PALS in Cardiac Arrest
PALS in Cardiac Arrest
When a pediatric patient goes into cardiac arrest, the goal of the PALS resuscitation team is to achieve ROSC (return of spontaneous circulation). ROSC is the return of an organized cardiac rhythm and the presence of a palpable pulse. An increase in ETCO2 and a measurable blood pressure are good signs of ROSC. Clinically, the patient’s color and breathing return to normal during ROSC.
PALS teaches providers to treat cardiac arrest with:
- Recognition of shockable and nonshockable rhythms
- Establishing vascular access
- Early defibrillation if indicated
- Medication therapy
- Advanced airway management
Rhythm Assessment of Shockable and Nonshockable Rhythm
Distinguishing shockable rhythms from nonshockable rhythms guides the PALS provider to the correct algorithm. The applicable PALS algorithm then guides the clinician to the recommended CPR sequence, delivery of shocks, and administration of cardiac arrest medications.
Since an algorithm is written as a process flow, it may seem that the interventions are performed sequentially. However, a high-performance PALS team successfully carries out many of the PALS resuscitation steps synchronously rather than sequentially.
Child Connected to Defibrillator
Vascular Access
When treating a patient in cardiac arrest, the team must establish vascular access as quickly as possible. Peripheral intravenous (IV) access is the preferred route of drug administration. If the team cannot quickly start a peripheral IV, interosseous (IO) access should be attained. If neither IV nor IO access can be achieved quickly enough, the endotracheal tube (ET tube) is an acceptable route for certain resuscitation medications. More advanced vascular access procedures, such as a peripheral vein cutdown or central venous catheterization, may be considered as well.
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Vascular Access
Manual IO Insertion from 25 Years Ago
Contemporary IO Placement
Defibrillation
Defibrillation depolarizes a significant mass of the myocardium in order to terminate ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT). Defibrillation also stimulates the pacemaker cells to resume an organized rhythm. Restoring an organized rhythm is just one step to ensure survival. The heart muscle must also be able to achieve enough cardiac output to achieve ROSC or a palpable central pulse.
When the team decides to defibrillate a child, chest compressions should be continued while the device is charging. Once charged, a team member places the paddles in the correct position and clears everyone away from the patient. After the first shock, CPR should be immediately resumed.
VF refractory to defibrillation is likely due to poor cardiac perfusion; hence, chest compressions are essential because they support blood flow to the coronary circulation and brain. Chest compressions increase the chance of a return of spontaneous circulation and should be resumed for 2 minutes prior to assessing the child for a pulse or the need for subsequent defibrillation.
Chest compressions should also be rapidly resumed after delivering a shock from an AED in out-of-hospital cardiac arrest.
Chest compressions should be continued for 2 minutes after the conversion of VF to a sinus rhythm because most patients with VF convert to PEA immediately after shock delivery. The PALS provider should check for a pulse or a change in other physiologic monitoring, such as ETCO2.
Key Takeaway
Immediately resume compressions after defibrillation.
Drug Therapies in Cardiac Arrest
Drugs used in cardiac arrest increase coronary and cerebral perfusion and optimize blood flow to vital organs. Drug therapy also restores myocardial contractility and increases the heart rate. Medications also treat arrhythmias and other causes of cardiac arrest.
Medications for Cardiac Arrest
Medications for Cardiac Arrest