Push Hard And Push Fast: The Who, How, And Why Of Pediatric Advanced Life Support (PALS)

Bell, Marisa K. MD, FAAP
Lowe, Calvin MD, FAAP
Inaba, Alson S. MD, FAAP, PALS - NF
Witt, Michael MD, MPH, FACEP, FAAP

¹Authors
²Attending Physician, Childrens Emergency Transport Team, Department of Pediatrics, Division of Emergency and Transport Medicine, Childrens Hospital Los Angeles, Los Angeles, CA
³Medical Director, Childrens Emergency Transport Team; Attending Physician, Department of Pediatrics, Division of Emergency and Transport Medicine, Childrens Hospital Los Angeles, Univeristy of Southern California and the Keck School of Medicine, Los Angeles, CA
⁴Peer Reviewers
⁵Pediatric Emergency Medicine Attending Physician, Kapiolani Medical Center For Women And Children; Associate Professor Of Pediatric, University Of Hawaii John A Burns School Of Medicine; PALS National Faculty (Hawaii 2002–2007); AHA National ECC PROAD Subcommittee (2005–2008)
⁶Medical Director, Pediatric Emergency Medicine, Eliot Hospital, Manchester, NH

Date of original release: November 1, 2009

Date of most recent review: October 10, 2009

Termination date: November 1, 2012

Medium: Print and Online

Method of participation: Print or online answer form and evaluation Prior to beginning this activity, see “Physician CME Information.”

Pediatric Emergency Medicine Practice 6(11):p 1-25, November 2009.

It's 11:00, and you are called to pick up an 11-year-old girl from an outside hospital. Her problem is described simply as “respiratory distress.” Upon arrival, you find a hypoxic, hypotensive patient who is being intubated. Blood is spewing out of the endotracheal (ET) tube. You have no intravenous (IV) or intraosseous (IO) access yet. Is there a medication that can be delivered via the ET tube that will help reverse pulmonary hemorrhage and hypotension?

At 18:00 that same day you are in an ambulance going to pick up a 9-year-old boy with “congenital heart disease” who suddenly collapsed at home. The 9-1-1 response team found a pulseless and apneic patient. Bagvalve- mask ventilations and chest compressions were initiated. One round of epinephrine was administered, and one shock was delivered at 2 J/kg for pulseless ventricular tachycardia (VT). When you arrive, you find an intubated patient with mottled, cool skin and 1+ pulses. Later you are in the back of the ambulance, en route to your pediatric intensive care unit. You note 4- to 8-beat runs of VT on your monitor. Are these real or are they an artifact caused by the bumpy road? At this point you plug in the pediatric defibrillator pads and palpate for pulses. Before you can hit the “Manual” button, the display on the defibrillator reads “shock advised.” Should you blindly follow the machine's instructions or verify the findings clinically? How many joules should you deliver? Should you start cardiopulmonary resuscitation (CPR)? If so, what is the appropriate ratio of breaths-to-chest compressions?

At 14:55 on your next shift, you get a call to pick up a 3-week-old baby from a community ER who is in unstable supraventricular tachycardia (SVT). As you make your way over there, you advise the staff to skip vagal maneuvers (because he is in unstable SVT) and recommend giving adenosine and, ultimately, performing synchronized cardioversion. Although both these maneuvers have correctly been attempted several times by staff at the community ER, and again by your team upon arrival, the baby continues to be in unstable SVT. What is the next step?