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.
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 1/3rd 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 5th 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 1st 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 1st 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.
PrepLadder Medical
Get access to all the essential resources required to ace your medical exam Preparation. Stay updated with the latest news and developments in the medical exam, improve your Medical Exam preparation, and turn your dreams into a reality!