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Pediatric advanced life support (PALS) is a course offered by the
American Heart Association The American Heart Association (AHA) is a nonprofit organization in the United States that funds cardiovascular medical research, educates consumers on healthy living and fosters appropriate cardiac care in an effort to reduce disability and deat ...
(AHA) for health care providers who take care of children and infants in the
emergency room An emergency department (ED), also known as an accident and emergency department (A&E), emergency room (ER), emergency ward (EW) or casualty department, is a medical treatment facility specializing in emergency medicine, the acute care of pati ...
, critical care and
intensive care unit 220px, Intensive care unit An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that provides intensi ...
s in the hospital, and out of hospital ( emergency medical services (EMS)). The course teaches healthcare providers how to assess injured and sick children and recognize and treat respiratory distress/failure, shock, cardiac arrest, and arrhythmias.


Basic Life Support (BLS)

PALS builds upon AHA's Pediatric
Basic Life Support Basic life support (BLS) is a level of medical care which is used for patients with life-threatening illnesses or injuries until they can be given full medical care by advanced life support providers (paramedics, nurses, physicians). It can be p ...
(BLS). Providers should follow th
AHA's Pediatric BLS Algorithms
for single and ≥ 2 person rescuer. The most essential component of BLS and PALS cardiac arrest care is high quality cardiopulmonary resuscitation (CPR). CPR should begin with a check for responsiveness, getting help, and activating the emergency response system. After this, the provider should assess for breathing and a pulse ( brachial pulse in infant and carotid pulse in child) - all within 10 seconds. If no pulse and no breathing or only gasping, start CPR. CPR consists of chest compressions followed by rescue breaths - for single rescuer do 30 compressions and 2 breaths (30:2), for > 2 rescuers do 15 compressions and 2 breaths (15:2). The rate of chest compressions should be 100-120 compressions/min and depth should be 1.5 inches for infants and 2 inches for children. Chest compressions differ between infants and children. For infants, chest compressions can be done with the two-fingers technique (single rescuer) or two-thumbs encircling hands technique (2 rescuer). In the two-fingers technique, the provider uses their index and middle finger to press down on the infant's
sternum The sternum or breastbone is a long flat bone located in the central part of the chest. It connects to the ribs via cartilage and forms the front of the rib cage, thus helping to protect the heart, lungs, and major blood vessels from injury. Sha ...
, below the nipples. In the two-thumb encircling hands technique, the provider's hands should wrap around the chest with both thumbs pressing down on the infant's sternum. For children, chest compressions should be done with the provider placing the heel of one hand over the child's lower chest and pressing down while keeping their arms straightened at the elbow. If help hasn't arrived after 2 minutes, the provider should call for help again and get an automatic external defibrillator (AED). Once help and the AED arrives, the provider should place the AED pads on the child, making sure to not disrupt chest compressions. The AED will let the provider know if the child has a shockable
heart rhythm The cardiac conduction system (CCS) (also called the electrical conduction system of the heart) transmits the signals generated by the sinoatrial node – the heart's pacemaker, to cause the heart muscle to contract, and pump blood through the ...
. If shockable, give a
shock Shock may refer to: Common uses Collective noun *Shock, a historic commercial term for a group of 60, see English numerals#Special names * Stook, or shock of grain, stacked sheaves Healthcare * Shock (circulatory), circulatory medical emerge ...
and then immediately resume CPR.


Assessment

PALS teaches a systematic assessment approach so that the health care provider can quickly identify any life-threatening conditions and treat them. The PALS systematic approach algorithm begins with a quick initial assessment followed by checking for responsiveness, pulse, and breathing. If the child has no pulse and isn't breathing, start
CPR Cardiopulmonary resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spont ...
. If the child has a pulse but isn't breathing, provide
ventilation Ventilation may refer to: * Ventilation (physiology), the movement of air between the environment and the lungs via inhalation and exhalation ** Mechanical ventilation, in medicine, using artificial methods to assist breathing *** Ventilator, a m ...
and give oxygen (when possible). Once it has been established that the child has a pulse, is breathing, and doesn't require immediate life saving treatment, the provider will begin their primary assessment followed by a secondary assessment and further diagnostic workup. Continuous reassessments should be done to reassess for life-threatening conditions.


Initial assessment

The initial assessment is meant to be a very quick assessment performed within the first few seconds of interacting with a child and it utilizes the acronym ABC - appearance, breathing, and color. The provider will assess appearance (level of consciousness and responsiveness, speaking or crying), breathing (breathing or not breathing, increased work of breathing, abnormal breath sounds), and color (pale, mottled, cyanotic, bleeding).


Primary assessment

The primary assessment uses the acronym ABCDE - airway, breathing, circulation, disability, exposure. Airway - assess airway patency (open/patent, unobstructed vs obstructed) and if the patient will need assistance maintaining their airway Breathing - assess respiratory rate, respiratory effort, lung sounds, airway sounds, chest movement,
oxygen saturation Oxygen saturation (symbol SO2) is a relative measure of the concentration of oxygen that is dissolved or carried in a given medium as a proportion of the maximal concentration that can be dissolved in that medium at the given temperature. It ca ...
via
pulse oximetry Pulse oximetry is a noninvasive method for monitoring a person's oxygen saturation. Peripheral oxygen saturation (SpO2) readings are typically within 2% accuracy (within 4% accuracy in 95% of cases) of the more accurate (and invasive) reading o ...
Circulation - assess heart rate, heart rhythm, pulses, skin color, skin temperature, capillary refill time,
blood pressure Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure ...
Disability - assess neurological function with AVPU pediatric response scale (alert, voice, painful, unresponsive), pediatric
Glasgow coma scale The Glasgow Coma Scale (GCS) is a clinical scale used to reliably measure a person's level of consciousness after a brain injury. The GCS assesses a person based on their ability to perform eye movements, speak, and move their body. These thr ...
(eye opening, motor response, verbal response), pupil response to light (normal,
pinpoint Pinpoint or pin point may refer to: * Pinpoint citation * Pin-point method (ecology) * Microsoft Pinpoint * Pinpoint Oxford * Pinpoint pupil * Pinpoint aka waypoint *Pin Point, Georgia, an unincorporated community in Chatham County, Georgia, U.S.A. ...
, dilated, unilateral dilated), blood glucose test (low blood sugar/
hypoglycemia Hypoglycemia, also called low blood sugar, is a fall in blood sugar to levels below normal, typically below 70 mg/dL (3.9 mmol/L). Whipple's triad is used to properly identify hypoglycemic episodes. It is defined as blood glucose bel ...
can cause
altered mental status An altered level of consciousness is any measure of arousal other than normal. Level of consciousness (LOC) is a measurement of a person's arousability and responsiveness to stimuli from the environment. A mildly depressed level of consciousn ...
) Exposure - assess temperature/ fever, signs of trauma (cuts, bleeding, bruises, burns, etc.), skin (
petechia A petechia () is a small red or purple spot (≤4 mm in diameter) that can appear on the skin, conjunctiva, retina, and mucous membranes which is caused by haemorrhage of capillaries. The word is derived from Italian , 'freckle,' of obscure origi ...
e,
purpura Purpura () is a condition of red or purple discolored spots on the skin that do not blanch on applying pressure. The spots are caused by bleeding underneath the skin secondary to platelet disorders, vascular disorders, coagulation disorders, ...
, etc.)


Secondary assessment

Once the primary assessment is completed, the provider can do a secondary assessment which consists of a complete physical exam and focused
medical history The medical history, case history, or anamnesis (from Greek: ἀνά, ''aná'', "open", and μνήσις, ''mnesis'', "memory") of a patient is information gained by a physician by asking specific questions, either to the patient or to other peo ...
. The information asked in the medical history uses the acronym SAMPLE -
signs and symptoms Signs and symptoms are the observed or detectable signs, and experienced symptoms of an illness, injury, or condition. A sign for example may be a higher or lower temperature than normal, raised or lowered blood pressure or an abnormality showi ...
, allergies, medications (prescribed, over the counter, vitamins, herbal), past medical history (any medical problems, prior surgeries), last meal (helpful information to know because it can affect when a child can have surgery or receive
anesthesia Anesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prevention of pain), paralysis (muscle relaxation), ...
), events (onset of illness and events leading up to illness). Parts of the history that are especially important for children include asking about medications that the child could have gotten into (e.g., if a pill fell on the floor or an unlocked medicine cabinet), history of prematurity, birth history, and
immunizations Immunization, or immunisation, is the process by which an individual's immune system becomes fortified against an infectious agent (known as the immunogen). When this system is exposed to molecules that are foreign to the body, called ''non-se ...
.


Respiratory distress and failure

Providers must be able to identify respiratory problems that are easily treatable (e.g., treated with oxygen, suctioning/ clearing airway, albuterol, etc.) and those that can rapidly progress to life-threatening conditions. Respiratory distress can progress to respiratory failure which can progress to
cardiac arrest Cardiac arrest is when the heart suddenly and unexpectedly stops beating. It is a medical emergency that, without immediate medical intervention, will result in sudden cardiac death within minutes. Cardiopulmonary resuscitation (CPR) and possi ...
. Once respiratory complaints have progressed to
cardiac arrest Cardiac arrest is when the heart suddenly and unexpectedly stops beating. It is a medical emergency that, without immediate medical intervention, will result in sudden cardiac death within minutes. Cardiopulmonary resuscitation (CPR) and possi ...
, death and neurological damage are more likely to occur. For this reason, providers should aim to identify and treat respiratory conditions before they progress and worsen.


Recognition


Signs and symptoms

Common signs of respiratory distress * increased work of breathing * nasal flaring (nostrils widening during breathing) * accessory muscle use (using muscles other than the
diaphragm Diaphragm may refer to: Anatomy * Thoracic diaphragm, a thin sheet of muscle between the thorax and the abdomen * Pelvic diaphragm or pelvic floor, a pelvic structure * Urogenital diaphragm or triangular ligament, a pelvic structure Other * Diap ...
and
intercostal muscles Intercostal muscles are many different groups of muscles that run between the ribs, and help form and move the chest wall. The intercostal muscles are mainly involved in the mechanical aspect of breathing by helping expand and shrink the size of ...
during breathing (e.g.,
sternocleidomastoid The sternocleidomastoid muscle is one of the largest and most superficial cervical muscles. The primary actions of the muscle are rotation of the head to the opposite side and flexion of the neck. The sternocleidomastoid is innervated by the access ...
)) * retractions (collapse of parts of the chest during breathing) (e.g., suprasternal, substernal, sternal, intercostal, subcostal, supraclavicular) * head bobbing (in infants) * grunting *
tachypnea Tachypnea, also spelt tachypnoea, is a respiratory rate greater than normal, resulting in abnormally rapid and shallow breathing. In adult humans at rest, any respiratory rate of 1220 per minute is considered clinically normal, with tachypnea b ...
(too fast breathing) * pallor (pale skin) *
tachycardia Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. Heart rates above the resting rate may be normal ( ...
(fast heart rate) * agitation and anxiety Respiratory distress can progress and worsen to respiratory failure. Signs of respiratory failure include the following * decreased work of breathing * eventual pauses in or altogether stopping breathing (apnea) *
bradypnea Bradypnea is abnormally slow breathing. The respiratory rate at which bradypnea is diagnosed depends on the age of the person, with the limit higher during childhood. Age ranges * Age 0–1 year < 30 breaths per minute * Age 1–3 years < 25 br ...
(too slow breathing) * decreased or absent air movement * abnormal breath sounds *
cyanosis Cyanosis is the change of body tissue color to a bluish-purple hue as a result of having decreased amounts of oxygen bound to the hemoglobin in the red blood cells of the capillary bed. Body tissues that show cyanosis are usually in locations ...
(blue skin) * exhaustion and unresponsiveness * can't speak or cough


Types of respiratory problems

* upper airway obstruction - e.g.,
croup Croup, also known as laryngotracheobronchitis, is a type of respiratory infection that is usually caused by a virus. The infection leads to swelling inside the trachea, which interferes with normal breathing and produces the classic symptoms ...
,
epiglottitis Epiglottitis is the inflammation of the epiglottis—the flap at the base of the tongue that prevents food entering the trachea (windpipe). Symptoms are usually rapid in onset and include trouble swallowing which can result in drooling, changes ...
, foreign body aspiration,
anaphylaxis Anaphylaxis is a serious, potentially fatal allergic reaction and medical emergency that is rapid in onset and requires immediate medical attention regardless of use of emergency medication on site. It typically causes more than one of the follo ...
,
retropharyngeal abscess Retropharyngeal abscess (RPA) is an abscess located in the tissues in the back of the throat behind the posterior pharyngeal wall (the retropharyngeal space). Because RPAs typically occur in deep tissue, they are difficult to diagnose by physical ...
, enlarged/swollen
tonsil The tonsils are a set of lymphoid organs facing into the aerodigestive tract, which is known as Waldeyer's tonsillar ring and consists of the adenoid tonsil, two tubal tonsils, two palatine tonsils, and the lingual tonsils. These organs play ...
s * lower airway obstruction - e.g.,
asthma Asthma is a long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wheezing, co ...
, bronchiolitis * lung tissue disease - e.g.,
pneumonia Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severit ...
,
pneumonitis Pneumonitis describes general inflammation of lung tissue. Possible causative agents include radiation therapy of the chest, exposure to medications used during chemo-therapy, the inhalation of debris (e.g., animal dander), aspiration, herbicide ...
,
pulmonary edema Pulmonary edema, also known as pulmonary congestion, is excessive liquid accumulation in the tissue and air spaces (usually alveoli) of the lungs. It leads to impaired gas exchange and may cause hypoxemia and respiratory failure. It is due ...
* disordered control of breathing - often described as "breathing funny"; e.g.,
seizure An epileptic seizure, informally known as a seizure, is a period of symptoms due to abnormally excessive or synchronous neuronal activity in the brain. Outward effects vary from uncontrolled shaking movements involving much of the body with lo ...
,
overdose A drug overdose (overdose or OD) is the ingestion or application of a drug or other substance in quantities much greater than are recommended.
, trauma,
coma A coma is a deep state of prolonged unconsciousness in which a person cannot be awakened, fails to respond normally to painful stimuli, light, or sound, lacks a normal wake-sleep cycle and does not initiate voluntary actions. Coma patients exhi ...
,
neuromuscular disease A neuromuscular disease is any disease affecting the peripheral nervous system (PNS), the neuromuscular junction, or skeletal muscle, all of which are components of the motor unit. Damage to any of these structures can cause muscle atrophy and wea ...
s


Management


Initial management

The initial management for respiratory distress uses the acronym ABC - airway, breathing, circulation. Airway * support the airway by making sure that it is open/patent (child can do this on their own or provider may have to open airway with head tilt-chin lift or jaw thrust (if suspected cervical spine injury)) * clear the airway as needed (e.g., suctioning mucus/secretions in nose and throat, removing foreign bodies, etc.) * consider adding airway adjuncts such as nasopharyngeal airway (NPA) or oropharyngeal airway (OPA) (if no gag reflex) Breathing * monitor oxygen saturation with a pulse ox * give supplemental oxygen * give inhaled medications (e.g., albuterol,
epinephrine Adrenaline, also known as epinephrine, is a hormone and medication which is involved in regulating visceral functions (e.g., respiration). It appears as a white microcrystalline granule. Adrenaline is normally produced by the adrenal glands and ...
) as needed * manually ventilate as needed (e.g., bag mask ventilation) * prepare for advanced airway Circulation * monitor vitals (e.g.,
heart rate Heart rate (or pulse rate) is the frequency of the heartbeat measured by the number of contractions (beats) of the heart per minute (bpm). The heart rate can vary according to the body's physical needs, including the need to absorb oxygen and excr ...
,
blood pressure Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure ...
) * establish vascular access (for medications and fluids) as needed


Advanced airways

Advanced airways may be necessary if the child can't maintain their airway on their own and isn't responding to other methods of ventilation and oxygenation. Advanced airways use medical equipment to allow for open airways and ease of ventilation and medication delivery. Types of advanced airways include supraglottic devices (devices that lie above the
glottis The glottis is the opening between the vocal folds (the rima glottidis). The glottis is crucial in producing vowels and voiced consonants. Etymology From Ancient Greek ''γλωττίς'' (glōttís), derived from ''γλῶττα'' (glôtta), v ...
such as OPA, NPA,
laryngeal mask airway A laryngeal mask airway (LMA), also known as laryngeal mask, is a medical device that keeps a patient's Respiratory tract, airway open during anaesthesia or while they are Unconsciousness, unconscious. It is a type of supraglottic airway device. ...
), infraglottic devices (devices that lie below the glottis and go into the
trachea The trachea, also known as the windpipe, is a cartilaginous tube that connects the larynx to the bronchi of the lungs, allowing the passage of air, and so is present in almost all air- breathing animals with lungs. The trachea extends from t ...
such as
endotracheal tube A tracheal tube is a catheter that is inserted into the trachea for the primary purpose of establishing and maintaining a patent airway and to ensure the adequate exchange of oxygen and carbon dioxide. Many different types of tracheal tubes ar ...
(
intubation Intubation (sometimes entubation) is a medical procedure involving the insertion of a tube into the body. Patients are generally anesthetized beforehand. Examples include tracheal intubation, and the balloon tamponade with a Sengstaken-Blake ...
)), and surgery (incision below the glottis such as
cricothyrotomy A cricothyrotomy (also called cricothyroidotomy) is an incision made through the skin and cricothyroid membrane to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, angioedema, or ...
and
tracheotomy Tracheotomy (, ), or tracheostomy, is a surgical airway management procedure which consists of making an incision (cut) on the anterior aspect (front) of the neck and opening a direct airway through an incision in the trachea (windpipe). The r ...
). Surgical advanced airways are typically performed intubation and other less invasive methods fail or are contraindicated or when the child will need long term
mechanical ventilation Mechanical ventilation, assisted ventilation or intermittent mandatory ventilation (IMV), is the medical term for using a machine called a ventilator to fully or partially provide artificial ventilation. Mechanical ventilation helps move a ...
.


Intubation

To perform an intubation, the health care provider should be able to perform the steps of
rapid sequence intubation In advanced airway management, rapid sequence induction (RSI) – also referred to as rapid sequence intubation or as rapid sequence induction and intubation (RSII) or as crash induction – is a special process for endotracheal intubation that is ...
(preparation, preoxygenation, pretreatment, paralysis and sedation, positioning, placement of tube, postintubation management).


Further management

Further management should be based on the specific medical condition the child has. For example, if the child is experiencing respiratory distress secondary to
asthma Asthma is a long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wheezing, co ...
, management would include albuterol,
inhaled corticosteroids Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are involve ...
, supplemental
oxygen Oxygen is the chemical element with the symbol O and atomic number 8. It is a member of the chalcogen group in the periodic table, a highly reactive nonmetal, and an oxidizing agent that readily forms oxides with most elements ...
, and more depending upon the severity of the asthma.


Shock

Shock Shock may refer to: Common uses Collective noun *Shock, a historic commercial term for a group of 60, see English numerals#Special names * Stook, or shock of grain, stacked sheaves Healthcare * Shock (circulatory), circulatory medical emerge ...
is defined as inadequate blood flow (
perfusion Perfusion is the passage of fluid through the circulatory system or lymphatic system to an organ or a tissue, usually referring to the delivery of blood to a capillary bed in tissue. Perfusion is measured as the rate at which blood is deliver ...
) in the body, causing tissues and organs to (1) not get enough oxygen and nutrients and (2) have trouble getting rid of toxic products of metabolism (e.g.,
lactate Lactate may refer to: * Lactation, the secretion of milk from the mammary glands * Lactate, the conjugate base of lactic acid Lactic acid is an organic acid. It has a molecular formula . It is white in the solid state and it is miscible with w ...
). It is important to recognize and treat shock as early as possible because the body requires oxygen and nutrients to function and without them, organs can eventually shut down and people can die. Common signs of shock include weak pulses,
altered mental status An altered level of consciousness is any measure of arousal other than normal. Level of consciousness (LOC) is a measurement of a person's arousability and responsiveness to stimuli from the environment. A mildly depressed level of consciousn ...
,
bradycardia Bradycardia (also sinus bradycardia) is a slow resting heart rate, commonly under 60 beats per minute (BPM) as determined by an electrocardiogram. It is considered to be a normal heart rate during sleep, in young and healthy or elderly adults, ...
or
tachycardia Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. Heart rates above the resting rate may be normal ( ...
, low urine output,
hypotension Hypotension is low blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood. Blood pressure is indicated by two numbers, the systolic blood pressure (the top number) and the di ...
, and pale, cold skin. Treating shock focuses on increasing blood flow and oxygen delivery to tissues and organs before organs are permanently damaged. This section will discuss the recognition and management of shock.


Recognition


Shock severity

The severity of shock is typically based on
systolic blood pressure Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure" r ...
. For this reason, measuring blood pressure is an important way to assess shock; however, blood pressure machines may not be very accurate if pulses are weak and the arms and legs (where the blood pressure is measured) are poorly perfused. Compensated shock is when the body is able to compensate through various mechanisms (e.g., raising the heart rate, increasing systemic vascular resistance, and more) to keep the systolic blood pressure in a normal range. Hypotensive/ decompensated shock is when the body cannot maintain systolic blood pressure in the normal range, and it becomes too low (
hypotensive Hypotension is low blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood. Blood pressure is indicated by two numbers, the systolic blood pressure (the top number) and the dias ...
).


Types of shock

There are 4 main types of shock: hypovolemic, distributive, cardiogenic, and obstructive.


Hypovolemic shock

Hypovolemic shock Hypovolemic shock is a form of shock caused by severe hypovolemia (insufficient blood volume or extracellular fluid in the body). It could be the result of severe dehydration through a variety of mechanisms or blood loss. Hypovolemic shock is a ...
is caused by low blood volume (hypovolemia) and is the most common cause of shock in pediatric patients. Common causes of volume loss include
diarrhea Diarrhea, also spelled diarrhoea, is the condition of having at least three loose, liquid, or watery bowel movements each day. It often lasts for a few days and can result in dehydration due to fluid loss. Signs of dehydration often begin w ...
, vomiting,
hemorrhage Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, v ...
, not drinking enough, burns, osmotic diuresis (e.g.,
diabetic ketoacidosis Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus. Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion and occasionally loss of ...
), and
third space The human body and even its individual body fluids may be conceptually divided into various fluid compartments, which, although not literally anatomic compartments, do represent a real division in terms of how portions of the body's water, solute ...
losses. Signs of hypovolemic shock are related to the low blood volume and decreased blood flow to extremities (e.g., cold extremities, slow
capillary refill Capillary refill time (CRT) is defined as the time taken for color to return to an external capillary bed after pressure is applied to cause blanching. It can be measured by holding a hand higher than heart-level and pressing the soft pad of a f ...
, and weak distal pulses).


Distributive shock

Distributive shock is caused by abnormally distributed blood throughout the body which causes some parts of the body to receive inadequate blood supply. Common causes of distributive shock include
sepsis Sepsis, formerly known as septicemia (septicaemia in British English) or blood poisoning, is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage is follo ...
,
anaphylaxis Anaphylaxis is a serious, potentially fatal allergic reaction and medical emergency that is rapid in onset and requires immediate medical attention regardless of use of emergency medication on site. It typically causes more than one of the follo ...
, and head or spinal cord injury (
neurogenic shock Neurogenic shock is a distributive type of shock resulting in hypotension (low blood pressure), often with bradycardia (slowed heart rate), caused by disruption of autonomic nervous system pathways. It can occur after damage to the central nervo ...
). * Septic shock is typically caused by an infection or inflammation in the body. Signs of septic shock include
fever Fever, also referred to as pyrexia, is defined as having a temperature above the normal range due to an increase in the body's temperature set point. There is not a single agreed-upon upper limit for normal temperature with sources using val ...
or
hypothermia Hypothermia is defined as a body core temperature below in humans. Symptoms depend on the temperature. In mild hypothermia, there is shivering and mental confusion. In moderate hypothermia, shivering stops and confusion increases. In severe ...
,
petechia A petechia () is a small red or purple spot (≤4 mm in diameter) that can appear on the skin, conjunctiva, retina, and mucous membranes which is caused by haemorrhage of capillaries. The word is derived from Italian , 'freckle,' of obscure origi ...
, and
purpura Purpura () is a condition of red or purple discolored spots on the skin that do not blanch on applying pressure. The spots are caused by bleeding underneath the skin secondary to platelet disorders, vascular disorders, coagulation disorders, ...
. Lab tests might show
leukocytosis Leukocytosis is a condition in which the white cell (leukocyte count) is above the normal range in the blood. It is frequently a sign of an inflammatory response, most commonly the result of infection, but may also occur following certain parasi ...
or
leukopenia Leukopenia () is a decrease in the number of leukocytes (WBC). Found in the blood, they are the white blood cells, and are the body's primary defense against an infection. Thus the condition of leukopenia places individuals at increased risk of ...
,
metabolic acidosis Metabolic acidosis is a serious electrolyte disorder characterized by an imbalance in the body's acid-base balance. Metabolic acidosis has three main root causes: increased acid production, loss of bicarbonate, and a reduced ability of the kidneys ...
with high
lactate Lactate may refer to: * Lactation, the secretion of milk from the mammary glands * Lactate, the conjugate base of lactic acid Lactic acid is an organic acid. It has a molecular formula . It is white in the solid state and it is miscible with w ...
, and more. * Anaphylactic shock is caused by an
allergen An allergen is a type of antigen that produces an abnormally vigorous immune response in which the immune system fights off a perceived threat that would otherwise be harmless to the body. Such reactions are called allergies. In technical t ...
and common signs include facial swelling, throat swelling,
hives Hives, also known as urticaria, is a kind of skin rash with red, raised, itchy bumps. Hives may burn or sting. The patches of rash may appear on different body parts, with variable duration from minutes to days, and does not leave any long-last ...
,
wheezing A wheeze is a continuous, coarse, whistling sound produced in the respiratory airways during breathing. For wheezes to occur, some part of the respiratory tree must be narrowed or obstructed (for example narrowing of the lower respiratory tract ...
, etc.


Cardiogenic shock

Cardiogenic shock Cardiogenic shock (CS) is a medical emergency resulting from inadequate blood flow due to the dysfunction of the ventricles of the heart.Textbooks of Internal MedicinHarrison's Principles of Internal Medicine 16th Edition, The McGraw-Hill Compan ...
is caused by abnormal heart function or problems within the heart that impair pumping of blood within the heart. Common causes of cardiogenic shock include congenital heart diseases,
arrhythmia Arrhythmias, also known as cardiac arrhythmias, heart arrhythmias, or dysrhythmias, are irregularities in the heartbeat, including when it is too fast or too slow. A resting heart rate that is too fast – above 100 beats per minute in adult ...
s,
myocarditis Myocarditis, also known as inflammatory cardiomyopathy, is an acquired cardiomyopathy due to inflammation of the heart muscle. Symptoms can include shortness of breath, chest pain, decreased ability to exercise, and an irregular heartbeat. Th ...
(inflammation of the heart muscle),
cardiomyopathy Cardiomyopathy is a group of diseases that affect the heart muscle. Early on there may be few or no symptoms. As the disease worsens, shortness of breath, feeling tired, and swelling of the legs may occur, due to the onset of heart failure. ...
(impairment of the heart's ability to pump), trauma/injury of the heart, drug or poison toxicity. Common signs include tachycardia, distant pulses, and worsening with giving fluids.


Obstructive shock

Obstructive shock Obstructive shock is one of the four types of shock, caused by a physical obstruction in the flow of blood. Obstruction can occur at the level of the great vessels or the heart itself. Causes include pulmonary embolism, cardiac tamponade, and te ...
is caused by disrupted flow of blood to the heart or flow of blood out of the heart. Common causes include
tension pneumothorax A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve i ...
,
cardiac tamponade Cardiac tamponade, also known as pericardial tamponade (), is the buildup of fluid in the pericardium (the sac around the heart), resulting in compression of the heart. Onset may be rapid or gradual. Symptoms typically include those of obstructi ...
,
pulmonary embolism Pulmonary embolism (PE) is a blockage of an artery in the lungs by a substance that has moved from elsewhere in the body through the bloodstream ( embolism). Symptoms of a PE may include shortness of breath, chest pain particularly upon breathin ...
, and ductal dependent congenital heart defects (conditions that worsen when the
ductus arteriosus The ''ductus arteriosus'', also called the ''ductus Botalli'', named after the Italian physiologist Leonardo Botallo, is a blood vessel in the developing fetus connecting the trunk of the pulmonary artery to the proximal descending aorta. It a ...
closes after birth) (e.g.,
hypoplastic left heart syndrome Hypoplastic left heart syndrome (HLHS) is a rare congenital heart defect in which the left side of the heart is severely underdeveloped and incapable of supporting the systemic circulation. It is estimated to account for 2-3% of all congenital he ...
and
coarctation of the aorta Coarctation of the aorta (CoA or CoAo), also called aortic narrowing, is a congenital condition whereby the aorta is narrow, usually in the area where the ductus arteriosus (ligamentum arteriosum after regression) inserts. The word ''coarctation' ...
). *
Tension pneumothorax A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve i ...
: a build up of air in the pleural space of the lungs causing compression and collapse of the lung. Common signs include trauma to the chest, distended neck veins, tracheal deviation (away from side of injury), and decreased breath sounds on side of injury. *
Cardiac tamponade Cardiac tamponade, also known as pericardial tamponade (), is the buildup of fluid in the pericardium (the sac around the heart), resulting in compression of the heart. Onset may be rapid or gradual. Symptoms typically include those of obstructi ...
: a build up of fluid or blood in the space surrounding the heart (
pericardium The pericardium, also called pericardial sac, is a double-walled sac containing the heart and the roots of the great vessels. It has two layers, an outer layer made of strong connective tissue (fibrous pericardium), and an inner layer made ...
) causing compression of the heart. Common signs include muffled heart sounds and
pulsus paradoxus Pulsus paradoxus, also paradoxic pulse or paradoxical pulse, is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg. When the drop i ...
. *
Pulmonary embolism Pulmonary embolism (PE) is a blockage of an artery in the lungs by a substance that has moved from elsewhere in the body through the bloodstream ( embolism). Symptoms of a PE may include shortness of breath, chest pain particularly upon breathin ...
: obstruction of a
pulmonary artery A pulmonary artery is an artery in the pulmonary circulation that carries deoxygenated blood from the right side of the heart to the lungs. The largest pulmonary artery is the ''main pulmonary artery'' or ''pulmonary trunk'' from the heart, and ...
or a branch of the pulmonary arteries most commonly by a clot causing blocked flow of blood out of or back into the heart. Children with predispositions to forming clots such as those with
sickle cell disease Sickle cell disease (SCD) is a group of blood disorders typically inherited from a person's parents. The most common type is known as sickle cell anaemia. It results in an abnormality in the oxygen-carrying protein haemoglobin found in red b ...
, cancer, coagulation disorders, and
central venous catheter A central venous catheter (CVC), also known as a central line(c-line), central venous line, or central venous access catheter, is a catheter placed into a large vein. It is a form of venous access. Placement of larger catheters in more centr ...
s are more likely to have pulmonary emboli. Common signs include worsening heart and lung function as evidenced by chest pain,
tachycardia Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. Heart rates above the resting rate may be normal ( ...
,
shortness of breath Shortness of breath (SOB), also medically known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing di ...
,
heart failure Heart failure (HF), also known as congestive heart failure (CHF), is a syndrome, a group of signs and symptoms caused by an impairment of the heart's blood pumping function. Symptoms typically include shortness of breath, excessive fatigue, ...
, and more.


Management

Management of shock should be based on the type of shock. When the type of shock hasn't been identified yet, the provider should start with some initial treatments and labs. All children with suspected shock should receive supplemental
oxygen Oxygen is the chemical element with the symbol O and atomic number 8. It is a member of the chalcogen group in the periodic table, a highly reactive nonmetal, and an oxidizing agent that readily forms oxides with most elements ...
, ventilation if in respiratory distress (via nasal canula, high flow nasal canula, noninvasive ventilation, or
mechanical ventilation Mechanical ventilation, assisted ventilation or intermittent mandatory ventilation (IMV), is the medical term for using a machine called a ventilator to fully or partially provide artificial ventilation. Mechanical ventilation helps move a ...
), and treatment for life-threatening conditions. Providers should establish vascular access (
intravenous Intravenous therapy (abbreviated as IV therapy) is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutrie ...
access
IVs Intravenous therapy (abbreviated as IV therapy) is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutrie ...
with a large caliber needle] and if that isn't possible, Intraosseous infusion, intraosseous access (IO) or Central venous catheter, central venous line). Providers should also obtain initial lab studies including a Blood sugar level, rapid blood glucose, basic metabolic panel (BMP) (measures serum
electrolyte An electrolyte is a medium containing ions that is electrically conducting through the movement of those ions, but not conducting electrons. This includes most soluble salts, acids, and bases dissolved in a polar solvent, such as water. Upon ...
s,
blood urea nitrogen Blood urea nitrogen (BUN) is a medical test that measures the amount of urea nitrogen found in blood. The liver produces urea in the urea cycle as a waste product of the digestion of protein. Normal human adult blood should contain 6 to 20 mg/dL ...
, and
creatinine Creatinine (; ) is a breakdown product of creatine phosphate from muscle and protein metabolism. It is released at a constant rate by the body (depending on muscle mass). Biological relevance Serum creatinine (a blood measurement) is an importa ...
),
lactic acid Lactic acid is an organic acid. It has a molecular formula . It is white in the solid state and it is miscible with water. When in the dissolved state, it forms a colorless solution. Production includes both artificial synthesis as well as nat ...
level,
complete blood count A complete blood count (CBC), also known as a full blood count (FBC), is a set of medical laboratory tests that provide information about the cells in a person's blood. The CBC indicates the counts of white blood cells, red blood cells and ...
(CBC), and urine dipstick.


Fluids

The provider should start
crystalloid fluids Fluid replacement or fluid resuscitation is the medical practice of replenishing bodily fluid lost through sweating, bleeding, fluid shifts or other pathologic processes. Fluids can be replaced with oral rehydration therapy (drinking), intravenous ...
(
normal saline Saline (also known as saline solution) is a mixture of sodium chloride (salt) and water. It has a number of uses in medicine including cleaning wounds, removal and storage of contact lenses, and help with dry eyes. By injection into a vein ...
or lactated Ringers). For compensated shock give 10-20 ml/kg over 5-20 min and for hypotensive shock, give 20 ml/lg over 5-10 min. However, if there are signs that the patient has too much fluid (fluid overload) such as worsening respiratory distress,
jugular venous distention The jugular venous pressure (JVP, sometimes referred to as ''jugular venous pulse'') is the indirectly observed pressure over the venous system via visualization of the internal jugular vein. It can be useful in the differentiation of different for ...
,
crackles Crackles are the clicking, rattling, or crackling noises that may be made by one or both lungs of a human with a respiratory disease during inhalation. They are usually heard only with a stethoscope ("on auscultation"). Pulmonary crackles are a ...
,
hepatomegaly Hepatomegaly is the condition of having an enlarged liver. It is a non-specific medical sign having many causes, which can broadly be broken down into infection, hepatic tumours, or metabolic disorder. Often, hepatomegaly will present as an abdo ...
, then fluids should not be given. With continued signs of shock and no signs of fluid overload, kids can continue to receive 10-20 ml/kg of fluids with a max of 60 ml/kg in the first hour. However, if cardiogenic shock is suspected, kids should receive less fluids over a longer time (e.g., 5-10 ml/kg over 15-30 min).


Hypovolemic shock

Hypovolemic shock is mainly treated with fluid replacement, as described in the fluids section above. If the hypovolemic shock is caused by a hemorrhage, then the provider should obtain
blood type A blood type (also known as a blood group) is a classification of blood, based on the presence and absence of antibodies and inherited antigenic substances on the surface of red blood cells (RBCs). These antigens may be proteins, carbohydrates ...
, blood cross match, and coagulation studies ( PT, INR, PTT). In hemorrhagic shock, patients should receive blood or blood products if they aren't improving with fluids.


Distributive shock

Distributive shock is mainly treated with fluid replacement, as described in the fluids section above, and
vasopressors An antihypotensive agent, also known as a vasopressor agent or simply vasopressor, or pressor, is any substance, whether endogenous or a medication, that tends to raise low blood pressure. Some antihypotensive drugs act as vasoconstrictors to in ...
. For those with suspected septic shock, providers should obtain
blood culture A blood culture is a medical laboratory test used to detect bacteria or fungi in a person's blood. Under normal conditions, the blood does not contain microorganisms: their presence can indicate a bloodstream infection such as bacteremia ...
,
urinalysis Urinalysis, a portmanteau of the words ''urine'' and ''analysis'', is a panel of medical tests that includes physical (macroscopic) examination of the urine, chemical evaluation using urine test strips, and microscopic examination. Macroscopic e ...
,
urine culture Bacteriuria is the presence of bacteria in urine. Bacteriuria accompanied by symptoms is a urinary tract infection while that without is known as asymptomatic bacteriuria. Diagnosis is by urinalysis or urine culture. ''Escherichia coli'' is the ...
, c-reactive protein (CRP) (marker of inflammation),
procalcitonin Procalcitonin (PCT) is a peptide precursor of the hormone calcitonin, the latter being involved with calcium homeostasis. It arises once preprocalcitonin is cleaved by endopeptidase. It was first identified by Leonard J. Deftos and Bernard A. Ro ...
(marker of inflammation),
fibrinogen Fibrinogen (factor I) is a glycoprotein complex, produced in the liver, that circulates in the blood of all vertebrates. During tissue and vascular injury, it is converted enzymatically by thrombin to fibrin and then to a fibrin-based blood cl ...
,
D-dimer D-dimer (or D dimer) is a fibrin degradation product (or FDP), a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis. It is so named because it contains two D fragments of the fibrin protein joined by a cros ...
,
bilirubin Bilirubin (BR) ( Latin for "red bile") is a red-orange compound that occurs in the normal catabolic pathway that breaks down heme in vertebrates. This catabolism is a necessary process in the body's clearance of waste products that arise from t ...
labs, and more. Those in anaphylactic shock should be treated with intramuscular epinephrine.


Cardiogenic shock

Cardiogenic shock typically worsens with fluids. Providers should obtain an ECG and
echocardiogram An echocardiography, echocardiogram, cardiac echo or simply an echo, is an ultrasound of the heart. It is a type of medical imaging of the heart, using standard ultrasound or Doppler ultrasound. Echocardiography has become routinely used in th ...
for patients suspected to have cardiogenic shock. Treatment can include
vasopressors An antihypotensive agent, also known as a vasopressor agent or simply vasopressor, or pressor, is any substance, whether endogenous or a medication, that tends to raise low blood pressure. Some antihypotensive drugs act as vasoconstrictors to in ...
, inotropes, and treatment of any
arrhythmia Arrhythmias, also known as cardiac arrhythmias, heart arrhythmias, or dysrhythmias, are irregularities in the heartbeat, including when it is too fast or too slow. A resting heart rate that is too fast – above 100 beats per minute in adult ...
s.


Obstructive shock

Obstructive shock is treated by treating the underlying cause of the shock. Tension pneumothorax is treated with a
chest tube A chest tube (also chest drain, thoracic catheter, tube thoracostomy or intercostal drain) is a surgical drain that is inserted through the chest wall and into the pleural space or the mediastinum in order to remove clinically undesired substance ...
and needle thoracostomy which allows the air to get out of the pleural space. Cardiac tamponade is treated with
pericardiocentesis Pericardiocentesis (PCC), also called pericardial tap, is a medical procedure where fluid is aspirated from the pericardium (the sac enveloping the heart). Anatomy and Physiology The pericardium is a fibrous sac surrounding the heart composed o ...
which removes the fluid from the pericardium and decompresses the heart. Pulmonary embolism is treated with
anticoagulant Anticoagulants, commonly known as blood thinners, are chemical substances that prevent or reduce coagulation of blood, prolonging the clotting time. Some of them occur naturally in blood-eating animals such as leeches and mosquitoes, where t ...
s (prevent body from making more clots) and if bad enough,
thrombectomy Mechanical thrombectomy, or simply thrombectomy, is the interventional procedure of removing a blood clot (thrombus) from a blood vessel. It is commonly performed in the cerebral arteries (interventional neuroradiology). The effectiveness of throm ...
(surgical removal of clots). Ductal dependent congenital heart defects are treated with
prostaglandin E1 Prostaglandin E1 (PGE1), also known as alprostadil, is a naturally occurring prostaglandin which is used as a medication. In infants with congenital heart defects, it is delivered by intravenous infusion, slow injection into a vein to open the d ...
/ alprostadil which keeps the
ductus arteriosus The ''ductus arteriosus'', also called the ''ductus Botalli'', named after the Italian physiologist Leonardo Botallo, is a blood vessel in the developing fetus connecting the trunk of the pulmonary artery to the proximal descending aorta. It a ...
open.


Cardiac Arrest

Cardiac arrest Cardiac arrest is when the heart suddenly and unexpectedly stops beating. It is a medical emergency that, without immediate medical intervention, will result in sudden cardiac death within minutes. Cardiopulmonary resuscitation (CPR) and possi ...
occurs when the heart stops working and blood stops moving throughout the body. In infants and children, cardiac arrest is typically caused by (1) hypoxic/asphyxial arrest and less commonly by (2) sudden cardiac arrest due to heart problems or arrhythmias. In adults, cardiac arrest is usually caused by heart problems such as
acute coronary syndrome Acute coronary syndrome (ACS) is a syndrome (a set of signs and symptoms) due to decreased blood flow in the coronary arteries such that part of the heart muscle is unable to function properly or dies. The most common symptom is centrally l ...
. Hypoxic/asphyxial cardiac arrest is a result of progressive respiratory failure and/or shock. For this reason, it is important to treat respiratory failure and shock early so that they don't progress to cardiac arrest. Sudden cardiac arrest is typically caused by arrhythmias such ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT). These arrhythmias are more common in kids with
hypertrophic cardiomyopathy Hypertrophic cardiomyopathy (HCM, or HOCM when obstructive) is a condition in which the heart becomes thickened without an obvious cause. The parts of the heart most commonly affected are the interventricular septum and the ventricles. This r ...
, cardiac
channelopathies Channelopathies are a group of diseases caused by the dysfunction of ion channel subunits or their interacting proteins. These diseases can be inherited or acquired by other disorders, drugs, or toxins. Mutations in genes encoding ion channels, wh ...
(e.g.,
long QT syndrome Long QT syndrome (LQTS) is a condition affecting repolarization (relaxing) of the heart after a heartbeat, giving rise to an abnormally lengthy QT interval. It results in an increased risk of an irregular heartbeat which can result in fainting, ...
),
myocarditis Myocarditis, also known as inflammatory cardiomyopathy, is an acquired cardiomyopathy due to inflammation of the heart muscle. Symptoms can include shortness of breath, chest pain, decreased ability to exercise, and an irregular heartbeat. Th ...
, drugs (e.g.,
cocaine Cocaine (from , from , ultimately from Quechua: ''kúka'') is a central nervous system (CNS) stimulant mainly used recreationally for its euphoric effects. It is primarily obtained from the leaves of two Coca species native to South Am ...
,
digoxin Digoxin (better known as Digitalis), sold under the brand name Lanoxin among others, is a medication used to treat various heart conditions. Most frequently it is used for atrial fibrillation, atrial flutter, and heart failure. Digoxin is o ...
),
commotio cordis Commotio cordis (Latin, "agitation of the heart") is an often lethal disruption of heart rhythm that occurs as a result of a blow to the area directly over the heart (the precordial region) at a critical time during the cycle of a heart beat, pro ...
, and anomalous coronary artery. There are many causes of reversible cardiac arrest and the mnemonic "H's and T's" is used to remember these causes.


Recognition

Signs of cardiac arrest include no pulse (within 10 seconds), no breathing or only gasping, and unresponsiveness. As mentioned above, cardiac arrest in kids is mainly a result of respiratory failure and shock, so providers need to treat those conditions quickly and be on the look out for signs of cardiac arrest. Because cardiac arrest can also be caused by arrhythmias, providers should get ECGs of these patients. The 4 main cardiac arrest rhythms are ventricular fibrillation (VF), pulseless
ventricular tachycardia Ventricular tachycardia (V-tach or VT) is a fast heart rate arising from the lower chambers of the heart. Although a few seconds of VT may not result in permanent problems, longer periods are dangerous; and multiple episodes over a short period ...
(pVT),
asystole Asystole (New Latin, from Greek privative a "not, without" + ''systolē'' "contraction") is the absence of ventricular contractions in the context of a lethal heart arrhythmia (in contrast to an induced asystole on a cooled patient on a heart-lu ...
, and pulseless electrical activity (PEA). * ventricular fibrillation (VF): disorganized and rapid quivering of the ventricles * pulseless
ventricular tachycardia Ventricular tachycardia (V-tach or VT) is a fast heart rate arising from the lower chambers of the heart. Although a few seconds of VT may not result in permanent problems, longer periods are dangerous; and multiple episodes over a short period ...
(pVT): organized wide
QRS complex The QRS complex is the combination of three of the graphical deflections seen on a typical electrocardiogram (ECG or EKG). It is usually the central and most visually obvious part of the tracing. It corresponds to the depolarization of the ri ...
es with no pulse *
asystole Asystole (New Latin, from Greek privative a "not, without" + ''systolē'' "contraction") is the absence of ventricular contractions in the context of a lethal heart arrhythmia (in contrast to an induced asystole on a cooled patient on a heart-lu ...
: no cardiac electrical activity, ECG shows a flat line * pulseless electrical activity (PEA): no pulses but ECG shows organized electrical activity (not VF or asystole); not a specific rhythm


Management

Treatment of pediatric cardiac arrest follows the American Heart Association's (AHA) Pediatric Cardiac Arrest Algorithm. The goals of treatment are to obtain return of spontaneous circulation (ROSC), meaning that the heart starts working on its own. Once cardiac arrest is recognized, high quality
CPR Cardiopulmonary resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spont ...
needs to be started immediately. After starting chest compressions, the provider should (1) give ventilations (via
bag mask A bag valve mask (BVM), sometimes known by the proprietary name Ambu bag or generically as a manual resuscitator or "self-inflating bag", is a hand-held device commonly used to provide Modes of mechanical ventilation, positive pressure ventilation ...
) and oxygen, (2) attach monitor/
defibrillator Defibrillation is a treatment for life-threatening cardiac arrhythmias, specifically ventricular fibrillation (V-Fib) and non-perfusing ventricular tachycardia (V-Tach). A defibrillator delivers a dose of electric current (often called a ''coun ...
pads or ECG
electrode An electrode is an electrical conductor used to make contact with a nonmetallic part of a circuit (e.g. a semiconductor, an electrolyte, a vacuum or air). Electrodes are essential parts of batteries that can consist of a variety of materials ...
s to the child so that defibrillations (aka shocks) can be given if needed, and (3) establish vascular access (IV, IO). Attaching the defibrillator and establishing vascular access should NOT interrupt chest compressions. Once the monitor/defibrillator is connected, the provider should assess the heart rhythm. Of the 4 cardiac arrest rhythms, VF and pVT are shockable rhythms and
asystole Asystole (New Latin, from Greek privative a "not, without" + ''systolē'' "contraction") is the absence of ventricular contractions in the context of a lethal heart arrhythmia (in contrast to an induced asystole on a cooled patient on a heart-lu ...
and
PEA The pea is most commonly the small spherical seed or the seed-pod of the flowering plant species ''Pisum sativum''. Each pod contains several peas, which can be green or yellow. Botanically, pea pods are fruit, since they contain seeds and d ...
are unshockable rhythms. Shockable rhythms are rhythms that can improve with a shock and thus, should receive a shock. Unshockable rhythms are rhythms that won't improve with a shock and thus, should NOT receive a shock. The monitor/defibrillator will either tell the providers if the rhythm is shockable ( automated external defibrillators (AED)) or the providers will be able to read the ECG and determine for themselves if the rhythm is shockable (manual defibrillators). If shockable, give a shock then resume CPR. If not shockable, continue CPR, give epinephrine, and consider an advanced airway. After every 2 minutes of giving CPR the provider should reassess the patient's heart rhythm to see if it is shockable or unshockable, and give a shock if it is shockable. This 2 minute cycle of CPR and rhythm assessment should continue until it is determined by the providers that further management is unlikely to save the patient. For patients with shockable rhythms who haven't achieved ROSC, providers can give epinephrine after 2 shocks and amiodarone or lidocaine after 3 shocks. Throughout CPR and rhythm assessments, the providers should be treating any suspected reversible causes of cardiac arrest (H's and T's listed above). Defibrillations/shocks * first shock should be 2 J/kg * second shock should be 4 J/kg * all other shocks should be ≥ 4 J/kg with max of 10 J/kg Medicines that can be given during treatment of cardiac arrest are listed below. The doses listed below are for IV/IO medicationa. Medications via endotracheal tube (ET) are often given at higher doses. *
epinephrine Adrenaline, also known as epinephrine, is a hormone and medication which is involved in regulating visceral functions (e.g., respiration). It appears as a white microcrystalline granule. Adrenaline is normally produced by the adrenal glands and ...
: 0.01 mg/kg every 3–5 minutes with max single dose of 1 mg *
amiodarone Amiodarone is an antiarrhythmic medication used to treat and prevent a number of types of cardiac dysrhythmias. This includes ventricular tachycardia (VT), ventricular fibrillation (VF), and wide complex tachycardia, as well as atrial fibril ...
: 5 mg/kg initially, can repeat 2 more times (total of 3 doses), max of 300 mg per dose, max 15 mg/kg, given for refractory VF and pVT *
lidocaine Lidocaine, also known as lignocaine and sold under the brand name Xylocaine among others, is a local anesthetic of the amino amide type. It is also used to treat ventricular tachycardia. When used for local anaesthesia or in nerve blocks, lid ...
: 1 mg/kg initially with continuous infusion of 20-50 mcg/kg/min after, given for refractory VF and pVT *
magnesium sulfate Magnesium sulfate or magnesium sulphate (in English-speaking countries other than the US) is a chemical compound, a salt with the formula , consisting of magnesium cations (20.19% by mass) and sulfate anions . It is a white crystalline solid, ...
: 25–50 mg/kg diluted in 10 ml D5W (5% dextrose) and infused over 1–2 minutes, max 2g per dose, given for pulseless
torsades de pointes ''Torsades de pointes, torsade de pointes'' or ''torsades des pointes'' (TdP) (, , translated as "twisting of peaks") is a specific type of abnormal heart rhythm that can lead to sudden cardiac death. It is a polymorphic ventricular tachycardia t ...
(a type of ventricular tachycardia)


Arrhythmias

PALS providers should be able to identify and treat different types of abnormal pediatric heart rhythms including bradyarrhythmias, tachyarrhythmias, and cardiac arrest rhythms (discussed above). In defining heart rates that are too slow or too fast, it is important to understand the ranges of pediatric heart rates by age. Normal ranges of pediatric heart rates change with age, with heart rates being faster closer to birth and slower closer to adulthood.


Bradyarrythmias

Bradycardia Bradycardia (also sinus bradycardia) is a slow resting heart rate, commonly under 60 beats per minute (BPM) as determined by an electrocardiogram. It is considered to be a normal heart rate during sleep, in young and healthy or elderly adults, ...
is defined as a slow heart rate for a child's age. Bradycardia associated with signs of shock (altered mental status, hypotension, etc.) can be an early warning sign for cardiac arrest. Signs of bradycardia include fatigue, confusion, dizziness, and lightheadedness. Possible causes of bradycardia include hypoxia,
hypothermia Hypothermia is defined as a body core temperature below in humans. Symptoms depend on the temperature. In mild hypothermia, there is shivering and mental confusion. In moderate hypothermia, shivering stops and confusion increases. In severe ...
, and certain medications. Types of bradyarrhythmias *
sinus bradycardia Sinus bradycardia is a sinus node dysfunction giving a heart rate that is lower than the normal 60–100 beats per minute (bpm) in humans. Bradycardia is generally defined to be a heart rate of under 60 bpm. Signs and symptoms The decreased hea ...
: normal rhythm, slow rate * atrioventricular block ** first degree: prolonged PR interval (> 0.20 seconds) ** second degree *** mobitz type I (wenckebach): progressive lengthening of PR interval then dropped beat (p wave with no QRS) *** mobitz type II: equal PR intervals with intermittent dropped beats (p wave with no QRS) **
third degree ''Third Degree'' is a 1986 album by Johnny Winter and the final one of the trilogy he made for Alligator Records. For the occasion Winter temporarily reunited with Tommy Shannon and Uncle Red Turner, who were the rhythm section on his first thre ...
: complete dissociation between
p wave A P wave (primary wave or pressure wave) is one of the two main types of elastic body waves, called seismic waves in seismology. P waves travel faster than other seismic waves and hence are the first signal from an earthquake to arrive at any ...
and
QRS complex The QRS complex is the combination of three of the graphical deflections seen on a typical electrocardiogram (ECG or EKG). It is usually the central and most visually obvious part of the tracing. It corresponds to the depolarization of the ri ...
, atria and ventricles are beating independent of one another


Management

Providers should follow the AHA's Pediatric Bradycardia With a Pulse Algorithm. As always, provides need to support airway, breathing, and circulation and begin CPR if needed. Bradyarrythmias with signs of shock can be treated with epinephrine and atropine in order to increase heart rate. If medications aren't helping, providers can consider cardiac pacing. * epinephrine: 0.01 mg/kg every 3–5 minutes *
atropine Atropine is a tropane alkaloid and anticholinergic medication used to treat certain types of nerve agent and pesticide poisonings as well as some types of slow heart rate, and to decrease saliva production during surgery. It is typically given ...
: 0.02 mg/kg, can repeat one time, max dose 0.5 mg, min dose of 0.1 mg


Tachyarrhythmias

Tachycardia Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. Heart rates above the resting rate may be normal ( ...
is defined as a fast heart rate for a child's age. Signs of tachycardia are similar to bradycardia but also include palpitations, decreased feeding/eating, and irritability. Tachyarrhythmias are fast abnormal heart rhythms. Types of tachyarrhythmias * sinus tachycardia: normal rhythm (normal p waves), fast rate, heart rate usually < 220 bpm (beats per minute) in infants and < 180 bpm in kids * supraventricular tachycardia (SVT): abnormal rhythm (abnormal p waves), fast rate, originates above the ventricles, heart rate usually > 220 bpm in infants and > 180 bpm in kids, narrow QRS (< 0.09 seconds) * ventricular tachycardia (VT): fast rate, originates in the ventricles, wide QRS (> 0.09 seconds)


Management

Providers should follow the AHA's Pediatric Tachycardia With a Pulse Algorithm. As always, provides need to support airway, breathing, and circulation and begin CPR if needed. Management of tachyarrhythmias depends on if the child is stable or unstable (experiencing cardiopulmonary compromise: signs of shock, hypotension, altered mental status). Unstable tachyarrhythmia is treated with synchronized cardioversion - initially 0.5-1 J/kg but can increase to 2 J/kg if smaller dose is not working. Stable tachyarrhythmia treatment is subcategorized based on narrow QRS vs. wide QRS. If narrow QRS/ SVT, perform
vagal maneuver A vagal maneuver is an action used to stimulate the parasympathetic nervous system by activating the vagus nerve. The vagus nerve is the longest nerve of the autonomic nervous system and helps regulate many critical aspects of human physiology, i ...
s and give
adenosine Adenosine (symbol A) is an organic compound that occurs widely in nature in the form of diverse derivatives. The molecule consists of an adenine attached to a ribose via a β-N9- glycosidic bond. Adenosine is one of the four nucleoside building ...
. If wide QRS/ VT with regular rhythm and monomorphic QRS, the provider can give adenosine and should consult pediatric
cardiology Cardiology () is a branch of medicine that deals with disorders of the heart and the cardiovascular system. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular h ...
for recommendations. *
adenosine Adenosine (symbol A) is an organic compound that occurs widely in nature in the form of diverse derivatives. The molecule consists of an adenine attached to a ribose via a β-N9- glycosidic bond. Adenosine is one of the four nucleoside building ...
: first dose 0.1 mg/kg with max 6 mg, second dose 0.2 mg/kg with max 12 mg


Criticism

PETA Peta or PETA may refer to: Acronym * Pembela Tanah Air, a militia established by the occupying Japanese in Indonesia in 1943 * People for the Ethical Treatment of Animals, an American animal rights organization * People Eating Tasty Animals, a ...
has criticized the use of animals in PALS training which the organization calls "cruel and unnecessary". PETA says that hundreds of PALS training centers have begun using simulators in response to concerns regarding the animals' welfare. The American Heart Association neither endorses nor requires the use of animals in intubation training. =See also= * Advanced Pediatric Life Support (APLS) *
Advanced Cardiac Life Support Advanced cardiac life support, advanced cardiovascular life support (ACLS) refers to a set of clinical guidelines for the urgent and emergent treatment of life-threatening cardiovascular conditions that will cause or have caused cardiac arrest, ...
(ACLS) *
Neonatal Resuscitation Program The Neonatal Resuscitation Program is an educational program in neonatal resuscitation that was developed and is maintained by the American Academy of Pediatrics. This program focuses on basic resuscitation skills for newly born infants. With the ...
(NRP) =References= =External links=
American Heart Association

Pediatric Advanced Life Support Course -- PALS
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