AMERSSOCIATION Associations | SCRITICAL-CARE NURSES life is why PALS Normal Heart Rates* (beats/min) (breaths/min) Age ‘Awake Rate Sleeping Rate | Age Neonate 100-205 90-160 Infant Infant 100-180 90-160 Toddler Toddler 98-140 80-120 Preschooler Preschooler 80-120 65-100 School-aged child School-aged child 75-118 58-90 Adolescent 60-100 Mean Arterial Pressure (mm Hg)* Birth (12 h, <1000 9) 39-59 28-425 Birth (12 h, 3 kg) 60-76 48-57 Neonate (96 h) 67-84 45-60 Infant (1-12 mo) 72-104 50-62 Toddler (1-2 y) 86-106 49-62 Preschooler (3-5 y) 89-112 58-69 ‘School-aged child (6-9 y) 97-115 66-72 Preadolescent (10-12 y) 102-120 71-79 Adolescent (12-15 y) 110-131 73-84 Aways consider the patient's normal range and clinical condition. Hear rate will normally increase with fever or tess. {Syetote and castoc blood pressure ranges assume Sh percentile for height for chien 1 year and older. ‘Moa arterial presoures(chasioke presoure + kiference between systolc and castokcpressure/3) for 1 year ‘and older, essuming 50th percentile for height ‘Approximately equal to postconception age in weeks (may add 6 mm Ha). Fecroavced from Hezineh MF. Chicren are diferent. i: Hezinski MF, ed. Nursing Care of the Citclly Chi Sebea ot Lovie, MO: Mosby, 2013-1-18, copyright Elsevier. Data from Gemeli M, Manganaro R. Mami C, De tes F Longtunal stig of blood pressure dunng the 1st year of ie. Eur J Peckatr. 1990:149(5)318-220; CROKE Ta: Kitterman JA, Pibbs RH, Gregory GA Tooley WH. Aortic blood pressure during the fist 12 hours Me infarte with bith weight 610 to 4.220 grams. Pecfarcs. 1981;67(5)607-613; Haque IU, Zaitsky AL, Faatyes ofthe evidence forthe lower limit of systole and mean arterial pressure in children. Pdlatr Crt Caro Fane O90} 100.144 and National High Blood Pressure Education Program Working Group on High Blood, Paar Chacren and Adolescents. The Fourth Feport on the Diagnosis, Evaluation, and Treatment of High Bre Pressure n Chidien and Adolescents. Bethesda, MD: National Heart, Lung, and Blood institute; 2008 NIH publication 05-5267. 15-1046 RI1/16 © 2016 American Heat Associaton SBN $78-1-61669-560-6 Printed inthe USAShock Algorithm Pediatric Sep Initial stabilization Identify Signs of Septic Shock (as below or per protocol) « Altered mental status firitabilty or decreased level of consciousness) « Altered heart rate (tachycardia or, less commonly, bradyeardia) «* Altered temperature (fever or hypothermia) « Altered perfusion (prolonged or “tlash” capillary refi; ool or very warm extremities; plethoric appearance, mottled color or pallor, possible eochymosis or purpura; decreased urine output) «Hypotension: May or may not be present Immediate (10-15 min) Initial Stabilization « Monitor and support airway, breathing, and circulation > Monitor heart rate, blood pressure, and pulse oximetry ceebish vascular access (V oF 10); draw blood for culture and eetetonal laboratory studies, including glucose and calcium do not | delay antibiotic or fuid therapy « Antibiotics: Give broad-spectrum antibiotics Senne blusos: Give 20 mL/kg isotonic crystalloid Boles (10 7AAG, | Fetheonates and those with pre-existing cardiovascular compromise) | for neonatetuly after each bolus. Repeat as needed to teat shock: Stop rales, repiratory distress, or hepatomegaly develens. yretics if needed Goale of therapy: Improved mental status, normalization of Pest adequate systolic and diastolic Blood pressure, First hour _ Yes | « Obtain experveritical care consultation wsoactive drugs: (consider erica ‘care consultation « Initiate and titrate vas i old extremities, delayed capillary refil, and/or low blood pressure: Epinephrine (use dopamine if epinephrine is not available) ios, “flash” capillary ily diastolic) pnric Septic Shock Algorithm (continued) LE Therapies intended for the critical care environment and expertise «= Establish central venous and intra-arterial pressure monitoring + Continue epinephrine/norepinephrine (as above) and bolus fluid therapy as needed to treat shock Verify adequate airway, oxygenation, and ventilation > Evaluate cortisol if at risk for relative adrenal insufficiency; consider stress- dose hydrocortisone | Critical care goals of therapy: ScvO. 270%, adequate BP, normalized HR, | adequate cardiac output/index and organ perfusion | = J Scvo, <70% ‘Scvo,270% ‘Sevo,270% ‘With poor With poor perfusion ‘Signs of perfusion and ‘and warm shock cold extremities extremities despite resolved despite norepinephrine epinephrine ‘administration administration po ( Provide additional fluid ‘+ Provide additional ‘© Monitor in boluses as needed fluid boluses as Icu '* Transfuse if Hgb <10 g/dL. needed = Support * Continue epinephrine + Cor organ therapy norepinephrine function + BP low: Add therapy + Treat norepinephrine if diastolic + Add additional infection BP iow; consider additional vasopressor source | inotropic and vasoactive therapy and * Evaluate drug therapy as needed inotropic therapy | septic + IfBP adequate: Add as needed shock milrinone and/or additional | | * Support organ prevention, vasodilator therapy; funetion | detection, consider adding inotropic Goals of care: | and therapy drug Improved SevO,, * Support organ function normalized HR and Goals of care: Improved | | BP, adequate cardiac ‘Sovo,, normalized HR and BP, output/index and adequate cardiac output/index ‘organ perfusion and organ perfusion | eS SRC Sry 1 Carton, Crna Wt 3 Oa rc Cr Car Me. 200837 ean nT a Oona neeDrugs Us: oT Drug erature hata | ‘Adenosine Albuterol svt © 0.1 mg/kg IV/IO rapid push (max 6 mg), second dose 0.2 m¢ 94 mat .9/kg VO rapid push ‘Asthma, naphvaisronchospan),Pyperalmi set to porte via ralation 4 20 rnutes PAN with spacer (or ET itintubated) | Nebuler 25 mg/dose (wt <20 kg) or § mg/dose (1 >20 kg) va inhaat 20 minutes PRN —s | « Zontinuous nebulizer: 0.5 mg/kg per hour via inhalation (max 20 mg/h) ‘Amiodarone 507 VT th peo) SUT ATIVAN le! ovr 20 to 60 minutes (max 300 mh repeat to daly max 18 (2.2 in adolescents) nah nee " ~—s Pulsoless arrest fe, VF/pulseless VT) caree peg WD bok ran 900 ma repeat to daly max 15 mga (22 9 in adlescents) ‘Atropine sulfate Bradycardia (symptomatic) 2 1O.02 mylkg IW/O (max single dose 0.5 mg), may repeat dose once in 3 to § minutes, max total dose child 1 mg, max total dose adolescent 3 mg # 0,04 to 0.06 ma/kg ET ‘Toxins/overdose (eg, organophosphate, carbamate) TO? years: 0.05 mg/kg IVAO initially; then repeated and doubling the dose every 5 minutes until muscarinic symptoms reverse «Siz years: 11mg IV/O initially, then repeated and doubling the dose every 5 minutes Until muscarinic symptoms reverse Calcium Hypocalcemia, hyperkalemia, hy a, calcium channel blocker overdose 2°20 mafkg (0.2 mL/kg) IVAO siow push during arrest, repeat PRN chloride 10% Calcium Hypocalcemie, hyperkalemia, hypermagnesemia, calcium channel blocker overdose = 60 ma/kg (0.6 mL/kg) IVAO slow push during arrest repeat PRN ‘Croup = 0.6 mg/kg PO/IM/IV (max 16 mg) Hypoglycemia 20.5 901 kg IVAO (D,.W 2 to 4 mL/kg; DscW 5 to 10. mUKS) Heart failure, cardiogenic shock + 2 to 20 mea/kg per minute IV/O infusion; titrate to desired effect Cardiogenic shock, distributive shock Fe to 20 megkg per minute [VO infusion; titrate to desired effect Epinephrine Pulseless arrest, bradycardia (symptomatic) Poor molkg (0-1 mL/kg of the 0.1 mg/mL concentration) VO q 3 to § minutes (max single dose 1 mq) «Or mghtg (0.1 mL/kg of the 1 mg/mL concentration) ET q 3 fo 5 minutes Hypotensive shock Hyp Pte't mog/kg per minute IV/IO infusion (consider higher doses it needed) | ‘Anaphylaxis | + iM autoinjector 0.3 mg (for patient weighing 230 ka) (for patient weighing 10 to 30 ka) «Qo mg/kg (0.01 mL/kg of the 1 mg/mL concentration) IM 18 minutes PRN {max single dose 0.3 mg) © 0.01 mg/kg (0.1 mL/kg of the 0.1 mg/ml. concentration) IVAO (max single dose 1 mg) it hypotensive « Oro 1 Sacgrkg per minute NO infusion if hypotension persists despite fis anc IM injection Asthma + OT ma/kg (0.01 mL/kg ofthe 1 mg/mL concentration) subcutaneously @ 15 mutes (max 0.3 mg or 0 rl) Croup *'0.25 to 0.5 mL racemic solution (2.25%) mixed in 3 mL NS via inbalaticn | Sima B mi of the 1 mg/mL concentration) epinephrine mixed with 3 mL. NS (which ) oF IM junior autoinjector 0.15 mg | q3t0 5 minutes —— yields 0.25 mL racemic epinepirine solution ve mnalatonDrugs Used in PALS (continued) oe Etomidate RSI #02 to 0.4 ma/kg IV/IO infused over 30 to 60 seconds (max 20 mg) will produce rapid sedation that lasts for 10 to 15 minutes, Eee Hydrocortisone ‘Adrenal insufficiency ‘2 mg/kg IV bolus (max 100 mg) Ipratropium ‘Asthma ‘+ 250 to 500 meg via inhalation q 20 minutes PRN x 3 doses Lidocaine VF/pulseless VT, wide-complex tachycardia (with pulses) #1 mg/kg IV/O bolus ‘+ Maintenance: 20 to 50 mog/kg per minute IV/IO infusion (repeat bolus dose if infusion initiated >15 minutes after inital bolus) + 2to3 mg/kg ET Magnesium sulfate ‘Asthma (refractory status asthmaticus), torsades de pointes, hypomagnesemia ‘+ 25 to 50 mg/kg IV/IO bolus (max 2 g) (pulseless V7) or aver 10 to 20 minutes (VT with pulses) or siow infusion over 15 to 30 minutes (status asthmaticus) Methyl- prednisolone ‘Asthma (status asthmaticus), anaphylactic shock * Load: 2 mg/kg IV/IO/IM (max 60 rng): only use acetate salt IM {+ Maintenance: 0.5 mg/kg IV/O q 6 hours (max 120 mg/d) ‘Milinone ‘Myocardial dysfunction and increased SVA/PVR. ‘= Loading dose: 50 meg/kg IVAO over 10 to 60 minutes followed by 0.25 to 0.75 mog/kg per minute IV/1O infusion. ‘Narcotic (opiate) reversal ‘+ Total reversal required (for narcotic toxicity secondary to overdose): 0.1 mg/kg IVAG/M/suibcutaneous bolus q 2 minutes PRN (max 2 mg) ++ Total reversal not required (eg, for respiratory depression associated with therapeutic narcotic use): 1 10 5 mog/kg IVO/IM/subcutaneousty; titrate to desired effect, ‘+ Maintain reversal: 0.002 to 0.16 mg/kg per hour VO infusion Nitrogiyeerin Heart failure, cardiogenic shock * Initiate at 0.25 to 0.5 mog/kg per minute IV/1O infusion: titrate by 1 mog/kg per minute @ 15 to 20 minutes as tolerated. Typical dose range 1 10 5 moa/kg per minute (max 10 meg/kg per minute) «In adolescents, start with 5 to 10 mcg per minute (not per kilogram per minute) and Increase to max 200 meg per minute Cardiogenic shock (ie, associated with high SVR), severe hypertension #03 10 1 meg/kg per minute intial dose; then titrate up to 8 megrkg per minute PRN Norepinephrine Hypotensive (usually distributive) shock (le, low SVR and fluid refractory) #°0-1 to.2 meg/kg per minute IV/I0 infusion; titrate to desired effect, Procainamide ‘SVF, atrial flutter, VT (with pulses) #18 mg/kg IV/O load over 30 to 60 minutes (do not use routinely with amiodarone) | Prostaglandin E,(PGE,) ‘Ductal-dependent congenital heart disease (all forms) = 0.05 to 0-1 meg/kg per minute IV/O infusion initially; then 0.01 to 0.05 mog/kg per minute IV/O) Terbutaline ‘Metabolic acidosis (severe), hyperkalemia 1 mEq/kg IV/IO sion bolus Sodium channel blocker overdose (og, tricyclic antidepressant) #7} to 2 mEg/kg IV/IO bolus until serum pH is >7 45 (750 to 7.55 for severe potsoning) followed by IV/0 infusion of 150 mEq NaHCOy'_ solution titrated to maintain alkalosis ‘Asthma (status asthmaticus), hyperkalemia sates Seeegjta pormnts NAO nfuson; consider 10 mogik VO oad over S minutes + Tormogieg subcutaneously q 10 to 15 minutes unt IVAO infusion i initiated (max single dose 0.4 ma) Catecholamine-resistant hypotension ott0b2 to 000 univ per minute (2 to 2 milluntskg per minute) continuous infusionCoded Length-Based Tape Pediatric Color- Resuscitation © pure AsapiNo9 ‘ou ‘Sumuyparcenou ‘GUN ‘ouiseBOSeU 'ON ‘snoUaKENuI fy ‘snoessoe: IA 2002 146ukdoD “1 ‘amysuIooUT ‘ou So¥nSNU oypeNY BuosULAY Ka f0 818 es10nas aun Uo 821g aqny FREY ROP Bun ‘vorsoRed tam Pewadey KueduoD PUR UOsUREIC ‘uo%20g 810 20 AouedLeUr9 SUBD »,MO}OSOIE WOH peIdeDY zove von 2-02 oc-o1 a a zor zor on ove erat err ree oF o ove st st 3 st st ozion eet oz-a Et zat vee weemws ——pIND Pm pmo Pro Pwo zor on on on on oO Soro: Bre ua) wbu0, sose = erat so she se. zit iso, sor “ose ny “owoean 3e0 BNE ous Peuro0s pou sy pewO.Oy —_powoSe _peunooe _peunooe ny murore PeHPOOS — peynoUNg's — PeYADUN O'S POUMOUNS'D PEHNOUNO'y PeYNOUNS'e paYyNDUN ge eam 13 anno. perunai0 pana ben (cz) 9008 Moenge hues, — Rbwacg = Oensz = wOeASZWBRRSL | wOeag st oo eB oy oe oe 0 09 9 os os semi 0 wo = mpeg Owaped pe ey owed ommepeg om on ou PueIped = PIO)‘+ Asystole/PEA + 10 or 14 * Organized rhythm — check pulse * Pulse present (ROSC) ~ post-cardiac arrest careDoses/Details for the oakley Pediatric Cardiac Arrest Algorithm onus ‘* Push hard (2% of anteroposterior diameter of chest) and fast (100-120/min) and allow complete chest recoil. * Minimize interruptions in compressions. * Avoid excessive ventilation. * Rotate compressor every 2 minutes, or sooner if fatigued. * If no advanced airway, 15:2 compression-ventilation ratio. Potters tears cae deco First shock 2 u/kg, second shock 4 J/kg, subsequent shocks 24 J/kg, maximum 10 U/kg or adult dose Prem * Epinephrine IO/IV dose: 0.01 mg/kg (0.1 mL/kg of the 0.1mg/mL concentration). Repeat every 3-5 minutes. If no |O/IV access, may give endotracheal dose: 0.1 mg/kg (0.1 mL/kg of the 1 mg/mL concentration). Amiodarone IO/IV dos 5 mg/kg bolus during cardiac arrest. May repeat up to 2 times for refractory VE/pulseless VT. Lidocaine 10/1V dose: Initial: 1 mg/kg loading dose. Maintenance: 20-50 meg/kg per minute infusion (repeat bolus dose if infusion initiated >15 minutes after initial bolus therapy). * Endotracheal intubation or supraglottic advanced airway * Waveform capnography or capnometry to confirm and monitor ET tube placement * Once advanced ainway in place, give 1 breath every 6 seconds (10 breaths/min) with continuous chest compressions Roa tess neu errr om aces 5)) * Pulse and blood pressure * Spontaneous arterial pressure waves with intra-arterial monitoring emery Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypoglycemia Hypo-/hyperkalemia Hypothermia Tension pneumothorax Tamponade, cardiac Toxins Thrombosis, pulmonary Thrombosis, coronary Estimating Endotracheal Tube Size The formula for estimation of proper endotracheal tube size (internal diameter [i.d,)) for children 2 to 10 years of age, based on the child's age: Uncutfed endotracheal tube size (mm id.) = (age in years/4) +4 ‘The formula for estimation of a cuffed endotracheal tube size is as follows: Cuffed endotracheal tube size (mm i.d.) = (age in years/4) + 3.5 Typical cutfed inflation pressure should be <20 to 25 cm H,0.PALS Systematic Approach AlgorithmPediatric Bradycardia With a Pulse Pr ec i phy Dole et Epinephrine 1O/1V dose: 0.01 mg/kg (0.1 mUkg of the 0.1 mg/mL concentra- tion). Repeat every 3-5 minutes. If IO/V access not available but endotracheal (ED) tube in place, may give ET dose 0.1: mg/kg (0.1 mL/kg of the 1 mg/mL. concentration). Atropine IO/IV dose: 0,02 mg/kg. May repeat once. Minimum Hf pulseless arrest develops, goto Cardiac | | mim sgl dose Algor 0.5 mg.Pediatric Tachycardia With a Pulse and Poor Perfusion Algorithm Identify and treat underlying cause + Maintain patent airway; assist breathing as necessary © Oxygen ¢ Cardiac monitor to identify rhythm; monitor blood pressure and oximetry + IOMV access + 12-Lead ECG if available; don't delay therapy Wide (20.09 sec) Narrow {s0.09 sec) Probable Probable Possible ‘sinus supraventricular _ventricular tachycardia tachycardia * Compatible © Compatible history history (vague, consistent with nonspecific); known cause history of abrupt * P waves rate changes Present/normal - riaise seoent/ . Ri abnorm: heady ‘+ HR not variable Infants: Infants: rate | rate usually usually 2220/min | <220/min . Coico ra * Children: rate wea usually <180/min Search for |/ Consider and | __ vagal treat cause | maneuvers (No delays) fo IN ]O/V access present, give adenosine consultation or * IFIOAV access not available, or if adenosine advised ineffective, , synchronized cardioversion Bogin with 0.5- 1 J/kg; if not effective, increase to 2Jikg. Sedate | if needed, but don't delay Adenosine | lon dose: | First dose: 0.1 mg/kg rapid bolus (maximum: 6 mg), ‘Second dose: (0.2 mo/kg rapid bolus (maximum second dose: 12mg) ‘Amiodarone IO/IV dose: 5 mg/kg over 20-60 minutes or Procainamide IOMV dose: 15 mg/kg over 30-60 minutes Do not routinely administer amiodarone and procainamide together. '* Amiodarone '* ProcainamidePy Ee us Cel 4 PN te ee ize Ventilation and Oxygenation 1s Tate FiO, to maintain oxyhemiogiobin saturation 949%-99% (or as appropriate to the patient's condition}; if possible, wean FI, if saturation is 100%. «= Consider advanced airway placement and waveform « Irposabe, target a PCO; that is appropriate for the patient's condition and limit exposure to severe “Possible ‘Assess for and Treat Persistent Contributing Factors: ‘Shock Hypovolemia ‘© Identify and treat | Hypoxia ‘contributing factors? | Hydrogen ion (acidosis) '* Consider 20 mL/kg Hypoglycemia IVAO boluses of Hypo-/nyperkaleria isotonic crystalloid. Hypothermia Consider smaller Tension pneumothorax boluses (eg, Tamponade, cardiac 10 mL/kg) if poor: Toxins: cardiac function Thrombosis, pulmonary suspected. | Thrombosis, coronary * Consider the need Trauma for inotropic and/or vasopressor support for fluid-refractory ‘shock. + Monitor for and treat agitation and seizures. * Monitor for and treat hypoglycemia. ‘ sis blood gas, serum electrolytes, and calcium. freien‘ remains comatose after resuscitation lac arrest, maintain targeted temperature eagetement, including aggressive treatment of 1 (eSse,sonsutaton and pati nt transport to Estimation of Maintenance Fluid Requirements © Infants <10 kg: 4:mLkg per hour Example: For an 8-kg infant estimated maintenance fluid rate = 4 mL/kg per hour x 8 kg 32 mL per hour Children 10-20 kg: 40 mL per hour + 2 mU/kg per hour for each kg above 40kg Example: For a 15-kg child, estimated maintenance fluid rate 40 mL per hour + (2 mL/kg per hour x 5 kg) 30 mL. per hour * Children >20 kg: 60 mL per hour + 1 mLUkg per hour for each kg above 20 kg Example: For a 28-kg child, estimated maintenance fluid rate 60 mL per hour + (1 mU/kg per hour x 8 ka) =68 mL per hour After intial stabilization, adjust the rate and composition of intravenous fiuids based on the patient's clinical condition and state of hydration. in general, provide a continu- ous infusion of a dextrose- containing solution for infants. Avoid hypotonic solutions in critically il children; for most ppatients, use isotonic fluid such as normal saline (0.9% NaC) or lactated Ringer's solution with or without dextrose, based on the child's clinical status. a