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Pediatric Advanced Life Support (PALS) - Exam-Oriented Review for Emergency Physicians

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1. EPIDEMIOLOGY & KEY CONCEPTS (High-Yield)

Exam pearl: Because children arrest from respiratory causes, they benefit from conventional CPR (compressions + ventilations), unlike adults where compression-only CPR is acceptable. Compression-only CPR is inferior in pediatric arrests from asphyxia.

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2. AGE DEFINITIONS (PALS)

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3. RECOGNIZING ARREST / PRE-ARREST

Pediatric Assessment Triangle (PAT)

• Appearance (TICLS: Tone, Interactiveness, Consolability, Look/Gaze, Speech/Cry)
• Work of Breathing
• Circulation to skin (color, mottling, pallor)

Normal Vital Signs by Age

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4. CPR - HIGH-QUALITY COMPRESSIONS

Key Parameters

Compression Technique by Age

Exam pearl: For infants, the 2-thumb encircling technique generates greater cardiac output and coronary perfusion pressure than the 2-finger technique. Use it when a second rescuer is available.

ETCO₂ in CPR

• Target ETCO₂ >20 mmHg to indicate adequate compressions
• Sudden rise in ETCO₂ signals ROSC
• If ETCO₂ consistently <10 mmHg despite optimal CPR, prognosis is poor

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5. AIRWAY & VENTILATION

BVM vs Endotracheal Intubation

• For pre-hospital arrest: 2019 PALS update recommends bag-mask ventilation - ETI does not improve survival and may worsen outcomes (delays compressions; OR 0.82 for survival, no benefit)
• For in-hospital arrest: insufficient evidence to mandate ETI over BVM
• If ETI performed: aim for 8-10 breaths/min without interrupting compressions

Airway Sizes (Exam Classics)

• ET tube size = (Age/4) + 4 (uncuffed) or (Age/4) + 3.5 (cuffed)
• Preferred: cuffed ETT in all ages (avoids multiple attempts)
• Verify placement with waveform capnography

Jaw Thrust vs Head-Tilt/Chin-Lift

• Jaw thrust preferred if cervical spine injury suspected
• Head-tilt/chin-lift is standard for non-trauma

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6. VASCULAR ACCESS

1. Peripheral IV (2 attempts max - 90 seconds)
2. Intraosseous (IO) - if IV fails; should be obtained within 60-90 seconds of arrest
3. Central venous access

• Proximal tibia (most common)
• Distal tibia
• Distal femur
• Humeral head (EZ-IO)

Exam pearl: IO is equivalent to IV for drug delivery in arrest. All resuscitation drugs can be given IO. If epinephrine is given via ETT: dose is 10× the IV dose (0.1 mg/kg of 1:1000).

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7. PALS CARDIAC ARREST ALGORITHM (2020 AHA)

AHA 2020 Pediatric Cardiac Arrest Algorithm

Shockable (VF / pulseless VT)

1. Start CPR + O₂ + attach monitor
2. Shock: 2 J/kg
3. CPR 2 min + IV/IO access
4. Shock: 4 J/kg
5. CPR 2 min + Epinephrine every 3-5 min
6. Shock: ≥4 J/kg (max 10 J/kg or adult dose)
7. CPR 2 min + Amiodarone or Lidocaine + treat reversible causes
8. Continue loops; check rhythm every 2 min

Non-Shockable (Asystole / PEA)

1. Start CPR + O₂
2. CPR 2 min + IV/IO access + Epinephrine ASAP (repeat every 3-5 min)
3. Consider advanced airway
4. Treat reversible causes (H's and T's)
5. Check rhythm every 2 min; if converts to shockable → go to shockable arm

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8. DRUG THERAPY IN ARREST

Medications for Pediatric Cardiac Arrest

Exam pearl: Epinephrine dose via ETT is 10× IV dose = 0.1 mg/kg of 1 mg/mL (1:1000) concentration. IV/IO dose uses 0.1 mg/mL (1:10,000) concentration.

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9. H's AND T's - REVERSIBLE CAUSES

Pediatric-specific emphasis: Hypoxia and hypovolemia are the most common reversible causes in children.

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10. PEDIATRIC BRADYCARDIA ALGORITHM

1. Identify and treat underlying cause (O₂, airway, IO/IV access)
2. Is there cardiopulmonary compromise? (hypotension, AMS, shock)
   • No → support ABCs, observe
   • Yes → If HR <60/min with poor perfusion despite O₂/ventilation → CPR
3. If bradycardia persists:
   • Epinephrine 0.01 mg/kg IV/IO (repeat every 3-5 min); or
   • Atropine 0.02 mg/kg (for increased vagal tone or primary AV block); min 0.1 mg, max 0.5 mg
   • Consider transcutaneous pacing
4. If pulseless arrest develops → Cardiac Arrest Algorithm

Exam pearl: In pediatrics, bradycardia is most commonly due to hypoxia - treat the airway first. Atropine is for vagal causes/AV block, NOT hypoxic bradycardia.

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11. PEDIATRIC TACHYCARDIA ALGORITHM

Step 1: Evaluate QRS Duration

• Narrow QRS (≤0.09 sec)
• Wide QRS (>0.09 sec)

Step 2: Sinus Tachycardia vs SVT (Narrow Complex)

SVT Treatment (Narrow Complex)

1. Vagal maneuvers (ice water to face in infants; Valsalva in older children) - first-line, no delays
2. Adenosine 0.1 mg/kg rapid IV bolus (max 6 mg); if ineffective → 0.2 mg/kg (max 12 mg)
3. Synchronized cardioversion 0.5-1 J/kg; if ineffective → 2 J/kg (sedate if possible, do NOT delay)

Wide Complex Tachycardia

• Possible VT - evaluate for cardiopulmonary compromise
  • With compromise → Synchronized cardioversion
  • Without compromise + regular + monomorphic QRS → consider adenosine; consult expert; consider amiodarone or procainamide

Exam pearl - WPW: Avoid adenosine, digoxin, beta-blockers, calcium channel blockers in WPW. Use procainamide (first-line for SVT in WPW) or cardioversion.

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12. DEFIBRILLATION & CARDIOVERSION

• One contact: right of sternum at 2nd intercostal space
• Other contact: left midclavicular line at xiphoid level

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13. POST-CARDIAC ARREST CARE (ROSC)

Exam pearl: Post-ROSC hypotension and hyperoxia are independently associated with worse neurological outcomes and mortality.

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14. PEDIATRIC SEPTIC SHOCK

Recognition

• Tachycardia + signs of decreased perfusion (delayed cap refill >2s, mottling, altered mental status)
• Hypotension is a LATE sign in children (maintained by compensatory tachycardia/vasoconstriction)
• "Compensated shock" = shock WITHOUT hypotension - critical to recognize

Management (Golden Hour Bundle)

1. 0-15 min: Obtain IV/IO access; labs (CBC, BMP, lactate, blood culture, glucose); IV/IO fluid bolus
2. Fluid resuscitation: 10-20 mL/kg NS or LR bolus; titrate to signs of perfusion; reassess after each bolus
3. Antibiotics: Broad-spectrum IV within 1 hour of recognition
4. Vasopressors (if fluid-unresponsive): Norepinephrine or epinephrine for fluid-refractory shock
5. Hydrocortisone: for catecholamine-refractory shock with suspected adrenal insufficiency

Exam pearl: The 2020 Surviving Sepsis Campaign moved AWAY from mandating aggressive fluid resuscitation (no longer 3×20 mL/kg). Reassess after each bolus and stop if signs of fluid overload (crackles, hepatomegaly, worsening O₂).

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15. TERMINATION OF RESUSCITATION

• Pediatric CPA lasting >20 minutes without ROSC is associated with poor outcome
• Exception: Hypothermic arrest - continue until rewarmed ("not dead until warm and dead")
• If hypothermia is responsible and cardiac electrical activity is present, continue resuscitation

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QUICK REFERENCE: PALS DOSE SUMMARY CARD

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TOP 10 PALS EXAM TRAPS

1. C:V ratio = 15:2 (pediatric single/2-rescuer without advanced airway) - NOT 30:2
2. Minimum atropine dose = 0.1 mg - doses <0.1 mg can cause paradoxical bradycardia
3. ETT epinephrine dose = 0.1 mg/kg (10× the IV dose)
4. First defibrillation = 2 J/kg, not 1 or 3 J/kg
5. Bradycardia + hypoxia in children - treat airway FIRST before medications
6. CPR starts at HR <60/min with poor perfusion, not just HR <60
7. Adenosine is ineffective or potentially harmful in WPW - use procainamide
8. Compression-only CPR is inferior in pediatric asphyxial arrest
9. Hypotension is a LATE sign of shock in children
10. Hypothermia = continue resuscitation regardless of duration

What's Covered (18 Sections)

1. Epidemiology - stroke types and frequencies
2. Pathophysiology - CBF thresholds, penumbra, ICH injury mechanisms
3. Anatomy of stroke syndromes - anterior/posterior circulation, lacunar syndromes with full tables (including Wallenberg, locked-in, ACA/MCA/PCA territories)
4. TIA - tissue-based definition, ABCD² score, risk stratification
5. Hemorrhagic stroke - ICH sites and frequencies, clinical presentations, ICH Score
6. Stroke recognition scales - FAST, LAPSS, Cincinnati, full NIHSS with scoring
7. Imaging - CT findings (hyperdense MCA, insular ribbon, etc.), CT with actual case images, CTA, CTP, DWI-FLAIR mismatch
8. Time goals - NINDS door-to-needle targets
9. IV thrombolysis - alteplase vs tenecteplase, time windows, full inclusion/exclusion criteria, sICH management
10. BP management - separate targets for ischemic/pre-tPA/post-tPA/ICH
11. Mechanical thrombectomy - LVO criteria, DAWN/DEFUSE3 extended windows
12. ICH management - anticoagulation reversal, surgical indications, ICP management
13. SAH - Hunt-Hess grade, diagnosis, nimodipine
14. Stroke mimics - 10+ conditions with differentiating features
15. CT findings table
16. Secondary prevention - antiplatelet, anticoagulation, statins, carotid surgery
17. Drug doses quick reference card
18. Top 12 exam traps