What are the initial management steps for pediatric cardiac arrest, respiratory distress, and shock according to PALS (Pediatric Advanced Life Support) guidelines?

PALS Initial Management: Cardiac Arrest, Respiratory Distress, and Shock

For pediatric cardiac arrest, immediately verify scene safety, check responsiveness and pulse simultaneously with breathing assessment (≤10 seconds), and start high-quality CPR with 15:2 compression-to-ventilation ratio when two rescuers are present, or 30:2 for a single rescuer, while activating emergency response and retrieving an AED. 1

Cardiac Arrest Management

Initial Assessment and Activation

• Verify scene safety first before approaching any pediatric patient 1
• Check responsiveness by tapping and shouting for the child 1
• Simultaneously assess breathing and pulse within 10 seconds—look for no breathing or only gasping while palpating for pulse 1
• Activate emergency response system immediately if cardiac arrest is suspected 1

CPR Initiation Based on Findings

If pulse absent or HR <60/min with poor perfusion:

• Start CPR immediately without delay 1
• Single rescuer: Perform 30 compressions followed by 2 breaths 1
• Two or more rescuers: Switch to 15 compressions followed by 2 breaths (pediatric-specific ratio) 1
• Push hard and push fast: Deliver compressions at 100-120/minute with adequate depth 2
• Minimize interruptions in chest compressions and allow complete chest recoil 2

If pulse present but no normal breathing:

• Provide rescue breathing at 1 breath every 2-3 seconds (20-30 breaths/minute) 1
• Reassess pulse every 2 minutes—if pulse becomes absent, immediately start CPR 1

Defibrillation Protocol

For witnessed sudden collapse:

• Immediately retrieve AED/defibrillator after activating emergency response 1
• Apply AED as soon as available and follow prompts 1

For unwitnessed collapse:

• Start CPR first for approximately 2 minutes before retrieving AED if alone 1
• Use AED immediately when it becomes available 1

Rhythm assessment and shock delivery:

• Check rhythm using AED or manual defibrillator 1
• If shockable (VF/pVT): Deliver 1 shock at 2 J/kg (first dose should be 1.7-2.5 J/kg range), then immediately resume CPR for 2 minutes 1, 3
• If non-shockable: Resume CPR immediately for 2 minutes 1
• Continue cycles until advanced life support arrives or child shows signs of life 1

Critical Pitfall

Avoid energy doses outside 1.7-2.5 J/kg range for first defibrillation, as doses >2.5 J/kg are associated with significantly lower survival to hospital discharge in pediatric patients with VF 3

Respiratory Distress Management

Assessment Priorities

• Verify scene safety and check responsiveness 1
• Assess breathing quality—distinguish between normal breathing, labored breathing, and absent/gasping respirations 1
• Check pulse simultaneously with breathing assessment (≤10 seconds) 1

Intervention Based on Findings

If breathing present with pulse:

• Monitor continuously until emergency responders arrive 1
• Provide supplemental oxygen if available and indicated 4
• Position appropriately to maintain airway patency 1

If inadequate breathing with pulse present:

• Initiate rescue breathing at 1 breath every 2-3 seconds 1
• Reassess pulse every 2 minutes 1
• If HR drops <60/min with poor perfusion, immediately start CPR 1

Key Context

Most pediatric cardiac arrests result from progression of respiratory failure and shock rather than primary cardiac events, making early recognition and intervention for respiratory distress critical to preventing arrest 5, 6

Shock Management

Recognition and Initial Response

• Assess for signs of poor perfusion: altered mental status, weak pulses, prolonged capillary refill, cool extremities 1
• Check heart rate: If HR <60/min with signs of poor perfusion, this represents bradycardia with shock requiring immediate CPR 1

Immediate Interventions

For bradycardia with poor perfusion (HR <60/min):

• Start CPR immediately using 15:2 ratio (two rescuers) or 30:2 ratio (single rescuer) 1
• Do not delay for additional assessment—bradycardia with poor perfusion in children is a pre-arrest rhythm 1

For shock with adequate heart rate:

• Maintain airway and breathing support 1
• Prepare for potential deterioration to cardiac arrest 5
• Monitor continuously for development of bradycardia 1

Evidence-Based Rationale

Bradyarrhythmia, asystole, or PEA represent the initial rhythm in more than 50% of pediatric in-hospital cardiac arrests, with survival rates of 22-40% when these rhythms are present 6. Early recognition and immediate CPR initiation are essential for optimizing outcomes 5, 2.