Pediatric Advanced Life Support (PALS): Pediatric Cardiac Arrest 

Updated: May 10, 2018
  • Author: James J Lamberg, DO; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Pediatric Advanced Life Support (PALS): Asystole/Pulseless Electrical Activity (PEA)

PALS: Pediatric Arrest

1. The initial evaluation is as follows: [1, 2, 3, 4]

  • Activate emergency response system.
  • Initiate pediatric basic life support (BLS) algorithm.

2. The initial intervention is as follows:

  • Start high-quality cardiopulmonary resuscitation (CPR).
  • Administer oxygen if hypoxemic.
  • Attach monitor/defibrillator.
  • Monitor blood pressure and oximetry.

3. Check rhythm, as follows:

  • Shockable rhythm = Ventricular fibrillation or pulseless ventricular tachycardia (VF/VT)
  • Nonshockable rhythm = Asystole/pulseless electrical activity (PEA)

Shockable Rhythm

1. Initial treatment of VT/VF, as follows:

  • Defibrillate immediately.
  • Continue CPR for 2 minutes.
  • Obtain intravenous (IV)/intraosseous (IO) access.
  • Consider advanced airway, end-tidal carbon dioxide tension (PETCO 2).

2. Administer vasopressor (epinephrine q3-5min).

3. Check pulse and rhythm every 2 minutes, as follows:

  • If nonshockable, see Nonshockable Rhythm (below).
  • If shockable, see Shockable Rhythm (above) and administer amiodarone or lidocaine after second defibrillation attempt.
  • Rotate chest compressors.
  • Identify and treat reversible causes.

4. If return of spontaneous circulation (ROSC), see PALS: Post-Cardiac Arrest Care.

Nonshockable Rhythm

1. Initial treatment of asystole/PEA is as follows:

  • Continue CPR for 2 minutes.
  • Obtain intravenous (IV)/intraosseous (IO) access.
  • Consider advanced airway, end-tidal carbon dioxide tension (PETCO 2).

2. Administer vasopressor (epinephrine q3-5min).

3. Check pulse and rhythm every 2 minutes, as follows:

  • If nonshockable, see Nonshockable Rhythm (above).
  • If shockable, see Shockable Rhythm (above).
  • Rotate chest compressors.
  • Identify and treat reversible causes.

4. If return of spontaneous circulation (ROSC), see PALS: Post-Cardiac Arrest Care.

CPR Quality

See the list below:

  • Push hard and fast, at least one-third anteroposterior (AP) chest diameter and 100-120 compressions per minute.
  • Allow complete chest recoil.
  • Minimize interruptions in compressions.
  • Avoid excessive ventilation.
  • Rotate compressor every 2 minutes or if fatigued.
  • Compression-to-ventilation ratio is 30:2 for a single rescuer, 15:2 for multiple rescuers.
  • Continuous compressions if advanced airway present, asynchronous ventilation (children) or timed ventilation (infants)

Shock Energy

See the list below:

  • 2 J/kg first shock
  • 4 J/kg second shocks
  • ≥4 J/kg subsequent shocks, maximum 10 J/kg or adult dose

Drug Therapy

See the list below:

  • Epinephrine 0.01 mg/kg IV/IO q3-5min; use 1:10000 concentration (0.1 mL/kg)
  • Epinephrine 0.1 mg/kg endotracheal tube (ETT) q3-5min, use 1:1000 concentration (0.1 mL/kg), not preferred route
  • Amiodarone 5 mg/kg IV/IO, may repeat up to 2 times for refractory VF/VT
  • Lidocaine 1 mg/kg IV/IO loading dose, 20-50 mcg/kg/min maintenance infusion
  • Flush medications with fluid after and elevate extremity for 10-20 seconds.
  • Combining medications is not recommended and may cause harm.
  • Routine use of sodium bicarbonate is not recommended and may cause harm.

Advanced Airway

See the list below:

  • Endotracheal tube (ETT) or supraglottic airway (SGA)
  • Waveform capnography to confirm and monitor ET tube placement
  • Ventilation every 6 seconds asynchronous with compressions
  • Stop CPR for no longer than 10 seconds for the placement of an advanced airway.

Return of Spontaneous Circulation

Signs of ROSC are as follows:

  • Pulse and blood pressure present
  • Abrupt sustained increase in PETCO 2 (typically >40 mm Hg)
  • Spontaneous arterial pressure waves with intra-arterial monitoring

Reversible Causes (H’s and T’s)

See the list below:

  • H's: hypovolemia, hypoxia, H+ (acidosis), hypokalemia, hyperkalemia, hypothermia, hypoglycemia
  • T's: toxins cardiac, tamponade (cardiac), tension pneumothorax, thrombosis (pulmonary, coronary)

Most Recent Guideline Changes

Changes from the 2010 guidelines include the following:

  • Simultaneous breathing and pulse check in less than 10 seconds
  • Administer epinephrine as soon as feasible after the onset of cardiac arrest due to an initial nonshockable rhythm.
  • Provide opioid overdose education, either alone or coupled with naloxone distribution and training, to persons at risk for opioid overdose.

Changes from the 2010 PALS guidelines include the following:

  • Amiodarone or lidocaine is equally acceptable for the treatment of shock-refractory VT/VF in children.
  • There is no evidence to support the routine use of atropine as a premedication to prevent bradycardia in emergency pediatric (age >1 year) intubations.
  • For septic shock, the initial fluid bolus is 20 mL/kg.
  • For children who are comatose in the first several days after cardiac arrest, fever should be treated aggressively.
  • For comatose children resuscitated from out-of-hospital cardiac arrest (OHCA), maintain either 5 days of normothermia or 2 days of initial continuous hypothermia (32˚C-34˚C) followed by 3 days of normothermia.