EMERGENCY MEDICAL CONSULTANTS INC.

Florida’s Premier Provider Of Quality Medical Training Programs

Nationally Accredited and OSHA Programs
CEU Provider
Since 1988

PEDIATRIC ADVANCED LIFE SUPPORT

Participant Preparation Packet 2017– 2020

This information is derived from the 2015 ECC guidelines

This packet contains prep information for the PALS Course as well as EKG and BLS reviews.
We strongly recommend completing these exams prior to the course.

-MANDATORY REQUIREMENTS-
You must bring the AHA PALS textbook to class with your completes online AHA Self Assessment.
Instructions can be found on page ii of your purple PALS textbook. Passing score= 70%
(If a score of 70% is not achieved in each section, please review the text and retest the section).

★!If you are attending the BLS section following, refer to page 42 for additional instructions.
(There is mandatory pretest if you are choosing to do BLS)

Course Date/Time: ____________________________________ Location: __________________________________________

Name: __________________________________________________________________________________________________
© 2017 Emergency Medical Consultants
This material protected by Copyright and may not be reproduced without written consent

(772) 878-3085 * Fax: (772) 878-7909 * Email: info@medicaltraining.cc

2017B 597 SE Port Saint Lucie Blvd * Port Saint Lucie, Florida 34984
Visit Our Website- www.medicaltraining.cc
2
 EMERGENCY MEDICAL CONSULTANTS INC.
Florida’s Premier Provider Of Quality Medical Training Programs
Nationally Accredited and OSHA Programs
CEU Provider
Since 1988

This copyrighted prep packet is a supplement for those students taking PALS with EMC.

Welcome to the latest American Heart Association Pediatric Advanced Life Support course sponsored by Emergency Medical
Consultants Inc. The Full training course is two days. The refresher course is one day only. NOT ALL 2 DAY COURSES HAVE A ONE
DAY REFRESHER COMPONENT – PLEASE VERIFY WITH OUR OFFICE IF WE ARE OFFERING A ONE DAY COURSE AND WHICH DAY IT
WILL BE.

The PALS course stresses early recognition and management of pre-terminal events rather than merely “running a pedi code”. We
use no stress, small group interactive skills and scenario stations to present the information in a fun, relaxed atmosphere. We are
pleased you have chosen our program and are sure you will find the course informative and worthwhile.

In order to keep our programs “Stress Free” and assure all participants meet the AHA requirements for proficiency, a certain amount
of home study is required prior to the actual class. The AHA mandates participants have access to the latest textbook, review it, and
suggest completing the pretest prior to entering the program. If you do not have access to a textbook, please call Laerdal at 1-888-
562-4242. Or, you may purchase the textbook through our office.

The evaluation process consists of a written exam, on which participants are required to score at least 84% and two patient
management scenarios requiring appropriate treatment. Again, these stations are designed to be user friendly and low stress.

We work very hard to keep our programs upbeat, relevant and at a level ALL participants who have prepared will pass with ease.
Our faculty is always available to explain information or procedures, just ask.

All information is based on the American Heart Association PALS standards at the time of printing and thought to be correct.
Providers are encouraged to review the PALS textbook and their specific policies prior to implementing any procedures or
administering any medication based on this study packet.

This packet contains prep information and a pretest. The AHA text provides information to access their online pre-test information
at www.heart.org/eccstudent. On page 6 of your text will give you a code/password.

For more EKG practice, log onto www.Skillstat.com

If you have any questions or comments feel free to call our office at 772-878-3085.

We look forward to seeing you in the PALS program.

Shaun Fix
President, Emergency Medical Consultants Inc.

(772) 878-3085 * Fax: (772) 878-7909 * Email: info@medicaltraining.cc

597 SE Port Saint Lucie Blvd * Port Saint Lucie, Florida 34984
Visit Our Website… EMCmedicaltraining.com
3
 PALS 2015-AHA Guideline Updates
The latest PALS guidelines from the American Heart Association 2015 ECC Committee were published in late
2015 and implementation began in early 2016. These guidelines will be utilized from 2016 through 2020.
This section contains a brief synopsis of the guidelines that were new in 2015, as well as a rationale.

CPR Changes- Children & Infants

As with adults-Call for nearby help as soon as the victim is found unconscious. Simultaneous assessment of
pulse and respirations is also indicated for infants and children. If not present, activate the emergency response
system or call for backup.

New Change: Infant/ Child Chest Compression Depth—Rescuers should provide chest compressions that
depress the chest at least 1/3rd of the anteroposterior diameter of the chest in pediatric patients
(approximately 1.5” in infants up to one year- to 2” in children up to the onset of puberty.) Once children have
reached puberty –the recommended depth of compression is, again, same as the adult, at least 2’ but not
over 2.4”.
Rationale: A pediatric study observed improved 24 hour survival when compression depth is at least 2 inches.
Judgment of compression depth is difficult at the bedside, and the use of a feedback device that provides such
information may be useful, if available.

New Change: Infant/Child Compression Rate—the adult, child and infant compression rate is now the same,
100-120.
Rationale: To maximize educational consistency and retention, pediatric experts have adopted the same
compression rate as recommended for adult BLS.

New Change: Compression only CPR—Conventional CPR (rescue breath and chest compressions) should be
provided for infants and children in cardiac arrest. “Compression only” is the least preferred method.
Rationale: The asphyxial nature of most pediatric patients necessitates ventilation as part of effective CPR.
Large registry studies have demonstrated worse outcomes for presumed asphyxial pediatric cardiac arrest
patients, which compromise the vast majority of out-of-hospital pediatric arrests that were treated only with
compression only CPR.

New Change: CPR with an Advanced Airway in Place—With an advanced airway in place, deliver 1 breath
every 6 seconds (10 breaths per minute) while continuous chest compressions are being performed.
Rationale: This simple single rate for adults, children and infants-rather than a range of breaths per minute-
should be easier to learn, remember and perform.

As always- with adults, infants and children, make every effort to minimize interruptions in CPR to less than 10
seconds.
All above BLS changes apply to the pediatric/infant patient in addition to the PALS specific new
recommendations:

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 PALS Specific Changes

New Change: Fluid Resuscitation—For children in shock, an initial fluid bolus of 20ml/kg is reasonable.
However, if the child has a febrile illness-administration of IV fluids should be undertaken with caution as it
may actually be harmful. This is especially true in clinical settings where access to critical care resources
(ventilators and inotropic drugs) are limited.
Rationale: The current recommendation continues to emphasize the administration of IV fluids for children
with septic shock. However, in certain resource limited settings, excessive fluid boluses given to febrile children
may lead to complications when appropriate equipment and expertise are not available to effectively address
them.

New Change: Atropine for Endotracheal Intubation—There is no evidence to support the routine use of
atropine as a premedication to prevent bradycardia in emergency pediatric intubations.
Rationale: Recent evidence is conflicting as to whether atropine prevents bradycardia and other arrhythmias
during emergency intubation in children.

New Change: Antiarrhythmic Medications for shock refractory VF or pulseless VT-Amiodarone or Lidocaine is
equally acceptable for treatment of shock refractory ventricular fibrillation (VF) or pulseless ventricular
tachycardia (pVT).
Rationale: Recent studies have indicated that lidocaine was associated with higher rates of survival, return of
spontaneous circulation (ROSC) and increased 24 hour survival rate that amiodarone. However, neither
lidocaine nor amiodarone administration was associated with improved survival to hospital discharge.

New Change: Targeted Temperature Management—For comatose children who are comatose in the first few
days following cardiac arrest (in or out of hospital), temperature should be monitored closely and fever should
be treated aggressively.
If the arrest occurred out of hospital, the comatose child can maintain either 5 days of normothermia (36-
37.5C) or 2 days of initial continuous hypothermia (32-34C) followed by 3 days of normothermia. For children
who remain comatose after in-hospital cardiac arrest, there is insufficient data to recommend hypothermia
over normothermia.
Rationale: A study comparing hypothermia vs normothermia showed no difference in functional outcome at 1
year between the 2 groups. There was also no additional complications in the group that was treated with
therapeutic hypothermia.

5
 Pediatric Advanced Life Support
Syllabus
Approx 14 hours

Two Day Full Training Program

Day One

Program Introduction
Overview of PALS Science
Management of Respiratory Failure
Break
Overview of Rhythms / Algorithms
Skills Review – Respiratory Management, Vascular Access, Review CPR standards
Lunch
Skills stations
1. Respiratory Emergencies, Airway management
2. Shock, Vascular Access IV & IO Skills, medication & broselow review
3. BLS – Child and Infant CPR and AED

Day Two

Putting scenario management together / Team Concept

Group Review of Patient Cases
Break
Patient Case management Scenarios / Simulations
1. Shock and Trauma
2. Respiratory Emergencies
3. Cardiac Cases
Lunch
Evaluations
1. Written Exam
2. Scenario Management Evaluations

6
 Pediatric Advanced Life Support
Syllabus

One Day- Refresher Program

Approx 7 hours

GENERALLY PRESENTED THE FIRST DAY OF 2 DAY PROGRAM

Program Introduction
Overview of PALS science
Pediatric Assessment, Recognition of Respiratory Failure and Shock Review
Break
Overview of Rhythms / Algorithms
Skills Review, Respiratory Management, Vascular Access, Review CPR Standards
Lunch
Group Review of Case Management
1. Cardiac Cases
2. Respiratory Cases
3. Shock Cases
BLS Child & Infant Skills Check-off
Evaluations
1. Written Exam
2. Scenario Management Evaluations

7
 ASSESSING KIDS

Think like the Child

“A giant stranger is coming after me”
“Mom says don’t talk to strangers”
“If I say I’m OK they’ll leave”

Unique issues when dealing with children

They don’t think we are heroes when we are there to treat them
Medically, they “hide” illness and injury by maintaining normal vital signs
Head injuries and liver bleeds are 2 culprits that can cause a slow deterioration

Tips for dealing with children

Understand MOST of us don’t get to regularly evaluate signs and symptoms in kids
Remember they may present a little differently
Assess the conscious child from across the room initially
If appropriate, use the parents for psychological first aid
Talk to the child about himself and his toys to gain a rapport
Unlike adults, stable kids will generally stay that way if we support their ABC’s

*Continually review the unique presentation of respiratory and circulatory compromise in children since it
differs from the adult patients we are used to dealing with

Good resources for pediatric information

American Academy of Pediatrics 847-434-4000 www.aap.org
American College of Emergency Physicians 800-798-1822 www.ACEP.org
EMSC 202-844-4927 www.ems-c.org
National Safe Kids Campaign 202-662-0600 www.safekids.org
National Center for Injury Prevention and Control 770-488-1506 www.ohcinfo@cdc.gov

Heart Rate Resp Rate Lowest acceptable (systolic)BP

Infant (<1 yr) 100-180 Infant (<1 yr) 30-53 Infant (1mo-1yr) 70
Toddler (1-3 yrs) 98-140 Toddler (1-3 yrs) 22-37 Children 1-10yrs 70 + (age in years x 2)
Preschool (3-5 yrs) 80-120 Preschool (3-5 yrs) 20-28 > 10 yrs 90
School Ages (5-10 yrs) 75-118 School Ages (5-10 yrs) 18-25
Adolescent (>10 yrs) 60-100 Adolescent (>10 yrs) 12-20

*Heart rate and resp rate may be lower while asleep

8
 PEDIATRIC ASSESSMENT SEQUENCE
*INITIAL IMPRESSION
“Sick or not sick”
Initial Pediatric Assessment
General Appearance Most Crucial

Appearance Work of Breathing

Degree of interactivity Tripod or sniffing position
Muscle tone Retractions
Verbal response or cry Audible breath sounds
Assessment
Triangle

Circulation to Skin
Pale
Mottled
Cynotic
Obvious bleeding/ Petechia purpura

*EVALUATE

Primary Assessment
Airway Breathing Circulation Disability Exposure
Patent? Present? Present? Level of expose body
Noiseless? Rate extremities consciousness and
Effort cap refill exposure control
Sounds

Secondary Assessment
Physical Exam SAMPLE History Bedside Tests
Head *Symptoms *Past history *Vital signs
to toe *Allergies *Last intake *Glucose
as needed *Meds *Events causing incident *Monitors (O2,EKG)

*IDENTIFY

Respiratory Problem Circulatory Problem Cardiac Problem

(Shock) (Tachy, Brady or CP Failure)

*INTERVENE
Manage
C – support Circulation = from EKG to vascular access, fluids or meds as needed
Tertiary Assessment / Management
A – position Airway if needed
B – manage Breathing = blow by O2 to BVM, intubation or meds as needed
9
 * Labs * Cultures * X-rays * Medications * Cardiac Tx * Specialty Consult
RESPIRATORY DISTRESS / RESPIRATORY FAILURE
The key to pediatric resuscitation is to recognize early and treat aggressively before the child decompensates.

Respiratory distress
Four types of Respiratory Problems
Potential respiratory failure: Increased work of breathing
• Tachypnea Upper airway obstruction
• Tachycardia Stridor
• Anxiety /Agitation / Irritability Voice change/drooling
• Retractions ↑ inspiratory effort
• Nasal flaring
Probable respiratory failure: Lower airway obstruction
Asthma, bronchiolitis
• Lethargy
↑ expiratory effort
• Head bobbing Prolonged expiratory phase
• Grunting Cough
• Cyanosis / Pallor Wheezing
Respiratory failure: Inadequate ventilation or oxygenation Possible ↓ air movement
• Slow respirations
• ↓ SaO2 Lung tissue disease
Cardiopulmonary failure: Pneumonia
Pulmonary edema
• Agonal breathing- inadequate respiratory effort
Grunting
• Bradycardia Crackes (rales)
Decreased air movement
Respiratory Management Hypoxia
Maintain airway
• Usually done by patient if awake Disordered control of breathing
• For decreased level of consciousness place in “sniffing position” Irregular rate & pattern
(supine with neck and head slightly elevated) Variable effort/ Inadequate effort
Assist with oxygen – only enough to maintain saturation between 94-99% Central apnea
• Blow-by, if alert and apprehensive
• Direct mask if the child will accept and needs it
• Bag valve mask for low rate or tidal volume
• Intubation - see indications below
Consider intubation by a skilled professional for the following:
• Unconscious in profound shock
• Any patient requiring bag valve mask ventilations for more than one minute
o respiratory arrest
o respiratory depression not responding to bag-valve-mask ventilations
o bradycardia not responding to bag valve mask ventilations
o tachypnea with poor tidal volume not responding to bag-valve-mask

If an intubated patient suddenly deteriorates think “DOPE”

• Displaced tube
• Obstructed tube
• Pneumothorax
• Equipment failure (i.e. ventilator failure, ambu failure, O2 empty, etc.)
(not necessarily in that order)

10
 SHOCK
Shock: inadequate perfusion to meet the metabolic demands of the tissues.

Question #1: Is there a reason for this child to be in shock?

Early signs
• Tachycardia
• Decreased perfusion of skin – cool, pale or mottled, delayed capillary refill
• Altered mentation
• Discrepancy in volume between peripheral and central pulses

Septic shock may have brisk capillary refill with bounding central pulses

Hypotension is a late sign of shock

Compensated shock – patient showing signs of shock with a normal B/P

Hypotensive shock – shock with hypotension (generally not seen until 30% fluid loss)

Treatment:
• Assess CAB’s
• Maintain Airway
• Administer high flow O2
• Maintain Body Temperature
• Monitor EKG and Pulse oximetry
• Obtain vascular access (IV or IO)
• Administer Fluid Bolus’s 20 ml/kg NS OR LR in under 20 min. Repeat PRN
• Consider vasopressors for refractory, cardiac, or septic shock
• Reduce oxygen demand
o support breathing
o control pain and anxiety
o manage fever

11
If IV access is not readily accessible in a patient in arrest, near arrest or profound shock, proceed with
intraosseous infusion.

IV tips:
• Don’t tie the tourniquet too tight
• Use transilluminator if available
• Immobilize the child if necessary flush the angiocath with heparin flush solution or saline
• Leave the plug off the end of the angiocath
• Bevel down for small or superficial veins
• Use skin prep (i.e. benzoin) and lots of tape
• Secure to IV board if necessary
In the trauma patient with shock give two fluid boluses; if symptoms are still present consider packed cells or
blood.

The latest guidelines recommend CO2 Waveform Capnography

• Remember normal CO2 is 35-45

• CO2 is acid
• High CO2 - denotes respiratory acidosis
- Ventilate more effectively and more frequently
• Low CO2 - during cardiac arrest indicates low perfusion
• May be common during arrest due to CPR being the only perfusion
• (compressions are only about 20% as effective as normal blood flow)
• Goal is to maintain CO2 above 10 mmHg
If CO2 remains below 10mmhg throughout code, survival is virtually “0”
• CO2 waveforms provide a more sensitive and rapid evaluation of respiratory function than pulse oximetry
• Specifically evaluating PERFUSION

Use End tidal CO2 (after intubation) to evaluate:

• ET tube placement (Is there any Co2 ?)

• Effectiveness of Compressions, is the Co2 level above 20mmhg?
- if not, evaluate compressions

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 CARDIOPULMONARY FAILURE
Bradycardia (below 60/min) with Agonal Breathing

Assess CAB’s
Ventilate
Administer 100% Oxygen
Intubate when appropriate
Assess Vital Signs
Obtain vascular access

Cardiorespiratory Compromise?
Poor perfusion
Hypotension
Respiratory distress

No Yes
Observe Perform chest compressions if despite
Support CAB’s oxygenation & ventilation:
Transport peds facility Heart rate <60/min

Continue CPR until rate sustains at greater than 60 min, ideally over 80 -100

Epinephrine
IV/IO: 0.01 mg/kg 1:10,000

Repeat Epinephrine every 3 -5 minutes at same dose

Atropine
0.02 mg/kg (usually not used in children < 1 year)
Min. dose: 0.1 mg
Max single dose: 0.5 mg for child
1.0 mg for adolescent
May be repeated once

Consider pacemaker

Consider treatable causes

Hypoxia
Hypoglycemia
Hypothermia
Herniation of brain stem

13
In general, children require defibrillation much less frequently than adults, however more recent studies
confirm ventricular fibrillation is more prevalent than previously thought and may be missed due to the fact
that EKG’s may not be initiated as rapidly as in adults.

DEFIBRILLATOR – REQUIRED KNOWLEDGE

JOULE (WATT SECONDS) SETTINGS:

DEFIBRILLATION: 2 J/kg First attempt, 4 J/kg later attempts

(higher doses may be considered up to 10 J/kg)
CARDIOVERSION: 0.5-1.0 J/kg. May increase to 2 J/kg

1. Knows how to turn monitor AND defibrillator on

2. Knows how to set current (joules)
3. Knows how to set sync button for perfusing rhythms
4. Knows how to discharge paddles to patient
5. Knows how to QUICK LOOK / Paddle function vs. lead select
6. Knows where to position paddles/ pads
Automated External Defibrillator
7. Knows how to change to pediatric paddle size Shocks at preset energy levels

8. Knows indications for use:

Ventricular fibrillation
Ventricular Tachycardia
Supraventricular tachycardia
9. Knows to clear the patient area
10. Knows what interface media to use – jell or pads
11. Knows current to use in children and infants

Physio Control Lifepak Model: Manual Defibrillator

Operator chooses energy level

AED – (Automatic defibrillator) can be used on all children and infants. Ideally, use pediatric
pads because they reduce the energy as it comes from the defibrillator. If pediatric pads are
not available, adult pads may be used, as the risk of allowing ventricular fibrillation to
deteriorate into asystole is greater than the risk posed by the higher energy of the AED using
adult defibrillation doses.

14
 Skills Review for Healthcare Providers
The CAB's of CPR
Simultaneously Determine unresponsiveness and check for effective breathing
If unresponsive: call a “code” or 911

C = Circulation- Check for a pulse Max - 10 seconds. If pulse is not definite, begin compressions.
A = Airway- Open airway (head tilt/chin lift)
B = Breaths- Give 2 breaths then back to compressions
D = Defibrillator- Attach a manual defibrillator or AED

CPR Reference
Adults (> puberty) Children (1 - puberty) Infants (< 1yr)

Rescue breathing, Victim definitely has 10-12 breaths/min 12-20 breaths/min 12-20 breaths/min
a pulse recheck pulse every 2 minutes recheck pulse every 2 minutes recheck pulse every 2 minutes
Compression landmark Middle of the chest, Middle of the chest, 1 finger below nipple line

No pulse between the nipples between the nipples

(or pulse <60 in infant or child with

poor perfusion)

Compressions are performed with Heel of 2 hands Heel of 1 or 2 hands 2 fingers OR

2 thumbs when using
encircling hands technique

Rate of compressions per minute 100-120/min 100-120/min 100-120/min

Compression depth 2-2.4 inches At least 1/3 depth of chest At least 1/3 depth of chest
2 inches 1 ½ inches

Ratio of compressions to breaths 30:2 30:2 30:2

*Once an advanced airway is placed Change compressors and 15:2 if 2 rescuer 15:2 if 2 rescuer
ventilations will be 1 every 6 sec. with reevaluate every 2 min
Change compressors and Change compressors and
continual compressions. reevaluate every 2 min reevaluate every 2 min

Foreign Body Airway Obstruction

* If not rapidly removed call Emergency Medical Service *
Conscious choking
Adult Child Infant

Abdominal Thrusts Abdominal Thrusts 5 Back Blows/5 Chest Thrusts

Unconscious choking
Adult Child Infant
Begin CPR Begin CPR
Call a “code”
or call 911 If second rescuer is present, If second rescuer is present,
Begin CAB’s of CPR send them to call a “code” or 911, send them to call a “code” or 911,
Before giving breaths: otherwise, call after 2 min of CPR otherwise, call after 2 min of CPR
look in mouth for foreign body, Before giving breaths: Before giving breaths:
remove object if it is seen. look in mouth for foreign body, look in mouth for foreign body,
remove object if it is seen. remove object if it is seen.
Repeat cycles of CPR if needed
Repeat cycles of CPR if needed Repeat cycles of CPR if needed
15
 Cardiac Rhythm Disturbances
Most children do not have significant cardiac dysrhythmias causing instability (do not take this to mean that children never have
cardiac dysrhythmias). In general rhythm disturbances in children are treated emergently when the patient is symptomatic or if the
rhythm is likely to deteriorate.

In children, rhythms are classified as:

Tachy (Fast):
First sign of stress
Look for causes other than cardiac (i.e. fever, pain, hypovolemia)
Not considered SVT unless 220 in infant, 180 in child.
Signs of SVT – no p wave, HR does not vary with activity, abrupt onset, narrow complex
Wide complex (>.09 sec or 2 boxes) may be v-tach
Brady (Slow) Causes:
Hypoxia
Hypothermia
Hypoglycemia
Collapse (Absent):
Frequently the end result of prolonged hypoxia and/or acidosis
May be Agonal/Asystole, pulseless electrical activity (PEA) or v-fib/pulseless v-tach

Newborn Resuscitation
Quick History: Multiple birth? Prematurity? Meconium? Narcotic Use?
Quick Assessment: Term of gestation? Amniotic fluid clear? Breathing or crying? Good muscle tone?

Term Newborn Vital Signs

Heart rate (awake): 100 to 180 bpm
Respiratory rate: 30 to 60 breaths/min
Systolic blood pressure: 55 to 90 mm Hg
Diastolic blood pressure: 25 to 55 mm Hg

APGAR SCORE Initial Assessment and

Sign 0 1 2 Stabilization Outside the Delivery Room
Heart rate (bpm) Absent Slow (<100 beats/min >100 beats/min
Assess and support*: Airway (position and clear)
Breathing (stimulate to breathe)
Respirations Absent Slow, irregular Good, crying
Circulation (assess heart rate and color)
Temperature (warm and dry)
Muscle tone Limp Some flexion Active motion
Always needed
Reflex irritability No response Grimace Cough, sneeze, cry Drying, warm, position, stimulate
by newborns
(to a catheter in
the nares, tactile Oxygen
Needed less
stimulation) Bag Valve Mask
Frequently
Color Blue or pale Pink body with Completely pink Compressions
Blue extremities Intubation
Rarely needed by newborns
7 – 10 Normal Medication
4 – 6 Moderately depressed requires O2 and stimulation
* Note ABC is still used in newborns
0 – 3 Severely depressed requires resuscitation

Meconium
• Suction Mouth and nose, only if obstructed
• Intubate and suction using meconium aspirator, only in depressed neonates with thick meconium present.
• Repeat with new ETT until clear
• Then start pyramid
16
 Initial Management of the Pediatric Arrest
“The Panic Zone”
Shaun Fix

I. Introduction
Perhaps the greatest stressor for the medical provider is dealing with and managing the uncommon
cardiac arrest in the pediatric population. While adult “codes” are routine, “pedi codes” become hectic,
frantic, ad chaotic- thus, the “load and go” response takes over. This session is designed to give
participants a brief overview of the pediatric arrest pathophysiology, expected outcomes and a simple
format to effectively apply BLS and ALS procedures in order to give your patient their best chance for
survival.

II. Learning objectives

At the end of this program the participant will be able to:
1. Discuss the pathophysiology of the pediatric arrest in contrast to the adult.
2. Discuss expected outcomes for the pediatric patient who arrests
3. Explain the use of oxygen and bag valve mask in the pediatric patient
4. Describe intubation differences in the pediatric population
5. State which medications can be given via the endotracheal tube.
6. Discuss the importance of proper BLS procedures-CPR, immobilization, O2 and temperature regulation
7. State the indications and procedures for intraosseous access
8. Explain the concept of a precalculated pharmacology system

III. Discussion / Summary

The prognosis for the pediatric patient who suffers cardiac or respiratory arrest is poor; the only real way
to reduce child deaths is to stress prevention. The most common causes are respiratory in nature, thus, in
the nontraumatized patient it is imperative that providers manage the victim with excellent CPR,
appropriate airway procedures and oxygenation, shock control, and initial medications where the patient
lies to give the child the greatest chance of survival.

Things to keep in mind:

Ø Children may not be small adults- but the principles of care are unchanged. Circulation, Airway, and
Breathing support can be accomplished rapidly and with little difficulty by the initial responding
providers.

Ø Excellent ACLS with poor BLS is of no value. Immediate BLS management and CPR are of paramount
importance.

Ø Medical codes should receive ALS treatment where the patient lies- Along with good CPR, oxygen,
upgraded airway, intraosseous infusion, and initial pharmacology if possible within a reasonable time.

Ø Trauma is still treated in the operating room. Secure C-spine and airway “Load and Go” with
secondary treatment, IV’s and meds enroute.
Ø Cool is the rule! As our stress levels increase, our patient care levels decrease.

17
 Medications for Pediatric Cardiac Arrest & Symptomatic Arrhythmias
Note: The standard recommendation is to have some type of pre calculated drug chart or length based tape for dosing.

Drug Dose (pediatric) Remarks

Adensine 0.1mg/kg IV/IO (max 6 mg) Rapid IV/IO bolus
Repeat dose 0.2mg/kg (max 12 mg) Rapid flush
Amiodarone 5mg/kg IV/IO IV bolus
(pulseless VT/VF) May repeat dose up to 2 times
Amiodarone Loading: 5mg/kg IV/IO Repeat to max
(perfusing tachy rhythms) over 20-60 min 15mg/kg/day IV
Ativan (Lorazepam) 0.05-0.1 mg/kg IV/IO/IM Max single dose 4mg

Atropine sulfate 0.02 mg/kg IV/IO Min dose: 0.1mg

May double for 2nd dose Max single dose
0.5mg child

Ca2+ chloride 10% 20 mg/kg IV/IO (0.2ml/kg) Give slowly

Dopamine 2-20 mcg/kg/min 1600 mcg/ml concentration
Dobutamine 2-20 mcg/kg/min 2000 mcg/ml concentration

Epinephrine for arrest 0.01mg/kg IV/IO Repeat every 3 – 5 min

Or bradycardia *ETT: 0.1mg/kg (10 X’s the IV dose)
Epinephrine infusion 0.1-1 mcg/kg/min Concentrations: 0.1 mg/ml (100 mcg/ml)
For 3-7 kg pts: 0.05 mg/ml (50 mcg/ml)
Glucose 0.5-1 g/kg IV/IO 10%= 5 -10ml/kg
25% = 2 - 4 ml/kg
50% = 1 – 2 ml/kg
Lidocaine 1mg/kg IV/IO Equally acceptable as Amiodarone in vf/pvt
Lidocaine infusion 20-50mcg/kg/min Concentrations: 4000 mcg/ml
After 1mg/kg loading dose For 3 -7 kg pts: 8000 mcg/ml
Magnesium sulfate 25-50 mg/min IV/IO over Max dose 2g
10-20 min
Naloxone 0.1mg/kg up to 2.0mg Titrate to desired effect
IV/IO/IM
Procainamide 15 mg/kg IV/IO Give over 30 – 60 min

Sodium 1mEq/kg per dose Push slowly & only

Bicarbonate If ventilation is adequate
Valium (Diazepam) 0.1-0.3 mg/kg IV/IO or Max single dose 5 mg
0.5 mg/kg rectal (rectal max single dose 10 mg)
*Endotracheal Tube doses (ETT) or Lido, Epi, Atropine & Narcan are acceptable but discouraged
18
 Pediatric Asystole
“Circle of Life”
Core Concepts of Resuscitation
Assess C A B’s & Begin CPR
Attach monitor / defibrillator
Administer Oxygen
Continually provide CPR in 2 min cycles
30 compressions/2 breaths 1 rescuer
15 compressions/2 breaths 2 rescuer
Stop briefly every 2 min to assess

[Secondary procedures]
Secure Airway when appropriate / Monitor CO2
Obtain Vascular Access

Continually provide CPR in 2 min cycles then stop briefly to reassess rhythm

Epinephrine (give as soon as possible)

IV/IO: 0.01 mg/kg 1:10,000

Repeat Epinephrine Q 3-5 minutes

Identify & treat causes:

H’s
Hypovolemia
Hypoxia
Hydrogen ions (acidosis)
Hypothermia
Hypo/hyperkalemia.
Anytime Hypoglycemia
in the
T’s
sequence
Toxins
Trauma
Tamponade (cardiac)
Tension pneumothorax
Thrombosis (pulmonary or coronary)
Too slow or too fast
19
 Pulseless Electrical Activity
Could be any rhythm other than pulseless VF or VT

“Circle of Life”
Core Concepts of Resuscitation
Assess C A B’s & Begin CPR
Attach monitor / defibrillator
Administer Oxygen
Continually provide CPR in 2 min cycles
30 compressions/2 breaths 1 rescuer
15 compressions/2 breaths 2 rescuer
Stop briefly every 2 min to assess

[Secondary procedures]
Secure Airway when appropriate / Monitor CO2
Obtain Vascular Access

Epinephrine (give as soon as possible)

IV/IO: 0.01 mg/kg 1:10,000

Repeat Epinephrine Q 3 -5 minutes

Identify and treat causes:

H’s
Hypovolemia
Hypoxia
Hydrogen ions (acidosis)
Hypothermia
Hypo/hyperkalemia.
Anytime Hypoglycemia
in the
sequence T’s
Toxins
Trauma
Tamponade (cardiac)
Tension pneumothorax
Thrombosis (pulmonary or coronary)
Too slow or too fast

20
 Pediatric Ventricular Fibrillation/Pulseless Ventricular Tachycardia
“Circle of Life”
Core Concepts of Resuscitation
Assess C A B’s & Begin CPR
Attach monitor / defibrillator
Defibrillate 2 J/kg
Administer Oxygen
Continually provide CPR in 2 min cycles
Stop briefly every 2 min to assess and defibrillate

[Secondary procedures]
Secure Airway when appropriate / Monitor CO2
Obtain Vascular Access

Defibrillate 4 J/kg 2 minutes after first defibrillation

Epinephrine
IV/IO: 0.01 mg/kg 1:10,000

Defibrillate 4 J/kg if VF or pulseless VT

May consider:
Amiodarone 5mg/kg IV or IO Lidocaine 1mg/kg
(equally effective
as Amiodarone)
Defibrillate 4 J/kg if VF or pulseless VT
or
Magnesium sulfate
Repeat Epinephrine every 3 -5 min at the same dose 25-50 mg/kg ONLY
Continue 2 min of CPR after each dose if Torsades
or
hypomagnesemia
Defibrillate 4 J/kg is suspected

May repeat Amiodarone every 5 min up to 15mg/kg

Defibrillate 4 J/kg
Identify and Treat causes between defibrillation
Anytime in the sequence:
H’s-Hypovolemia, Hypoxia, Hydrogen ions (acidosis), Hypothermia, Hypo/hyper kalemia, Hypoglycemia
T’s-Toxins, Trauma, Tamponade, Tension Pneumo, Thrombus (pulm or coronary), Too fast or too slow.

21
 Bradycardia
Cardiopulmonary Failure
Bradycardia (below 60/min) with Agonal Breathing

Assess C A B’s
Ventilate
Administer oxygen as needed
Intubate when appropriate
Obtain vascular access
Assess vital signs

Cardio-respiratory compromise?
Poor perfusion
Hypotension
Respiratory distress

No Yes
Observe Perform chest compressions if despite
Support CAB’s oxygenation & ventilation: Heart rate <60/min
Transport peds facility
Continue CPR until rate sustains at greater than 60 min, ideally over 80 - 100

Epinephrine
IV/IO: 0.01 mg/kg 1:10,000

Repeat Epinephrine every 3-5 minutes at same dose

Atropine
0.02 mg/kg (usually not used in children < 1 year)
Min. dose:0.1 mg
Max single dose: 0.5 mg for child
1.0 mg for adolescent
May be repeated once

Consider pacemaker

Consider treatable causes

Anytime Hypoxia
in the Hypoglycemia
sequence Hypothermia
Herniation of brain stem

22
 Wide Complex Tachycardia (>.09 sec)
Assumed to be
Ventricular Tachycardia, Stable
(no signs of shock)
Asses C A B’s
Maintain airway
Oxygen, as needed
EKG and pulse oximeter
Assess vital signs

Consider 12 lead ECG and expert consult especially if stable

Establish vascular access

Amiodarone 5 mg/kg over 20-60 min

May consider:

Procainamide 15mg/kg
Successful conversion? over 30-60 min
or
Lidocaine 1mg/kg
(do not routinely
Yes No administer multiple
antiarrhythmic meds)

Consider Expert
Consult Synchronized cardioversion 0.5 J/kg to 1 J/kg
(may increase to 2 J/kg)

Consider Expert Consult

*May choose to try one dose of adenosine 0.1mg/kg to determine if the rhythm is SVT with
aberrancy.

23
 Wide Complex (>.09 sec)
Assumed to be
Ventricular Tachycardia, Unstable
(signs of poor perfusion / shock)

Assess C A B’s
Maintain airway
Oxygen, as needed
EKG & pulse oximeter
Assess vital signs
Code equipment prepared

Expert Consult & 12 lead ECG when appropriate

Immediate synchronized cardioversion

0.5-1.0 J/kg
(consider sedation, do not delay cardioversion)

Attempt 2nd synchronized cardioversion up to 2J/kg

If unsuccessful or rapid reoccurrence

May consider:

Amiodarone 5mg/kg IV
over 20-60 min
or
Procainamide 15mg/kg IV
over 30-60 min
(do not routinely
administer multiple
antiarrhythmic meds)

Then a 3rd synchronized cardioversion up to 2 J/kg

Rate: over 180 for children; over 220 for infants

24
 Narrow Complex Tachycardia
Assumed to be
Supraventricular Tachycardia, Stable
Assess C A B’s
Maintain airway
Oxygen, as needed
EKG & pulse oximeter
Assess vital signs

Consider 12 lead ECG & expert consult

Vagal maneuvers
(ice or straw)

Establish vascular access

Adenosine 0.1 mg/kg IV rapidly

Followed by rapid flush
(may double dose and repeat x 1)

Expert pediatric consult

Rate: over 180 for children; over 220 for infants

25
 Narrow Complex Tachycardia
Supraventricular Tachycardia, Unstable
(signs of poor perfusion / shock)

Assess C A B’s
Maintain Airway
Oxygen, as needed
Assess vital signs
Code equipment prepared

Consider 12 lead ECG & expert consult when appropriate

Consider vagal maneuvers

if not critically unstable
(ice or straw)

If IV/IO is already in place & pt is not critical

Adenosine 0.1mg/kg IV rapidly
followed by rapid flush
OR

Synchronized cardioversion
0.5 - 1.0 J/kg
Sedate if possible (must not delay cardioversion)

If unsuccessful
nd
2 synchronized cardioversion up to 2 joules/kg

May consider:

Amiodarone 5mg/kg IV
over 20-60 min Then a 3rd synchronized cardioversion up to 2 J/kg
or
Procainamide 15mg/kg
IV over 30-60 min
(do not routinely
administer multiple
antiarrhythmic meds)
26
 Pediatric Shock
Poor perfusion pre or post resuscitation
Hypoperfusion from any cause
Assess C A B’s
Maintain Airway
Administer Oxygen, as needed
Maintain body temperature
Monitor EKG & Pulse oximetry

Emergency Vascular Access (IV or IO)

Always assess for and treat hypoglycemia, hypocalcemia, and acidosis

ASSESS FOR AND MAINTAIN AN ADEQUATE HEART RATE AND RHYTHM

Shock from Trauma Cardiac Related Shock Septic Shock

20 ml/kg NS or LR Rapidly 5- ml/kg NS or LR 20 ml/kg NS or LR (administer

(provided lungs are clear) fluids carefully in a febrile illness)
3 – 4 x’s in the first hour
Continued signs of poor perfusion Correct Glucose and Calcium level
Continued signs of poor perfusion Give broad spectrum antibiotic
within 1 hour
20 ml/kg NS or LR Rapidly
nd
Along with 2 fluid bolus Contact / Transfer to
Continued signs of poor perfusion consider: specialized ICU

rd
3 infusion of 20 ml/kg NS/LR Consider:
or Dopamine at 10 – 20 mcg/kg/min Dopamine 10 -20 mcg/kg/min
10 ml/kg packed RBC’s mixed with or or
NS Epinephrine 0.1 – 1mcg/kg/min Epinephrine 0.1 – 1 mcg/kg/min
Repeat Q 20-30 min as needed NorEpi 0.1 – 2 mcg/kg/min NorEpi 0.1 – 2 mcg/kg/min

↓
Address the problem (surgery?) ICU options based Scv02
and administer whole blood Consider expert consultation & B/P
*Norepinephrine/vasopresson
*Hgb transfusion
*Dobutamine

Post Cardiac Arrest- Induced Targeted Temperature Management (TTM):

For the resuscitated child who remains comatose, TTM may be beneficial. (32 – 34°C / low 90’s F)
For comatose children resuscitated out of hospital, it is reasonable to maintain either 5 days of
normothermia (36-37°C) or 2 days of continuous hypothermia (32 – 34°C), followed by 3 days of
normothermia. Current studies showed no difference in outcome after 1 year between randomized
groups that received either hypothermia or normothermia. For children who were resuscitated in-
hospital, there is insufficient data to recommend hypothermia over normothermia.

27
 Pediatric Post Resuscitation Care
Return of Spontaneous Circulation (ROSC)

Optimize oxygenation and ventilation

Appropriate ETT placement

end tidal CO2 or capnography – tube is in airway
CXR – depth of insertion
Maintain O2 sat 94-99%
ensures adequate oxygenation
prevents risk of reperfusion injury related to excessive oxygen
Ventilate to maintain CO2 levels appropriate to patient’s condition
monitor indirectly by capnography
monitor directly by ABG

Optimize cardiac output - Cardiac output = stroke volume x heart rate

Stroke volume is determined by preload, contractility, and afterload

Increase preload by administering fluid boluses

May not tolerate 20mL/kg due to poor myocardial function post arrest; try 5-10mL/kg over 10-20 min
Improve contractility by correcting hypoglycemia and/or electrolyte imbalances including hypocalcemia
Inotropes (dopamine) and/or inodilators (milranone) may be needed
Avoid hypotension – treat with fluids and/or vasopressors
Maintain HR appropriate for age – aggressively treat any tachy or brady arrhythmias
Maintain adequate hemoglobin concentrations

Optimize neurologic outcome

Aggressively treat hyperthermia, hypotension, hypoglycemia, and hypoxia all of which can cause
secondary brain injury.
Aggressively treat seizures which may result from: hypoglycemia, electrolyte imbalance, or
underlying brain injury. Seizures increase the metabolic demand; correct the cause if possible.

Mild hypothermia is common post arrest and should not be aggressively treated.
Children resuscitated from out of hospital arrest should be maintained at either 5 days of normothermia
(96.8-99.5oF) or 2 days of initial continuous hypothermia (89.6-93.2oF) then 3 days of normothermia.

Transport as needed for most appropriate level of care.

28
 Supplemental Info
Special Needs Children
Medical and technological advances have allowed critically ill or injured children to live longer lives. Many of these 12 million
children will be encountered at home, in schools, or in non-medical care facilities.

These patients present special challenges in assessment and management. The caretaker can be a great help in determining
what is “normal” and what is unique for this particular patient.

Common technological support includes tracheostomies, ventilators, CSF shunts and gastrostomy tubes. Troubleshooting
complications with these devices can be accomplished using a modified version of the DOPE mnemonic for evaluating ET
tubes.

Tracheostomy Tubes
The patient may or may not have a patent upper airway allowing ventilation or oral intubation in the emergency setting.
Another trach tube or a standard ET tube can be placed in the stoma if needed. Possible complications:
• D – dislodged tube
• O – obstructed tube
• P – pneumothorax
• E – equipment failure
Home Ventilators
The caregiver should be familiar with the ventilator type, function and settings for the child. Identifying and treating the
causes of acute respiratory distress in the ventilator dependent patient must be done immediately. Possible causes of the
deteriorating child who is ventilator dependent may include:
• D – displaced or disconnected tubing or ET or trach tube
• O – obstruction of air flow – ventilator or trach tube
• P – pneumothorax or patient condition (i.e. – respiratory diseases)
• E – equipment failure – try to manually ventilate the patient
Central Venus Catheters
These sites may have external ports requiring regular “flushing” or be placed under the skin showing a visible “port” which
must be accessed through the skin and require monthly “flushing”.
Common causes of CVC related complications include:
• D – displacement or disconnection causing serious bleeding
• O – obstruction – clots or kinking of the catheter
• P – pulmonary embolus, pneumothorax, pericardial tamponade
• E – equipment failure – leaking, cracking or infection
Feeding Tubes
Used for nutrition or medications in children who have nutritional, developmental or swallowing problems.
Potential complications for feeding catheters include:
• D – displacement
• O – obstructed
• P – peritonitis, perforation, pneumoperitoneum
• E – equipment failure – the tubing or the feeding pump
CSF Shunts
Used in patients who are unable to drain or reabsorb CSF from the ventricles in the brain. This may be due to medical
conditions, trauma or neoplasms. The shunt is a catheter placed in the brain, which drains fluid to the abdominal or thoracic
cavity for reabsorbtion. Emergencies involving CSF shunts may include:
• D – displacement – patient may show signs of ↑ ICP
• O – obstruction – SI/SX include headache irritability, N/V, bulging fontanelle are signs of ↑ ICP
• P – peritonitis, perforation, pseudo cyst – all presenting as acute abdomen or shock
• E – equipment failure – leaking, kinking or cracking of the shunt causing signs of infection or ↑ ICP

29
 Supplemental Info
Common Pediatric Emergencies
Seizures
Most common pediatric medical emergency
Fever is the most common cause
• Febrile seizures alone are not life threatening (but how do you know fever is truly the cause?)
• No alcohol or cool baths – these can lead to shivering and increase temp.
Status Epilepticus – 2 or more seizures without regain in consciousness or 1 continuous seizure lasting
more than 15-20 minutes.

Treatment
CAB’s
Prevent Injury, Lateral recumbnant position (for airway maintenance)
Vascular access if unstable or in status seizures
Ativan IM or IV, IO (0.1mg/kg)
Midazolam IV,IN, IM, IO (0.1mg/kg)
Valium IV, IO (0.1-0.2mg/kg) or rectal (0.5mg/kg) or

Most seizures last less than 5 minutes and need no treatment except opening the airway, suction, and O2

Fever
Remove clothing
Tylenol (15mg/kg) or Motrin (10mg/kg)

Sepsis
Initially manage shock and fever
Appropriate antibiotics
Consider sepsis specific facility

Meningitis
Watch for S/S of increased ICP
May be life threatening if not caught early

Symptoms
Fever (may be only presenting symptom in infant)
Bulging fontanel
Irritability
Lethargy
Nuchal rigidity
S/S increased ICP

Treatment
Initially manage shock, ICP, and fever
Appropriate labs
Appropriate antibiotics
30
 Head Injuries
Common in Pediatrics – large head compared to body
Concussion
Pathophysiology
Swelling – no actual damage to brain tissue

Assessment
Vomiting
Sleepiness
Neuro checks WNL

Management
CAB’s
Observe for:
• S/S increased ICP
• S/S hemorrhage/contusion

Intracranial Hemorrhage/Contusion
Pathophysiology- Bleeding within the brain tissue

Assessment
S/S of concussion + neuro deficits
Lethargy or loss of consciousness
Seizures
Unequal or sluggish pupils
Hemiparesis, hemiparalysis

Management
CAB’s
Close observation
Surgical intervention

Increased Intracranial Pressure

Assessment (Cushing’s Triad)
Hypertension
Bradycardia
Irregular respirations

Management
CAB’s
Consider elevating head
Maintain adequate ventilations (pCO2 approx. 30)
Hyperventilation reserved for rapidly deteriorating patients (may need rapid surgical intervention)
Corticosteroids
Mannitol may be considered by some if no bleed
31
 Respiratory Distress

“Noisy breathing is obstructed breathing”

Managing the respiratory distress is more important than diagnosing

Croup Epiglottitis
Usually < 3 yrs old Usually 3-6 yrs old
“Sick” for a couple of days Sudden onset
Low grade fever High fever
Not “toxic” appearing “Toxic” appearing
Drooling – dysphagia
“Tripod”

Both
Stridor
“Barky” cough

Asthma
RAD (reactive airway disease) – bronchoconstriction
Tightness reduces airflow and thus may decrease wheezing

Pneumonia / Bronchiolitis
Infiltrates
Respiratory distress with coarse breath sounds, rales, rhonchi, and possibly wheezing

General management
Psychological first aid
Airway as appropriate – position of comfort sniffing position
O2 as tolerated – blow by BVM ETT
Pulse oximeter, cardiorespiratory monitor
Initial IV therapy may be delayed
Nebulizer treatments
• Bronchodilators, for asthma, and possibly pneumonia and bronchiolitis
§ (Albuterol 1.25-2.5 mg/dose)
• Racemic epinephrine 0.05mL/kg/dose for croup (not used for epiglottitis)

Steroids for croup

32
 SIDS

Sudden Infant Death Syndrome (SIDS) is the sudden and unexplained death of an infant under one year
of age.

SIDS, sometimes known as “crib death”, is the major cause of death in babies from 1 month to 2 year of
age. The death is sudden and unpredictable, most often in a seemingly healthy baby, and usually during
sleep. Most SIDS deaths occur between ages 1 and 4 months, affecting more boys than girls, and
occurring more often in the fall, winter and early spring months.

Reducing the Risk of SIDS

Sleep position
• Unless contraindicated, healthy babies should sleep on their backs
• If the side lying sleep position is chosen, the baby’s lower arm should be positioned forward to
prevent him from rolling into a prone position

Sleep surface
• The baby should sleep on a firm mattress. Fluffy blankets, waterbeds, sheepskin, or pillows
should not be used as a sleep surface

Temperature
• Room temperature should be moderate; not cold, but not warmer than is comfortable for adults
Smoke free environment
• Babies and young children exposed to smoke have higher incidence of colds and other
respiratory infections, as well as increased risk for SIDS

Routine healthcare
• Routine well and sick baby visits as well as receiving vaccinations on time reduce the risk of SIDS

Prenatal care
• Early and regular prenatal care can help reduce the risk of SIDS
• The risk of SIDS is higher for babies whose mothers smoked during pregnancy

Breastfeeding
• Breastfeeding provides enhanced immune protection for infants

33
 Written Pre Course Examination
1. You are called to evaluate a 9 month old infant. You have assessed that the infant is unresponsive and are now
simultaneously checking for breathing and pulse. Where are you palpating for a pulse and how long should it take?
A. Carotid, not more than 10 seconds
B. Brachial, not more than 20 seconds
C. Carotid, not more than 15 seconds
D. Brachial, not more than 10 seconds

2. A 2 year old is brought into the emergency room following a fall from his highchair. The child is unresponsive and has slow,
irregular respirations. What is the most likely cause of this child’s respiratory failure?
A. Upper airway obstruction
B. Disordered control of breathing
C. Blunt chest trauma
D. Lower airway obstruction

Use the following scenario to answer the next 2 questions:

A 4 year old child with a 3 day history of vomiting, diarrhea, and poor PO intake is brought into the ER by her dad. She is
afebrile, heart rate is 132, respirations are 22 and unlabored, capillary refill is 5, central pulses are present, peripheral pulses
are weak, blood pressure is 80/52.

3. You determine that this child is in:

A. Hypovolemic shock
B. Obstructive shock
C. Distributive, septic shock
D. Cardiogenic shock

4. She has received 4 normal saline boluses of 20mL/kg. Her heart rate is 90/min and capillary refill is < 2 seconds, but she
remains very lethargic. Which diagnostic test should be done first?
A. CT scan of the brain
B. EEG
C. Blood glucose
D. ABG

Use the following scenario to answer the next 2 questions:

Due to a cluster of seizures at home, a 6 year old girl is given Diastat (rectal diazepam gel) by her dad. He called EMS because
her seizures continued. The child received IV lorazepam en route and is no longer seizing on arrival to the ER. She is
unresponsive with snoring respirations, rate of 6/min and poor chest rise.

5. Your best initial intervention is:

A. Reposition and insert and oral airway
B. Administer flumazenil
C. Administer naloxone
D. Apply O2 via nonrebreather mask

6. Post resuscitative care includes monitoring the patient’s O2 saturation. Which of the following saturation is best
recommended?
A. 94-99%
B: 95-100%
C. >94%
D. >97%

34
7. You are a member of the code team responding to a code in pediatrics. On arrival, high quality one person CPR is being
correctly performed on a 3 year old boy with a ratio of _____. Now that the team has arrived, 2 person CPR will begin with a
ratio of _____.
A. 15:2, 30:2
B. 30:2, 15:2
C. 15:2, 5:1
D. 30:2 for both

8. In spite of positioning and oral airway insertion an unresponsive patient’s respirations are slow and irregular. What should
be your next intervention?
A. Apply O2 via nonrebreather mask
B. Perform endotracheal intubation
C. Provide bag-mask ventilation
D. administer albuterol sulfate via nebulizer

9. You are the team leader during a resuscitation attempt on a 7 year old child. The monitor is just applied and shows the
following rhythm. There is no pulse.

You instruct the team to defibrillate at _____. Your next instruction should be _____.
A. 2 J/kg, Recheck the rhythm
B. 1 J/kg, Administer Amioderone
C. 4 J/kg, Check for a pulse
D. 2 J/kg, Resume compressions

10. Which of the following is not an element of high quality pediatric CPR?
A. Compression rate of 100-120/min
B. Compression depth of 1/4 – 1/3 the depth of the chest
C. Allowing complete recoil between compressions
D. Pulse checks every 2 minutes

Use the following scenario to answer the next 5 questions:

An 8 year old oncology patient presents to the ER with a fever that started this morning. The child is lethargic. Axillary temp is
102.7, heart rate 144, respiratory rate 26 with increased work of breathing, blood pressure 80/52, pulses are bounding with
capillary refill <2. Chemistry drawn on arrival shows lactic acidosis.

11. You accurately assess _____ because _____.

A. Hypotensive shock, systolic blood pressure is < 86
B. Compensated shock, systolic blood pressure is > 70
C. No shock, the capillary refill is <2
D. Cardiogenic shock, the heart rate is > 140

12. This child is mostly likely in:

A. Hypovolemic shock
B. Distributive, neurogenic shock
C. Distributive, Septic shock
D. Obstructive shock

35
13. Which of the following is the best indicator of the severity of the shock?
A. Blood pressure
B. Heart rate
C. Temperature
D. Capillary refill

14. You have decided to give this child a fluid bolus. Which of the following would you give?
A. 20mL/kg 5% dextrose in 0.45% normal saline over 1 hour
B. 20mL/kg normal saline over < 20 min
C. 10mL/kg lactated ringers over 30 min
D. 15mL/kg 5% dextrose in water over 1 hour

15. What else should this child receive within a short time of arrival to the ER?
A. Cardiology consult
B. Chest x-ray
C. Neurology consult
D. Broad spectrum antibiotic

16. You are asked to perform in a role that is outside your scope of practice and therefore ask for a different role. This is an
example of:
A. Knowing your limitations
B. Expecting special treatment
C. Not being a team player
D. Being too lazy to learn new roles

17. You are assessing a child with increased respiratory effort. On auscultation you hear crackles (rales). This helps you
identify that this child has:
A. Lower airway obstruction
B. Upper airway obstruction
C. Disordered control of breathing
D. Lung tissue disease

18. Which of the following would indicate upper airway obstruction?

A. Crackles (rales)
B. Increased inspiratory effort and stridor
C. Prolonged expiratory phase and wheezing
D. Slow, irregular respirations

19. A 1 year old child is in cardiac arrest and does not have an IV site. What is your best intervention?
A. Immediately insert an IO
B. Give epinephrine via the ETT
C. Have 2 people try repeatedly to start an IV
D. Ask the doctor to insert a central line

20. While providing care at a camp, you discover a 6 year old child unresponsive with no pulse. You shout for help but no one
comes. You should:
A. Leave the child to activate EMS, then return and perform CPR
B. Do CPR while continuing to shout for help hoping someone hears you
C. Do CPR for 2 minutes, leave to activate EMS, restart CPR
D. Activate EMS after doing CPR for 10 minutes

36
Use the following scenario to answer the next 2 questions:
A Grandmother brings an unresponsive 10 month old to the ER. The baby’s skin is cool and pale, capillary refill is 6 seconds,
respirations are labored with retractions and insp crackles (rales) auscultated in the bases, blood pressure is 64/40. The
monitor shows the following with a heart rate of 260/min.

21. This condition describes:

A. Unstable supraventricular tachycardia
B. Stable supraventricular tachycardia
C. Ventricular tachycardia
D. Sinus tachycardia

22. Immediate treatment is:

A. Start an IV, give adenosine slow IV push
B. 20mL/kg normal saline bolus
C. Defibrillation at 2 J/kg
D. Synchronized cardioversion at 0.5-1 J/kg

23. Which of the following children needs immediate attention?

o
A. 2 year old with a temperature of 99.9 F
B. 5 year old with nasal congestion and O2 sat 95% on room air
C. 4 year old with blood pressure 88/50
D. 10 month old with head bobbing and grunting

24. You are assessing a 1 year old with the following vital signs:
heart rate 120, respiratory rate 30, blood pressure 84/56. Which of these indicates a problem?
A. None, these are all normal values
B. Heart rate
C. Respiratory rate
D. Blood pressure

25. Using the AVPU scale, how would you document LOC for an 18 month old sitting on mom’s lap looking around, who cries
when you approach and is easily consoled by mom?
A. Awake
B. Voice
C. Pain
D. Unresponsive

37
Use the following scenario to answer the next 3 questions:
An unresponsive 7 year old girl is brought in to the ER by mom. Her skin is cool and cyanotic, respiratory rate is 6, her O2 sat
is 86% on room air and her blood pressure is 74/38. Central pulses are weak,peripheral pulses are absent. The monitor
displays the following rhythm:

26. What rhythm is most consistent with the above strip and clinical presentation?
A. PEA
B. Sinus bradycardia
C. Normal sinus rhythm
D. Third degree heart block

27. What is the most common cause of this rhythm in infants and children?
A. Drug overdose
B. Hyperglycemia
C. Dehydration
D. Hypoxia

28. What should your initial action be?

A. Fluid bolus with 20mL/kg normal saline
B. Cardioversion with 0.5-1 J/kg
C. Provide bag-mask ventilation with 100% O2
D. Administer narcan

29. Which of the following is indicative of respiratory failure in a 9 year old child?
A. Productive cough with inspiratory crackes (rales) heard on ausculation
B. O2 sat of 68% on room air and 84% on O2 via nonrebreather
C. Prolonged expiratory phase with end expiratory wheezing heard on auscultation
D. Respiratory rate of 32 with accessory muscle use

30. A 3 year old boy is brought in to the ER by dad with a 2 day history of low grade fevers and barky cough. As you enter the
room you see that the child is alert, skin is pink, and his respirations are labored with suprasternal retractions and stridor.
What medication would you give first?
A. Nebulized albuterol
B. Broad spectrum antibiotic
C. Nebulized epinephrine
D. Tylenol

31. What would you expect to assess in a child with lower airway obstruction?
A. Increased inspiratory effort and stridor
B. Slow, irregular respiratory pattern
C. Retractions and crackles (rales) on auscultation
D. Prolonged expiratory phase and wheezing

32. During a code the team leader instructs you to give a medication dose that you believe to be incorrect. How would you
respond?
A. Give the dose you are told to give; the team leader is in charge.
B. Refuse saying, “I can’t give that. It’s the wrong dose”.
C. Give the med in the dose you believe to be correct.
D. Tactfully clarify by saying, “did you mean to say ___________”
38
33. An unresponsive 5 year old is brought into the emergency room. Skin is cool and cyanotic. There are no palpable pulses.
The monitor shows the following rhythm.

What is this condition?

A. Normal sinus rhythm
B. PEA
C. Sinus bradycardia
D. First degree heart block

34. You are assessing a 10 year old boy brought to the ER after falling out of a tree. What finding would indicate to you that
immediate intervention is needed?
A. Sytolic blood pressure of 94
B. Heart rate of 88
C. Warm, moist skin
D. Decreased level of consciousness

35. A lethargic 2 year old is brought into the ER by her mom. She has a respiratory rate of 76 with deep retractions and nasal
flaring. O2 sat is 94% on room air. She is afebrile, her skin is warm and dry, capillary refill is brisk. As you bring her back to a
room you notice that her respirations have become less labored and her respiratory rate has dropped to 20. This is an
indication that:
A. The child is going into respiratory failure
B. The child is improving
C. The child is going into shock
D. The child is feeling less anxious since she is at the hospital

36. Which of the following children is in respiratory distress?

A. 4 year old with audible inspiratory stridor
B. 2 year old with a head injury decreased respiratory effort and a respiratory rate of 10
C. 7 year old with an O2 sat of 97%
D. 2 month old with a respiratory rate of 50

37. You are evaluating an 11 year old with a known allergy to bee stings who was brought in after encountering a swarm of
bees and being stung several times. Which of the following would you be likely to see?
A. Lung tissue disease
B. Hypovolemic shock
C. Upper airway and possibly lower airway obstruction
D. Disordered control of breathing

39
Use the following scenario to answer the next 3 questions:
Your patient is an unresponsive 3 year old girl. Her skin is cool and cyanotic. She is not breathing and has no palpable pulses.
Your team begins high quality CPR. You attach a monitor and the following rhythm is displayed:

38. What is this rhythm?

A. Ventricular tachycardia
B. Supraventricular tachycardia
C. Asystole
D. Ventricular Fibrillation

39. Your priority is:

A. Defibrillate at 2 J/kg
B. Fluid bolus of 20mL/kg over 5-10min
C. Synchronized cardiovert at 0.5-1 J/kg
D. Administer adenosine 0.1mg/kg

40. There is no change. Your team continues high quality CPR. What would you do next?
A. Defibrillate at 4 J/kg
B. Fluid bolus of 20mL/kg over 5-10min
C. Synchronized cardiovert at 0.5-1 J/kg
D. Administer adenosine 0.1mg/kg

40
 ANSWER SHEET PRETEST
PALS Written Evaluation
1. D
2. B
3. A
4. C
5. A
6. A
7. B
8. C
9. D
10. B
11. A
12. C
13. A
14. B
15. D
16. A
17. D
18. B
19. A
20. C
21. A
22. D
23. D
24. A
25. A
26. B
27. D
28. C
29. B
30. C
31. D
32. D
33. B
34. D
35. A
36. A
37. C
38. D
39. A
40. A

41
EMERGENCY MEDICAL CONSULTANTS INC.
Florida’s Premier Provider Of Quality Medical Training Programs
Nationally Accredited and OSHA Programs
CEU Provider
Since 1988

The following pages contain a Pretest for anyone

choosing to complete the BLS course
after ACLS or PALS .

This information in this packet comes from the

2015 BLS textbook; Please use the book to review.

You must score a 76% (-7)

In order to take this program

Completing these test questions prior to the course

is mandatory if you plan on attending the CPR section
after the PALS program.

(772) 878-3085 * Fax: (772) 878-7909 * Email: info@medicaltraining.cc

597 SE Port Saint Lucie Blvd * Port Saint Lucie, Florida 34984
Visit Our Website- www.medicaltraining.cc
42
43
 Skills Review for Healthcare Providers
The CAB's of CPR
Simultaneously Determine unresponsiveness and check for effective breathing
If unresponsive: call a “code” or 911

C = Circulation- Check for a pulse Max - 10 seconds. If pulse is not definite, begin compressions.
A = Airway- Open airway (head tilt/chin lift)
B = Breaths- Give 2 breaths then back to compressions
D = Defibrillator- Attach a manual defibrillator or AED

CPR Reference
Adults (> puberty) Children (1 - puberty) Infants (< 1yr)

Rescue breathing, Victim definitely has 10-12 breaths/min 12-20 breaths/min 12-20 breaths/min
a pulse recheck pulse every 2 minutes recheck pulse every 2 minutes recheck pulse every 2 minutes

Compression landmark Middle of the chest, Middle of the chest, 1 finger below nipple line

No pulse between the nipples between the nipples

(or pulse <60 in infant or child with

poor perfusion)
Compressions are performed with Heel of 2 hands Heel of 1 or 2 hands 2 fingers OR
2 thumbs when using encircling
hands technique
Rate of compressions per minute 100-120/min 100-120/min 100-120/min

Compression depth 2-2.4 inches At least 1/3 depth of chest At least 1/3 depth of chest
2 inches 1 ½ inches

Ratio of compressions to breaths 30:2 30:2 30:2

*Once an advanced airway is placed Change compressors and 15:2 if 2 rescuer 15:2 if 2 rescuer
ventilations will be 1 every 6 sec. with reevaluate every 2 min
Change compressors and Change compressors and
continual compressions. reevaluate every 2 min reevaluate every 2 min

Foreign Body Airway Obstruction

* If not rapidly removed call Emergency Medical Service *
Conscious choking
Adult Child Infant

Abdominal Thrusts Abdominal Thrusts 5 Back Blows/5 Chest Thrusts

Unconscious choking
Adult Child Infant

Call a “code” Begin CPR Begin CPR

or call 911 If second rescuer is present, If second rescuer is present,
Begin CAB’s of CPR send them to call a “code” or 911, send them to call a “code” or 911,
Before giving breaths: otherwise, call after 2 min of CPR otherwise, call after 2 min of CPR
look in mouth for foreign body, Before giving breaths: Before giving breaths:
remove object if it is seen. look in mouth for foreign body, look in mouth for foreign body,
remove object if it is seen. remove object if it is seen.
Repeat cycles of CPR if needed Repeat cycles of CPR if needed Repeat cycles of CPR if needed

44
 INFORMATION TO KEEP IN MIND:
1. Know the maximum time that should be spent checking for the presence of a pulse.

2. Know the preferred techniques/devices for providing ventilations if you are a single
rescuer versus having multiple resources in the professional setting.

3. Know the concept of scene safety/awareness before providing care.

4. Know which patients require ventilations and which require ventilations plus
compressions.

5. Know the best way to open the airway for an Adult, Child, Infant or spinally injured
patient.

6. Know the location, depth and rate of compressions for an Adult, Child and Infant.

7. Know when to start compressions for an Adult, Child and Infant, be able to explain chest
recoil (release) and high quality CPR.

8. Know the compression to ventilation ratio for both 1 and 2-rescuer for Adult, Child and
Infant.

9. Know how to reduce the incidence of air being introduced into the patient’s stomach
versus their lungs.

10. Understand how an AED affects the heart (shock to organize the rhythm), and know the
steps for using an AED on an Adult, Child or Infant; pediatric use and placement.

11. Know how to incorporate CPR before, during and after AED use.

12. Know the changes in CPR, which are incorporated once a victim has an advanced airway
“tube” placed by a medical professional.

13. Know the sequence, procedures and roles for 1 rescuer versus 2-rescuer CPR.

14. Know the procedures for conscious and unconscious choking for Adult, Child and Infant.

15. Know how to determine effectiveness of ventilations and compressions being provided
during CPR

16. Know the elements of effective team dynamics and communicating during an
emergency.
45
46
 MANDATORY BLS Pre-Course Exam

1. An elderly woman collapses to the floor in a bingo hall. Your first action should be:

A. Open the airway and give 2 breaths.

B. Go grab the defibrillator off the wall in the hallway.
C. Yell out/ call for help while simultaneously assessing for pulse and respirations.
D. Check for a carotid pulse.

2. You are performing 1 rescuer CPR on a 75-year-old female with a history of chest pain and diabetes. An
AED has just been made available to you. What is the first action that you should take at this time?

A. Finish the 5 cycles of chest compressions that you have started.

B. Place the AED pads on the chest.
C. Secure an electrical outlet to plug the AED into.
D. Turn the AED on.

3. You are attending your nephew’s birthday party when a 5 year old child suddenly starts choking on a hotdog.
What should you do?

A. Administer 2 rescue breaths.

B. Perform a blind sweep of the victim’s mouth.
C. Deliver 5 back-slaps.
D. Position yourself behind the child and administer abdominal thrusts (Heimlich Maneuver).

4. Opioids are medications that are used to treat pain but have a high potential for abuse. Addiction rate to the
medications is a growing problem and they can cause respiratory and or cardiac arrests. Currently, more adults
die every year from opioid overdoses than car accidents. What is the name of the medication that is utilized to
reverse the effects of respiratory depression?

A. Naloxone.
B. Ativan.
C. Lasix.
D. Magnesium Sulfate.

5. Your middle age neighbor is mowing his grass when he clutches his chest and drops to the ground. He has no
pulse or respirations. Your son calls 911 while you initiate chest CPR. How fast should the compression rate be?

A. 100 compressions per minute.

B. 100-120 compressions per minute.
C. 80-100 compressions per minute
D. 120-150 compressions per minute.

47
6. Bystanders have pulled a young woman with a pulse but no respirations out of a lake. One of them is
administering rescue breaths at a rate of one every 5-6 seconds while waiting for EMS to arrive. Which of the
following is true about rescue breaths?

A. Each breath should result in visible chest rise.

B. Give each breath over 1 second.
C. The pulse should be checked every 2 minutes..
D. All of the above

7. Which of the following situations will slightly delay AED usage while the situation is made safe for AED
application?

A. A person found lying on a metal floor inside a meat cooler.

B. A person found submerged in a bathtub.
C. A person who collapsed in snow.
D. A person who has a transdermal nitro patch on their arm.

8. When utilizing a bag valve mask device it is important to remember:

A. That this device requires training and is best suited for a 2-rescuer situation.
B. The E-C clamp technique should be used while lifting the jaw to provide a good seal.
C. To squeeze the bag for 1 second while watching the chest rise.
D. All of the above.

9. What is the correct ratio for compressions to ventilations in infant CPR with 2 rescuers present?

A. 20 compressions to 4 breaths.
B. 15 compressions to 2 breaths.
C. The rate remains 30 compressions to 2 breaths.
D. 15 compressions to 1 breath.

10. The maximum amount of time that should be taken to check for a pulse on an adult, infant or child is:

A. 15 seconds
B. 10 seconds
C. 30 seconds
D. 5 seconds

11. You are the second rescuer providing ventilations to an adult victim in cardiac arrest. You observe the hand
placement of the person who is providing compressions to be incorrect. You advise them to reposition their
hands. This is an example of what type of team dynamic communication?

A. Knowledge Sharing.
B. Closed Loop Communication.
C. Constructive Intervention.
D. Open Communication

48
12. While providing CPR to a victim, an AED becomes available and a shock is indicated and administered.
What should you do next?

A. Administer 2 more shocks; to total 3.

B. Immediately restart CPR, starting with compressions.
C. Give 2 breaths first then resume CPR.
D. Check the carotid pulse for no longer than 10 seconds.

13. What is the purpose of defibrillation?

A. To stop a chaotic rhythm and restore the heart’s normal rhythm.

B. To increase the rate of complete heart block.
C. To provide a blood pressure.
D. To treat cardiac standstill.

14. Current guidelines suggest that adult compressions should be administered at a depth of 2-2.4 inches. Which
of the following is not true regarding chest compression depth?

A. Compressions are often delivered too hard rather than too shallow.
B. It may be difficult to accurately judge compression depth without the use of a feedback device.
C. Consistent compression depth of at least 2 inches is associated with better outcomes.
D. Potential complications can occur at depths of greater than 2.4 inches.

15. What is the correct rate of ventilations to provide when an advanced airway is in place?

A. 1breath every 3-5 seconds.

B. 1 breath every 6-8 seconds.
C. 1 breath every 10 seconds.
D. 1 breath every 6 seconds.
16. You begin your shift on the med/surg floor. You begin your rounds and when you walk into a patient’s room,
you notice the patient has agonal respirations. What should you do first?

A. Give the patient oxygen

B. Check a pulse, and begin compressions if indicated
C. Do nothing, the patient is asleep
D. Begin the Heimlich maneuver

17. When is the two thumb encircling technique is used?

A. On an infant when two rescuers are available

B. When the infant is choking
C. When performing CPR on a pediatric victim
D. When performing one rescuer CPR on an infant and you become tired

49
 18. At the beginning of your work shift, you are assigned the role of compressor during a cardiac arrest. This is
known as:

A. Mutual respect
B. Closed loop communications
C. Clear roles and responsibilities
D. Constructive intervention

19. While assisting with a cardiac arrest, you are instructed to take over bag valve mask ventilations. You repeat
back “ you would like for me to take over bag valve mask ventilations.” In team dynamics, what is this called?

A. Closed loop communications

B. Knowing your limitations
C. Knowledge sharing
D. Mutual respect

20. In relation to the “Team concept” of resuscitation, if adequate medical staff is available, in order to reduce
fatigue and increase effectiveness of compressions the team should?

A. Assign several people to switch off on compressions every 2 min

B. Have each compressor work until they state they need relief
C. Put a rescuer on each side of the victim and rotate each set of 30 compressions
D. Always assign the largest, strongest person to compressions

21. You arrive to find a hospital maintenance worker lying on the ground, next to a ladder. He appears
unconscious, your first action should be?

A. Check for breathing and a pulse

B. Shake and shout, check unresponsiveness
C. Begin compressions at 30:2
D. Assure the area is safe for you to be in

22. After performing the choking procedure for a conscious victim who becomes unconscious, the next
procedure is to?

A. Perform a finger sweep

B. Attempt ventilations
C. Straddle the victim
D. Begin CPR compressions

23. High quality CPR is the critical component to resuscitation, especially compressions; which concept is
correct?

A. Compression depth has a higher priority than recoil or relaxation

B. Compression and recoil (refill) are equally important
C. Ventilation is the priority for all victims
D. 30 ventilations per minute are optimum for the best outcome

50
24. When performing compressions on a child for CPR or unconscious foreign body airway procedures the
proper depth is?

A. ½" or ½ the depth of the chest

B. 1 ½ " to 2 1 ½ " inches
C. Varies based on age and weight
D. 2" or 1/3 the depth of the chest

25. While at a school event, a teacher chokes on gum. He runs towards the office before falling unconscious.
Immediately after performing 30 compressions, the next step is?

A. Open the airway and look into the mouth before ventilating
B. Perform a finger sweep and attempt breaths
C. Readjust the airway with a jaw thrust maneuver
D. Check pulse for no more than 10 seconds

26. The resuscitation team is made up of various professionals with different levels of license and skill sets. In
order to function efficiently the team members must?

A. Wait for a physician to order CPR and defibrillation

B. Always be prepared to perform any skills, even if not licensed to
C. Realize their strengths, abilities and limitations
D. Decide if they feel CPR is worth the physical effort

27. A victim begins to choke, and you find them grabbing their throat and coughing uncontrollably, you should?

A. Perform the Heimlich maneuver

B. Perform the modified Heimlich maneuver
C. Perform chest thrust if they are pregnant or obese
D. Allow them to continue coughing

28. You are assisting with a cardiac arrest at a surgi- center. Someone brings in an AED that you are not familiar
with, in relation to utilizing this:

A. Have an overhead page put out for someone familiar with the unit
B. Perform 2 minutes of CPR, then apply the pads
C. Wait for EMS or someone familiar with the AED before using
D. Turn on the unit and follow the directions

29. The accepted ratio of compressions to ventilations for a 6 year old drowning victim when only 1 rescuer is
available is?

A. 15:1
B. 30:1
C. 30:2
D. 15:2

51
30. AED Pads require firm contact to the skin to be most effective, which of the following will negatively effect
that contact?

A. Water on the patients chest

B. Suntan oil on the skin
C. Hair on the chest
D. All of the above

52
NAME:

COURSE: Mandatory Pre Test Questions for those completing BLS after ACLS or PALS

# MISSED: GRADE:

1. A B C D
2. A B C D
3. A B C D
4. A B C D REMINDER:
5. A B C D
6. A B C D You must score a 76% to be
7. A B C D eligible for the BLS Completion
8. A B C D section after ACLS or PALS
9. A B C D
10. A B C D
11. A B C D
12. A B C D
13. A B C D
14. A B C D
15. A B C D
16. A B C D
17. A B C D
18. A B C D
19. A B C D
20. A B C D
21. A B C D
22. A B C D
23. A B C D
24. A B C D
25. A B C D
26. A B C D
27. A B C D
28. A B C D
29. A B C D
30. A B C D

53