ICF PALS FINAL

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<div class="lesson-title">Pediatric Chain of Survival</div> The Pediatric Chain of Survival is a foundational concept in PALS, highlighting the essential sequential steps required to maximize survival rates and improve neurological outcomes during cardiac emergencies in infants and children. Unlike adult cardiac arrest, which is often primarily caused by cardiac issues, pediatric cardiac arrest is frequently secondary to respiratory problems, shock, or other underlying conditions. Therefore, the Pediatric Chain of Survival emphasizes prevention and the critical importance of early intervention in pediatric patients. Each link plays a vital role in improving outcomes and ensuring that every moment counts during a critical situation. <h3>The Links of the Pediatric Chain of Survival:</h3> <ol> <li>Prevention of Arrest: In children, cardiac arrest is often a secondary event, resulting from progressive respiratory distress or failure, shock (inadequate tissue perfusion), or other underlying medical conditions. Preventing these conditions through early recognition and timely intervention is paramount. This includes a variety of measures: <ul> <li>Injury Prevention: Implementing safety measures to prevent common childhood injuries, such as car seat safety, pool safety, and fall prevention.</li> <li>Management of Chronic Illnesses: Effectively managing chronic conditions like asthma, congenital heart disease, and diabetes to prevent exacerbations that could lead to cardiopulmonary compromise.</li> <li>Early Recognition of Respiratory Distress/Failure and Shock: Educating parents and caregivers about the early signs of respiratory distress (e.g., increased work of breathing, retractions, nasal flaring) and shock (e.g., rapid heart rate, weak pulse, cool extremities) so they can seek timely medical attention.</li> <li>Immunizations: Vaccinations help prevent infectious diseases that can sometimes lead to severe complications, including respiratory distress and even cardiac arrest in rare cases.</li> </ul> </li> <li>Early CPR: High-quality CPR is crucial in pediatric resuscitation. Because children often arrest due to hypoxia (lack of oxygen), effective chest compressions and ventilations are essential to maintain oxygen delivery to vital organs and prevent further deterioration. Key aspects of high-quality CPR in children include: <ul> <li>Appropriate Compression Rate and Depth: Compressions should be delivered at a rate of 100-120 compressions per minute and at a depth appropriate for the child's size (approximately 1/3 the anterior-posterior diameter of the chest).</li> <li>Minimizing Interruptions: Interruptions to chest compressions should be minimized to maintain consistent blood flow.</li> <li>Effective Ventilations: Providing adequate ventilations with supplemental oxygen is essential to address the underlying hypoxia.</li> </ul> </li> <li>Activation of the Emergency Response System: Calling for help early is essential. Prompt activation of the emergency medical services (EMS) system ensures that advanced pediatric care, including paramedics and specialized pediatric transport teams, is dispatched quickly. This is crucial as specialized pediatric equipment, medications, and expertise are often needed to manage pediatric emergencies effectively.</li> <li>Early Advanced Care: Rapid intervention by trained professionals with pediatric expertise is essential. This includes: <ul> <li>Advanced Airway Management: Performing advanced airway techniques such as endotracheal intubation or insertion of a supraglottic airway device when necessary.</li> <li>Medication Administration with Correct Pediatric Dosing: Administering appropriate medications at correct weight-based dosages.</li> <li>Defibrillation (When Indicated): Performing defibrillation or synchronized cardioversion when indicated for shockable rhythms (ventricular fibrillation and pulseless ventricular tachycardia).</li> </ul> </li> <li>Post-Cardiac Arrest Care: After return of spontaneous circulation (ROSC), specialized post-resuscitation care is crucial to prevent secondary brain injury and other complications. This includes: <ul> <li>Targeted Temperature Management (TTM): Implementing targeted temperature management (therapeutic hypothermia) to protect the brain.</li> <li>Hemodynamic Support: Managing blood pressure and ensuring adequate perfusion to vital organs.</li> <li>Management of Underlying Conditions: Identifying and treating the underlying cause of the cardiac arrest to prevent recurrence.</li> </ul> </li> </ol> Understanding and strengthening each link in the Pediatric Chain of Survival is essential for both lay rescuers and healthcare professionals who care for children. By acting decisively, following these principles, and emphasizing prevention, lives can be saved and recovery outcomes improved. [[Next Lesson: High-Quality CPR in Infants and Children|High-Quality CPR]] [[Back to Welcome to PALS Provider Course|PALS Provider Certification Course]]

<div class="lesson-title">High-Quality CPR in Infants and Children</div> High-quality cardiopulmonary resuscitation (CPR) is one of the most critical components of Pediatric Advanced Life Support (PALS). It serves as the foundation of successful resuscitation efforts and can significantly increase survival rates and improve neurological outcomes after cardiac arrest in infants and children. Performing effective chest compressions and providing adequate ventilations ensures that oxygen continues to flow to vital organs, maintaining oxygen delivery to the heart and brain. Understanding and mastering the components of high-quality CPR in infants and children is essential for both lay rescuers and healthcare professionals. <h3>Key Components of High-Quality CPR:</h3> <ol> <li>Compression Depth: Achieving the correct compression depth is crucial for generating adequate blood flow. <ul> <li>Infants (1 month to 1 year): Compress at least one-third the anterior-posterior (front-to-back) diameter of the chest, which is approximately 1.5 inches (4 cm). For single rescuers, use two fingers placed just below the nipple line. For two rescuers, use the two-thumb encircling hands technique, placing the thumbs on the sternum just below the nipple line and encircling the chest with the hands.</li> <li>Children (1 year to puberty): Compress at least one-third the anterior-posterior diameter of the chest, which is approximately 2 inches (5 cm). For smaller children, use the heel of one hand. For larger children, use two hands (as in adult CPR). Avoid compressing over the xiphoid process (the bony projection at the bottom of the sternum).</li> </ul> </li> <li>Compression Rate: Maintain a consistent and steady compression rate of 100–120 compressions per minute for both infants and children. Use a metronome or a device with a built-in metronome if available to help maintain the correct rate.</li> <li>Chest Recoil (Allow Full Chest Recoil): Allowing the chest to fully recoil after each compression is essential. This allows the heart to refill with blood, maximizing the effectiveness of each subsequent compression. Leaning on the chest between compressions prevents full recoil and reduces the effectiveness of CPR.</li> <li>Minimal Interruptions: Interruptions in chest compressions should be kept to an absolute minimum (less than 10 seconds). Continuous compressions are crucial for maintaining consistent blood flow and improving the chances of a successful outcome. Switch compressors every 2 minutes (or sooner if the compressor becomes fatigued) to maintain compression quality.</li> <li>Ventilations (Breaths): Providing adequate ventilations is essential for oxygenating the blood. <ul> <li>With an Advanced Airway (e.g., Endotracheal Tube or Supraglottic Airway): Once an advanced airway is in place, deliver 1 breath every 6 seconds (10 breaths per minute) without pausing chest compressions. This is known as asynchronous ventilation.</li> <li>Without an Advanced Airway (Bag-Mask Ventilation): When using a bag-mask device without an advanced airway, deliver 2 breaths after every 15 compressions for two rescuers (15:2 ratio) or 2 breaths after every 30 compressions for a single rescuer (30:2 ratio). Each breath should be delivered over 1 second, with enough volume to produce visible chest rise. Avoid excessive ventilation, which can cause gastric distention and other complications.</li> </ul> </li> </ol> <h3>Why High-Quality CPR Matters:</h3> Effective CPR serves as a life-saving bridge, maintaining circulation and oxygen delivery to vital organs until advanced care (such as defibrillation, medication administration, and treatment of underlying causes) is available. Without high-quality chest compressions and appropriate ventilations, the chances of survival and good neurological outcomes drop significantly with every passing minute. By understanding and mastering these techniques, you can provide the best possible care during cardiac emergencies in infants and children and significantly improve their chances of survival. [[Next Lesson: Airway Management in Infants and Children|Airway Management Basics]] [[Back to Pediatric Chain of Survival|Pediatric Chain of Survival]]

<div class="lesson-title">Airway Management in Infants and Children</div> Airway management is a cornerstone of Pediatric Advanced Life Support (PALS), as it ensures proper oxygenation and ventilation of an infant or child experiencing a cardiac or respiratory emergency. Due to significant anatomical and physiological differences compared to adults, airway management in pediatric patients requires specific techniques and considerations. Without a clear and open airway, even the most effective chest compressions and ventilations will fail to deliver adequate oxygen to vital organs. Mastering basic airway techniques in infants and children is crucial for providing life-saving care, especially in the critical early stages of resuscitation. <h3>Key Anatomical and Physiological Differences in Pediatric Airways:</h3> <ul> <li>Larger Occiput (Back of the Head): Infants and young children have a proportionally larger occiput (the back of the head). This can cause the head to flex forward when the child is placed supine (lying on their back), potentially obstructing the airway. Proper positioning is crucial to prevent this.</li> <li>Larger Tongue Relative to Oral Cavity: Infants and young children have a relatively larger tongue compared to the size of their oral cavity. This increases the risk of airway obstruction caused by the tongue falling back and blocking the airway.</li> <li>Narrower Trachea (Windpipe): The trachea (windpipe) in infants and children is significantly narrower than in adults. Even slight swelling or obstruction (e.g., from edema, foreign body, or infection) can significantly compromise the airway and make breathing difficult or impossible.</li> <li>Shorter Neck: The shorter neck in infants and children can make it more challenging to visualize the vocal cords during endotracheal intubation (placement of a breathing tube).</li> <li>Obligate Nasal Breathers (Infants up to approximately 6 months): Infants up to approximately 6 months of age are primarily obligate nasal breathers, meaning they preferentially breathe through their noses. Nasal congestion, therefore, can cause significant respiratory distress in this age group.</li> </ul> <h3>Basic Airway Techniques:</h3> <ol> <li>Head-Tilt/Chin-Lift Maneuver (Modified for Infants): The head-tilt/chin-lift maneuver is used to open the airway by lifting the tongue away from the back of the throat. However, it must be modified for infants to avoid overextension of the neck, which can actually obstruct the airway. <ul> <li>Infants: Avoid excessive head extension. Use a gentle head tilt and chin lift, placing a small folded towel or pad under the shoulders (not the head) if needed to maintain a neutral "sniffing" position. The sniffing position aligns the ear with the shoulder.</li> <li>Children: In older children, the technique is similar to adults, but still avoid hyperextension of the neck.</li> </ul> </li> <li>Jaw-Thrust Maneuver: The jaw-thrust maneuver is the preferred technique for opening the airway in patients with suspected cervical spine injury, as it minimizes neck movement. <ul> <li>Performance: Position yourself at the top of the patient’s head. Place your fingers under the angles of the mandible (jawbone) and lift the jaw upward and forward. Use your thumbs to gently depress the lower lip to open the mouth slightly. The jaw-thrust can be performed with or without head tilt, depending on the suspicion of neck injury.</li> </ul> </li> </ol> <h3>Detailed Steps for Each Maneuver:</h3> <ul> <li>Head-Tilt/Chin-Lift (Modified): <ol> <li>Place one hand on the forehead and apply gentle pressure to tilt the head back slightly.</li> <li>Use the fingertips of your other hand to gently lift the chin forward. Avoid pressing on the soft tissues under the chin, as this can obstruct the airway.</li> <li>In infants, avoid excessive head extension. A small folded towel or pad can be placed under the shoulders to help maintain a neutral "sniffing" position.</li> </ol> </li> <li>Jaw-Thrust: <ol> <li>Position yourself at the top of the patient’s head.</li> <li>Place your index and middle fingers under the angles of the mandible (jawbone).</li> <li>Place your thumbs on the patient’s cheeks or cheekbones.</li> <li>Lift the jaw upward and forward to open the airway. Avoid tilting the head or moving the neck if a cervical spine injury is suspected.</li> </ol> </li> </ul> <h3>Why Basic Airway Management Matters:</h3> Basic airway maneuvers are often the first and most critical steps in managing an unresponsive infant or child and play a vital role in ensuring oxygen delivery during an emergency. These techniques are relatively quick to perform, require minimal equipment (often only the rescuer's hands), and can significantly improve ventilation and oxygenation while more advanced airway interventions (such as endotracheal intubation) are being prepared or are becoming available. Effective basic airway management can buy precious time and significantly improve the chances of a positive outcome. [[Next Lesson: Advanced Airway Techniques in Infants and Children|Advanced Airway Techniques]] [[Back to High-Quality CPR in Infants and Children|High-Quality CPR]]

<div class="lesson-title">Advanced Airway Techniques in Infants and Children</div> When basic airway management techniques (such as head-tilt/chin-lift and jaw-thrust) are insufficient to maintain a patent airway, advanced airway techniques become essential. These techniques provide more effective ventilation and oxygenation for infants and children experiencing respiratory distress, respiratory failure, or cardiac arrest. Advanced airway management is crucial during prolonged resuscitation efforts or in situations where basic maneuvers fail to maintain an open airway. Mastering the use of advanced airway devices ensures optimal oxygen delivery and prevents complications caused by inadequate ventilation. <h3>Common Advanced Airway Devices in Pediatrics:</h3> <ol> <li>Nasopharyngeal Airway (NPA): The NPA is a flexible tube inserted through the nostril into the nasopharynx (the space behind the nasal cavity). It helps maintain an open airway by bypassing obstructions in the upper airway, such as the tongue. <ul> <li>Use in Pediatrics: NPAs are generally well-tolerated in semi-conscious or conscious patients who still have a gag reflex, as they are less likely to trigger vomiting or discomfort compared to oropharyngeal airways (OPAs). They are not suitable for patients with facial trauma or suspected basilar skull fractures.</li> <li>Sizing: Correct sizing is essential. The appropriate length is estimated by measuring the distance from the tip of the nose to the earlobe.</li> </ul> </li> <li>Oropharyngeal Airway (OPA): The OPA is a rigid, curved plastic device inserted into the patient’s mouth to prevent the tongue from obstructing the airway. <ul> <li>Use in Pediatrics: OPAs are used only in unconscious patients who lack a gag reflex. Inserting an OPA in a conscious or semi-conscious patient may induce vomiting, laryngospasm (spasm of the vocal cords), or airway trauma.</li> <li>Sizing: Correct sizing is crucial. The appropriate size is determined by measuring the distance from the corner of the mouth to the angle of the jaw.</li> <li>Insertion Technique: The OPA is inserted with the tip pointing towards the roof of the mouth and then rotated 180 degrees once it reaches the back of the throat.</li> </ul> </li> <li>Laryngeal Mask Airway (LMA): The LMA is a supraglottic airway device, meaning it sits above the vocal cords rather than being inserted into the trachea. It consists of an inflatable cuff that seals around the laryngeal inlet, providing a relatively secure airway for ventilation. <ul> <li>Use in Pediatrics: LMAs are relatively easy to insert and are commonly used in emergency situations, during transport, or during short procedures when endotracheal intubation is not immediately feasible or necessary. They are a good option for rescuers with less experience in intubation.</li> <li>Advantages: Easier to insert than an endotracheal tube, less training required, and less risk of complications such as tracheal injury.</li> <li>Limitations: Does not provide the same level of airway protection as an endotracheal tube (e.g., against aspiration).</li> </ul> </li> <li>Endotracheal Intubation (ET Intubation): Endotracheal intubation is considered the gold standard for airway management, providing the most secure and definitive airway. This technique involves inserting a tube directly into the trachea through the mouth or nose. <ul> <li>Use in Pediatrics: ET intubation is indicated in cases where other airway devices are ineffective, when prolonged mechanical ventilation is required, or when there is a high risk of aspiration.</li> <li>Requires Advanced Training: Endotracheal intubation requires advanced training and skill. It is crucial to have proper training and experience to perform this procedure safely and effectively in pediatric patients.</li> <li>Confirmation of Placement: After intubation, proper placement must be confirmed using multiple methods, including: <ul> <li>Direct visualization of the tube passing through the vocal cords.</li> <li>Auscultation of bilateral breath sounds.</li> <li>Observation of chest rise and fall.</li> <li>Capnography (measuring the amount of carbon dioxide in exhaled breath), which is the most reliable method.</li> </ul> </li> </ul> </li> </ol> <h3>Key Considerations for Advanced Airway Management in Pediatrics:</h3> <ul> <li>Choose the Right Device for the Situation: The choice of airway device depends on several factors, including the patient’s level of consciousness, airway anatomy (including age and size), the clinical situation, and the rescuer’s skill level and experience. For example, an OPA is appropriate only for an unconscious patient without a gag reflex, while an NPA may be used in a semi-conscious patient.</li> <li>Confirm Proper Placement After Insertion: After inserting any airway device, it is crucial to confirm proper placement using multiple methods. Look for effective chest rise with ventilation, auscultate for bilateral breath sounds (equal on both sides of the chest), and listen for minimal air leakage around the device. Capnography is the most reliable method for confirming endotracheal tube placement and monitoring the effectiveness of ventilation.</li> <li>Secure the Device to Prevent Displacement: Once the airway is established and confirmed, it is essential to secure the device using tape, straps, or other appropriate securing mechanisms. This prevents accidental displacement during resuscitation efforts, patient movement, or transport.</li> </ul> Advanced airway management is a critical skill in PALS, as it provides the foundation for effective ventilation and oxygenation in critical situations. Proper selection, placement, and securement of these devices can significantly improve patient outcomes and ensure the success of resuscitation efforts. [[Next Lesson: Vascular Access|Vascular Access]] [[Back to Airway Management Basics|Airway Management Basics]]

<div class="lesson-title">Vascular Access in Infants and Children</div> Establishing vascular access is a critical step in Pediatric Advanced Life Support (PALS) for delivering essential medications, fluids, and blood products during the resuscitation of infants and children. Prompt and reliable vascular access is crucial for stabilizing patients experiencing shock, dehydration, or other critical illnesses. While peripheral intravenous (IV) access is the preferred initial method, intraosseous (IO) access provides a rapid and reliable alternative, especially in emergency situations where IV access is difficult to obtain or delayed. <h3>Types of Vascular Access in Pediatrics:</h3> <ol> <li>Peripheral Intravenous (IV) Access: Peripheral IV access is the preferred method for drug and fluid delivery whenever possible. It allows for the administration of a wide range of medications and fluids and is generally less invasive than IO access. <ul> <li>Common Sites in Infants and Children: <ul> <li>Hands and Forearms: Veins in the dorsal (back) aspect of the hand and the forearm are often readily accessible.</li> <li>Antecubital Fossa (Elbow Crease): The antecubital fossa may be used in older children.</li> <li>Feet: Veins in the feet can be used, especially in infants.</li> <li>Scalp Veins (Infants): Scalp veins can be a useful option in infants, particularly when peripheral access in the extremities is challenging.</li> </ul> </li> <li>Challenges in Pediatrics: Smaller vein sizes, dehydration, shock, and peripheral vasoconstriction can make peripheral IV access challenging in pediatric patients. Multiple attempts by skilled personnel are often required.</li> </ul> </li> <li>Intraosseous (IO) Access: IO access is a rapid, safe, and reliable alternative when peripheral IV access is difficult or cannot be obtained quickly. It provides direct access to the venous system via the bone marrow cavity, allowing for rapid infusion of fluids, medications, and blood products. <ul> <li>Preferred Sites in Infants and Children: <ul> <li>Proximal Tibia (Just Below the Knee): The proximal tibia is the preferred IO insertion site in infants and children due to its large, flat surface and relatively thin cortex.</li> <li>Distal Femur (Above the Knee): The distal femur can be used as an alternative site, particularly in older children.</li> <li>Proximal Humerus (Upper Arm): The proximal humerus can be used by trained personnel, but it requires specific training and may be more challenging in smaller children.</li> </ul> </li> <li>Advantages of IO Access: <ul> <li>Rapid and easy to establish, even in emergency situations.</li> <li>Provides access to the central circulation.</li> <li>Allows for the administration of all medications and fluids that can be given intravenously.</li> </ul> </li> </ul> </li> </ol> <h3>Steps for Establishing Vascular Access:</h3> <ul> <li>Peripheral IV Access: <ol> <li>Select an appropriate vein based on size and visibility.</li> <li>Apply a tourniquet proximal to the chosen site (if appropriate for the patient’s size).</li> <li>Cleanse the skin with an antiseptic solution (e.g., chlorhexidine, povidone-iodine).</li> <li>Insert the catheter using a smooth, steady motion.</li> <li>Advance the catheter over the needle into the vein.</li> <li>Remove the needle and advance the catheter.</li> <li>Secure the catheter in place with appropriate dressing and securement devices.</li> <li>In infants, transillumination (shining a light through the skin) can help visualize veins.</li> </ol> </li> <li>IO Access: <ol> <li>Locate the appropriate insertion site (typically the proximal tibia, 1-3 cm below the tibial tuberosity on the flat medial surface).</li> <li>Cleanse the skin with an antiseptic solution.</li> <li>Use a specifically designed IO needle and inserter (manual or power-driven).</li> <li>Advance the needle through the bone cortex into the marrow cavity using a twisting motion.</li> <li>Confirm placement by: <ul> <li>Loss of resistance as the needle enters the marrow cavity.</li> <li>Aspiration of bone marrow (although this is not always obtained).</li> <li>Free flow of fluids when infused.</li> </ul> </li> <li>Secure the IO needle in place.</li> </ol> </li> </ul> <h3>Key Points for Pediatric Patients Regarding Vascular Access:</h3> <ul> <li>Smaller Vein Sizes: Pediatric patients have significantly smaller vein sizes, requiring the use of smaller gauge catheters (e.g., 22-24 gauge in infants and young children).</li> <li>Difficulty with Venous Access: Factors such as dehydration, shock, peripheral vasoconstriction, and small size can make peripheral IV access extremely challenging in pediatric patients. IO access should be considered early in the resuscitation process if peripheral IV access is not readily obtained within a few attempts.</li> <li>Importance of Anatomical Landmarks: Familiarity with pediatric anatomical landmarks, especially for IO insertion, is crucial for successful and safe placement. Accurate identification of the insertion site minimizes the risk of complications such as growth plate injury or compartment syndrome.</li> <li>Rapid Fluid Boluses and Medication Administration: Fluid boluses are often administered rapidly in pediatric resuscitation to address hypovolemia or shock. IO access allows for the rapid and efficient infusion of fluids, medications, and blood products, making it a vital tool in pediatric emergencies.</li> </ul> [[Next Lesson: Recognition and Initial Assessment in Infants and Children|Recognition and Initial Assessment]] [[Back to Advanced Airway Techniques in Infants and Children|Advanced Airway Techniques]]

<div class="lesson-title">Recognition and Initial Assessment in Infants and Children</div> Early recognition of distress and a systematic assessment of an infant or child’s condition are vital components of PALS, as they allow healthcare providers to prioritize interventions and significantly improve patient outcomes. A structured approach ensures that no critical detail is missed, particularly in high-stress emergency situations where rapid decision-making is essential. The Pediatric Assessment Triangle (PAT) and the ABCDE approach provide reliable and complementary frameworks for evaluating a patient’s status and determining the most urgent needs. <h3>The Pediatric Assessment Triangle (PAT):</h3> The PAT is a rapid visual assessment tool that allows for immediate "across-the-room" evaluation of a child's overall physiological condition *without requiring hands-on contact*. It focuses on three key components that reflect the child's overall well-being: <ul> <li>Appearance (Overall Impression): This assesses the child’s level of consciousness or alertness, muscle tone (movement and posture), and interaction with the environment (e.g., eye contact, response to stimuli). Look for signs of: <ul> <li>Alertness: Is the child awake, interactive, and responsive to voice or touch?</li> <li>Tone: Does the child have good muscle tone, or are they floppy or limp?</li> <li>Interactiveness: Is the child interacting appropriately with their surroundings or caregivers?</li> <li>Consolability: Can the child be consoled by caregivers?</li> <li>Look/Gaze: Does the child have a fixed gaze or avoid eye contact?</li> <li>Speech/Cry: Is the child’s cry strong or weak, or are they making any sounds at all?</li> </ul> </li> <li>Work of Breathing: This assesses the child’s respiratory effort. Observe the child’s breathing pattern and look for signs of increased work of breathing, such as: <ul> <li>Retractions: Inward pulling of the skin between the ribs, above the clavicles (supraclavicular), or below the ribcage (subcostal).</li> <li>Nasal Flaring: Widening of the nostrils with each breath.</li> <li>Head Bobbing: The head bobs forward with each breath, often seen in infants.</li> <li>Use of Accessory Muscles: Use of muscles in the neck, abdomen, or shoulders to assist with breathing.</li> <li>Abnormal Breath Sounds: Stridor (high-pitched whistling sound), grunting (short, low-pitched sound at the end of expiration), or wheezing.</li> </ul> </li> <li>Circulation to Skin: This assesses the child’s circulatory status by observing skin color and perfusion. Look for signs of: <ul> <li>Pallor: Pale skin color, indicating poor perfusion.</li> <li>Mottling: Patchy discoloration of the skin, suggesting poor circulation.</li> <li>Cyanosis (Bluish Discoloration): Bluish discoloration of the skin, particularly around the lips and fingertips, indicating low oxygen levels in the blood.</li> </ul> </li> </ul> <h3>The ABCDE Approach (Integrated with PAT):</h3> The ABCDE approach provides a more detailed, hands-on assessment that builds upon the initial impression gained from the PAT. It follows a systematic approach to identify and manage life threats: <ol> <li>Airway: Assess airway patency (openness). Look for signs of obstruction, such as: <ul> <li>Stridor: A high-pitched, whistling sound indicating upper airway obstruction.</li> <li>Snoring or Gurgling: Noisy breathing sounds that suggest partial airway obstruction.</li> <li>Inability to Speak or Cry: Inability to produce sounds indicates complete airway obstruction.</li> </ul> Use appropriate airway maneuvers (head-tilt/chin-lift or jaw-thrust) as needed to open the airway.</li> <li>Breathing: Evaluate the rate, effort, and adequacy of ventilation: <ul> <li>Respiratory Rate: Count the number of breaths per minute.</li> <li>Respiratory Effort: Observe for signs of increased work of breathing (as described in the PAT).</li> <li>Breath Sounds: Listen for normal, diminished, or absent breath sounds in all lung fields.</li> <li>Oxygen Saturation (SpO2): Use a pulse oximeter to measure the percentage of oxygen in the blood.</li> </ul> Provide supplemental oxygen and/or ventilatory support (e.g., bag-mask ventilation, advanced airway) as needed.</li> <li>Circulation: Assess the adequacy of circulation by evaluating: <ul> <li>Heart Rate: Count the heart rate. Tachycardia (fast heart rate) or bradycardia (slow heart rate) can indicate circulatory problems.</li> <li>Pulse Quality: Assess the strength and regularity of peripheral pulses (e.g., radial, brachial, femoral). Weak or thready pulses can indicate poor perfusion.</li> <li>Capillary Refill: Press on a nail bed or forehead and observe how quickly the color returns. Delayed capillary refill (greater than 2 seconds) suggests poor peripheral circulation.</li> <li>Skin Color and Temperature: Assess skin color (pallor, mottling, cyanosis) and temperature (cool, clammy skin can indicate shock).</li> </ul> Look for signs of shock, such as tachycardia, weak pulses, delayed capillary refill, and cool, clammy skin.</li> <li>Disability (Neurological Status): Assess the child’s neurological status using: <ul> <li>AVPU Scale: A quick assessment of alertness (A), response to verbal stimuli (V), response to pain (P), and unresponsiveness (U).</li> <li>Pediatric Glasgow Coma Scale (GCS): A more detailed assessment of level of consciousness, evaluating eye opening, verbal response, and motor response.</li> </ul> Look for changes in level of consciousness, pupillary response (size, equality, reactivity to light), and motor function.</li> <li>Exposure (and Environment): Expose the patient to assess for injuries, rashes, or other visible signs that may provide clues to the underlying problem. It is also essential to maintain the patient’s body temperature to prevent hypothermia, especially in infants and young children, who are more susceptible to heat loss.</li> </ol> <h3>Key Considerations in Pediatric Assessment:</h3> <ul> <li>Age-Appropriate Assessment: Adapt your assessment techniques and interpretation of findings to the child’s age and developmental stage. For example, assessing interaction and communication will differ significantly between a newborn and a school-aged child.</li> <li>Parental Presence and Involvement: The presence of a parent or caregiver can often provide valuable information about the child’s baseline condition and help calm the child during a stressful situation. Involving parents or caregivers in the assessment process can also be beneficial.</li> <li>Potential for Rapid Deterioration: Children can decompensate quickly, meaning their condition can deteriorate rapidly. Therefore, continuous monitoring and frequent reassessment are crucial to detect changes early and intervene promptly.</li> </ul> The PAT and ABCDE approach provide a structured and complementary framework for rapidly assessing and managing critically ill or injured infants and children. By using these tools systematically, healthcare providers can identify and address life-threatening conditions promptly, significantly improving patient outcomes. [[Next Lesson: Bradycardia in Infants and Children|Bradycardia Algorithm]] [[Back to Vascular Access in Infants and Children|Vascular Access]]

<div class="lesson-title">Bradycardia in Infants and Children</div> Bradycardia in infants and children is defined as a heart rate slower than the normal range for their age. It's crucial to understand that unlike in adults, where bradycardia can often be a primary cardiac issue, in children, it is most frequently a secondary response to hypoxia (low oxygen levels), respiratory distress or failure, shock, or other underlying physiological stressors. Recognizing bradycardia and, more importantly, promptly identifying and treating the underlying cause are crucial in pediatric patients. The PALS approach emphasizes addressing the root cause while simultaneously supporting the child's heart rate and circulation. <h3>Recognizing Bradycardia in Infants and Children:</h3> <ul> <li>Age-Specific Heart Rate Ranges: Normal heart rates vary significantly with age in pediatric patients. It's essential to be familiar with the normal ranges for different age groups to accurately identify bradycardia: <ul> <li>Infants (0-1 year): Normal heart rate is typically 100-160 bpm. Bradycardia in infants is generally defined as a heart rate less than 100 bpm. However, it's critical to note that a heart rate below 60 bpm in an infant is a critical emergency and requires immediate intervention.</li> <li>Children (1-10 years): Normal heart rate is typically 60-140 bpm. Bradycardia in this age group is generally defined as a heart rate less than 60 bpm.</li> <li>Children (10+ years): Normal heart rate is typically 60-100 bpm, similar to adults. Bradycardia is generally defined as a heart rate less than 60 bpm.</li> </ul> </li> <li>Signs and Symptoms of Significant Bradycardia: Significant bradycardia is defined as bradycardia that is causing signs and symptoms of poor perfusion. These signs and symptoms can include: <ul> <li>Poor Perfusion: Cool extremities, delayed capillary refill (greater than 2 seconds), weak or absent peripheral pulses.</li> <li>Altered Mental Status: Decreased level of consciousness, irritability, lethargy, or unresponsiveness.</li> <li>Hypotension (Low Blood Pressure): Although hypotension is a late sign of decompensation in children, it is a critical finding in the presence of bradycardia.</li> </ul> </li> </ul> <h3>PALS Approach to Managing Bradycardia:</h3> <ol> <li>Ensure Adequate Oxygenation and Ventilation: The most common and often immediately reversible cause of bradycardia in children is hypoxia. The first priority is to ensure a patent airway, provide supplemental oxygen (100% if available), and assist ventilations with a bag-valve-mask (BVM) if the child is not breathing adequately or has inadequate respiratory effort. Effective ventilation is often the most important intervention.</li> <li>Identify and Treat the Underlying Cause: While addressing oxygenation and ventilation, simultaneously look for and treat reversible causes of bradycardia. Remember the "H's and T's": <ul> <li>Hypoxia: Low oxygen levels (the most common cause).</li> <li>Hypovolemia: Low blood volume (e.g., due to dehydration or bleeding).</li> <li>Hydrogen Ion (Acidosis): An abnormal increase in acidity in the body fluids.</li> <li>Hypo/Hyperkalemia: Abnormally low or high potassium levels.</li> <li>Hypothermia: Low body temperature.</li> <li>Tension Pneumothorax: Air trapped in the chest cavity, compressing the lungs and heart.</li> <li>Tamponade (Cardiac): Fluid buildup around the heart, restricting its ability to pump.</li> <li>Toxins: Drug overdose or poisoning.</li> <li>Thrombosis (Pulmonary or Coronary): Blood clots in the lungs or heart arteries.</li> </ul> </li> <li>Pharmacological Intervention (If Bradycardia Persists Despite Adequate Oxygenation and Ventilation): If the bradycardia persists despite adequate oxygenation and ventilation and treatment of reversible causes, pharmacological intervention may be necessary: <ul> <li>Epinephrine: Epinephrine is the first-line medication for symptomatic bradycardia in children. It increases heart rate and strengthens cardiac contractions. The recommended dose is 0.01 mg/kg IV/IO (0.1 mL/kg of 1:10,000 solution). This dose can be repeated every 3-5 minutes as needed.</li> <li>Atropine: Atropine may be considered for bradycardia that is likely due to increased vagal tone (e.g., from airway manipulation or certain medications) or AV block. However, it is less commonly used as a first-line medication in pediatric bradycardia compared to adults. The dose is 0.02 mg/kg IV/IO (minimum dose 0.1 mg).</li> <li>Pacing (Transcutaneous or Transvenous): If medications are ineffective in improving the heart rate and perfusion, transcutaneous pacing (TCP) may be considered. However, TCP is often poorly tolerated in awake children and may require sedation. Transvenous pacing is a more invasive procedure typically performed in a hospital setting.</li> </ul> </li> </ol> <h3>Key Differences from Adult Bradycardia Management:</h3> <ul> <li>Emphasis on Oxygenation and Ventilation: In children, bradycardia is usually a secondary response to hypoxia or other underlying physiological stress. Therefore, the primary focus is on ensuring adequate oxygenation and ventilation first.</li> <li>Less Frequent Use of Atropine as First-Line Medication: Atropine is less commonly used as a first-line medication in pediatric bradycardia compared to adults. Epinephrine is generally the preferred initial pharmacologic agent.</li> </ul> [[Next Lesson: Tachycardia in Infants and Children|Tachycardia Algorithm]] [[Back to Recognition and Initial Assessment in Infants and Children|Recognition and Initial Assessment]]

<div class="lesson-title">Tachycardia in Infants and Children</div> Tachycardia in infants and children is defined as a heart rate faster than the normal range for their age. While some degree of tachycardia can be a normal physiological response to stress, exercise, or excitement, persistent or significantly elevated heart rates can be a sign of underlying problems such as fever, dehydration, pain, anxiety, infection, or cardiac abnormalities. It's crucial to differentiate between stable and unstable tachycardia and to identify and address the underlying cause. The PALS approach focuses on stabilizing the child's condition and treating the root cause. <h3>Recognizing Tachycardia in Infants and Children:</h3> <ul> <li>Age-Specific Heart Rate Ranges: Normal heart rates vary significantly with age in pediatric patients. Therefore, accurate identification of tachycardia requires knowledge of age-appropriate heart rate ranges: <ul> <li>Infants (0-3 months): Normal heart rate is typically 85-205 bpm.</li> <li>Infants (3 months-2 years): Normal heart rate is typically 100-190 bpm.</li> <li>Children (2-10 years): Normal heart rate is typically 60-140 bpm.</li> <li>Children (10+ years): Normal heart rate is typically 60-100 bpm (similar to adults).</li> </ul> </li> <li>Signs and Symptoms of Unstable Tachycardia: Recognizing signs of instability is crucial for prompt intervention. Unstable tachycardia is defined as tachycardia associated with signs and symptoms of poor perfusion, indicating inadequate tissue oxygen delivery: <ul> <li>Poor Perfusion: Cool extremities, delayed capillary refill (greater than 2 seconds), weak or absent peripheral pulses, decreased urine output.</li> <li>Altered Mental Status: Decreased level of consciousness, irritability, lethargy, or unresponsiveness.</li> <li>Hypotension (Low Blood Pressure): Although often a late sign in children, hypotension is a critical finding in the presence of tachycardia.</li> <li>Other signs may include: Signs of heart failure (e.g., respiratory distress, crackles in the lungs), chest pain, or dizziness.</li> </ul> </li> </ul> <h3>PALS Approach to Managing Tachycardia:</h3> <ol> <li>Assess for Signs of Instability: The first step is to rapidly determine if the tachycardia is causing signs of hemodynamic instability (poor perfusion, altered mental status, or hypotension). If any of these signs are present, the child is considered unstable and requires immediate intervention (synchronized cardioversion).</li> <li>Ensure Adequate Oxygenation and Ventilation: Regardless of stability, ensure the child has adequate oxygenation and ventilation. Provide supplemental oxygen (100% if available) and assist ventilations with a bag-valve-mask (BVM) if needed.</li> <li>Identify and Treat the Underlying Cause: While stabilizing the child, simultaneously attempt to identify and treat the underlying cause of the tachycardia. Consider and treat reversible causes such as: <ul> <li>Fever: Treat with antipyretics (e.g., acetaminophen, ibuprofen).</li> <li>Dehydration: Provide fluid resuscitation.</li> <li>Pain: Administer appropriate analgesia.</li> <li>Anxiety: Provide reassurance and comfort.</li> <li>Electrolyte Imbalances: Correct any electrolyte abnormalities.</li> <li>Hypovolemia: Treat with fluid resuscitation.</li> <li>Hypoxia: Ensure adequate oxygenation and ventilation.</li> </ul> </li> <li>Management of Unstable Tachycardia: If the child is unstable, the treatment of choice is synchronized cardioversion. <ul> <li>Synchronized Cardioversion: This involves delivering a controlled electrical shock synchronized to the child's R wave on the ECG to terminate the abnormal rhythm. The initial dose is 0.5-1 joules/kg. If the first shock is unsuccessful, the dose can be increased to 2 joules/kg for subsequent shocks.</li> </ul> </li> <li>Management of Stable Tachycardia: If the child is stable (no signs of poor perfusion, altered mental status, or hypotension), the following interventions can be considered: <ul> <li>Vagal Maneuvers: In some cases of stable supraventricular tachycardia (SVT), vagal maneuvers (e.g., ice to the face, Valsalva maneuver in older children) can be attempted to slow the heart rate. However, these are often less effective in infants and young children.</li> <li>Adenosine (for SVT): If vagal maneuvers are unsuccessful, adenosine is the drug of choice for stable SVT. It is given as a rapid IV push followed by a saline flush. The initial dose is 0.1 mg/kg IV rapid push (maximum first dose: 6 mg). If the first dose is ineffective, a second dose of 0.2 mg/kg IV rapid push can be given (maximum second dose: 12 mg).</li> </ul> </li> </ol> <h3>Key Differences from Adult Tachycardia Management:</h3> <ul> <li>Emphasis on Synchronized Cardioversion for Unstable Tachycardia: In children, synchronized cardioversion is the primary treatment for unstable tachycardia, whereas in adults, other medications may be considered before cardioversion in some cases.</li> <li>Weight-Based Medication Dosing: The doses of medications like adenosine and other antiarrhythmics are weight-based in children, requiring careful calculation and administration.</li> </ul> [[Next Lesson: Cardiac Arrest in Infants and Children|Cardiac Arrest Algorithm]] [[Back to Bradycardia in Infants and Children|Bradycardia Algorithm]]

<div class="lesson-title">Cardiac Arrest in Infants and Children</div> Cardiac arrest is a life-threatening emergency in which the heart suddenly stops pumping blood effectively, resulting in the cessation of circulation and oxygen delivery to vital organs. In infants and children, cardiac arrest is often secondary to respiratory failure, shock (inadequate tissue perfusion), or congenital heart defects, rather than primarily a cardiac event as is more common in adults. Early recognition of the signs of cardiac arrest and immediate, effective intervention are crucial to maximizing survival rates and improving neurological outcomes. The PALS Cardiac Arrest Algorithm provides a structured, evidence-based approach to managing this critical situation. <h3>Recognizing Cardiac Arrest in Infants and Children:</h3> <ul> <li>Absence of a Pulse: The absence of a palpable pulse in a central artery (brachial in infants, carotid or femoral in children) confirms that the heart is not effectively pumping blood. It's crucial to check for a pulse for at least 5 seconds but no more than 10 seconds.</li> <li>Unresponsiveness and Absence of Normal Breathing: Infants and children in cardiac arrest will be unresponsive to stimuli and either not breathing or exhibiting only agonal gasps (infrequent, gasping breaths that are not effective for ventilation). Agonal gasps should be considered a sign of cardiac arrest.</li> </ul> <h3>Shockable Rhythms in Pediatric Cardiac Arrest:</h3> <ul> <li>Ventricular Fibrillation (VF): VF is a chaotic, disorganized electrical activity in the ventricles that prevents coordinated contractions and thus effective pumping of blood. VF is a relatively common cause of sudden cardiac arrest and typically responds well to defibrillation (electrical shock).</li> <li>Pulseless Ventricular Tachycardia (pVT): pVT is a rapid, organized rhythm originating in the ventricles but without a palpable pulse. Like VF, it results in no effective cardiac output and is treated with defibrillation and medication. pVT can be monomorphic (consistent QRS complexes) or polymorphic (varying QRS complexes).</li> </ul> <h3>Non-Shockable Rhythms in Pediatric Cardiac Arrest:</h3> <ul> <li>Asystole: Asystole is a flatline or near-flatline tracing on the ECG, indicating the absence of any organized electrical activity in the heart. Asystole is treated with high-quality CPR and medications but is associated with a poorer prognosis than shockable rhythms.</li> <li>Pulseless Electrical Activity (PEA): PEA is defined as organized electrical activity visible on the ECG but without an accompanying palpable pulse. This indicates that the heart's electrical system is working, but the heart muscle is not contracting effectively or at all. Management of PEA focuses on identifying and addressing the underlying cause (the "H's and T's").</li> </ul> <h3>PALS Cardiac Arrest Algorithm:</h3> <ol> <li>Initiate CPR and Provide Oxygen: Immediately begin high-quality chest compressions and provide supplemental oxygen (100% if available) to optimize oxygenation. Attach a defibrillator or cardiac monitor as soon as available to identify the cardiac rhythm. <ul> <li>CPR Details: Maintain a compression rate of 100-120 per minute and a depth of at least one-third the anterior-posterior diameter of the chest. Minimize interruptions in chest compressions. Ensure effective ventilations with adequate chest rise.</li> </ul> </li> <li>If the Rhythm is Shockable (VF/pVT): <ul> <li>Defibrillation: Deliver 1 shock using the defibrillator. The recommended energy dose is 2 joules/kg for the first shock.</li> <li>Immediate CPR: Immediately resume high-quality CPR for 2 minutes (approximately 5 cycles of 30:2 compressions to ventilations if no advanced airway is in place, or continuous compressions with 1 breath every 6 seconds if an advanced airway is present).</li> <li>Epinephrine: Administer epinephrine (0.01 mg/kg IV/IO) after the second shock (if the rhythm remains VF/pVT) to enhance coronary and cerebral perfusion. Repeat epinephrine every 3-5 minutes as needed.</li> <li>Amiodarone or Lidocaine (for Refractory VF/pVT): If VF or pVT persists after multiple shocks and epinephrine administration, consider administering an antiarrhythmic medication such as amiodarone (5 mg/kg IV bolus) or lidocaine (1 mg/kg IV bolus).</li> </ul> </li> <li>If the Rhythm is Non-Shockable (Asystole/PEA): <ul> <li>Continue High-Quality CPR: Continue high-quality CPR, focusing on effective chest compressions and ventilations.</li> <li>Epinephrine: Administer epinephrine (0.01 mg/kg IV/IO) as soon as IV/IO access is established. Repeat every 3-5 minutes.</li> <li>Identify and Treat Reversible Causes (H's and T's): Actively search for and treat reversible causes of cardiac arrest.</li> <li>Rhythm Checks: Reassess the cardiac rhythm every 2 minutes (during pulse checks) to determine if it has transitioned to a shockable rhythm.</li> </ul> </li> </ol> <h3>Key Interventions in Pediatric Cardiac Arrest:</h3> <ul> <li>Ensure High-Quality CPR: Effective chest compressions are absolutely critical for maintaining circulation and oxygen delivery during cardiac arrest. Focus on minimizing interruptions, achieving the correct compression rate and depth, and allowing full chest recoil.</li> <li>Identify and Treat Reversible Causes (H's and T's): Identifying and treating reversible causes is essential for successful resuscitation. Remember the "H's and T's": Hypoxia, Hypovolemia, Hydrogen ion (acidosis), Hypo/Hyperkalemia, Hypothermia, Tension pneumothorax, Tamponade (cardiac), Toxins, and Thrombosis (pulmonary or coronary).</li> </ul> By following the PALS Cardiac Arrest Algorithm and focusing on high-quality CPR and the identification and treatment of reversible causes, healthcare providers can deliver structured, evidence-based care to maximize the chances of survival and improve neurological outcomes in infants and children experiencing cardiac arrest. Rapid identification of the cardiac rhythm and swift application of defibrillation (when indicated), medications, and effective CPR are the cornerstones of successful resuscitation. [[Next Lesson: Stroke Recognition and Management|Stroke Recognition and Management]] [[Back to Tachycardia in Infants and Children|Tachycardia Algorithm]]

<div class="lesson-title">Stroke Recognition and Management</div> Stroke is a medical emergency that occurs when blood flow to a part of the brain is interrupted, depriving brain tissue of oxygen and nutrients. This interruption can be caused by a blockage (ischemic stroke, the most common type) or a rupture of a blood vessel (hemorrhagic stroke). Rapid recognition of stroke symptoms and immediate intervention are essential to minimize brain damage, reduce long-term disability, and improve patient outcomes. Timely treatment, particularly with thrombolytic (clot-busting) medications or mechanical thrombectomy (clot removal), can significantly enhance the chances of recovery. The ACLS guidelines emphasize the importance of early identification, prompt activation of emergency services (911 or your local emergency number), and swift transport to specialized stroke centers equipped for advanced diagnostic imaging and treatment. <h3>Recognizing Stroke Symptoms:</h3> The FAST acronym is a simple, memorable, and highly effective tool for recognizing the most common stroke symptoms and prompting quick action: <ul> <li>F – Facial Drooping: Ask the person to smile. Does one side of the face droop, or does the smile appear uneven? Check for facial numbness or weakness.</li> <li>A – Arm Weakness: Ask the person to raise both arms. Does one arm drift downward, or is the person unable to raise one arm at all? Check for arm numbness or weakness.</li> <li>S – Speech Difficulty: Ask the person to repeat a simple phrase, such as "The sky is blue." Listen for slurred speech, difficulty forming words, or inability to speak.</li> <li>T – Time to Call Emergency Services: If you observe any of these signs, even if they disappear, it is *time to call emergency services immediately*. Time is of the essence in stroke management. Every minute that passes without treatment increases the risk of permanent brain damage. Note the time of symptom onset, as this information is crucial for treatment decisions.</li> </ul> <h3>Initial Assessment and Management in the Field/Emergency Department:</h3> <ol> <li>Activate Emergency Response System (EMS): The very first action upon recognizing stroke symptoms is to call emergency medical services (911 or your local emergency number). This initiates the chain of survival for stroke patients, ensuring rapid transport and access to specialized care.</li> <li>Perform ABCs (Airway, Breathing, Circulation): Assess and stabilize the patient’s airway, breathing, and circulation. Ensure a patent airway, provide supplemental oxygen if the patient is hypoxic (low oxygen levels), and monitor vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation) closely.</li> <li>Obtain a Focused Patient History: Gather a focused patient history, including: <ul> <li>Time of Symptom Onset: This is the *most critical* piece of information. The time the patient was last seen "normal" is crucial for determining eligibility for thrombolytic therapy (tPA).</li> <li>Past Medical History: Ask about any prior strokes, heart disease, diabetes, hypertension, bleeding disorders, or recent surgeries.</li> <li>Medications: Obtain a list of all current medications, especially anticoagulants (blood thinners).</li> </ul> </li> <li>Rapid Neurological Examination: Perform a rapid neurological examination using standardized stroke scales such as the National Institutes of Health Stroke Scale (NIHSS). This helps quantify the severity of the stroke and guides treatment decisions.</li> <li>Transport to a Designated Stroke Center: Ensure the patient is transported as quickly as possible to a designated stroke center equipped with CT or MRI imaging capabilities and a multidisciplinary stroke team. These facilities are best equipped to provide advanced stroke care, including thrombolytic therapy and mechanical thrombectomy.</li> </ol> <h3>Fibrinolytic Therapy (tPA):</h3> Fibrinolytic therapy with tissue plasminogen activator (tPA) is a medication that can dissolve blood clots and restore blood flow to the brain in ischemic stroke. However, it must be administered within a specific time window from symptom onset. <ul> <li>Eligibility Criteria: tPA is typically administered within 3-4.5 hours of symptom onset for eligible patients who meet specific criteria and do not have any contraindications. Eligibility criteria may vary slightly based on local protocols.</li> <li>Contraindications: There are several contraindications to tPA administration, including: <ul> <li>Active internal bleeding.</li> <li>Recent surgery (within 14 days).</li> <li>History of hemorrhagic stroke.</li> <li>Uncontrolled hypertension (high blood pressure).</li> <li>Recent head trauma.</li> <li>Known bleeding disorders.</li> </ul> </li> <li>Monitoring During and After tPA Administration: During and after tPA administration, close monitoring is essential to detect any potential complications, such as: <ul> <li>Bleeding (especially intracranial hemorrhage).</li> <li>Angioedema (swelling of the face, tongue, or throat).</li> <li>Neurological changes (worsening or improvement of symptoms).</li> </ul> </li> </ul> Rapid action and adherence to established stroke protocols and the ACLS Stroke Algorithm can dramatically improve outcomes for stroke patients. Recognizing the signs of stroke early, immediately activating the emergency response system, and ensuring timely transport to a stroke center are essential steps in minimizing brain damage and maximizing the patient's potential for recovery. [[Next Lesson: Post-Resuscitation Care|Post-Resuscitation Care]] [[Back to Cardiac Arrest Algorithm|Cardiac Arrest Algorithm]]

<div class="lesson-title">Post-Resuscitation Care in Infants and Children</div> Achieving return of spontaneous circulation (ROSC) is a critical milestone in resuscitation, signifying the restoration of organized cardiac activity and perfusion. However, post-resuscitation care is equally crucial, as it focuses on stabilizing the patient, preventing secondary injury (especially to the brain), and optimizing long-term outcomes. This phase of care is essential for maximizing survival and minimizing neurological damage following cardiac arrest. A systematic, multidisciplinary approach ensures that all aspects of patient care are addressed effectively. <h3>Key Components of Post-Resuscitation Care in Infants and Children:</h3> <ol> <li>Optimize Ventilation and Oxygenation: Maintaining adequate oxygenation and ventilation is paramount to prevent further hypoxic injury. <ul> <li>Oxygen Saturation (SpO2): Maintain SpO2 at or above 94% using supplemental oxygen as needed. Titrate oxygen to avoid hyperoxia (excess oxygen), which can also be harmful.</li> <li>Ventilation: Avoid excessive ventilation (hyperventilation), as it can reduce cardiac output and cerebral perfusion due to decreased venous return. Monitor end-tidal CO2 (ETCO2) levels to ensure adequate ventilation without over-ventilation. A target ETCO2 of 35-40 mmHg is generally recommended. If an advanced airway is in place, continue mechanical ventilation.</li> </ul> </li> <li>Monitor Hemodynamics (Circulation): Ensuring adequate blood pressure and cardiac output is essential to support organ perfusion and prevent further ischemia. <ul> <li>Blood Pressure Support: Use fluids (crystalloids or blood products if indicated) to restore intravascular volume if the patient is hypotensive. If fluids are insufficient to maintain adequate blood pressure, consider using vasopressors such as norepinephrine or dopamine.</li> <li>Target Blood Pressure: The target systolic blood pressure should be age-appropriate (generally above 90 mmHg in older children, with lower targets for infants). Mean arterial pressure (MAP) should be maintained at 65 mmHg or higher.</li> <li>Continuous Monitoring: Continuous monitoring of vital signs (heart rate, blood pressure, respiratory rate, SpO2, ETCO2) is essential.</li> </ul> </li> <li>Perform Frequent Neurological Assessments: Regularly evaluate the patient’s neurological status to detect early signs of brain injury or deterioration. <ul> <li>Level of Consciousness: Assess responsiveness using tools like the AVPU scale (Alert, Verbal, Pain, Unresponsive) or the Pediatric Glasgow Coma Scale (GCS).</li> <li>Pupillary Response: Monitor pupillary size, equality, and reactivity to light.</li> <li>Motor Function: Assess motor strength and movement.</li> <li>Seizure Monitoring and Management: Monitor for seizures, which are common after cardiac arrest. Treat seizures promptly with appropriate anticonvulsant medications.</li> </ul> </li> <li>Targeted Temperature Management (TTM): Targeted temperature management (therapeutic hypothermia), maintaining a controlled temperature between 32–36°C (89.6-96.8°F) for 24 hours, has been shown to improve neurological outcomes in patients who remain comatose after ROSC. <ul> <li>Initiation of Cooling: Begin cooling as soon as possible after ROSC in eligible patients.</li> <li>Methods of Cooling: Cooling can be achieved using various methods, including cooling blankets, ice packs, and intravascular cooling devices.</li> <li>Monitoring for Complications: Closely monitor for complications associated with TTM, such as arrhythmias, shivering, electrolyte imbalances, and infection.</li> </ul> </li> <li>Identify and Treat Underlying Causes: Determining and treating the underlying cause of the cardiac arrest is crucial to prevent recurrence. This involves a thorough evaluation to identify and manage conditions such as: <ul> <li>Myocardial Infarction: Heart attack.</li> <li>Hypoxia: Low oxygen levels.</li> <li>Electrolyte Imbalances (e.g., hyperkalemia): Abnormally high or low levels of electrolytes in the blood.</li> <li>Toxic Ingestions/Overdoses: Drug overdoses or poisonings.</li> <li>Sepsis: Severe infection.</li> <li>Other reversible factors from the "H's and T's" (Hypovolemia, Hydrogen ion [acidosis], Hypothermia, Tension pneumothorax, Tamponade [cardiac], Toxins, Thrombosis [pulmonary or coronary]).</li> </ul> </li> </ol> <h3>Overall Goals of Post-Resuscitation Care:</h3> <ul> <li>Prevent Secondary Brain Injury: Optimizing oxygen delivery, ensuring adequate organ perfusion, and controlling temperature are crucial for minimizing secondary brain injury, which is a major determinant of long-term neurological outcome.</li> <li>Identify and Treat Reversible Causes: Promptly identifying and addressing underlying conditions reduces the risk of recurrent cardiac arrest and improves overall outcomes.</li> <li>Provide Comprehensive, Multidisciplinary Support: Post-resuscitation care requires a multidisciplinary approach involving physicians, nurses, respiratory therapists, and other healthcare professionals. This includes ongoing monitoring, medication management, rehabilitation, and psychosocial support for the patient and their family.</li> </ul> Post-resuscitation care is a complex and crucial phase of resuscitation that requires advanced monitoring, therapeutic interventions, and comprehensive supportive care to give patients the best possible chance at recovery. By diligently following these guidelines and working as a coordinated team, healthcare providers can significantly improve survival rates and neurological outcomes in infants and children who have achieved ROSC. [[Next Lesson: Medications in ACLS|Medications in PALS]] [[Back to Stroke Recognition and Management|Stroke Recognition and Management]]

<div class="lesson-title">Medications in PALS</div> Medications are a crucial component of Pediatric Advanced Life Support (PALS), playing a vital role in restoring normal cardiac rhythms, enhancing circulation, and addressing underlying causes of cardiac arrest and arrhythmias in infants and children. Proper use of medications, in conjunction with high-quality CPR and defibrillation (when indicated), significantly improves patient outcomes. A thorough understanding of the indications, *weight-based* dosages, administration routes, and potential side effects for each medication is essential for effective pediatric resuscitation. <h3>Key PALS Medications:</h3> <ul> <li>Epinephrine: Epinephrine is a primary medication used in pediatric cardiac arrest management. It acts as a potent vasoconstrictor (narrowing blood vessels), which improves coronary and cerebral perfusion pressure during CPR, increasing the likelihood of return of spontaneous circulation (ROSC). It also has positive inotropic (strengthening heart contractions) and chronotropic (increasing heart rate) effects. <ul> <li>Indications: Used for pulseless arrest (VF, pVT, asystole, PEA) and symptomatic bradycardia unresponsive to oxygenation and ventilation.</li> <li>Dosage: The recommended dose is 0.01 mg/kg IV/IO (0.1 mL/kg of 1:10,000 solution).</li> <li>Administration: Administer every 3–5 minutes during CPR. Early and regular administration is associated with improved chances of ROSC.</li> </ul> </li> <li>Amiodarone: Amiodarone is an antiarrhythmic medication used for shock-refractory ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT) that persists despite defibrillation and epinephrine administration. <ul> <li>Indications: Used for VF/pVT that is unresponsive to defibrillation and epinephrine.</li> <li>Dosage: The recommended dose is 5 mg/kg IV/IO as a bolus dose.</li> <li>Mechanism of Action: Amiodarone stabilizes the heart’s electrical activity, making it a critical second-line therapy after defibrillation fails.</li> </ul> </li> <li>Atropine: Atropine is an anticholinergic medication that blocks the effects of the vagus nerve, which can slow the heart rate. <ul> <li>Indications: May be considered for symptomatic bradycardia that is likely due to increased vagal tone (e.g., from airway manipulation) or AV block. It is less commonly used as a first-line medication in pediatric bradycardia compared to adults, where epinephrine is preferred.</li> <li>Dosage: The recommended dose is 0.02 mg/kg IV/IO (minimum dose 0.1 mg).</li> <li>Caution: Atropine is not effective for bradycardia caused by hypoxia. Ensuring adequate oxygenation and ventilation is the priority.</li> </ul> </li> <li>Adenosine: Adenosine is an antiarrhythmic medication used to terminate stable supraventricular tachycardia (SVT). It works by temporarily slowing conduction through the AV node, which can interrupt the re-entry circuit causing the SVT. <ul> <li>Indications: Used for stable SVT.</li> <li>Dosage: The initial dose is 0.1 mg/kg IV rapid push (maximum first dose: 6 mg). If the first dose is ineffective, a second dose of 0.2 mg/kg IV rapid push can be given (maximum second dose: 12 mg).</li> <li>Administration: Adenosine must be administered as a rapid IV push followed by a rapid saline flush to ensure it reaches the heart quickly.</li> </ul> </li> </ul> <h3>General Principles of Medication Administration in PALS:</h3> <ul> <li>Weight-Based Dosing: All medication doses in PALS are calculated based on the child's weight in kilograms (kg). Accurate weight estimation or measurement is crucial for safe and effective medication administration. Using a Broselow tape (a color-coded length-based tape measure) can be helpful for estimating weight and medication doses in emergency situations.</li> <li>Rapid Administration: Medications should be delivered via the fastest available and most reliable route, typically intravenous (IV) or intraosseous (IO). These routes ensure rapid onset of action during resuscitation. If peripheral IV access is difficult to obtain, establish IO access promptly.</li> <li>Flush the Line After Administration: After administering a medication, flush the IV or IO line with 2–5 mL of normal saline (depending on the child’s size) to ensure the full dose reaches the central circulation.</li> <li>Continuous Monitoring of Effects and for Side Effects: Continuously assess the patient’s response to medications. Monitor for desired effects, such as return of a pulse or conversion of an abnormal rhythm to a normal sinus rhythm. Also, be vigilant for potential side effects and be prepared to manage them appropriately.</li> </ul> A deep understanding of PALS medications, their indications, dosages, routes of administration, and potential side effects ensures that healthcare providers can respond confidently and effectively during pediatric resuscitation. Medications, when combined with high-quality CPR and timely defibrillation (when indicated), form the backbone of advanced life support for children and significantly improve the chances of survival and positive neurological outcomes. [[Next Lesson: Special Resuscitation Scenarios in Pediatrics|Special Resuscitation Scenarios]] [[Back to Post-Resuscitation Care in Infants and Children|Post-Resuscitation Care]]

<div class="lesson-title">Special Resuscitation Scenarios in Pediatrics</div> Not all pediatric cardiac arrests follow typical patterns, and certain unique situations demand modifications to standard PALS protocols. Recognizing these special scenarios and tailoring resuscitation efforts accordingly can significantly improve outcomes. These scenarios often involve specific pathophysiological processes that require adjustments to standard interventions. Special resuscitation scenarios in pediatrics include submersion (drowning), foreign body aspiration, trauma, and other specific conditions where standard PALS interventions may need to be adjusted. <h3>Submersion (Drowning):</h3> <ul> <li>Focus on Oxygenation and Ventilation: Hypoxia is the primary insult in submersion injuries. Aggressive and early oxygenation and ventilation are crucial. Even after successful resuscitation, these patients are at high risk for ongoing respiratory complications, including acute respiratory distress syndrome (ARDS).</li> <li>Consider Cervical Spine Injury: If there is any suspicion of trauma associated with the submersion incident (e.g., diving injury), stabilize the cervical spine during airway management using manual in-line stabilization.</li> <li>Rewarming: Hypothermia is common in submersion victims, especially in cold water. Initiate active rewarming measures as soon as possible. This may include removing wet clothing, applying warming blankets, and administering warm intravenous fluids.</li> <li>Pulmonary Edema: Be prepared to manage pulmonary edema (fluid in the lungs), which is a common complication of submersion injuries. This may require positive pressure ventilation and diuretics.</li> </ul> <h3>Foreign Body Aspiration:</h3> <ul> <li>Conscious Child with Airway Obstruction: If the child is conscious but choking and unable to speak, cough effectively, or breathe, perform abdominal thrusts (Heimlich maneuver) for children older than 1 year.</li> <li>Unconscious Infant: For unconscious infants, provide a combination of back blows and chest thrusts. Place the infant face down over your forearm, supporting the head and neck, and deliver five back blows between the shoulder blades. Then, turn the infant face up and deliver five chest thrusts using two fingers in the same location as chest compressions for CPR.</li> <li>Direct Laryngoscopy and Magill Forceps: If basic maneuvers are unsuccessful in removing the foreign body, direct laryngoscopy (visualization of the airway with a laryngoscope) and Magill forceps (specialized forceps for foreign body removal) may be needed to visualize and remove the obstruction. This is typically performed by experienced personnel.</li> </ul> <h3>Trauma:</h3> <ul> <li>Control of Hemorrhage (Bleeding Control): Prioritize control of any external bleeding using direct pressure, pressure dressings, or tourniquets as needed. Hemorrhage is a major cause of shock and death in trauma patients.</li> <li>Spinal Immobilization: If there is any suspicion of spinal injury (e.g., from a fall, motor vehicle accident, or diving injury), immobilize the spine using a cervical collar and a backboard.</li> <li>Fluid Resuscitation for Hemorrhagic Shock: Aggressive fluid resuscitation with crystalloids (e.g., normal saline or lactated Ringer's solution) or blood products may be necessary to treat hemorrhagic shock (shock due to blood loss).</li> <li>**Consider Pneumothorax/Hemothorax:** Be vigilant for signs of pneumothorax (air in the chest cavity) or hemothorax (blood in the chest cavity), which can complicate resuscitation efforts in trauma patients.</li> </ul> <h3>Other Special Considerations:</h3> <ul> <li>Sepsis (Severe Infection): Recognize and treat sepsis promptly with appropriate antibiotics and aggressive fluid resuscitation. Sepsis can lead to shock and multi-organ dysfunction.</li> <li>Congenital Heart Disease: Children with congenital heart disease (heart defects present at birth) may require specialized management during resuscitation. Consultation with a pediatric cardiologist or a center with expertise in congenital heart disease is strongly recommended if available. Standard PALS algorithms may need to be modified based on the specific cardiac defect.</li> <li>Asthma Exacerbation:** Severe asthma exacerbations can lead to respiratory failure and cardiac arrest. Aggressive bronchodilator therapy (e.g., albuterol), corticosteroids, and magnesium sulfate may be necessary.</li> <li>**Anaphylaxis (Severe Allergic Reaction):** Anaphylaxis can cause rapid airway swelling and circulatory collapse. Treatment includes epinephrine, antihistamines, and corticosteroids.</li> </ul> Special resuscitation scenarios require quick thinking, careful assessment, and adaptations to standard PALS protocols. By understanding these unique situations and applying the appropriate modifications, healthcare providers can deliver more effective, lifesaving care tailored to the specific needs of the child. [[Next Lesson: Teamwork and Communication in PALS|Teamwork and Communication in PALS]] [[Back to Medications in PALS|Medications in PALS]]

<div class="lesson-title">Teamwork and Communication in PALS</div> Effective teamwork and clear communication are absolutely fundamental to success during a pediatric resuscitation effort. In the high-stakes, time-critical environment of PALS, where rapid decisions and coordinated actions are essential, a well-functioning team ensures that everyone understands their role, contributes effectively, and works cohesively to achieve the best possible outcomes for the child. Clear, concise, and closed-loop communication minimizes errors, improves efficiency, reduces stress, and ultimately enhances patient care. <h3>Key Team Dynamics in PALS Resuscitation:</h3> <ol> <li>Clearly Defined Roles and Responsibilities: Assigning specific tasks and responsibilities to each team member is essential to avoid duplication of effort, confusion, and omissions of critical tasks. Examples of roles include: <ul> <li>Team Leader: Oversees the resuscitation, makes critical decisions, and delegates tasks.</li> <li>Compressor: Performs chest compressions.</li> <li>Airway Manager: Manages the airway and provides ventilations.</li> <li>Medication Administrator: Prepares and administers medications.</li> <li>Monitor/Recorder: Monitors vital signs, records events, and communicates information to the team.</li> </ul> Clearly defined roles ensure that every critical task is covered efficiently and effectively.</li> <li>Closed-Loop Communication: Closed-loop communication is a crucial technique that ensures clarity, accuracy, and accountability. When an instruction or order is given, the recipient *repeats it back* to the sender to confirm understanding (e.g., "Administer 0.01 mg/kg epinephrine IV/IO." "0.01 mg/kg epinephrine IV/IO, administering now."). The sender then acknowledges the confirmation (e.g., "Correct."). This process prevents miscommunication, ensures that orders are heard and understood correctly, and allows for immediate correction if needed.</li> <li>Designated Team Leader: A designated team leader is essential for coordinating the resuscitation effort. The team leader serves as the central decision-maker, overseeing the entire resuscitation process. Their responsibilities include: <ul> <li>Assigning tasks and responsibilities to team members.</li> <li>Ensuring adherence to the PALS algorithm.</li> <li>Monitoring the overall progress of the resuscitation.</li> <li>Anticipating needs and proactively preparing for the next steps.</li> <li>Facilitating clear communication among team members.</li> </ul> A strong and effective leader fosters confidence, promotes teamwork, and keeps the team organized and focused, especially under pressure.</li> <li>Mutual Respect and Constructive Feedback: A supportive and respectful team environment encourages all team members to voice concerns, ask clarifying questions, suggest improvements, or point out potential errors without fear of reprimand or judgment. This culture of respect and open communication is essential for identifying and addressing potential problems quickly and improving team performance. Constructive feedback should be provided in a timely and respectful manner to enhance future performance.</li> </ol> <h3>Key Responsibilities of the Team Leader:</h3> <ul> <li>Monitor Progress and Provide Direction: The team leader continuously evaluates the team's performance, monitors the patient's condition, and ensures that all interventions align with the current PALS algorithm. The leader provides clear direction and guidance to the team, keeping everyone focused on the priorities.</li> <li>Delegate Tasks Effectively: The team leader assigns responsibilities clearly and confirms that each task is completed correctly and as expected. Effective delegation prevents gaps in care, avoids duplication of effort, and maintains a smooth and efficient workflow.</li> <li>Anticipate Needs and Plan Ahead: The team leader proactively guides the team by anticipating the next steps in the resuscitation process. This includes preparing for interventions such as defibrillation, medication administration (with correct pediatric dosing and appropriate equipment readily available), and advanced airway management.</li> </ul> <h3>Essential Communication Techniques for Effective Teamwork:</h3> <ul> <li>Use Clear and Concise Language: Avoid jargon or ambiguous terms. Use clear, simple language that everyone on the team can understand.</li> <li>Speak Clearly and Loudly Enough to Be Heard: In a noisy and stressful environment, it's essential to speak clearly and loudly enough to be heard by all team members.</li> <li>Use Closed-Loop Communication (as described above): This is one of the most effective ways to prevent miscommunication and ensure accuracy.</li> <li>Maintain a Calm and Assertive Tone: Speaking in a calm, confident, and assertive tone helps reduce stress and maintains focus during high-pressure situations. Avoid shouting or panicking, as this can escalate the situation and impair team performance.</li> <li>Briefings and Debriefings: Briefings (short team meetings before the resuscitation) can help the team prepare and assign roles. Debriefings (after the event) provide an opportunity to review the team's performance, identify areas for improvement, and reinforce positive behaviors.</li> </ul> Effective teamwork and communication are essential for optimizing outcomes in pediatric resuscitation. By implementing these strategies, healthcare providers can function as a highly effective team, improving the chances of survival and positive neurological outcomes for critically ill or injured children. [[Back to Special Resuscitation Scenarios in Pediatrics|Special Resuscitation Scenarios]]

<div class="lesson-title">PALS Provider Certification Course</div> Welcome to your Pediatric Advanced Life Support (PALS) Certification course! This comprehensive program is specifically designed to equip healthcare professionals, including physicians, nurses, paramedics, and other allied health personnel, with the specialized knowledge and skills necessary to effectively recognize and manage life-threatening emergencies in infants and children. Unlike adult patients, pediatric patients present unique physiological and developmental characteristics that require tailored assessment and intervention strategies. Whether you’re a seasoned healthcare provider or someone seeking to enhance your ability to save young lives, this course will prepare you to take decisive action, improve patient outcomes, and lead resuscitation efforts with confidence in pediatric emergencies. <h3>What You’ll Learn:</h3> Upon completion of this PALS course, you will gain proficiency in a wide range of critical skills and knowledge areas, including: <ul> <li>The Foundational Principles of PALS: This includes a deep understanding of the unique physiological differences between pediatric and adult patients, the importance of early recognition and intervention in pediatric emergencies, and the critical role of effective teamwork and communication during resuscitation efforts. You will learn about: <ul> <li>The Pediatric Chain of Survival: Understanding the specific steps in the pediatric Chain of Survival, which emphasizes prevention of cardiac arrest, early CPR, rapid activation of emergency medical services (EMS), effective advanced life support, and integrated post-cardiac arrest care. The chain emphasizes prevention and early intervention to avoid progression to cardiac arrest.</li> <li>Pediatric Assessment Triangle (PAT): This rapid assessment tool helps to quickly evaluate a child's overall condition based on appearance, work of breathing, and circulation to the skin.</li> </ul> </li> <li>Key Algorithms and Strategies for Managing Pediatric Emergencies: You will learn and practice using the key algorithms and strategies for managing common pediatric emergencies, including: <ul> <li>Respiratory Distress and Failure: Recognizing the signs and symptoms of respiratory distress and failure in infants and children, and implementing appropriate interventions, including oxygen therapy, airway management, and ventilatory support.</li> <li>Shock: Identifying different types of shock (hypovolemic, cardiogenic, distributive) in pediatric patients and implementing appropriate fluid resuscitation and pharmacologic interventions.</li> <li>Cardiac Arrest: Mastering the PALS cardiac arrest algorithm, including high-quality CPR, defibrillation (when indicated), and medication administration.</li> </ul> </li> <li>Advanced Techniques for Airway Management, Defibrillation, and Medication Administration: This section focuses on the practical skills needed to manage critical situations: <ul> <li>Airway Management: Performing basic and advanced airway maneuvers, including bag-mask ventilation, endotracheal intubation, and supraglottic airway placement.</li> <li>Effective Defibrillation: Understanding the principles of defibrillation and performing synchronized cardioversion and defibrillation using appropriate energy levels for pediatric patients.</li> <li>Medication Administration in Critical Scenarios: Learning the appropriate medications, dosages, and routes of administration for pediatric patients in various emergency situations, with careful consideration of weight-based dosing and age-specific considerations.</li> </ul> </li> </ul> <h3>How to Navigate:</h3> This course is structured as a progressive learning experience, with each lesson building upon the knowledge and skills acquired in previous lessons. We recommend proceeding through the lessons in sequential order to maximize your understanding of PALS concepts. Each lesson is designed to be self-contained, providing in-depth explanations, illustrative diagrams, and real-world applications and scenarios to ensure your grasp of the material. You can easily move forward to the next lesson or revisit previous lessons at any time using the navigation links provided at the bottom of each page. Upon completing all lessons and successfully passing the final exam, you’ll earn your PALS certification, a testament to your ability to confidently and competently handle life-threatening emergencies in infants and children. [[Start the Course|Pediatric Chain of Survival]]

<div class="lesson-title">PALS Certification Course - Table of Contents</div> This table of contents provides an overview of the PALS Certification Course and links to each lesson. You can use this page to navigate to any section of the course. <h3>Course Modules:</h3> <ul> <li> Introduction <ul> <li><a class="toc-link" href="[[Start the Course|Pediatric Chain of Survival]]">Welcome to PALS Certification</a></li> </ul> </li> <li> Foundational Concepts <ul> <li><a class="toc-link" href="[[Pediatric Chain of Survival]]">Pediatric Chain of Survival</a></li> <li><a class="toc-link" href="[[High-Quality CPR]]">High-Quality CPR in Infants and Children</a></li> <li><a class="toc-link" href="[[Airway Management Basics]]">Airway Management in Infants and Children</a></li> <li><a class="toc-link" href="[[Advanced Airway Techniques]]">Advanced Airway Techniques</a></li> <li><a class="toc-link" href="[[Vascular Access]]">Vascular Access in Infants and Children</a></li> <li><a class="toc-link" href="[[Recognition and Initial Assessment]]">Recognition and Initial Assessment</a></li> </ul> </li> <li> PALS Algorithms <ul> <li><a class="toc-link" href="[[Bradycardia Algorithm]]">Bradycardia in Infants and Children</a></li> <li><a class="toc-link" href="[[Tachycardia Algorithm]]">Tachycardia in Infants and Children</a></li> <li><a class="toc-link" href="[[Cardiac Arrest Algorithm]]">Cardiac Arrest in Infants and Children</a></li> </ul> </li> <li> Advanced Topics <ul> <li><a class="toc-link" href="[[Stroke Recognition and Management]]">Stroke Recognition and Management</a></li> <li><a class="toc-link" href="[[Post-Resuscitation Care]]">Post-Resuscitation Care</a></li> <li><a class="toc-link" href="[[Medications in PALS]]">Medications in PALS</a></li> <li><a class="toc-link" href="[[Special Resuscitation Scenarios]]">Special Resuscitation Scenarios</a></li> <li><a class="toc-link" href="[[Teamwork and Communication in PALS]]">Teamwork and Communication in PALS</a></li> </ul> </li> </ul>