Pediatric advanced life support (PALS)
- Eric Fleegler, MD, MPH
Eric Fleegler, MD, MPH
- Assistant Professor of Pediatrics
- Harvard Medical School
- Monica Kleinman, MD
Monica Kleinman, MD
- Associate Professor of Anaesthesia (Pediatrics)
- Harvard Medical School
- Section Editor
- Susan B Torrey, MD
Susan B Torrey, MD
- Section Editor — Pediatric Resuscitation; Pediatric Trauma
- Director, Division of Pediatric Emergency Medicine
- Associate Professor of Emergency Medicine and Pediatrics (Clinical)
- NYU School of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
This topic will discuss the advanced components of recognition and treatment of respiratory failure, shock, cardiopulmonary failure, and cardiac arrhythmias in children.
Basic life support in children and guidelines for cardiac resuscitation in adults are discussed separately. (See "Pediatric basic life support for healthcare providers" and "Advanced cardiac life support (ACLS) in adults".)
The American Heart Association (AHA) PALS program provides a structured approach to the assessment and treatment of the critically ill pediatric patient [1,2]. The AHA guidelines for pediatric resuscitation were updated in 2015 to reflect advances and research in clinical care using new evidence from a variety of sources ranging from large clinical trials to animal models.
The PALS content includes:
●Overview of assessment
- American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary and Emergency Cardiovascular Care - Part 12. Pediatric advanced life support. https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-12-pediatric-advanced-life-support/ (Accessed on November 10, 2015).
- de Caen AR, Berg MD, Chameides L, et al. Part 12: Pediatric Advanced Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S526.
- Pediatric Advanced Life Support Provider Manual, Chameides L, Samson RA, Schexnayder SM, Hazinski MF (Eds), American Heart Association, Dallas 2012.
- Kleinman ME, de Caen AR, Chameides L, et al. Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Pediatrics 2010; 126:e1261.
- Kleinman ME, de Caen AR, Chameides L, et al. Part 10: Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122:S466.
- Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S876.
- American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - Part 11: Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality. ECCguidelines.heart.org (Accessed on October 15, 2015).
- Atkins DL, Berger S, Duff JP, et al. Part 11: Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S519.
- Andersen LW, Berg KM, Saindon BZ, et al. Time to Epinephrine and Survival After Pediatric In-Hospital Cardiac Arrest. JAMA 2015; 314:802.
- Tasker RC, Randolph AG. Pediatric Pulseless Arrest With "Nonshockable" Rhythm: Does Faster Time to Epinephrine Improve Outcome? JAMA 2015; 314:776.
- Lowry AW, Morales DL, Graves DE, et al. Characterization of extracorporeal membrane oxygenation for pediatric cardiac arrest in the United States: analysis of the kids' inpatient database. Pediatr Cardiol 2013; 34:1422.
- Ortmann L, Prodhan P, Gossett J, et al. Outcomes after in-hospital cardiac arrest in children with cardiac disease: a report from Get With the Guidelines--Resuscitation. Circulation 2011; 124:2329.
- Morris MC, Wernovsky G, Nadkarni VM. Survival outcomes after extracorporeal cardiopulmonary resuscitation instituted during active chest compressions following refractory in-hospital pediatric cardiac arrest. Pediatr Crit Care Med 2004; 5:440.
- Raymond TT, Cunnyngham CB, Thompson MT, et al. Outcomes among neonates, infants, and children after extracorporeal cardiopulmonary resuscitation for refractory inhospital pediatric cardiac arrest: a report from the National Registry of Cardiopulmonary Resuscitation. Pediatr Crit Care Med 2010; 11:362.
- Lasa JJ, Rogers RS, Localio R, et al. Extracorporeal Cardiopulmonary Resuscitation (E-CPR) During Pediatric In-Hospital Cardiopulmonary Arrest Is Associated With Improved Survival to Discharge: A Report from the American Heart Association's Get With The Guidelines-Resuscitation (GWTG-R) Registry. Circulation 2016; 133:165.
- Ferguson LP, Durward A, Tibby SM. Relationship between arterial partial oxygen pressure after resuscitation from cardiac arrest and mortality in children. Circulation 2012; 126:335.
- Del Castillo J, López-Herce J, Matamoros M, et al. Hyperoxia, hypocapnia and hypercapnia as outcome factors after cardiac arrest in children. Resuscitation 2012; 83:1456.
- Guerra-Wallace MM, Casey FL 3rd, Bell MJ, et al. Hyperoxia and hypoxia in children resuscitated from cardiac arrest. Pediatr Crit Care Med 2013; 14:e143.
- Bennett KS, Clark AE, Meert KL, et al. Early oxygenation and ventilation measurements after pediatric cardiac arrest: lack of association with outcome. Crit Care Med 2013; 41:1534.
- Topjian AA, French B, Sutton RM, et al. Early postresuscitation hypotension is associated with increased mortality following pediatric cardiac arrest. Crit Care Med 2014; 42:1518.
- Lin YR, Li CJ, Wu TK, et al. Post-resuscitative clinical features in the first hour after achieving sustained ROSC predict the duration of survival in children with non-traumatic out-of-hospital cardiac arrest. Resuscitation 2010; 81:410.
- Lin YR, Wu HP, Chen WL, et al. Predictors of survival and neurologic outcomes in children with traumatic out-of-hospital cardiac arrest during the early postresuscitative period. J Trauma Acute Care Surg 2013; 75:439.
- Srinivasan V, Spinella PC, Drott HR, et al. Association of timing, duration, and intensity of hyperglycemia with intensive care unit mortality in critically ill children. Pediatr Crit Care Med 2004; 5:329.
- Kong MY, Alten J, Tofil N. Is hyperglycemia really harmful? A critical appraisal of "Persistent hyperglycemia in critically ill children" by Faustino and Apkon (J Pediatr 2005; 146:30-34). Pediatr Crit Care Med 2007; 8:482.
- Abend NS, Topjian A, Ichord R, et al. Electroencephalographic monitoring during hypothermia after pediatric cardiac arrest. Neurology 2009; 72:1931.
- Kirkham F. Cardiac arrest and post resuscitation of the brain. Eur J Paediatr Neurol 2011; 15:379.
- Constantinou JE, Gillis J, Ouvrier RA, Rahilly PM. Hypoxic-ischaemic encephalopathy after near miss sudden infant death syndrome. Arch Dis Child 1989; 64:703.
- Moler FW, Silverstein FS, Holubkov R, et al. Therapeutic hypothermia after out-of-hospital cardiac arrest in children. N Engl J Med 2015; 372:1898.
- Moler FW, Silverstein FS, Holubkov R, et al. Therapeutic Hypothermia after In-Hospital Cardiac Arrest in Children. N Engl J Med 2017; 376:318.
- Fink EL, Clark RS, Kochanek PM, et al. A tertiary care center's experience with therapeutic hypothermia after pediatric cardiac arrest. Pediatr Crit Care Med 2010; 11:66.
- Doherty DR, Parshuram CS, Gaboury I, et al. Hypothermia therapy after pediatric cardiac arrest. Circulation 2009; 119:1492.
- Lin JJ, Hsia SH, Wang HS, et al. Therapeutic hypothermia associated with increased survival after resuscitation in children. Pediatr Neurol 2013; 48:285.
- Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD. The 100,000 lives campaign: setting a goal and a deadline for improving health care quality. JAMA 2006; 295:324.
- Chan PS, Jain R, Nallmothu BK, et al. Rapid Response Teams: A Systematic Review and Meta-analysis. Arch Intern Med 2010; 170:18.
- Sharek PJ, Parast LM, Leong K, et al. Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a Children's Hospital. JAMA 2007; 298:2267.
- Kotsakis A, Lobos AT, Parshuram C, et al. Implementation of a multicenter rapid response system in pediatric academic hospitals is effective. Pediatrics 2011; 128:72.
- Joffe AR, Anton NR, Burkholder SC. Reduction in hospital mortality over time in a hospital without a pediatric medical emergency team: limitations of before-and-after study designs. Arch Pediatr Adolesc Med 2011; 165:419.
- Mangurten J, Scott SH, Guzzetta CE, et al. Effects of family presence during resuscitation and invasive procedures in a pediatric emergency department. J Emerg Nurs 2006; 32:225.
- Dudley NC, Hansen KW, Furnival RA, et al. The effect of family presence on the efficiency of pediatric trauma resuscitations. Ann Emerg Med 2009; 53:777.
- Tinsley C, Hill JB, Shah J, et al. Experience of families during cardiopulmonary resuscitation in a pediatric intensive care unit. Pediatrics 2008; 122:e799.
- Curley MA, Meyer EC, Scoppettuolo LA, et al. Parent presence during invasive procedures and resuscitation: evaluating a clinical practice change. Am J Respir Crit Care Med 2012; 186:1133.
- Respiratory distress and failure
- Cardiopulmonary failure
- Heart rate and rhythm
- - Bradycardia
- - Tachycardia
- - Pulseless arrest
- RESUSCITATION GUIDELINES
- Bradycardia algorithm
- Tachycardia algorithm
- Pulseless arrest algorithm
- - Start CPR
- - Shockable rhythm
- - Asystole or pulseless electrical activity
- - Monitoring
- - Extracorporeal membrane oxygenation (ECMO) with CPR
- - Termination of resuscitation
- Early postresuscitation management
- - Maintain airway
- - Avoid low and high arterial oxygen
- - Monitor ventilation
- - Avoid recurrent shock
- - Maintain normal blood glucose
- - EEG monitoring
- - Targeted temperature management
- - Transfer to a pediatric center
- Rapid response teams
- Family presence during resuscitation
- SUMMARY AND RECOMMENDATIONS