Pediatric advanced life support (PALS) is a course offered by the American Heart Association (AHA) for health care providers who take care of children and infants in the emergency room, critical care and intensive care units in the hospital, and out of hospital (emergency medical services (EMS)). The course teaches healthcare providers how to assess injured and sick children and recognize and treat respiratory distress/failure, shock, cardiac arrest, and arrhythmias.
Basic Life Support (BLS)
PALS builds upon AHA's Pediatric Basic Life Support (BLS). Providers should follow the AHA's Pediatric BLS Algorithms for single and ≥ 2 person rescuer. The most essential component of BLS and PALS cardiac arrest care is high quality cardiopulmonary resuscitation (CPR). CPR should begin with a check for responsiveness, getting help, and activating the emergency response system. After this, the provider should assess for breathing and a pulse (brachial pulse in infant and carotid pulse in child) - all within 10 seconds. If no pulse and no breathing or only gasping, start CPR. CPR consists of chest compressions followed by rescue breaths - for single rescuer do 30 compressions and 2 breaths (30:2), for > 2 rescuers do 15 compressions and 2 breaths (15:2). The rate of chest compressions should be 100-120 compressions/min and depth should be 1.5 inches for infants and 2 inches for children. Chest compressions differ between infants and children. For infants, chest compressions can be done with the two-fingers technique (single rescuer) or two-thumbs encircling hands technique (2 rescuer). In the two-fingers technique, the provider uses their index and middle finger to press down on the infant's sternum, below the nipples. In the two-thumb encircling hands technique, the provider's hands should wrap around the chest with both thumbs pressing down on the infant's sternum. For children, chest compressions should be done with the provider placing the heel of one hand over the child's lower chest and pressing down while keeping their arms straightened at the elbow.
If help hasn't arrived after 2 minutes, the provider should call for help again and get an automated external defibrillator (AED). Once help and the AED arrives, the provider should place the AED pads on the child, making sure to not disrupt chest compressions. The AED will let the provider know if the child has a shockable heart rhythm. If shockable, give a shock and then immediately resume CPR.
Assessment PALS teaches a systematic assessment approach so that the health care provider can quickly identify any life-threatening conditions and treat them. The PALS systematic approach algorithm begins with a quick initial assessment followed by checking for responsiveness, pulse, and breathing. If the child has no pulse and isn't breathing, start CPR. If the child has a pulse but isn't breathing, provide ventilation and give oxygen (when possible). Once it has been established that the child has a pulse, is breathing, and doesn't require immediate life saving treatment, the provider will begin their primary assessment followed by a secondary assessment and further diagnostic workup. Continuous reassessments should be done to reassess for life-threatening conditions.
Pediatric vitals signs range according to age
Initial assessment The initial assessment is meant to be a very quick assessment performed within the first few seconds of interacting with a child and it utilizes the acronym ABC - appearance, breathing, and color. The provider will assess appearance (level of consciousness and responsiveness, speaking or crying), breathing (breathing or not breathing, increased work of breathing, abnormal breath sounds), and color (pale, mottled, cyanotic, bleeding).
Primary assessment The primary assessment uses the acronym ABCDE - airway, breathing, circulation, disability, exposure. Airway - assess airway patency (open/patent, unobstructed vs obstructed) and if the patient will need assistance maintaining their airway Breathing - assess respiratory rate, respiratory effort, lung sounds, airway sounds, chest movement, oxygen saturation via pulse oximetry Circulation - assess heart rate, heart rhythm, pulses, skin color, skin temperature, capillary refill time, blood pressure Disability - assess neurological function with AVPU pediatric response scale (alert, voice, painful, unresponsive), pediatric Glasgow Coma Scale (eye opening, motor response, verbal response), pupil response to light (normal, pinpoint, dilated, unilateral dilated), blood glucose test (low blood sugar / hypoglycemia can cause altered mental status) Exposure - assess temperature/ fever, signs of trauma (cuts, bleeding, bruises, burns, etc.), skin (petechiae, purpura, etc.)
Secondary assessment Once the primary assessment is completed, the provider can do a secondary assessment which consists of a complete physical exam and focused medical history. The information asked in the medical history uses the acronym SAMPLE - signs and symptoms, allergies, medications (prescribed, over the counter, vitamins, herbal), past medical history (any medical problems, prior surgeries), last meal (helpful information to know because it can affect when a child can have surgery or receive anesthesia), events (onset of illness and events leading up to illness). Parts of the history that are especially important for children include asking about medications that the child could have gotten into (e.g., if a pill fell on the floor or an unlocked medicine cabinet), history of prematurity, birth history, and immunizations.
Respiratory distress and failure Providers must be able to identify respiratory problems that are easily treatable (e.g., treated with oxygen, suctioning/ clearing airway, albuterol, etc.) and those that can rapidly progress to life-threatening conditions. Respiratory distress can progress to respiratory failure which can progress to cardiac arrest. Once respiratory complaints have progressed to cardiac arrest, death and neurological damage are more likely to occur. For this reason, providers should aim to identify and treat respiratory conditions before they progress and worsen.
Recognition
Signs and symptoms Common signs of respiratory distress
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