Difference between revisions of "PALS (Main)"

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''See [[critical care quick reference]] for drug doses by weight.''
IO access is a rapid, safe, effective, and acceptable route for
vascular access in children,172–179,181 and it is useful as the
initial vascular access in cases of cardiac arrest
*Use the largest paddles or self-adhering electrodes265–267 that
will fit on the child’s chest without touching (when possible,
leave about 3 cm between the paddles or electrodes
*[[Pediatric Pulseless Arrest]]
*[[PALS: Bradycardia]]
**Use [[Pediatric Pulseless Arrest]] algorithm if no pulse = PEA
Adult” size (8 to 10 cm) for children �10 kg
*[[PALS: Tachycardia]]
(� approximately 1 year)
● “Infant” size for infants �10 kg
*hypotension is defined as a systolic blood pressure:
60 mm Hg in term neonates (0 to 28 days)
70 mm Hg in infants (1 month to 12 months)
70 mm Hg � (2 � age in years) in children 1 to 10 years
90 mm Hg in children �10 years of age
**Push hard (≥ 1/3 chest diameter) and fast (≥100/min)
**NO perfusing rhythm
***15:2 ratio when do not have advanced airway
****Do not overventilate! (leads to decr venous return)
****Deliver breath with inspiratory time of 1s
***8-10 breaths per min when intubated
**YES perfusing rhythm
***Give rescue breaths 12-20 per min (“squeeze-release-release”)
==Advanced Airway==
*Cuffed and uncuffed ETT are acceptable
***<1yo - 3.5mm ETT
***1-2yo - 4mm ETT
***>2yo - 4 + (age/4)
***<1yo - 3mm ETT
***1-2yo - 3.5mm ETT
***>2yo - 3.5 + (age/4)
==Pulseless Arrest==
===Asystole and PEA===
*Give Epi 0.01 mg/kg (0.1 mL/kg 1:10,000) (max 1mg) q3-5min
*Rhythm check q2min
*Consider H's and T's
**Hydrogen ion
**Tension pneumo
**Thrombosis, pulmonary
**Thrombosis, coronary
===VF/Pulseless VT===
*Shock as quickly as possible and resume CPR immediately
**First shock 2 J/kg
**Second shock 4 J/kg
**Subsequent shocks ≥ 4 J/kg (max 10 J/kg)
*Give Epi if (shock + 2min CPR) fails to convert rhythm
*Perform pulse check/shock if appropriate q2min
*Give antiarrhythmic if (2nd shock +2min CPR) again fails
**1st line: Amiodarone
***5 mg/kg (max 300mg)
***May repeat twice up to 15mg/kg
**2nd line: Lidocaine
***1 mg/kg
***25-50mg/kg (max 2g) IV
***Only for polymorphic V-tach
*Assumes pulse and poor perfusion (low BP, AMS, shock)
**Start CPR if HR <60/min w/ poor perfusion
***Recheck after 2min; if poor perfusion persists:
****Give Epi 0.01 mg/kg (0.1 mL/kg 1:10,000)
****Give Atropine 0.02mg/kg
*****Only if due to incr vagal tone or AV block (not hypoxia)
****Transcutaneous pacing
*****Consider if bradycardia is due to complete heart block
If pulses are palpable and the patient has adequate
Narrow-Complex (<0.09 Second) Tachycardia
Supraventricular Tachycardia
Attempt vagal stimulation (Box 7) first, unless the patient
is hemodynamically unstable or the procedure will unduly
delay chemical or electric cardioversion (Class IIa, LOE C).
In infants and young children, apply ice to the face without
occluding the airway
In older children, carotid sinus massage or Valsalva maneuvers
are safe.
Pharmacologic cardioversion with adenosine (Box 8) is
very effective with minimal and transient side effects.300–304 If
IV/IO access is readily available, adenosine is the drug of
choice (Class I, LOE C). Side effects are usually transient.
300–304 Administer IV/IO adenosine 0.1 mg/kg using 2
syringes connected to a T-connector or stopcock; give
adenosine rapidly with 1 syringe and immediately flush
with �5 mL of normal saline with the other
If the patient is hemodynamically unstable or if adenosine
is ineffective, perform electric synchronized cardioversion
(Box 8). Use sedation, if possible. Start with a dose of 0.5
to 1 J/kg. If unsuccessful, increase the dose to 2 J/kg (Class
IIb, LOE C). If a second shock is unsuccessful or the
tachycardia recurs quickly, consider amiodarone or procainamide
before a third shock
Consider amiodarone 5 mg/kg IO/IV308,309 or procainamide
15 mg/kg IO/IV236 for a patient with SVT unresponsive to
vagal maneuvers and adenosine and/or electric cardioversion;
for hemodynamically stable patients, expert consultation
is strongly recommended prior to administration
(Class IIb, LOE C). Both amiodarone and procainamide
must be infused slowly (amiodarone over 20 to 60 minutes
and procainamide over 30 to 60 minutes), depending on the
urgency, while the ECG and blood pressure are monitored.
If there is no effect and there are no signs of toxicity, give
additional doses (Table 1). Avoid the simultaneous use of
amiodarone and procainamide without expert consultation.
Wide-Complex (>0.09 Second) Tachycardia
Adenosine may be useful in differentiating SVT from VT
and converting wide-complex tachycardia of supraventricular
origin (Box 12). Adenosine should be considered only
if the rhythm is regular and the QRS is monomorphic
Consider electric cardioversion after sedation using a
starting energy dose of 0.5 to 1 J/kg. If that fails, increase
the dose to 2 J/kg
Consider pharmacologic conversion with either intravenous
amiodarone (5 mg/kg over 20 to 60 minutes) or
procainamide (15 mg/kg given over 30 to 60 minutes)
while monitoring ECG and blood pressure. Stop or slow
the infusion if there is a decline in blood pressure or the
QRS widens
Treat signs of shock with a bolus of 20 mL/kg of isotonic
crystalloid even if blood pressure is normal
Do not routinely hyperventilate even in case of head injury
Whenever possible, provide family
members with the option of being present during resuscitation of
an infant or child
==See Also==
==See Also==
*[[AHA Recommendation Changes by Year]]
*[[Airway Sizes (Peds)]]
*[[Synchronized Cardioversion]]
*[[Post Cardiac Arrest]]
*[[ACLS (Main)]]
*[[ACLS (Treatable Conditions)]]
*[[Neonatal Resuscitation]]
*[[Newborn Resuscitation]]
*[[Pediatric Vital Signs]]
AHA 2010 Guidelines for PALS
[[Category:Critical Care]]

Latest revision as of 17:10, 27 June 2016