Pediatric Advanced Life Support

Pediatric Advanced Life Support (PALS) is a special training for emergency care of infants and children. The training is developed and provided by the American Heart Association. PALS contains everything a pediatrics specialist would need including Basic Life Support training and Advanced Life Support training. The entire training is modified according to the unique considerations of small children and infants. 

Learn more about this special training in this blog post and level up your NEET SS Pediatrics preparation. 

Let’s begin.

Meaning of terms 

A. Class of recommendation (COR): also caned strength of recommendation 

• 1 : Strong (benefit >>> Risk) – Recommended
• 2a: Moderate (benefit >> risk)-Can be considered
• 2b : No (benefit = Risk) - Not recommended
• 3 : 1 term (risk > benefit) - should be formed 

B. Level of evidence (LOE) 

• Level A : High Quality 
• Level B-R: Moderate from Randomized trials 
• Level B-NR: Moderate from non-randomized data 
• Level C-LD: Data with limitations of design or execution 
• Level C-EO: Consensus of expert opinion 

Pediatric chains of survival 

• IHCA = In hospital cardiac arrest 
• OHCA = Out of hospital cardiac arrest 

Key points and recommendation in PALS 2020 

Initiation of CPR 

• Lay Rescuers: Should begin CPR for any victim who is unresponsive, not breathing normally, and does not have signs of life; do not check for a pulse 
• Healthcare providers: Check pulse for 10s and begin compression until a definite pulse is felt 
• Initiate CPR with C-A-B than A-B-C

Components of High Quality CPR 

• In CPR, start chest compression with Rescue breaths in cardiac arrest. If unable to give rescue breaths, compressions alone to be given 
• Chest compression rate: 100-120/min
• Allow adequate chest recoil between 2 compressions 
• Depth of compressions: At least 1/3^rd the AP diameter of the chest, approximately 1.5 inches (4 cm) in infants and 2 inches (5 cm) in children 
• Postpuberty, adult compression is used for depth 5-6 cm 
• A Rhythm check every 2 min, lasting 10 sec 
• When giving CPR without an advanced airway
  • Single rescuer: Compression to ventilation ratio of 30:2 
  • Two rescuers: Compression to ventilation ratio of 15:2
• When giving CPR with an airway, give on breath every 2 - 3 sec i.e. target a RR of 20-30/min. Rates exceeding these may compromise Hemodynamics 

CPR Techniques 

• Infants 
  • Single rescuer: Two fingers techniques or 2 thumbs placed just below the inter-mammary line 
  • Two rescuer: The 2-thumb encircling hands techniques 
  • For infants, if the rescuer can't able to achieve adequate depth, it may be reasonable to use the heel of 1 hand 
• Children 
  • For children, we can use either a 1 or 2 hand technique for chest compressions 

Support surface for CPR 

• During IHCA, when available. activate the bed's "CPR mode” to increase mattes stiffness 
• If not, use a background or a firm surface to give chest compressions 

Opening the airway 

• No cervical injury suspected: Head tilt-chin lift maneuver 
• Suspected cervical spine injury. Jaw thrust without head tilt. If fails, use a head tilt-chin lift maneuver 

Advanced Airway intervention in CPR 

• Bag and mask ventilation is reasonable compared with advanced airway intervention, during cardiac arrest in OHCA

Drug Administration during CPK 

• For pediatrics in any setting, epinephrine is administered. IU/10 is preferable to endotracheal tube (ETT) administration 
• The initial dose of epinephrine should be within 5 minutes of starting chest compressions 
• For pediatric patient in any setting, it is reasonable to administer epinephrine every 3-5 min until ROSC is achieved
• Amiodarone or Lidocaine is used for shock-refractory VF/pVT. 
• In pediatric cardiac arrest: Routing administration of sodium bicarbonate is not recommended because of the Sodium channel blocker (e.g. tricyclic antidepressant) toxicity or absence of Hyperkalemia. And calcium administration is also not advised due to absence of calcium channel blocker overdose, documented Hypocalcaemia, Hyperkalemia or Hypermagnesemia.
• For resuscitation: Recommended medication dose is calculated by child's body weight while not exceeding the recommended dose for adults 

Management of VF/pVT 

• Energy dose of defibrillation
  • Initial dose is 2-4 J/kg, usually 2 J/kg 
  • For Refractory VF : 4J/ kg 
  • Subsequent doses: 4J/ Kg and even higher, not exceeding 10 J/kg or adult maximum dose 
• Coordination of shock therapy and CPR
  • Perform CPR till device is ready 
  • A single shock, then immediately start CPR 
  • Minimize interruptions of chest compressions 
• Type of Defibrillator
  • While using on AED: For infants and childrens, a manual defibrillator is advised whenever a shockable rhythm is identified under the influence of trained healthcare provider.
  • Use the largest paddles or self adhering electrodes that will fit on the child's chest place them antero-lateral or Antero-posterior.

Assessment of Resuscitation Quality

• If continuous invasive BP monitoring is available at the time of cardiac arrest, use diastolic BP to assess CPR quality 
• ETCO₂ monitoring may be considered to assess the quality of chest compressions, but exact values in children not determined 
• McCPR feedback devices. If available 
• ECG may be considered to identify potentially treatable causes of arrest, such as pericardial tamponade and inadequate ventricular filling, but the potential benefits should be weighed against the risk of interrupting chest compressions 

Post Cardiac Arrest Care and Monitoring

• Targeted temperature monitoring 
  • For infants and children between 24h and 18 yr of age, who remain comatose after OHCA or IHCA, use either TTM 32-34° C followed by TTM 36-37.5° C or only TTM 36-37.5° C
  • Continuous core temperature monitoring is needed during TTM 
• Hemodynamic monitoring and ventilation 
  • Continuous arterial pressure monitoring, if available 
  • After ROSC. use fluids/ drugs to maintain SBP above 5^th percentile for age 
  • Wean O₂ to target saturation 94-99% 
  • Target normoxemia and avoid Hypo and Hypercapnia
• Neuro-monitoring and Seizure, if available, For detecting non-convulsive seizures following cardiac arrest in patients with persistent encephalopathy 
  • Recommended to treat clinical seizure after cardiac arrest 
  • Reasonable to treat non-convulsive status epilepticus following cardiac arrest in consultation with experts 
• Prognostication following cardiac arrest 
  • EEG in the 1^st week post - arrest as 1 factor for prognostication 
  • Consider multiple factors when predicting outcomes in infants and children who survive cardiac arrest 
• Recovery 
  • Survivors need evaluation for Rehabilitation needs
  • For neurological evaluation, survivors should be referred for at least the 1^st year after cardiac arrest
  • During resuscitation of their infant or child family member should be present if possible. 

Evaluation of sudden unexplained cardiac 

• Consider autopsy and appropriate preservation of biological material for genetic analysis, if the child does not survive 
• If no cause is found on autopsy, refer to a healthcare provider of center with expertise in inherited cardiac disease and cardiac genetic counselling
• For infants, children and adolescent, who survive obtain a complete past medical and family history, review previous ECG's and refer to a cardiologist. 

Resuscitation in shock 

• Septic shock 
  • In patients with septic shock, advised dose of fluid in 10 ml/kg or  < 10 ml/kg aliquots with frequent reassessment 
  • Either isotonic crystalloid or colloids can be infants fluids 
  • Both Balanced or unbalanced solutions will be effective 
  • Providers should be reassess after every fluid bolus for responsiveness or signs of fluid overload 
• In infants and children with fluid - refractory septic shock, it is reasonable to use either epinephrine or norepinephrine as an initial vasoactive infusion 
  • If epinephrine and nor epinephrine are not available, dopamine may be considered 
• Cardiogenic shock 
  • Early expert consultation 
  • Me epinephrine, dopamine, dobutamine or milrinone as an inotropic infusion
• Acute traumatic hemorrhagic shock 
  • To administer blood products, when available, instead of crystalloid for ongoing volume resuscitation 

Treatment of Respiratory failure 

• Provides rescue breaths. 1 breath every 2 to 35 (20-30 breaths / min) 

Foreign body airway obstruction 

• If mild FBAO: Allow the child to remove by coughing, monitor
• If severe FBAO, deliver repeated cycles of 5 back blows (slaps) followed by 5 chest compressions until the object is expelled or the victim becomes unresponsive 
• Once unresponsive, start CPR: Remove any visible FB while opening the airway, but no blind finger sweeps 

Opioid related respiratory and cardiac arrest 

• In respiratory arrest patient. rescue breathing or bag-mask ventilation should be maintained until spontaneous breathing returns 
• For a patient with suspected opioid over dose who has a definite pulse but does not have normal breathing or only gasping is present (i.e. a respiratory arrest), give life support and administer IM or intranasal naloxone. 
• For patient in cardiac arrest related to opioid intake, standard resuscitation measure must be taken prior to naloxone administration
• Cricoid pressure during BMV to prevent gastric insufflations
• No routine use of cricoid pressure during intubation 
• If used, discontinue cricoid pressure, if it interferes with case of intubation or ventilation 
• Choose cuffed over unruffled ETTs for intubating infants and children 
• When a cuffed ETT is used, ETT size, position and cuff inflation pressure, usually <20-25 H₂O should be monitored. 
• Use atropine 0.02 mg/kg as a premedication to prevent bradycardia during emergency intubation with high risk of bradycardia e.g. succinylcholine use 
• For infants and children in all conditions with a perfusing rhythm, for confirming ETT placement, use exhaled CO₂ detection (colorimetric detection or capnography).

And that is everything you need to know about Pediatric Advanced Life Support or PALS. Hope you found this blog helpful for your NEET SS General Pediatrics preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.