Pediatric Advanced Life Support (PALS): Asystole/Pulseless Electrical Activity (PEA)
PALS: Pediatric Arrest
1. The initial evaluation is as follows: [1, 2, 3, 4]
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Activate emergency response system.
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Initiate pediatric basic life support (BLS) algorithm.
2. The initial intervention is as follows:
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Start high-quality cardiopulmonary resuscitation (CPR).
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Administer oxygen if hypoxemic.
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Attach monitor/defibrillator.
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Monitor blood pressure and oximetry.
3. Check rhythm, as follows:
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Shockable rhythm = Ventricular fibrillation or pulseless ventricular tachycardia (VF/VT)
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Nonshockable rhythm = Asystole/pulseless electrical activity (PEA)
Shockable Rhythm
1. Initial treatment of VT/VF, as follows:
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Defibrillate immediately.
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Continue CPR for 2 minutes.
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Obtain intravenous (IV)/intraosseous (IO) access.
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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:
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If nonshockable, see Nonshockable Rhythm (below).
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If shockable, see Shockable Rhythm (above) and administer amiodarone or lidocaine after second defibrillation attempt.
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Rotate chest compressors.
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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:
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Continue CPR for 2 minutes.
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Obtain intravenous (IV)/intraosseous (IO) access.
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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:
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If nonshockable, see Nonshockable Rhythm (above).
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If shockable, see Shockable Rhythm (above).
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Rotate chest compressors.
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Identify and treat reversible causes.
4. If return of spontaneous circulation (ROSC), see PALS: Post-Cardiac Arrest Care.
CPR Quality
See the list below:
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Push hard and fast, at least one-third anteroposterior (AP) chest diameter and 100-120 compressions per minute.
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Allow complete chest recoil.
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Minimize interruptions in compressions.
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Avoid excessive ventilation.
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Rotate compressor every 2 minutes or if fatigued.
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Compression-to-ventilation ratio is 30:2 for a single rescuer, 15:2 for multiple rescuers.
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Continuous compressions if advanced airway present, asynchronous ventilation (children) or timed ventilation (infants)
Shock Energy
See the list below:
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2 J/kg first shock
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4 J/kg second shocks
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≥4 J/kg subsequent shocks, maximum 10 J/kg or adult dose
Drug Therapy
See the list below:
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Epinephrine 0.01 mg/kg IV/IO q3-5min; use 1:10000 concentration (0.1 mL/kg)
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Epinephrine 0.1 mg/kg endotracheal tube (ETT) q3-5min, use 1:1000 concentration (0.1 mL/kg), not preferred route
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Amiodarone 5 mg/kg IV/IO, may repeat up to 2 times for refractory VF/VT
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Lidocaine 1 mg/kg IV/IO loading dose, 20-50 mcg/kg/min maintenance infusion
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Flush medications with fluid after and elevate extremity for 10-20 seconds.
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Combining medications is not recommended and may cause harm.
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Routine use of sodium bicarbonate is not recommended and may cause harm.
Advanced Airway
See the list below:
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Endotracheal tube (ETT) or supraglottic airway (SGA)
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Waveform capnography to confirm and monitor ET tube placement
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Ventilation every 6 seconds asynchronous with compressions
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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:
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Pulse and blood pressure present
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Abrupt sustained increase in PETCO 2 (typically >40 mm Hg)
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Spontaneous arterial pressure waves with intra-arterial monitoring
Reversible Causes (H’s and T’s)
See the list below:
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H's: hypovolemia, hypoxia, H+ (acidosis), hypokalemia, hyperkalemia, hypothermia, hypoglycemia
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T's: toxins cardiac, tamponade (cardiac), tension pneumothorax, thrombosis (pulmonary, coronary)
Most Recent Guideline Changes
Changes from the 2010 guidelines include the following:
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Simultaneous breathing and pulse check in less than 10 seconds
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Administer epinephrine as soon as feasible after the onset of cardiac arrest due to an initial nonshockable rhythm.
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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:
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Amiodarone or lidocaine is equally acceptable for the treatment of shock-refractory VT/VF in children.
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There is no evidence to support the routine use of atropine as a premedication to prevent bradycardia in emergency pediatric (age >1 year) intubations.
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For septic shock, the initial fluid bolus is 20 mL/kg.
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For children who are comatose in the first several days after cardiac arrest, fever should be treated aggressively.
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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.