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Medications
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PALS Algorithms
Pulseless Arrest — VF / pVT
1
Start CPR + attach monitor/defibrillator
100–120 compressions/min, ≥ 1/3 AP chest depth. Minimize interruptions. Give oxygen. Establish IV/IO access.
0:00
2
Rhythm check → Shockable (VF/pVT)
Defibrillate: 2 J/kg. Resume CPR immediately for 2 minutes.
2 min
3
Rhythm check → still shockable
Defibrillate: 4 J/kg. Resume CPR. Give epinephrine: 0.01 mg/kg IV/IO (0.1 mL/kg of 1:10,000). Repeat every 3–5 min.
4 min
4
Rhythm check → still shockable
Defibrillate: 4–10 J/kg (max 10 J/kg or adult dose). Give amiodarone 5 mg/kg IV/IO (max 300 mg) OR lidocaine 1 mg/kg IV/IO. Treat reversible causes.
6 min
5
Continue 2-min CPR cycles
Rhythm check every 2 min. Epinephrine every 3–5 min. Amiodarone may repeat ×2 (total 3 doses). Consider advanced airway. Treat H's and T's.
Ongoing
6
ROSC achieved → Post-arrest care
See Post-ROSC algorithm.
If ROSC
H's
Hypoxia — ensure adequate oxygenation
Hypovolemia — fluid bolus, consider hemorrhage
Hypo/Hyperkalemia — check electrolytes, ECG
Hypothermia — warm the patient
H⁺ (Acidosis) — consider bicarb if severe
T's
Tension pneumothorax — needle decompression
Tamponade — pericardiocentesis
Toxins — antidote, poison control
Thrombosis (PE) — thrombolytics
Thrombosis (coronary) — cath lab
Pulseless Arrest — PEA / Asystole
1
Start CPR + establish IV/IO
100–120 compressions/min. Minimize interruptions. Give oxygen. Confirm rhythm in ≥2 leads — asystole or PEA (organized rhythm, no pulse).
0:00
2
Epinephrine ASAP
0.01 mg/kg IV/IO (0.1 mL/kg of 1:10,000). Repeat every 3–5 minutes. Max single dose 1 mg.
ASAP
3
Rhythm check every 2 minutes
If shockable → switch to VF/pVT algorithm. If non-shockable → continue CPR. Consider advanced airway (avoid hyperventilation: 1 breath/6 sec with advanced airway).
Every 2 min
4
Treat reversible causes aggressively
PEA is usually caused by a reversible H or T. Identify and treat simultaneously with CPR.
Ongoing
5
ROSC achieved → Post-arrest care
See Post-ROSC algorithm.
If ROSC
H's
Hypoxia — ensure adequate oxygenation
Hypovolemia — fluid bolus, consider hemorrhage
Hypo/Hyperkalemia — check electrolytes, ECG
Hypothermia — warm the patient
H⁺ (Acidosis) — consider bicarb if severe
T's
Tension pneumothorax — needle decompression
Tamponade — pericardiocentesis
Toxins — antidote, poison control
Thrombosis (PE) — thrombolytics
Thrombosis (coronary) — cath lab
Bradycardia with Pulse
1
Assess for cardiopulmonary compromise
Signs of compromise: hypotension, acutely altered mental status, signs of shock, ischemic chest discomfort, acute heart failure.
Immediate
2
No compromise → observe and support
Support ABCs. Oxygen. IV access. 12-lead ECG. Identify and treat underlying cause. Expert consultation.
If stable
3
Compromise present → CPR if HR < 60 with poor perfusion
Start CPR if HR < 60/min with signs of poor perfusion despite oxygenation and ventilation.
If HR <60
4
Epinephrine
0.01 mg/kg IV/IO (max 1 mg). Repeat every 3–5 min. If epinephrine unavailable: atropine 0.02 mg/kg IV/IO (min 0.1 mg, max 0.5 mg) for vagally-mediated bradycardia.
With CPR
5
Consider cardiac pacing
Transcutaneous pacing for complete heart block or sinus node dysfunction unresponsive to medications.
If refractory
6
Treat underlying cause
Common causes: hypoxia (most common in children), vagal stimulation, heart block, drug toxicity (beta-blocker, CCB, digoxin), hypothermia, electrolyte disturbance.
P waves present, HR varies. Treat fever, pain, hypovolemia, anxiety. Do not attempt to cardiovert sinus tachycardia.
If sinus
3
SVT, stable → vagal maneuvers first
Ice to face (infant), Valsalva, carotid sinus massage (older child). If ineffective → adenosine.
If SVT, stable
4
Adenosine
First dose: 0.1 mg/kg rapid IV push (max 6 mg), fast flush. Second dose: 0.2 mg/kg (max 12 mg). Use proximal IV or central line; peripheral antecubital preferred over hand.
If SVT persists
5
SVT, unstable → synchronized cardioversion
0.5–1 J/kg. If ineffective: 2 J/kg. Sedate if possible (ketamine or midazolam). Do NOT delay cardioversion if severely compromised.
If unstable
6
Refractory SVT → expert consultation
Consider amiodarone 5 mg/kg IV over 20–60 min (not rapid bolus) or procainamide 15 mg/kg IV over 30–60 min. Do not use amiodarone + procainamide together.
If refractory
Tachycardia with Pulse — Wide QRS (≥ 0.09 sec)
1
Assume VT until proven otherwise
Wide QRS tachycardia in a child = VT until proven otherwise. Obtain 12-lead. Assess hemodynamic stability immediately.
Immediate
2
Unstable → synchronized cardioversion
0.5–1 J/kg, increase to 2 J/kg if ineffective. Sedate if time permits. Call for expert help.
If unstable
3
Stable → expert consultation + antiarrhythmic
Amiodarone 5 mg/kg IV over 20–60 min (max 300 mg). OR procainamide 15 mg/kg IV over 30–60 min. Do not use both. 12-lead ECG, continuous monitoring.
If stable
4
Consider reversible causes
Electrolyte disturbance (hypokalemia, hypomagnesemia), drug toxicity (TCA, digoxin), long QT syndrome, structural heart disease, myocarditis.
Ongoing
5
Torsades de Pointes (polymorphic VT with long QT)
Magnesium sulfate 25–50 mg/kg IV (max 2 g) over 10–20 min. Rapid push for pulseless Torsades. Avoid QT-prolonging drugs.
If Torsades
Post-ROSC Care
1
Airway and breathing
Advanced airway if not already placed. Avoid hyperventilation: target PaCO₂ 35–45 mmHg (or per team goal). SpO₂ 94–99% — avoid hyperoxia. Obtain CXR to confirm ETT position.
Immediate
2
Hemodynamic optimization
Target age-appropriate SBP (≥ 5th percentile). Fluid bolus 10–20 mL/kg for hypotension. Vasoactive infusion if fluid-refractory: epinephrine or norepinephrine. Avoid hypotension.
Immediate
3
Targeted Temperature Management (TTM)
For comatose survivors: TTM 32–36°C for 48h, then controlled rewarming. Avoid fever (> 37.5°C) for at least 72h. Continuous EEG monitoring.
First hours
4
Identify and treat the cause
12-lead ECG (look for STEMI, long QT, Brugada). Labs: glucose, electrolytes, lactate, troponin, ABG. Echo. Consider toxicology screen. CT head if traumatic arrest or concern for CNS event.
First hours
5
Glucose control
Treat hypoglycemia immediately. Avoid hyperglycemia (>180 mg/dL). Monitor glucose every 1–2h in first 24h.
Ongoing
6
Neuroprognostication
Do not prognosticate in first 72h (or 72h after rewarming if TTM used). EEG, SSEP, MRI brain. Serial neurological exams. Involve neurology and palliative care early.