest compressions. * Administer Epinephrine IV/IO (0.01 mg/kg every 3-5 min). * Consider Atropine IV/IO (0.02 mg/kg, min 0.1 mg, max 0.5 mg) for increased vagal tone or primary AV block. * Consider pacing (rare in children). ### Tachycardia - **Narrow QRS Tachycardia:** * **Sinus Tachycardia:** P waves present, variable HR, appropriate for clinical state. * Tx: Treat underlying cause (fever, pain, hypovolemia). * **SVT (Supraventricular Tachycardia):** No P waves or abnormal P waves, constant HR, often abrupt onset/offset. * Tx: Vagal maneuvers, Adenosine IV/IO (0.1 mg/kg, max 6 mg; then 0.2 mg/kg, max 12 mg), synchronized cardioversion (0.5-1 J/kg, then 2 J/kg). - **Wide QRS Tachycardia:** (Ventricular Tachycardia or SVT with aberrancy) * Often unstable; treat as V-tach until proven otherwise. * Tx: Amiodarone IV/IO (5 mg/kg over 20-60 min), Procainamide IV/IO (15 mg/kg over 30-60 min), synchronized cardioversion. ### Cardiac Arrest - **Recognize:** Unresponsive, no breathing/agonal gasps, no pulse. - **Algorithm:** 1. **Call for help/Activate EMS.** 2. **Start CPR:** * Compressions: 100-120/min, 1/3 anterior-posterior chest diameter (approx. 1.5 inches for infant, 2 inches for child). * Ratio: 15:2 (2-rescuer), 30:2 (1-rescuer). * Minimize interruptions. 3. **Attach Monitor/Defibrillator.** 4. **Shockable Rhythm (VF/Pulseless VT):** * Defibrillate: 2 J/kg, then 4 J/kg, then >4 J/kg (max 10 J/kg). * After 2nd shock, give Epinephrine IV/IO (0.01 mg/kg). * After 3rd shock, consider Amiodarone IV/IO (5 mg/kg) or Lidocaine IV/IO (1 mg/kg bolus). 5. **Non-Shockable Rhythm (Asystole/PEA):** * Administer Epinephrine IV/IO (0.01 mg/kg every 3-5 min). * Treat reversible causes (H's and T's). - **Reversible Causes (H's & T's):** * **H's:** Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo-/Hyperkalemia, Hypothermia, Hypoglycemia. * **T's:** Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (coronary/pulmonary), Trauma. ### Post-Cardiac Arrest Care - **Optimize ventilation & oxygenation:** Maintain SpO2 94-99%, EtCO2 35-45 mmHg. - **Optimize hemodynamics:** Maintain adequate perfusion and blood pressure. - **Targeted Temperature Management (TTM):** If comatose, consider 32-34°C for 12-24 hours, then 36-37.5°C. - **Treat seizures.** - **Monitor for organ dysfunction.** ### Key Medication Doses | Medication | Indication | Dose (IV/IO) | Notes | | :-------------- | :------------------- | :----------------------------------------- | :----------------------------------------------------------------- | | **Adenosine** | SVT | 0.1 mg/kg (max 6 mg), then 0.2 mg/kg (max 12 mg) | Rapid push, follow with flush. | | **Epinephrine** | Cardiac Arrest | 0.01 mg/kg (1:10,000 solution) every 3-5 min | High dose (0.1 mg/kg) for refractory shock/bradycardia (rare). | | | Symptomatic Bradycardia | 0.01 mg/kg (1:10,000 solution) every 3-5 min | | | | Shock (infusion) | 0.1-1 mcg/kg/min | Titrate to effect. | | **Atropine** | Symptomatic Bradycardia | 0.02 mg/kg (min 0.1 mg, max 0.5 mg) | For vagal-mediated bradycardia or AV block. | | **Amiodarone** | Pulseless VT/VF | 5 mg/kg bolus | Max 300 mg. | | | Perfusing Tachycardia | 5 mg/kg over 20-60 min | Max 300 mg. | | **Lidocaine** | Pulseless VT/VF | 1 mg/kg bolus, then 20-50 mcg/kg/min infusion | Alternative to Amiodarone. | | **Dopamine** | Shock (non-hypovolemic) | 2-20 mcg/kg/min | Titrate to effect; lower dose for renal, higher for inotropic/pressor. | | **Dextrose** | Hypoglycemia | D25W 2-4 mL/kg (infant), D10W 5-10 mL/kg (child) | Check blood glucose. | | **Naloxone** | Opioid Overdose | 0.1 mg/kg (max 2 mg) | Repeat as needed. | | **Sodium Bicarb** | Metabolic Acidosis (severe, prolonged arrest) | 1 mEq/kg | Only if adequate ventilation. | ### Airway Management - **Basic:** Head tilt-chin lift, jaw thrust, suction, OPA/NPA. - **Advanced:** Endotracheal Intubation (ETI), Laryngeal Mask Airway (LMA). * **ET Tube Size (uncuffed):** (Age in years / 4) + 4 * **ET Tube Size (cuffed):** (Age in years / 4) + 3.5 * **Depth (oral):** 3 x ET tube size * **Confirm Placement:** Chest rise, bilateral breath sounds, EtCO2 detector, chest X-ray.