Paediatric Advanced Life Support (PALS)

Because most paediatric cardiac arrests are primarily respiratory in cause, there is a greater emphasis on breathing in the paediatric than than the adult management of cardiac arrest.

Essentially, then, the main difference lies in starting, in the child, with two rescue breaths and then adopting a 15:2 ratio of chest compressions to breaths (compared to 30:1 in the adult) thereafter. Otherwise, chest compressions remain the mainstay of BLS in the child as in the adult. The other important consideration, particularly in neonates, is a blood glucose level (BGL).

The dose for the main drugs in the ALS are:

• Adrenaline 10 mcg / kg (0.1 mL/kg 1:10,000) to max 1.0 mg IV/IO
• Amiodarone 5 mg / kg IV/IO may repeat twice up to 15 mg/kg to max 300 mg

The energy level of defibrillation is 4 Joules / kg. In children under 8 years of age, the defibrillator should preferentially (almost exclusively) be used in manual mode. This allows for quicker charge and discharge, but requires a person trained in differentiating shockable and non-shockable rhythms. The non-shockable arrest rhythms—asystole and PEA—are seen more commonly in children than adults.

The most important thing is to completely familiarise yourself, in theory and in practice, with the BLS/ALS algorithms such that they become second nature to you. That frees-up the mental faculty, during an emergency, while cycling through the loops of the algorithm, for seeking out those reversible factors.

Reversible Factors — the “4Hs and 4Ts”:

4 Hs

• Hypoxia
• Hypovolaemia
• Hypokalaemia/Hyperkalaemia
• Hypothermia

4 Ts

• Tension Pneumothorax (PTX)
• Cardiac Tamponade
• Toxins
• Thrombosis – Pulmonary, Coronary

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Consider them, briefly but purposefully, one at a time:

First the 4 Hs

H is for Hypoxia

The clue that the primary problem is hypoxaemia will be in the history, on finding central cyanosis, and a decreased oximetry (SpO2) reflected also in the arterial blood gas.

Context: Respiratory Arrest / Airway Obstruction / Drowning / Anaphylaxis / Asthma

Manage by:

1. effective ventilation
2. high FiO2
3. treat underlying cause

H is for Hypovolaemia

Clues are in the history, in findings of dehydration (dry mucous membranes, poor skin turgor, sunken eyes), or signs of bleeding.

Context: Haemorrhage (trauma, post-surgery, perinatal) / Dehydration.

Manage with:

1. local pressure (for bleeding)
2. IV / IO access x 2
3. fluid bolus: 20 mL/kg Normal Saline or Hartmann’s or colloid
4. emergency surgery

H is for Hypo- or hyperkalaemia (and hypoglycaemia)

The clue that the primary problem is metabolic (don’t forget hypoglycaemia) is in the history, EUCs, findings of weakness/fatigue, and the ECG changes associated with a low or high serum potassium:

↑K: possible peaked T waves, widened QRS

Context: Renal Failure (ARF/CRF) / Metabolic Acidosis / Drugs

1. Give 10% Ca gluconate slow IV (alternatively, CaCl should be administered through a central line) to emergently stabilise myocardium, hopefully buying enough time to perform the following steps to reduce the serum potassium: (where .
   • salbutamol 2.5mg nebulised
   • sodium bicarbonate 8.4% IV
   • dextrose 10% / insulin (Actrapid)
   • cation exchange resins (e.g. Resonium)
   • dialysis

↓K: possible flattened / inverted T waves, u waves

Context: Drugs / Diarrhoea & Vomiting / Malnutrition

1. Give 5 mmol IV KCl replacement

H is for Hypo- and Hyperthermia

Clues are in the history, and a core body temperature of either < 30 degrees or over 40 degrees centigrade.

Context: Exposure / Sepsis / Drugs

Manage by:

• gentle handling and active warming: warm blankets, warm fluids, bypass
• cooling blankets, ice packs, cooled fluids, dantrolene (for malignant hyperthermia)

And now the 4 Ts

T is for Tension (PTX)

Clues are in the history, rapid hypoxia, ↓ air entry on the affected side, and distended neck veins:

Context: Post central line insertion / post cardiac intervention / fractured ribs / high ventilation pressures

Manage by:

1. needle decompression
2. followed by I/O intercostal catheter (ICC)

T is for Tamponade

Consider the history, any prior tachycardia or hypotension, any distended neck veins (but with equal air entry) and an emergent ultrasound:

Context: Chest trauma / Post cardiac surgery or intervention / post central line insertion / malignancy

Manage by:

1. surgical drainage
2. thoracotomy and pericardiotomy
3. pericardiocentesis using USS/Echo

T is for Toxins (and Poisons / Drugs)

Note the history, ant toxins at the scene, wide-ranging manifestations will depend on the poison:

Context: Intentional overdose / Accidental overdose

Manage by:

1. Identify drug/poison
2. administer specific antidote (get toxicological help early)
3. support life

T is for Thrombosis – pulmonary / coronary

Note the history, mottled chest, often unable to determine

Context: DVT / Atrial arrhythmia / long bone fractures / amniotic fluid embolism

Management:

1. percutaneous mechanical
2. thromboembolectomy
3. thrombolytics (and consider increasing length of time of CPR before terminating)

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Resuscitation of the Newborn:

1. Airway – suction
2. Bag & Mask – O2 8-15 L/min ⇒ ? OPA
3. IF HR not increase promptly to > 70 bpm
   1. ECC with two fingers over sternum and 1/3 chest depth @ 100 compressions per minute
      1. asystole (bradycardia) → adrenaline 2 ml/kg IV of 1:10,000
      2. VT / VF → defibrillate @ 2-4 J/kg → lignocaine 1 mg/kg IV

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Drugs

• 20 mL/kg Fluid bolus
• 4 J/kg DC shock (use paediatric pads)
• Adrenaline 10 mcg / kg
  • Formulation: [1:10,000 x 10 mL]
  • Dose: 1 mL for every 10 kg, IV bolus, every second loop
    • * if, instead, you use the [1:1000 x 1 mL] ampoule of Adrenaline, you will need to dilute that 1 mL with 9 mL Normal Saline *
  • Flush line with 5 mL Normal Saline
• Amiodarone 5 mg / kg
  • Formulation: [150mg/3 mL]
  • Draw up required dose and dilute to 2-10 mL of 5% Dextrose
  • Give over 5 minutes
  • Flush line with Normal Saline or 5% Dextrose
• Calcium gluconate 10%
• Dextrose 10%: 2.5 mL / kg
• Sodium Bicarbonate 8.4%

Other emergency drug doses:

• Atropine: 20 mcg / kg (dilute 600 mcg to 6 mL)
• Lignocaine:
• Magnesium sulphate:
• Midazolam: 0.1 mg / kg (dilute 5 mg to 5 mL)
• Morphine: 0.1 mg / kg
• Fentanyl: 2 mcg / kg
• Benzylpenicillin: 50 mg / kg
• Cefotaxime: 50 mg / kg
• Mannitol: 0.25 g / kg

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Annotations

• BLS = Basic Life Support
• ALS = Advanced Life Support
• I/O = Insertion of

SHOCKABLE RHYTHM: VF, pVT

• Ventricular Fibrillation (VF)
• Pulseless Ventricular Tachycardia (pVT)
  • ⇒ shock, continue CPR, +/- Adrenaline or amiodarone (depending on which loop of the cycle)

NON-SHOCKABLE RHYTHM: asystole, PEA

• Asystole: flatline on ECG
• PEA (pulseless electrical activity): a normal looking rhythm with no cardiac output
  • ⇒ continue CPR + Adrenaline (every second loop)

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References and Further Reading

• Resuscitation – CPG – Royal Children’s Hospital Melbourne
• Emergency drug doses – CPG – Royal Children’s Hospital Melbourne
• PRINT THE PAEDIATRIC EMERGENCY MEDICATION BOOK – Monash Children’s Hospital
• Paediatric advanced life support – Resuscitation Council (UK)