AHA Guidelines
NALS, PLS & PALS
Comprehensive notes for nursing students on Neonatal, Pediatric, and Pediatric Advanced Life Support protocols
Table of Contents
Introduction
The American Heart Association (AHA) provides evidence-based guidelines for resuscitation and emergency cardiovascular care. These guidelines are updated regularly to incorporate the latest scientific evidence and clinical best practices.
This comprehensive guide covers three critical life support protocols:
NALS
Neonatal Advanced Life Support focuses on the resuscitation and care of newborn infants, particularly in the first minutes after birth.
PLS
Pediatric Life Support covers basic life-saving techniques for infants and children, including CPR and management of airway obstruction.
PALS
Pediatric Advanced Life Support extends beyond basic measures to include advanced interventions like medication administration and arrhythmia management.
Why These Protocols Matter
These standardized approaches ensure that healthcare providers deliver consistent, high-quality care during pediatric emergencies. Proper application of these protocols can significantly improve patient outcomes during critical situations.
NALS: Neonatal Advanced Life Support
Overview
Neonatal Advanced Life Support (NALS) provides a structured approach to resuscitation of newborns. Approximately 10% of newborns require some assistance to begin breathing at birth, and about 1% need extensive resuscitative measures.
NALS Key Concepts Mind Map
Initial Assessment
- • Term gestation?
- • Good tone?
- • Breathing or crying?
Primary Interventions
- • Warm & maintain normal temperature
- • Position airway
- • Clear secretions
- • Dry, stimulate
Advanced Interventions
- • PPV (Positive Pressure Ventilation)
- • Chest compressions
- • Intubation
- • Medications
Continuous Evaluation
Heart Rate
Respiration
Oxygen Saturation
Key Principles of Neonatal Resuscitation
The Golden Minute
The first 60 seconds after birth (the “Golden Minute”) are critical for initiating resuscitation in newborns who need it. All steps of initial assessment and basic interventions should be completed within this time.
Progressive Approach
NALS follows a progressive approach, starting with the simplest interventions and advancing to more complex ones only as needed, based on the baby’s response.
Team-Based Care
Effective neonatal resuscitation requires well-coordinated teamwork with clear communication and defined roles.
Prevention of Hypothermia
Maintaining the newborn’s temperature is crucial as hypothermia is associated with increased mortality and morbidity.
MNEMONIC: “ABCD” of Neonatal Resuscitation
- Airway – Position head in “sniffing” position, clear secretions if needed
- Breathing – Stimulate breathing, provide PPV if required
- Circulation – Check heart rate, begin chest compressions if HR < 60/min despite adequate ventilation
- Drugs – Administer medications (epinephrine) if heart rate remains < 60/min despite effective ventilation and compressions
Neonatal Resuscitation Algorithm
Neonatal Resuscitation Algorithm (AHA 2020)
Antenatal counseling, team briefing, equipment check
Birth
Term gestation? Good tone? Breathing or crying?
YES
Infant stays with mother for routine care:
- Warm and maintain normal temperature
- Position airway
- Clear secretions if needed
- Dry
- Ongoing evaluation
NO
Warm and maintain normal temperature
Position airway, clear secretions if needed
Dry, stimulate
Apnea or gasping? HR below 100/min?
YES
- PPV
- SpO2 monitor
- Consider ECG monitor
Labored breathing or persistent cyanosis?
- Position and clear airway
- SpO2 monitor
- Supplementary O2 as needed
- Consider CPAP
Check heart rate
HR below 60/min?
YES
- Intubate if not already done
- Chest compressions coordinated with PPV (3:1 ratio)
- 100% O2
- ECG monitor
- Consider emergency UVC
HR persistently below 60/min?
- IV epinephrine
- Consider hypovolemia
- Consider pneumothorax
HR above 60/min?
YES
Continue PPV, adjust as needed based on heart rate and SpO2
Targeted Preductal SpO2
| 1 min | 60%-65% |
| 2 min | 65%-70% |
| 3 min | 70%-75% |
| 4 min | 75%-80% |
| 5 min | 80%-85% |
| 10 min | 85%-95% |
Post-resuscitation care
Team debriefing
Team debriefing
Critical Decision Points
- Initial assessment: Based on gestational age, muscle tone, and breathing/crying
- Ventilation: Initiate PPV if apneic or gasping, or if HR < 100/min
- Chest compressions: Start if HR < 60/min despite adequate ventilation for 30 seconds
- Medications: Consider epinephrine if HR remains < 60/min despite effective ventilation and compressions
Medications & Equipment
Essential Medications
| Medication | Indication | Dose & Route | Notes |
|---|---|---|---|
| Epinephrine | HR < 60/min despite ventilation and chest compressions | 0.1-0.3 mL/kg of 1:10,000 solution (0.01-0.03 mg/kg) IV/IO 0.5-1 mL/kg of 1:10,000 solution if given via ETT (less preferred) |
IV/IO route preferred; may repeat every 3-5 minutes if needed |
| Volume Expanders | Suspected hypovolemia or poor response to resuscitation | 10 mL/kg IV/IO May repeat as needed |
Normal saline (0.9% NaCl) or type O Rh-negative packed RBCs for blood loss |
| Dextrose | Documented hypoglycemia | 2 mL/kg of D10W IV/IO | Check glucose levels during prolonged resuscitation |
| Naloxone | No longer recommended as part of initial resuscitation | Not applicable | Focus on effective ventilation instead |
Essential Equipment
Airway Management
- Bulb syringe or mechanical suction
- Resuscitation bag with manometer and pressure relief valve
- Face masks (preterm, term newborn sizes)
- Oral airways (0, 00, 000 sizes)
- Laryngoscope with straight blades (0, 1)
- Endotracheal tubes (2.5, 3.0, 3.5, 4.0 mm)
- Stylets
- CO2 detectors
Circulation Management
- ECG monitor/electrodes
- Pulse oximeter with neonatal probe
- Umbilical vessel catheterization supplies
- Umbilical catheters (3.5F, 5F)
- Three-way stopcocks
- Syringes (1, 3, 5, 10, 20, 50 mL)
- Needles (25, 21, 18 gauge)
- IO needles
Other Essential Items
- Warmer/heat source
- Prewarmed towels or plastic wrap (for preterm infants)
- Hat
- Timer/clock with seconds display
- Stethoscope
- Tape for securing tubes
- Gloves and personal protective equipment
MNEMONIC: “WARM BABY” for Neonatal Equipment Preparation
- Warmer turned on
- Airway equipment ready (suction, bags, masks, tubes)
- Resuscitation area cleared
- Monitoring devices (ECG, pulse oximeter) ready
- Blankets/towels warmed
- Access tools ready (umbilical catheters, IO needles)
- Bag-mask device tested
- Your team briefed on roles
Special Considerations
Preterm Infants
- Temperature management: Use plastic wrap/bag for infants <32 weeks
- Ventilation: Consider early CPAP for spontaneously breathing preterm infants with respiratory distress
- Oxygen: Start with lower oxygen concentrations (21-30%) and titrate based on SpO2
- Delayed cord clamping: Recommended for 30-60 seconds if infant does not require resuscitation
Meconium-Stained Amniotic Fluid
- 2020 AHA Guidelines: Routine intubation for tracheal suctioning is NOT recommended
- Initial steps: Standard assessment and resuscitation regardless of meconium
- Non-vigorous infant: Begin PPV without delay for suctioning
- Suctioning: Only suction trachea if obstruction is suspected after PPV has been initiated
Discontinuing Resuscitation
If an infant has no detectable heart rate after 10 minutes of complete and adequate resuscitation efforts, discontinuation of resuscitation may be appropriate.
This decision should consider:
- Whether resuscitation was optimal
- Availability of advanced neonatal care
- Known prenatal conditions
- Gestational age
- Local guidelines and culture
Post-Resuscitation Care
- Monitoring: Continuous assessment of vital signs, oxygenation, ventilation
- Temperature: Maintain normal temperature (36.5-37.5°C)
- Glucose: Monitor and maintain normal glucose levels
- Therapeutic hypothermia: Consider for term/near-term infants with evolving moderate-severe HIE
- Team debriefing: Review resuscitation performance to identify improvements
Key Updates in 2020 Guidelines
- • Initial oxygen concentrations: 21% for term infants, 21-30% for preterm infants
- • Emphasis on maintaining normothermia, especially in preterm infants
- • No routine intubation for tracheal suctioning with meconium-stained fluid
- • Increased focus on family presence during resuscitation
- • Delayed cord clamping recommended when resuscitation not needed
PLS: Pediatric Life Support
Overview
Pediatric Life Support (PLS) refers to the basic life support techniques and interventions used for infants and children. It’s designed to provide immediate care for pediatric patients experiencing life-threatening conditions until more advanced medical care arrives.
PLS Core Concepts
Assessment
- • Scene safety
- • Responsiveness
- • Airway
- • Breathing
- • Circulation
Basic Interventions
- • Open airway
- • Rescue breathing
- • Chest compressions
- • Foreign body airway clearance
Equipment
- • AED use
- • Bag-mask ventilation
- • Basic airway devices
- • Barrier devices
Age-Specific Considerations
Infant (<1 year)
Child (1-8 years)
Older Child (8+ years)
Pediatric vs. Adult Differences
| Factor | Pediatric | Adult | Clinical Significance |
|---|---|---|---|
| Primary Cause | Often respiratory arrest leading to cardiac arrest | Often primary cardiac causes | Focus on ventilation is crucial in pediatrics |
| Airway Anatomy | Narrower, more anterior, larger tongue | More developed, wider | More difficult to manage, easily obstructed |
| Chest Wall | More compliant, less muscular | Less compliant, more muscular | Different compression technique needed |
| Compression Depth | At least 1/3 AP diameter (about 4 cm for infants, 5 cm for children) | At least 2 inches (5 cm) | Must adjust based on patient size |
| Compression:Ventilation | Single rescuer: 30:2 Two rescuers: 15:2 |
30:2 for all lay rescuers 30:2 for single HCP Continuous with advanced airway |
More frequent ventilation in pediatrics |
MNEMONIC: “CHILDS” for Pediatric Cardiac Arrest Causes
- Congenital heart defects
- Hypovolemia (dehydration, hemorrhage)
- Infection/sepsis
- Lung disease (respiratory failure)
- Dysrhythmias
- Sudden infant death syndrome/trauma
Pediatric BLS Algorithm
Pediatric Basic Life Support Algorithm (AHA 2020)
Verify scene safety
Check responsiveness
Shout for nearby help
Activate emergency response system via mobile device (if appropriate)
Shout for nearby help
Activate emergency response system via mobile device (if appropriate)
Look for no breathing or only gasping and check pulse
(simultaneously)
Is pulse definitely felt within 10 seconds?
(simultaneously)
Is pulse definitely felt within 10 seconds?
Normal breathing, pulse felt
Monitor until emergency responders arrive
No normal breathing, pulse felt
- Provide rescue breathing (1 breath every 2-3 seconds or 20-30 breaths/min)
- Assess pulse every 2 minutes
HR <60/min with signs of poor perfusion?
Yes
Start CPR
Start CPR
No
Continue rescue breathing
Continue rescue breathing
No breathing or only gasping, pulse not felt
Start CPR
Was this a witnessed sudden collapse?
Yes
Activate emergency response & get AED
Activate emergency response & get AED
No
Begin CPR immediately
Begin CPR immediately
- 1 rescuer: 30 compressions : 2 breaths
- 2 rescuers: 15 compressions : 2 breaths
- Use AED as soon as available
After about 2 minutes, if still alone, activate emergency response system and retrieve AED
Check rhythm with AED
Shockable rhythm?
Shockable rhythm?
Yes, shockable
- Give 1 shock
- Resume CPR immediately for 2 minutes
- Continue until ALS providers take over or the child starts to move
No, non-shockable
- Resume CPR immediately for 2 minutes
- Continue until ALS providers take over or the child starts to move
High-Quality CPR
- Rate: 100-120/min
- Depth: At least 1/3 AP diameter
- Allow complete chest recoil
- Minimize interruptions
- Avoid excessive ventilation
Key Algorithm Elements
Single Rescuer Sequence
- Ensure scene safety
- Check responsiveness
- If unresponsive, shout for help
- Position the victim
- Open airway (head tilt-chin lift)
- Check breathing and pulse (max 10 seconds)
- If no normal breathing but has pulse, give rescue breaths
- If no pulse, begin CPR at 30:2 compression-to-ventilation ratio
- After 2 minutes, if alone, activate emergency response system and get AED
- Use AED as soon as available
- Continue CPR until help arrives or child shows signs of life
Two Rescuer Sequence
- First rescuer begins assessment and CPR
- Second rescuer activates emergency response system and retrieves AED
- Upon return, second rescuer applies AED
- Rescuers switch to 15:2 compression-to-ventilation ratio
- Change compressor role every 2 minutes (or sooner if fatigued)
- Minimize interruptions during role switching
- Continue until ALS providers take over or child shows signs of life
Sequence Modifications
- • Witnessed collapse: Activate emergency response system first, then return to start CPR
- • Suspected trauma: Minimize movement of head and neck
- • Drowning victims: Give 2 rescue breaths before starting compressions
- • Suspected opioid overdose: If trained, administer naloxone while performing CPR
Key Techniques
Airway Management
Head Tilt-Chin Lift
Primary method for opening the airway in non-trauma situations:
- Place one hand on the forehead
- Place fingertips of other hand under the bony part of the lower jaw
- Tilt the head back slightly (neutral position for infants)
- Lift the chin to open the airway
Jaw Thrust
Used when trauma is suspected:
- Place fingers behind the angles of the lower jaw
- Lift the jaw forward
- Avoid tilting the head
Rescue Breathing
Mouth-to-Mouth/Mask
- Ensure open airway
- Pinch nose closed (mouth-to-mouth)
- Create a seal over mouth or mouth and nose (infants)
- Give breaths over 1 second each
- Watch for chest rise with each breath
- Allow for exhalation between breaths
Bag-Mask Ventilation
- Select appropriate mask size (covers from bridge of nose to chin)
- Create a good seal using E-C technique
- Squeeze bag to deliver breaths over 1 second
- Deliver enough volume to cause visible chest rise
- Avoid excessive ventilation
Chest Compressions
Infant Technique (< 1 year)
- Two-finger technique (single rescuer):
- Use 2 fingers placed just below the nipple line
- Push straight down at least 1/3 AP diameter (approx. 4 cm)
- Two-thumb technique (two rescuers):
- Place both thumbs side by side over lower half of sternum
- Encircle chest with fingers supporting the back
- Push straight down with thumbs
- More effective method when two rescuers available
- Rate: 100-120 compressions per minute
Child Technique (1-8 years)
- Use heel of one hand placed on the lower half of sternum
- For larger children or with two rescuers, use two-hand technique
- Push straight down at least 1/3 AP diameter (approx. 5 cm)
- Rate: 100-120 compressions per minute
Foreign Body Airway Obstruction
Conscious Child
- Perform abdominal thrusts (Heimlich maneuver)
- Repeat until object is expelled or child becomes unconscious
Conscious Infant
- Deliver 5 back blows between the shoulder blades
- Deliver 5 chest thrusts in the same location as chest compressions
- Alternate between back blows and chest thrusts
Unconscious Child/Infant
- Begin CPR sequence (check responsiveness, activate emergency response)
- Open airway and look in mouth for visible object
- Remove only if visible (no blind finger sweeps)
- Attempt ventilation; if unsuccessful, reposition head and try again
- If still unsuccessful, begin chest compressions
- Continue CPR cycle, checking mouth for visible object before each ventilation attempt
MNEMONIC: “PUSH HARD, PUSH FAST”
- Push at least 1/3 AP chest diameter
- Uniform rate of 100-120/min
- Straight down and up for efficient compressions
- Hard enough to achieve adequate depth
- Heels of hands for proper technique
- Allow complete chest recoil
- Rotate compressors every 2 minutes
- Don’t interrupt compressions unnecessarily
- Proper hand/finger position
- Uninterrupted when possible
- Straight arms, shoulders over hands
- High-quality is essential
- Force directed straight down
- Appropriate technique for age
- Stay on firm surface
- Time compressions consistently
Special Considerations
Respiratory Distress vs. Respiratory Failure
| Respiratory Distress | Respiratory Failure |
|---|---|
| Increased work of breathing | Inadequate respiratory effort |
| Tachypnea | Bradypnea or apnea |
| Adequate oxygenation | Hypoxemia despite oxygen |
| Alert, anxious | Decreased responsiveness |
| Retractions, nasal flaring | Poor air movement |
Early recognition of progression from distress to failure is critical for intervention.
AED Use in Children
- Children > 8 years: Use standard adult AED pads
- Children 1-8 years: Use pediatric dose-attenuator system if available. If not available, use standard AED
- Infants < 1 year: Manual defibrillator preferred. If not available, AED with pediatric dose attenuator is acceptable
- Pad placement: One pad on upper right chest, one pad on lower left chest. Ensure pads don’t touch
- Key point: Don’t delay defibrillation. If pediatric system unavailable, use standard AED for all children
Drowning
- Initial approach: Ensure scene safety before water rescue
- CPR modification: Begin with 5 rescue breaths before chest compressions
- Do not: Perform abdominal thrusts unless foreign body suspected
- Spinal precautions: Only if diving or trauma history
- All victims: Should receive medical evaluation even if apparently recovered
- Note: Hypothermia may be protective in cold-water drowning
Trauma Considerations
- Airway management: Use jaw thrust without head tilt to open airway
- Cervical spine: Maintain in-line stabilization during all interventions
- Compression technique: Standard, but maintain spinal alignment
- Hypovolemia: Major consideration in traumatic arrests
- Transport: Rapid transport to pediatric trauma center when possible
Special Healthcare Needs
- Tracheostomy: Ventilate through tracheostomy if present. If unable, ventilate through nose/mouth while occluding stoma
- Technology-dependent: Disconnect from ventilator for manual ventilation
- Central lines: May be used for medication administration if present
- Spinal muscular atrophy: Use caution with neck positioning
- Heart disease: Consider underlying cardiac conditions during resuscitation
Key Updates in 2020 Guidelines
- • Continued emphasis on high-quality CPR (rate, depth, recoil)
- • Use of mobile phones to activate emergency response system while staying with victim
- • Further emphasis on early use of AEDs
- • Recognition that many adolescents may require adult-sized equipment and dosing
- • Emphasis on “phone first” for witnessed sudden collapse of child, similar to adult protocol
PALS: Pediatric Advanced Life Support
Overview
Pediatric Advanced Life Support (PALS) extends beyond basic life support by incorporating advanced airway management, vascular access, medication administration, and treatment of specific arrhythmias and conditions that may lead to cardiac arrest in children.
PALS Core Components
Assessment
Primary
- Airway
- Breathing
- Circulation
- Disability
- Exposure
Secondary
- Focused history
- Detailed exam
- Vital signs
- Monitoring
- Labs/diagnostics
Interventions
Respiratory
- O2 therapy
- Airway positioning
- Advanced airways
- Ventilation
- Medications
Circulatory
- Vascular access
- Fluid therapy
- Medication admin
- Defibrillation
- Cardioversion
Cardiac Emergencies
- Cardiac arrest
- Bradycardia
- Tachycardia
- Post-resuscitation care
Shock States
- Hypovolemic
- Distributive
- Cardiogenic
- Obstructive
Specific Conditions
- Respiratory distress
- Poisoning/toxins
- Trauma
- Sepsis
PALS Systematic Approach
Identify
Recognize problem requiring intervention
Intervene
Provide appropriate treatment
Evaluate
Assess response to treatment
Repeat cycle as needed
Recognition of Respiratory Distress and Failure
| Assessment | Respiratory Distress | Respiratory Failure | Respiratory Arrest |
|---|---|---|---|
| Appearance | Anxious, fearful | Lethargic, confused | Unresponsive |
| Work of breathing | Increased (retractions, nasal flaring) | Severely increased or decreased | Absent |
| Respiratory rate | Tachypnea | Very rapid or bradypnea | Apnea |
| Air entry | Good to fair | Poor | Absent |
| Oxygenation | Normal to mild hypoxemia | Moderate to severe hypoxemia | Severe hypoxemia |
| Ventilation | Normal to mild hypercarbia | Hypercarbia | Severe hypercarbia |
MNEMONIC: “DOPE” – Causes of Acute Deterioration in Intubated Patients
- Displacement of endotracheal tube
- Obstruction of endotracheal tube
- Pneumothorax
- Equipment failure (ventilator malfunction, oxygen disconnection)
Cardiac Arrest Algorithm
Pediatric Cardiac Arrest Algorithm (AHA 2020)
Start CPR
• Begin bag-mask ventilation and give oxygen
• Attach monitor/defibrillator
Rhythm shockable?
VF/pVT
- Shock (2 J/kg first shock, 4 J/kg subsequent shocks)
- CPR for 2 minutes
- Establish IV/IO access
- Check rhythm – Still shockable?
Yes
- Shock (4 J/kg)
- CPR 2 min
- Epinephrine every 3-5 min
- Consider advanced airway
NoGo to Asystole/PEA pathway
- Check rhythm – Still shockable?
Yes
- Shock (4 J/kg)
- CPR 2 min
- Amiodarone or lidocaine
- Treat reversible causes
NoGo to Asystole/PEA pathway
Asystole/PEA
- CPR for 2 minutes
- Establish IV/IO access
- Epinephrine ASAP (0.01 mg/kg or 0.1 mL/kg of 0.1 mg/mL)
- CPR for 2 minutes
- Epinephrine every 3-5 min
- Consider advanced airway and capnography
- Check rhythm – Shockable?
Yes
Go to VF/pVT pathway
No- CPR 2 min
- Treat reversible causes
CPR Quality
- Push hard (≥1/3 AP chest diameter) and fast (100-120/min)
- Allow complete chest recoil
- Minimize interruptions
- Change compressor every 2 minutes
- If no advanced airway, 15:2 ratio with 2 rescuers
- If advanced airway, provide continuous compressions and ventilate every 2-3 seconds
Reversible Causes
- Hypovolemia
- Hypoxia
- Hydrogen ion (acidosis)
- Hypoglycemia
- Hypo-/hyperkalemia
- Hypothermia
- Tension pneumothorax
- Tamponade, cardiac
- Toxins
- Thrombosis (pulmonary, coronary)
Advanced Airway
- Endotracheal intubation or supraglottic airway
- Waveform capnography to confirm and monitor
Drugs
- Epinephrine: 0.01 mg/kg (0.1 mL/kg of 0.1 mg/mL)
- Amiodarone: 5 mg/kg IV/IO (max 300 mg)
- Lidocaine: 1 mg/kg IV/IO (max 100 mg)
If ROSC achieved, proceed to post-cardiac arrest care
Post-Cardiac Arrest Care
Respiratory Optimization
- Maintain oxygenation with SpO2 94-99%
- Avoid hyperventilation
- Target normal PaCO2 for age
- Secure advanced airway if not already done
- Confirm proper placement with waveform capnography
Hemodynamic Support
- Maintain appropriate blood pressure for age
- Administer fluids as needed
- Consider vasoactive medications if fluid-refractory shock
- Treat dysrhythmias
- Monitor ECG continuously
Neurological Care
- Maintain normothermia or consider targeted temperature management
- Avoid hyperthermia
- Treat seizures if they occur
- Consider glucose monitoring and maintain normoglycemia
- Avoid hypotension
Additional Considerations
- Search for and treat underlying causes
- Consider 12-lead ECG
- Obtain laboratory studies
- Consider chest X-ray
- Transport to appropriate critical care facility
Bradycardia Algorithm
Pediatric Bradycardia With a Pulse Algorithm (AHA 2020)
Patient with bradycardia
Assessment and support
- Maintain patent airway
- Assist breathing with positive pressure ventilation and oxygen as necessary
- Cardiac monitor to identify rhythm; monitor pulse, BP, and oximetry
Bradycardia persists?
Yes
- Support ABCs
- Consider oxygen
- Observe
- 12-Lead ECG
- Identify and treat underlying causes
No
- Continue supportive care
- Monitor patient
Cardiopulmonary compromise?
- Acutely altered mental status
- Signs of shock
- Hypotension
Yes
- Begin CPR if HR <60/min despite oxygenation and ventilation
- IV/IO access
- Epinephrine
- Atropine for increased vagal tone or primary AV block
- Consider transthoracic/transvenous pacing
- Identify and treat underlying causes
Possible Causes
- Hypoxia
- Hypothermia
- Head injury
- Heart block
- Heart transplant
- Toxin/poison/drugs
- Increased intracranial pressure
No
- Support ABCs
- Consider oxygen
- Observe
- 12-Lead ECG
- Identify and treat underlying causes
Medication Doses
- Epinephrine IV/IO: 0.01 mg/kg (0.1 mL/kg of 0.1 mg/mL). Repeat every 3-5 minutes.
- Atropine IV/IO: 0.02 mg/kg. May repeat once. Minimum dose 0.1 mg and maximum single dose 0.5 mg.
Check pulse every 2 minutes. Pulse present?
Yes
- Continue monitoring and supportive care
- Reassess for signs of cardiopulmonary compromise
No
Go to Pediatric Cardiac Arrest Algorithm
Clinical Pearls for Bradycardia Management
Bradycardia Assessment
- Normal heart rates vary by age
- Bradycardia is defined as heart rate below the normal range for age
- HR <60/min with poor perfusion requires immediate intervention
- Evaluate for cardiopulmonary compromise (altered mental status, hypotension, shock)
- Distinguish between primary cardiac causes and secondary to hypoxia/respiratory issues
Treatment Considerations
- Oxygenation and ventilation are the first priorities
- Only start chest compressions if HR <60/min with signs of poor perfusion despite oxygenation and ventilation
- Epinephrine is the primary drug for symptomatic bradycardia
- Atropine is primarily for bradycardia caused by vagal stimulation or AV block
- External pacing can be considered but should not delay other treatments
MNEMONIC: “HEART BLOCKS” – Common Causes of Pediatric Bradycardia
- Hypoxia (most common cause in children)
- Electrolyte abnormalities (hyperkalemia)
- Acidosis
- Respiratory failure
- Toxins, Trauma, Temperature (hypothermia)
- Blocks (congenital heart block)
- Low cardiac output states
- Omitted medications (for heart transplant patients)
- Cardiac surgery complications
- Kranial (increased intracranial pressure)
- Sinus node dysfunction
Tachycardia Algorithm
Pediatric Tachycardia With a Pulse Algorithm (AHA 2020)
Initial assessment and support
- Maintain patent airway; assist breathing as necessary
- Administer oxygen
- Cardiac monitor to identify rhythm; monitor pulse, blood pressure, and oximetry
- IV/IO access
- 12-Lead ECG if available
Evaluate rhythm with 12-lead ECG or monitor
Probable Sinus Tachycardia
- P waves present/normal
- Variable RR interval
- Infant rate usually <220/min
- Child rate usually <180/min
Probable Supraventricular Tachycardia
- P waves absent/abnormal
- RR interval not variable
- Infant rate usually ≥220/min
- Child rate usually ≥180/min
- History of abrupt rate change
QRS Duration
Narrow (≤0.09 sec)
Wide (>0.09 sec)
Cardiopulmonary compromise?
- Acutely altered mental status
- Signs of shock
- Hypotension
Yes
Synchronized cardioversion
(0.5-1 J/kg, may increase to 2 J/kg if ineffective)
Sedate if needed but don’t delay cardioversion
No
Based on QRS duration and rhythm assessment
Sinus Tachycardia
Search for and treat cause
- Fever
- Pain/agitation
- Hypovolemia
- Sepsis
- Anemia
- Hypoxemia
- Heart failure
- Toxin/poison/drugs
Supraventricular Tachycardia
Narrow QRS
- Consider vagal maneuvers if no delay to treatment
- Adenosine:
- First dose: 0.1 mg/kg (max 6 mg)
- Second dose: 0.2 mg/kg (max 12 mg)
- If adenosine ineffective or no IV/IO access, consider synchronized cardioversion
Wide QRS
- Consider adenosine if regular and monomorphic QRS
- Consider antiarrhythmic (amiodarone or procainamide)
- Consider electrical cardioversion
- Expert consultation advised
Medication Dosages
Adenosine
- First dose: 0.1 mg/kg rapid IV bolus (maximum: 6 mg)
- Second dose: 0.2 mg/kg rapid IV bolus (maximum: 12 mg)
- Follow each dose with saline flush
Synchronized Cardioversion
- Initial: 0.5-1 J/kg
- If ineffective, increase to 2 J/kg
- Sedate when possible but don’t delay for life-threatening situations
Distinguishing Tachycardia Types
| Feature | Sinus Tachycardia | Supraventricular Tachycardia | Ventricular Tachycardia |
|---|---|---|---|
| Rate | Usually <220/min (infant) <180/min (child) |
Usually ≥220/min (infant) ≥180/min (child) |
Variable, often >120/min |
| Rhythm | Regular, but varies slightly with respiration | Regular, fixed | Regular or irregular |
| P waves | Present, normal | Absent or abnormal | Often not visible, dissociated |
| QRS complex | Normal (≤0.09 sec) | Usually narrow (≤0.09 sec) | Wide (>0.09 sec) |
| Onset/Offset | Gradual | Sudden | Often sudden |
| Response to vagal maneuvers | Gradual slowing | Abrupt termination or no effect | Usually no effect |
| Common causes | Fever, pain, hypovolemia, sepsis, anemia | Accessory pathway, reentry mechanism | Cardiomyopathy, long QT, myocarditis, toxins |
MNEMONIC: “SVT FACT” – Supraventricular Tachycardia Features
- Sudden onset and offset
- Very regular R-R intervals
- Tachycardia that’s extremely fast for age
- Fixed rate that doesn’t vary with activity/crying
- Absent or abnormal P waves
- Children often show limited symptoms initially
- Terminated by adenosine if AVRT/AVNRT
Shock Management
Recognition of Shock
Shock is a state of inadequate tissue perfusion to meet the metabolic demands of the body. Early recognition and treatment are crucial to prevent progression to cardiopulmonary failure.
| Clinical Signs | Compensated Shock | Decompensated Shock |
|---|---|---|
| Mental Status | Anxious, irritable, confused | Lethargic, obtunded |
| Skin Perfusion | Cool extremities, delayed capillary refill (>2 sec) | Cold, mottled, gray, very delayed capillary refill |
| Pulses | Weak peripheral, strong central | Weak central |
| Blood Pressure | Normal (maintained by compensation) | Hypotension (late sign) |
| Heart Rate | Tachycardia | Severe tachycardia or bradycardia (ominous) |
| Respiratory Rate | Tachypnea | Tachypnea or respiratory failure |
| Urine Output | Decreased (<1 mL/kg/hr) | Minimal to none |
Types of Shock
Hypovolemic Shock
Cause: Inadequate intravascular volume
- Fluid loss (diarrhea, vomiting, burns)
- Hemorrhage (trauma, GI bleeding)
- Third-spacing (sepsis, capillary leak)
Management:
- Rapid fluid boluses: 20 mL/kg isotonic solution
- Reassess after each bolus
- May need blood products for hemorrhagic shock
Distributive Shock
Cause: Abnormal distribution of blood volume