What are the key areas to focus on when preparing for the Pediatric Advanced Life Support (PALS) exam?

PALS Exam Preparation: Key Focus Areas

To succeed on the PALS exam, you must master the systematic approach to pediatric cardiac arrest, including the BLS algorithm sequence, CPR quality metrics (15:2 compression-ventilation ratio with two rescuers, 100-120 compressions/minute, depth at least one-third anteroposterior chest diameter), recognition of shockable versus non-shockable rhythms, medication dosing (epinephrine 0.01 mg/kg IV/IO every 3-5 minutes), and management of bradycardia with poor perfusion (start CPR when HR <60/min with signs of poor perfusion). 1, 2

Core Resuscitation Algorithms

Pediatric BLS Algorithm Sequence

• Scene safety verification is the mandatory first step before any intervention 1, 3
• Simultaneous assessment of breathing (normal vs. gasping/absent) and pulse check within 10 seconds 1, 2
• Critical decision point: If HR <60/min with signs of poor perfusion, immediately start CPR—do not delay for any diagnostic maneuvers 2, 1
• Compression ratios: 30:2 for single rescuer, switching to 15:2 when second rescuer arrives 1, 2
• Witnessed sudden collapse: Activate emergency response and retrieve AED immediately before starting CPR 1
• Unwitnessed collapse: Start CPR first, then activate emergency response after approximately 2 minutes if still alone 1

CPR Quality Metrics (High-Yield for Exam)

• Compression depth: At least one-third of the anteroposterior diameter of the chest 2, 1
• Compression rate: 100-120 compressions per minute 4, 2
• Complete chest recoil after each compression 2
• Minimize interruptions in chest compressions 1
• Common pitfall: EMS providers frequently use continuous compressions before establishing an advanced airway—this is incorrect; use 15:2 ratio until advanced airway is placed 5

Cardiac Arrest Medications and Timing

Epinephrine Administration

• Dose: 0.01 mg/kg IV/IO (this is the single most important medication dose to memorize) 4, 1
• Timing: Administer as soon as vascular access is obtained 4
• Repeat interval: Every 3-5 minutes throughout resuscitation 4, 1
• Critical error to avoid: Studies show 35% of EMS teams fail to administer epinephrine, and 18% underdose—know this dose cold 5

Medications NOT to Use

• Atropine is NOT recommended for pediatric cardiac arrest—this is a common trap question 4, 1
• Atropine may be considered for bradycardia but epinephrine is preferred 1

Shock-Resistant VF/Pulseless VT

• Amiodarone versus lidocaine for shock-resistant rhythms (both are acceptable options per 2018 guidelines) 1
• Sodium bicarbonate and calcium have limited indications in pediatric arrest 1

Rhythm Recognition and Defibrillation

Shockable vs. Non-Shockable Rhythms

• Shockable: Ventricular fibrillation and pulseless ventricular tachycardia only 4
• Non-shockable: Asystole and PEA—resume CPR immediately without attempting defibrillation 4, 1
• Critical pitfall: Never waste time attempting to defibrillate asystole; this delays effective CPR and has no benefit 4

Defibrillation Specifics

• Energy doses, pad size/placement, and single versus stacked shocks are all exam topics 1
• Use AED as soon as available in witnessed collapse 1
• After shock delivery, immediately resume CPR for 2 minutes before rhythm check 1

Airway Management and Ventilation

Ventilation Rates (Memorize These Numbers)

• With pulse present: 1 breath every 2-3 seconds (20-30 breaths/minute) 1
• During CPR without advanced airway: 15:2 compression-ventilation ratio 1, 2
• With advanced airway in place: Specific ventilation rate during arrest (different from pulse-present rate) 1

Advanced Airway Considerations

• Cuffed versus uncuffed endotracheal tubes 1
• Confirmation devices for tube placement verification 1
• Cricoid pressure during intubation (know current recommendations) 1
• Common error: Delayed initiation of positive pressure ventilation in bradycardic children 5

Special Resuscitation Situations

Septic Shock Management

• Fluid resuscitation protocols 1
• Vasoactive drug selection and timing 1
• Corticosteroid use in refractory shock 1

Congenital Heart Disease

• Single ventricle physiology resuscitation modifications 1, 4
• Fontan/Hemi-Fontan circulation specific considerations 1
• Asystole in CHD patients: No defibrillation, immediate CPR with epinephrine 4

Trauma and Drowning

• Traumatic arrest management differs from medical arrest 1
• Submersion victims: All require ED transport with continuous monitoring even if awake, due to risk of delayed respiratory deterioration 3
• Hypothermia prevention and management in drowning 3

Arrhythmia Management (Non-Arrest)

Bradycardia Algorithm

• HR <60/min with poor perfusion = START CPR (this is non-negotiable) 1, 2
• Epinephrine preferred over atropine for symptomatic bradycardia 1
• Transcutaneous pacing as emergency intervention 1

Tachycardia Management

• Supraventricular tachycardia drug protocols 1
• Unstable ventricular tachycardia treatment 1
• Channelopathies recognition 1

Post-Cardiac Arrest Care

Immediate Post-ROSC Management

• Targeted temperature management protocols 1
• Oxygen and CO2 targets after ROSC 1
• Blood pressure control goals 1
• Neurologic monitoring including EEG use 1
• Seizure management 1

Prognostication

• Timing and methods for neuro-prognostication post-arrest 1
• Avoid premature withdrawal of care 1

Monitoring During Resuscitation

Physiological Monitoring Tools

• End-tidal CO2 monitoring during CPR (helps assess CPR quality and ROSC) 1
• Invasive blood pressure monitoring considerations 1
• Near-infrared spectroscopy (NIRS) applications 1
• Bedside ultrasound to identify perfusing rhythm 1

Drug Dosing and Vascular Access

Weight-Based Dosing Methods

• Calculation methods for pediatric drug doses (length-based tape systems, formulas) 1
• Know common medication doses beyond epinephrine 1

Vascular Access Routes

• Intraosseous (IO) versus intravenous (IV) access—both are acceptable, IO often faster in arrest 1
• IO placement success rates: PALS-trained providers achieve 100% success versus 55% in non-trained 6

High-Yield Procedural Skills

Skills That Differentiate PALS-Trained Providers

• Intubation success: 85% in PALS-trained versus 48% in non-trained providers 6
• Vascular access in shock/arrest: 100% success in PALS-trained versus 70% in non-trained 6
• IO line placement: 100% success in PALS-trained versus 55% in non-trained 6

Critical Exam Pitfalls to Avoid

• Never delay CPR when HR <60/min with poor perfusion—this is the most common critical error 2, 5
• Never use atropine as first-line in pediatric cardiac arrest 4
• Never attempt defibrillation for asystole—immediately resume CPR 4
• Never use continuous compressions before advanced airway is placed—use 15:2 ratio 5
• Never underdose epinephrine—0.01 mg/kg is the standard dose 5
• Never assume a drowning victim is stable even if awake—transport all for monitoring 3