Ventricular Fibrillation (VF) / Pulseless Ventricular ...



PALS Summary

Revised 7/1/18

Epinephrine:

|Condition/Pathology |Dosage |Special Notes |

|Pulseless Arrest, Bradycardia |0.01 mg/kg (0.1 mL/kg 1:10,000 ) max dosage 1 mg. |q-3-5 minutes IV/IO route |

|Hypotension |0.1- 1.0 mcg/kg/per minute infusion |IV/IO route |

|Anaphylaxis |0.01 mg/kg (0.01 mL/kg 1:000) |IM q 15 minutes |

| |0.01 mg/kg (0.1 mL/kg 1:10,000) |IV/IO q 3-5 minutes |

|Asthma |0.01 mg/kg (0.01 mL/kg 1:000) |Subq q 15 minutes |

|Croup |0.25 – 0.5 mg racemic solution (2.25%) mix in 3 mL of NS by inhaled nebulizer for |Nebulizer |

| |moderate to severe illness (stridor at rest) in infants or young children; up to 0.5 | |

| |mL mixed in 3 mL NS for older children or, | |

| |Prehospital: | |

| |0.5 mL/kg of 1:1000 epinephrine, maximum of 5 mL mixed with 3 mL of NS (which yields | |

| |0.25 mL racemic epinephrine). |Nebulizer |

|Toxins/Overdose |mg/kg (0.1 mL/kg 1:10,000) max dosage 1 mg. | |

|(Beta adrenergic Blockers, Calcium | | |

|Channel Blockers) |0.1- 1.0 mcg/kg/per minute infusion | |

Amiodarone: (Cordarone) V-Fib/pulseless VT Dose 5 mg.kg, repeat 5 mg/kg total dose of 15 mg/kg

Amiodarone: Stable VT or Stable SVT – 5 mg/kg over 20 - 60 minutes (maximum dose of 300 mg)

Atropine: 0.02mg/kg for symptomatic Bradycardia caused by vagal stimulation or primary AV block

(maximum dose of 1 mg for a child, total dose for adolescent 3 mg)

Larger doses may be required for organphosphate poisoning.

Adenosine: (adenocard) - Stable SVT 0.1 mg/kg (maximum 6 mg), repeat dose of 0.2 mg/kg

(maximum 12 mg)

Dextrose:

|Age |Concentration |Dosage range |

|Newborn to 1 month |D10W |0.5 - 1 g/kg (5 – 10 mL/kg) |

|1month to 2 years of age |D25W |0.5 - 1 g/kg (2 – 4 mL/kg) |

|> 2 years of age |D50W |0.5 - 1 g/kg (1 – 2 mL/kg) |

Dopamine: For Cardiogenic shock, Distributive shock – 2 – 20 mcg/kg/min, titrate to desired effect.

Naloxone: Narcotic (opiate) reversal – 0.1 mg/kg IV/IO/IM – max 2 mg.

ECG rhythms without a pulse:

|ECG Rhythms with No pulse |Medications for pulseless Rhythms |

|Ventricular Fibrillation (VF) |Epinephrine 0.01mg/kg & Amiodarone 5mg/kg |

|Ventricular Tachycardia (VT) |Epinephrine 0.01mg/kg & Amiodarone 5mg/kg |

|Asystole |Epinephrine 0.01mg/kg |

|Pulseless Electrical Activity (PEA) |Epinephrine 0.01mg/kg |

|Note: a normal appearance ECG rhythm without a pulse | |

Capnography

NOTE: In cardiac arrest the capnography needs to be greater than 10 mmHg, if 10 years old |90/systolic |

Modified Glasgow Coma Scale for Infants and Children (AVPU)

|Responses |Child |Infant |Score |

|Eye opening |Spontaneous |Spontaneous |4 |

| |To Speech |To Speech |3 |

| |To Pain |To Pain |2 |

| |none |none |1 |

|Best Verbal Response |Oriented, appropriate |Coos and babbles |5 |

| |Confused |Irritable, cries |4 |

| |Inappropriate words |Cries in response to pain |3 |

| |Incomprehensible sounds |Moans in response to pain |2 |

| |None |None |1 |

|Best motor Response | | | |

| |Obeys commands |Moves spontaneously and purposely |6 |

| |Localizes painful stimulus |Withdraws in response to touch |5 |

| |Withdraws in response to pain |Withdraws in response to pain |4 |

| |Flexion in response to pain |Abnormal flexion posture to pain |3 |

| |Extension in response to pain |Abnormal extension posture to pain |2 |

| |None |None |1 |

|Sudden deterioration in an Intubated patient (DOPE Mnemonic) |

|Displacement of the tube |The tube may be displaced out of the trachea or advanced into the right or left |

| |main bronchus |

|Obstruction of the tube |Caused by secretions, blood, pus, or foreign body |

| |Kinking of the tube |

|Pneumothorax |Usually results in a sudden deterioration in oxygenation and decreased chest |

| |expansion and breath sounds on the involved side. |

| |Tension pneumothorax may result in the above plus evidence of hypotension and a |

| |decrease in cardiac output. The trachea is usually shifted away from the |

| |involved side |

|Equipment failure |Disconnected of the oxygen supply from the ventilation system |

| |Leak in the ventilator circuit |

| |Failure of power supply to the ventilator |

| |Malfunction of valves in the bag or circuit |

|S/Sx of upper airway obstruction |S/Sx of Lower airway obstruction |

|Obstruction of the upper airways can occur in the nose, pharynx, or larynx |Obstruction of the lower airway (i.e., the airways within the thorax) can occur |

|Common Causes: FBAO, swelling of the airway (anaphylaxis, tonsillar hypertrophy, |in the lower trachea, the bronchi, or the bronchioles. |

|croup, or epiglottis) |Common causes: Asthma & bronchiolitis |

|Increased respiratory effort (nasal flaring, retractions) |Tachypnea |

|Change in voice (hoarseness), cry, or presence of a barking cough |Wheezing (most commonly expiratory but may be inspiratory or biphasic) |

|Stridor (usually inspiratory but may be biphasic |Increased respiratory effort (retractions, nasal flaring, and prolonged |

| |expiration) |

|Poor chest rise |Prolonged expiratory phase associated with increase expiratory effort ( |

| |expiration is an active rather than a passive process |

|Poor air entry on auscultation |Cough |

|S/Sx of Lung Tissue disease |S/Sx of Disordered control of breathing |

|This is a clinical condition that generally affects the lung at the level of the |An abnormal breathing pattern that produces signs of inadequate respiratory rate,|

|point where gas exchange occurs. It is often characterized by alveolar and small|effort, or both. |

|airway collapse or fluid-filled alveoli. |Common causes: seizures, CNS infections, head injury, brain tumor, hydrocephalus,|

|Common causes: Pneumonia (bacterial, viral, chemical) pulmonary edema (from CHF |neuromuscular disease. |

|and ARDS), pulmonary contusion (trauma), allergic reaction, toxins, vacuities, |Metabolic abnormalities and drug overdoses. |

|infiltrative disease. | |

|Tachypnea (often marked) |Variable or irregular respiratory rate (tachypnea alternating with bradypnea) |

|Increased respiratory effort |Variable respiratory effort |

|Grunting (produces early glottis closure during expiration. Grunting is a |Shallow breathing (frequently resulting in hypoxemia and hypercarbia |

|compensatory mechanisms to maintain positive airway pressure and prevent collapse| |

|of the alveoli and small airways) | |

|Crackles |Central apnea (i.e., apnea without any respiratory effort) |

|Diminished breath sounds | |

|Tachycardia | |

|Hypoxemia (may be refractory to administration of supplementary oxygen) | |

|Management of Respiratory Emergencies |

|Airway positioning 2. Suction 3. Oxygen 4. Pulse oximetry 5. ECG monitoring 6. capnography |

|Upper Airway Obstructions Specific Management |

|Croup |Nebulized epinephrine |

| |Corticosteroids (Dexamthasone) |

| |Severe cases ( Heliox – helium-oxygen mixtures) |

|Allergic Reaction-Anaphylaxis |IM epinephrine |

| |Albuterol |

| |Antihistamines H2 blocker |

| |Methylprednisolone or equivalent Corticosteroids |

| |For hypotension – 20 mL/kg crystalloids and unresponsive to fluids consider |

| |epinephrine infusion |

| |

|Lower Airway Obstruction Specific Management |

|Bronchiolitis |Nasal suctioning |

| |Bronchodilators |

|Asthma |Albuterol/Ipratropium |

| |Corticosteroids |

| |Subq/IM epinephrine |

| |Magnesium Sulfate |

| |Terbutaline |

| |

|Lung Tissue Specific Managements |

|Pneumonia/infectious/Chemical/Aspiration |Albuterol, antibiotics |

|Pulmonary edema cardiogenic or noncardiogenic- (ARDS) |Consider ventilator support with PEEP |

| |Consider CPAP |

| |Consider vasoactive support |

| |Consider diuretic |

| |

|Disordered Control of Breathing Specific Management |

|Increased ICP |Avoid hypoxia |

| |Avoid hypercarbia |

| |Avoid hyperthermia |

|Poisoning/Overdose |Antidote (if available) |

| |Contact poison control |

|Neuromuscular Disease |Consider noninvasive or invasive ventilator support |

Broselow Pediatric Emergency Tape

Medication |Gray

(3-5Kg) |Pink

(6-7kg) |Red

(8-9kg) |Purple

(10-11kg) |Yellow

(12-14kg) |White

(15-18kg) |Blue

(19-23kg) |Orange

(24-29kg) |Green

(30-36kg) | |Epinephrine

(0.01mg/kg) |0.04mg/

0.4mL |0.065mg/0.65mL |0.085mg/0.85mL |0.1mg/

1mL |0.13mg/

1.3mL |0.17mg/

1.7mL |0.21mg/

2.1mL |0.27mg/

2.7mL |0.33mg/

3.3mL | |Atropine

(0.02mg/kg) |0.1 mg/1mL |0.13mg/

1.3mL |0.17mg/ 1.7mL |0.21 mg/

2.1mL |0.26mg/

2.6mL |0.33mg/

3.3mL |0.42mg/ 4.2mL |0.5mg/

5mL |0.5mg/

5 mL | |Adenosine

(0.1mg/kg) |0.4mg/

0.13mL |0.65mg/

0.21mL |0.85mg/

0.28mL |1mg/

0.33mL |1.3 mg/

0.43mL |1.7mg/

0.56mL |2.1 mg/

0.7mL |2.7mg/

0.9mL |3.3mg/

1.1mL | |Adenosine

(0.2mg/kg) |0.8 mg/

0.26mL |1.3 mg/

0.43mL |1.7 mg/

0.56mL |2 mg/

0.66mL |2.6mg/

0.86mL |3.3mg/

0.1mL |4.2 mg/

1.4mL |5.4mg/

1.8mL |6.6mg/

2.2mL | |Amiodarone

(5mg/kg) |20mg/

0.4mL |32mg/

0.64mL |42mg/

0.84mL |50mg/

1mL |65mg/

1.3mL |80mg/

1.6mL |105 mg/

2.1mL

|130mg/

2.6mL |165mg/

3.3mL | |Naloxone

(0.1mg/kg)

IV-IO-IN-IM |0.4 mg |0.65mg |0.85mg |1 mg |1.3mg |1.6mg |2 mg |2mg |2mg | |

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Fast Heart Rate

Infants: rate usually ................
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