Overview/Definition
Definition:
• Pediatric Advanced Life Support (PALS) 2025 guidelines represent the latest evidence-based recommendations for pediatric resuscitation and critical care management
Updates focus on high-quality CPR, early recognition of deterioration, improved survival outcomes, and integration of new technologies and medications based on recent research findings.
Epidemiology:
• Pediatric cardiac arrest occurs in approximately 8,000-20,000 children annually in the United States with survival to discharge rates of 8-40% depending on location and circumstances
In-hospital cardiac arrest survival rates higher (30-40%) than out-of-hospital events (8-15%)
Post-arrest neurological outcomes major focus of updated guidelines.
Age Distribution:
• Cardiac arrest causes differ by age: infants commonly have respiratory causes, children have trauma/drowning, adolescents have cardiac arrhythmias similar to adults
Different resuscitation parameters and drug dosing required across pediatric age spectrum from neonates to adolescents approaching adult size.
Clinical Significance:
• Critical high-yield topic for DNB Pediatrics and NEET SS examinations focusing on algorithm changes, drug dosing updates, post-arrest care modifications, and quality improvement measures
Essential for emergency medicine, critical care, and general pediatrics practice with emphasis on prevention and early intervention strategies.
Age-Specific Considerations
Newborn:
• Neonatal resuscitation follows NRP guidelines distinct from PALS but coordination important for delivery room and NICU care
Transition from neonatal to pediatric algorithms typically at >28 days of age
Drug dosing and equipment sizing based on weight rather than age
Hypothermia protocols specific for neonates.
Infant:
• Infant algorithm modifications focus on respiratory causes of arrest being most common
Weight-based drug dosing critical with frequent need for intraosseous access
Compression-to-ventilation ratios differ (30:2 single rescuer, 15:2 two rescuers)
Equipment sizing based on length-based tape or age-specific charts.
Child:
• School-age children benefit from early defibrillation protocols with pediatric-specific energy dosing
Recognition of septic shock and cardiac rhythm abnormalities important
Medication dosing transitions from weight-based to adult protocols
Family-centered care considerations during resuscitation events.
Adolescent:
• Adolescent protocols increasingly resemble adult algorithms with considerations for drug abuse, psychiatric conditions, and pregnancy in females
Adult defibrillator pads and energy levels appropriate for patients >25-30kg
Transition planning for patients with chronic conditions requiring ongoing resuscitation planning.
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Clinical Presentation
Symptoms:
• Pre-arrest warning signs: altered mental status, severe respiratory distress, poor perfusion, bradycardia progressing to cardiac arrest
Respiratory arrest: absent or agonal breathing, weak pulse present initially
Cardiac arrest: unresponsive, pulseless, apneic
Post-arrest: coma, seizures, multi-organ dysfunction.
Physical Signs:
• Pre-arrest: tachycardia or bradycardia, hypotension, delayed capillary refill, decreased urine output, altered consciousness
During arrest: absent pulse, no spontaneous breathing, cyanosis, dilated pupils
ROSC (Return of Spontaneous Circulation): palpable pulse, measurable blood pressure, improved perfusion.
Severity Assessment:
• Assess severity using pediatric early warning systems (PEWS) for prevention
During arrest: continuous assessment of pulse, rhythm, perfusion, oxygenation
Post-arrest: neurological function, multi-organ assessment, prognostic indicators including initial rhythm, time to ROSC, lactate levels.
Differential Diagnosis:
• Reversible causes (H's and T's): hypoxia, hypovolemia, hydrogen ion (acidosis), hypo/hyperkalemia, hypothermia, toxins, tamponade, tension pneumothorax, thrombosis (pulmonary/coronary), trauma
Age-specific considerations: foreign body obstruction, child abuse, metabolic disorders, genetic conditions.
Diagnostic Approach
History Taking:
• Rapid history during resuscitation: events leading to arrest, known medical conditions, medications, allergies, last oral intake
SAMPLE history (Symptoms, Allergies, Medications, Past medical history, Last meal, Events)
Family presence and communication important for decision-making and support.
Investigations:
• Point-of-care testing during resuscitation: blood gas analysis, glucose, electrolytes, lactate
Chest X-ray if equipment available
Echocardiography if trained providers available for reversible causes assessment
Neurological monitoring post-arrest including continuous EEG when indicated.
Normal Values:
• Target values during resuscitation: end-tidal CO₂ 15-25 mmHg during CPR (higher values suggest good perfusion), post-ROSC targets vary by age
Blood pressure goals age-specific: systolic >70 + (2×age in years) mmHg
Oxygen saturation targets 94-99% post-arrest.
Interpretation:
• Monitor quality indicators: chest compression depth (at least 1/3 chest diameter), rate 100-120/min, complete recoil, minimal interruptions
End-tidal COâ‚‚ trending useful for perfusion assessment
Arterial blood gas interpretation guides ventilation and acid-base management post-arrest.
Management/Treatment
Acute Management:
• High-quality CPR with minimal interruptions, appropriate compression depth and rate
Defibrillation for shockable rhythms: 2-4 J/kg initial, 4-10 J/kg subsequent shocks
Epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000) every 3-5 minutes
Amiodarone 5 mg/kg for refractory VF/VT
Consider ECMO for refractory arrest in appropriate candidates.
Chronic Management:
• Post-arrest care focuses on neuroprotection: targeted temperature management 32-34°C for 24 hours if indicated, glucose control 80-180 mg/dL, seizure monitoring and treatment, hemodynamic support, family communication and support
Rehabilitation planning and long-term follow-up for survivors.
Lifestyle Modifications:
• Prevention strategies: water safety education, poison prevention, safe sleep practices, car seat safety, choking prevention
For survivors: activity restrictions based on neurological status, seizure precautions, medication compliance, regular follow-up care, family CPR training.
Follow Up:
• Immediate post-arrest: intensive care monitoring, neurological assessment, multi-organ support
Hospital discharge planning: home safety assessment, medication management, therapy referrals
Long-term follow-up: neurodevelopmental assessment, cardiac evaluation if indicated, family counseling and support services.
Age-Specific Dosing
Medications:
• Epinephrine: 0.01 mg/kg IV/IO (0.1 mL/kg of 1:10,000) every 3-5 minutes during arrest
Amiodarone: 5 mg/kg IV/IO bolus for VF/VT
Atropine: 0.02 mg/kg IV/IO (minimum 0.1 mg, maximum single dose 0.5 mg)
Calcium chloride: 20 mg/kg (0.2 mL/kg of 10%) for hypocalcemia/hyperkalemia.
Formulations:
• Epinephrine 1:10,000 (0.1 mg/mL) for IV/IO use, 1:1000 for intratracheal use only if vascular access unavailable
Amiodarone 50 mg/mL injection
Atropine 0.4 mg/mL injection
Pre-calculated drug dosing charts or length-based tapes recommended for accuracy.
Safety Considerations:
• Medication errors common during resuscitation: use pre-calculated charts, double-check dosing, avoid intracardiac injections
High-dose epinephrine (0.1 mg/kg) not recommended
Calcium only for specific indications (hyperkalemia, hypocalcemia, calcium channel blocker toxicity)
Avoid bicarbonate unless severe acidosis.
Monitoring:
• Continuous cardiac monitoring during and after arrest
Invasive blood pressure monitoring if available post-ROSC
End-tidal COâ‚‚ monitoring during CPR quality assessment
Frequent blood gas analysis post-arrest
Neurological monitoring including pupillary response, seizure assessment.
Prevention & Follow-up
Prevention Strategies:
• Primary prevention: injury prevention education, safe sleep campaigns, water safety, poison prevention, immunizations
Secondary prevention: early warning systems in hospitals, rapid response teams, family education on emergency recognition
Quality improvement programs to prevent in-hospital deterioration.
Vaccination Considerations:
• Standard immunizations prevent many conditions leading to pediatric arrest (pneumonia, meningitis)
Influenza vaccination reduces respiratory illness risk
Healthcare worker immunizations important for infection control in vulnerable post-arrest patients
Family education on vaccine-preventable disease prevention.
Follow Up Schedule:
• Post-arrest survivors: PICU monitoring until stable, step-down to ward when appropriate, outpatient follow-up within 1-2 weeks
Long-term follow-up: neurology at 3-6 months, cardiology if indicated, developmental assessment at 6-12 months, annual comprehensive evaluations.
Monitoring Parameters:
• Neurological recovery: Glasgow Coma Scale, seizure activity, developmental milestones, school performance
Cardiac function: echocardiography, exercise tolerance, arrhythmia monitoring
Quality of life measures for child and family
Long-term outcome tracking for quality improvement initiatives.
Complications
Acute Complications:
• During resuscitation: rib fractures, pneumothorax, liver laceration, medication errors, equipment malfunction
Post-arrest: cerebral edema, seizures, multi-organ failure, infection, arrhythmias
ROSC complications: reperfusion injury, hemodynamic instability, cardiac dysfunction.
Chronic Complications:
• Neurological sequelae: cerebral palsy, developmental delay, seizure disorder, behavioral changes, learning disabilities
Cardiac complications: cardiomyopathy, arrhythmias, sudden death risk
Psychological impact: PTSD in survivors and families, depression, anxiety, social functioning difficulties.
Warning Signs:
• Neurological deterioration: decreased consciousness, new seizures, focal neurological deficits, increased intracranial pressure signs
Cardiac instability: arrhythmias, heart failure signs, chest pain, syncope
Signs requiring urgent re-evaluation and possible escalation of care.
Emergency Referral:
• Immediate activation of emergency response for any pediatric arrest situation
ECMO consultation for refractory arrest if available
Specialized transport teams for interfacility transfer of post-arrest patients
Early consultation with organ donation organizations when appropriate.
Parent Education Points
Counseling Points:
• Explain arrest circumstances age-appropriately, emphasize medical team's best efforts, discuss realistic prognosis based on initial response and examination findings
Address family guilt and questions about prevention
Provide hope while being realistic about potential outcomes and recovery timeline.
Home Care:
• For survivors: medication adherence, seizure precautions if indicated, activity modifications based on neurological status, regular therapy appointments
Recognition of concerning signs requiring immediate medical attention
CPR training for family members when appropriate.
Medication Administration:
• Precise medication dosing for survivors with ongoing medical needs
Seizure medication compliance critical for patients with post-anoxic seizures
Pain management for post-arrest complications
Proper storage and administration of emergency medications when prescribed for home use.
When To Seek Help:
• Seek immediate medical attention for: altered consciousness, seizure activity, breathing difficulties, chest pain, unusual fatigue, new neurological symptoms
Contact healthcare team for: medication concerns, therapy questions, behavioral changes, school performance issues
Low threshold for evaluation given high-risk population.