Mastering the PALS Algorithm: A Quick Reference Cheat Sheet

Pediatric Advanced Life Support (PALS) is one of the most important life-saving strategies rescuers of all types should know. It allows for very specific and guided steps to address the life-threatening and emergent situations that can happen to children. Knowing the PALS algorithm for your situation enables a rescuer to use every second of their time to support that patient’s needs.

Nurses, doctors, EMS professionals, and anyone who needs to know how to handle a life-threatening situation with children should consider PALS Certification. The certification process will provide you with exceptional insight and guided demonstrations on when, how, and what to do in the event of a pediatric emergency situation.

One of the most important factors to know is that the PALS algorithm changes depending on the circumstances. By understanding the PALS algorithm thoroughly, you develop the necessary skills to act fast when seconds matter the most. You will find several specific types of PALS algorithms used today, including those for very specific conditions. While ideally, professionals will know all of these algorithms, some of the most important to study include the following:

• Pediatric post-resuscitation care
• Pediatric cardiac arrest
• Pediatric tachycardia
• Pediatric bradycardia
• Pediatric BLS (Basic Life Support)

Within each of those links is the specific algorithm associated with each situation. The algorithm spells out exactly what steps to take to know exactly what you need to do to preserve a child’s life. It is nearly always wise to download and maintain copies of these PALS algorithm sheets, especially if you are a professional.

What is a PALS Algorithm?

The PALS algorithm is a systemic approach to providing pediatric life support. Utilizing this approach, a rescuer will follow one step after the next to evaluate a patient and then manage their specific needs based on what is most important to do.

Time matters when a patient’s life is at risk. Children are even more complicated than adults in that they cannot explain what is happening. When seconds matter so much, it is critical to have a step-by-step and reliable approach to follow to react quickly to the needs of your patient.

In short, the PALS algorithm cheat sheet – a list of easy-to-read and follow steps – makes diagnosing and providing life-sustaining care to a young patient easier and more methodical. Instead of having to think about what you are doing, you can just do it.

What Is the Pediatric Basic Life Support Algorithm?

One of the most important algorithms to understand is the PALS BLS algorithm. In nearly all situations, this is the basic, foundational level of taking action when a child is critically ill.  To help you see how an algorithm works, consider the following:

In this situation, the BLS algorithm follows this pattern:

• Evaluate the situation. If a patient is unresponsive and not breathing normally, follow the next step.
• Activate the emergency response system and get an AED or defibrillator.
• Assess pulse. At this point, if there is not a definite pulse felt within 10 seconds, you begin to do CPR at a rate of 15 compressions and then two breaths.
• If after assessing the pulse there is a definite pulse, you would administer one breath every three seconds, add compressions if the pulse remains under 60 per minute with poor perfusion despite adequate oxygenation and ventilation. It also requires assessing the pulse every two minutes.

If you did not find a pulse and you are providing CPR at a rate of 15 compressions and two breaths, you’ll follow these steps:

• AED and Defibrillator use
• Assess for a shockable rhythm
• If there is no shockable rhythm, resume CPR immediately for two minutes and continue this process every two minutes until more advanced help arrives.
• If there is a shockable rhythm, administer one shock and resume CRP immediately for two minutes. They continue the same process of accessing the pulse.

It is important to know that this PALS algorithm does not eliminate the need for proper training and education. Be sure to consider the importance of purchasing and completing a PALS Certification.

PALS Bradycardia Algorithm

Another PALS algorithm process focuses on situations in which a patient shows signs of pediatric bradycardia with a pulse and poor perfusion. In this situation, a healthcare provider will need to move through a series of steps to provide the critically ill patient with the right type of care and treatment.

First, you will need to identify and treat any underlying cause present. To do that:

• Maintain the airway and assist in breathing when it is necessary
• If hypoxemic, administer oxygen to the patient
• Use a cardiac monitor to identify the patient’s heart rhythm
• Monitor both oxygen and blood pressure
• IO/IV access installation
• Assess a 12-lead ECG

With this information, if you find that the patient has persistent bradyarrhythmia, determine what the causes are. This may include hypotension, acute altered mental status, and signs of shock. If the patient has any of these signs, move through the following steps:

If the heart rate is under 60 beats per minute with poor perfusion despite providing oxygenation and ventilation, perform CPR. If bradycardia continues, move on to the following treatment:

• Epinephrine administration
• Atropine for increased vagal tone or primary AV block
• Consider transthoracic pacing and transvenous pacing
• Treat the underlying cause
• If a pulseless arrest occurs, use the Pediatric Cardiac Arrest Algorithm

In all situations, if bradycardia does not continue to be obvious, it should still be monitored over time, and a specialist consultation should be considered.

PALS Cardiac Arrest Algorithm

The PALS cardiac arrest algorithm is one of the most important tools to utilize as a rescuer. Though it is more complex than other algorithms because numerous potential outcomes can occur, using a PALS algorithm cheat sheet for cardiac arrest allows you to easily see each of the steps to take to navigate the process.

Though reading this may be more confusing than using the cheat sheet, here is how an algorithm chart like this can help you if you are faced with a situation where a child exhibits a lack of proper heart rate.

Activate emergency response first.

Start CPR by providing oxygen and attaching a monitor and defibrillator to the patient.

Next, determine if there is a shockable rhythm present. Let’s say NO shockable rhythm was detected. Follow this algorithm:

• PEA/Asystole
• Provide CPR for two minutes.
• Provide IV/IO access
• Provide epinephrine every three to five minutes without stopping CPR
• Consider advanced airway needs.

At this point, if there is still no shockable rhythm, you will continue CPR for an additional two minutes and try to treat any reversible causes. If no shockable rhythm results:

• Administer a shock.
• Provide CPR for two minutes
• Provide epinephrine every 3 to 5 minutes
• Consider advanced airway and capnography

If no shockable rhythm exists after this, administer another shock. Then provide:

• CPR for two minutes
• Amiodarone for lidocaine
• Treat reversible causes

Now, let’s take a step back to the beginning. You activated emergency response, started CPR, provided oxygen, and attached a monitor and defibrillator. In this example, a shockable rhythm is determined. You would follow the next steps:

• VF / PVT
• Administer a shock
• Provide CPR for two minutes
• IV/IO access without interruption in CPR

Then, determine if there is a shockable rhythm. If not, follow the same steps as above:

• Administer shock
• Provide CPR for two minutes, epinephrine every 3 to 5 minutes, and consider advanced airway and capnography
• If there is still no shockable rhythm, provide amiodarone or lidocaine and treat reversible causes

As you can see from the PALS cardiac arrest algorithm, having a flow chart that outlines each step is critical.

CPR Quality Matters

Keep in mind that providing quality CPR is critical in a critically ill child. Yet, a study reported by a group of researchers from the Children’s National Health System found that improving the quality of CPR provided throughout any of these algorithms and treatment processes can significantly improve a patient’s ability to see improvement.

The algorithm provides you with specific steps to take to provide care, but you must meet the quality CPR requirements as well.

For the PALS algorithm related to cardiac arrest, consider the following elements of CPR quality:

• Rate of 100 to 120 compressions each minute
• Compression depth for children should be one-third diameter of the chest. That is about 1.5 inches in an infant and 2 inches in children.
• Minimize any interruptions to the process.
• Do not over-ventilate the patient.
• Rotate the compressor every two minutes.
• In situations where there is no advanced airway, one provider uses a 30:2 compression ventilation ratio, and two providers use a 15:2 compression ventilation ratio.
• If there is an advanced airway, 10 to 15 breaths per minute for one provider and 20 to 30 breaths per minute for two providers with continuous chest compressions.

The PALS algorithm also provides instructions on providing care in these situations. Take a look at the following details (besides the expected CPR quality) that should be provided.

Shock Energy

According to the PALS algorithm, use the following shock energy for a child:

• First shock: 2 J/kg
• Second shock: 4 J/kg
• Subsequent shocks: ≥ 4 J/kg
• Maximum dose of the shock: 10 J/kg or adult dose

Return of Spontaneous Circulation

This indicates that the pulse and blood pressure have returned. In this situation, spontaneous arterial pressure waves with intra-arterial monitoring is necessary.

Advanced Airway

This includes a supraglottic advanced airway or the use of an ET intubation. Waveform capnography will confirm and then monitor the ET tube placement. Once the airway is established, provide one breath every 2 to 3 seconds, up to 20 to 30 breaths per minute.

Drug Therapy

Another core component of this treatment process relates to drug therapy. The following are the recommendations for PALS algorithm steps for cardiac arrest:

• Epinephrine IV/IO dose: 0.01 mg/kg (Repeat every 3 to 5 minutes; if there is no IO/IV access, may give an endotracheal dose of 0.1 mg/kg.)
• Amiodarone IV/IO dose: 5 mg/kg bolus during cardiac arrest (May repeat up to two times for refractory VF/pulseless VT.)

It is critical to know what to do in these situations for many reasons. For example, the Emergency Medicine Clinic’s research shows that in nearly all situations, cardiac arrest occurs as a secondary event that progresses from a primary respiratory event. Knowing this, you know to focus first on improving the patient’s breathing and follow the step-by-step process listed above.

The Benefits of Having a PALS Certification

It is quite important to point out that while these PALS algorithms are a critical lifeline for providers as they meet the needs of patients in real time, they do not provide the details that you need to confidently manage the entire process. In other words, you need the PALS certification as well. There are several key benefits to completing this course. Consider some of the most important benefits of the PALS Certification.

• PALS Certification is extensive. This type of certification provides education and training for child and infant CPR, changes to pediatric advanced life support, and provides a detailed, systemic approach to pediatric assessment. You learn a great deal, which helps you save the life of a patient.
• Certification is necessary for professional development. For many people in the medical field, having a PALS certification may be a requirement or a recommendation by their employer. Obtaining this certification enables you to provide quality care for critically ill patients.
• For a bystander or family member, it is a lifeline. If your child is chronically ill, has disabilities, or is in some other way at high risk for an emergency situation, it is critical to know how to take action to protect the child’s life. This certification enables that.

Consider the value of taking a PALS certification even if you do not fit any of the above profiles. A study by the Children’s Hospital of Philadelphia found that the number of pediatric out-of-hospital cardiac arrest events is low but high enough that having the ability to treat the patient can be essential. In other words, bystander education on how to care for a patient can improve the patient’s ability to survive.

Being able to provide critically ill patients with the specific care they need in a timely and efficient manner can save a life. Get your certifications to do this from Advanced Medical Certification. Our 100% online courses adhere to the ILCOR Standards and Guidelines, meaning you can be assured of the quality of your education and training in such a critical situation. Learn more about our BLS online certification now, or get your PALS certification renewed in no time.