PALS (Main)

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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

Adult” size (8 to 10 cm) for children �10 kg (� 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


  • Compressions
    • Push hard (≥ 1/3 chest diameter) and fast (≥100/min)
  • Ventilations
    • 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
    • Uncuffed
      • <1yo - 3.5mm ETT
      • 1-2yo - 4mm ETT
      • >2yo - 4 + (age/4)
    • Cuffed
      • <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
    • Hypovolemia
    • Hypoxia
    • Hydrogen ion
    • Hypo/hyperkalemia
    • Hypothermia
    • Tension pneumo
    • Tamponade
    • Toxins
    • 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
    • Magnesium
      • 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 perfusion:

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