PALS (Main)

Recommendations

• Use Heimlich for >1yr; back/chest thrusts for <1yr
• Treat shock w/ initial 20cc/kg bolus
  • Repeat boluses up to total of 60 mL/kg; thereafter pressors should be started
• Do not routinely hyperventilate even in cases of head injury
• Provide family w/ option of being present during resuscitation
• IO is useful as initial vascular access
• Self-Adhering Electrodes
  • Use largest size that will fit on child’s chest w/o touching
  • When possible leave 3cm between electrodes
  • Adult size for >10kg; infant size for <10kg
• Hypotension is defined as sys BP:
  • <60 (0 to 28 days)
  • <70 (1mo - 12mo)
  • <70 + (2 X age in yr) (1-10yr)
  • <90 (≥10yr)

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

Bradycardia

• Algorithm 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

Tachycardia

• Algorithm assumes pulse and adequate perfusion

Narrow-Complex

• Sinus tachycardia - treat underlying cause
• Supraventricular
  • Vagal stimulation (if will not delay meds/cardioversion)
    • Infants/young children: apply ice to face
    • Older children: Carotid sinus massage / Valsalva
  • Synchronized cardioversion
    • Use if unstable or adenosine ineffective
    • Give 0.5-1 J/kg; if unsuccessful increase to 2 J/kg
      • Give 2nd shock consider amiodarone OR procainamide before 3rd shock
        • Amiodarone 5 mg/kg over 20-60min
        • Procainamide 15 mg/kg over 30-60min
  • Adenosine
    • 0.1 mg/kg; immediately flush w/ 5cc NS

Wide-Complex

• Adenosine for differentiating SVT from VT
  • Consider only if rhythm is regular and QRS monomorphic
• Synchronized cardioversion
  • Give 0.5-1 J/kg; if unsuccessful increase to 2 J/kg
  • Give 2nd shock consider amiodarone OR procainamide before 3rd shock
    • Amiodarone 5 mg/kg over 20-60min
    • Procainamide 15 mg/kg over 30-60min

Source

AHA 2010 Guidelines for PALS