PALS Algorithm

The PALS (Pediatric Advanced Life Support) algorithm is a set of guidelines and procedures designed for healthcare providers to manage pediatric emergencies.

  • Shock
  • Cardiac arrest
  • Respiratory emergencies
  • Other life-threatening emergencies

PALS algorithms focus on the advanced assessment and treatment of critically ill or injured children. The PALS guidelines are updated regularly every 5 years by the American Heart Association and American Academy of Pediatrics based upon the International Liaison Committee on Resuscitation (ILCOR) consensus on science.

The listed below algorithms are the pediatric resuscitation algorithms required in different situations of cardiac arrest. These algorithms are step-by-step assessment processes for a child patient. The Pediatric Advanced Life Support Algorithms below are helpful in hospital settings and out of the hospital setting and in passing the PALS certification/recertification exam.

Pediatric Advanced Life Support

Important Factors in The PALS Protocol


Hypotension, or abnormally low blood pressure, is a key vital sign abnormality monitored in PALS as it reflects shock and inadequate end-organ perfusion. Identifying and properly managing hypotension is vital for reversing shock and preventing subsequent organ damage.

  • Assess and continuously monitor blood pressure - hypotension is defined as systolic BP <70mmHg in infants or <70 + (2x age in years) for children 1-10 years old.
  • Treat underlying causes of shock if evident (e.g. hypovolemia, sepsis).
  • Give 20mL/kg fluid bolus over 5-10 minutes and reassess. Continue boluses PRN to improve BP and clinical markers of perfusion.
  • If hypotension persists, consider vasoactive infusions like dopamine or epinephrine.


Hemodynamic monitoring involves analyzing cardiovascular variables like heart rate, cardiac output, oxygen delivery, and systemic vascular resistance to gauge the circulatory status and guide shock resuscitation methods.

  • Continuously monitor heart rate and assess clinical indicators of perfusion like capillary refill, mental status, pulses, and extremity temperature.
  • Target heart rate limits are 60-200bpm for infants and 60-180bpm for children.
  • Monitor cardiac rhythm for arrhythmias that may need treatment.

Airway, Breathing, Circulation, and Differential Diagnosis

The ABCs represent the basic assessment and interventions for stabilization - evaluating and establishing a pediatric patient's airway, ensuring adequate oxygenation and ventilation, and supporting circulation. Prioritizing the ABCs is fundamental in pediatric resuscitation.

  • Assess airway patency and protect the airway through positioning, suction, and adjuncts like OP or NP airways. Intubate if necessary.
  • Ensure adequate oxygenation and ventilation. O2 via nasal cannula, facemask or advanced airway at 100% FiO2. Assist ventilations with BVM if needed.
  • Assess circulation with BP, cap refill, pulses, and mentation. Give fluids and/or drugs for hypotension.

Differential Diagnosis

Generating a broad differential diagnosis list based on the clinical presentation is crucial for determining the likely underlying cause of cardiorespiratory instability and customizing therapeutic measures accordingly.

Advanced Airways

For children requiring prolonged ventilatory assistance who do not show improvement with initial basic airway maneuvers, establishing an advanced airway, such as through intubation, facilitates oxygenation and ventilation.


Defibrillation, or delivery of electrical current to stop life-threatening arrhythmias using an automatic external defibrillator (AED), helps restore organized electrical activity critical for myocardial contractions and cardiac output. Timely defibrillation is life-saving in pediatric shockable rhythms.

  • Attach the defibrillator as quickly as possible if profound bradycardia, no perfusing rhythm, or ventricular arrhythmias on the monitor.
  • If ventricular fibrillation or pulseless ventricular tachycardia - defibrillate at 2 J/kg. Escalate dose PRN.
  • For unstable SVT with poor perfusion - synchronized cardioversion at 0.5-1 J/kg, then increase the dose.

PALS Vital Signs

Normal ranges of a child's vital organs help determine stability versus pathology in pediatric patients based on age and should be continually reassessed. Abnormal vital signs in children can reflect decompensation, so awareness of normal ranges and monitoring trends is a critical component of PALS protocol and decision-making.

Heart Rate

The heart rate reflects the frequency of cardiac contractions and systemic perfusion. The pediatric resuscitation algorithm follows to manage the heart rate of pediatric patient to the normal, while the normal heart rate range varies by age:

Newborns (0-3 months): 100-180 beats per minute

Infants (3 months - 2 years): 100-180 bpm

Children (2-10 years): 60-140 bpm

Children over 10 years: 60-100 bpm

Respiratory Rate

The respiratory rate indicates the frequency of respiratory cycles per minute and the PALS protocol guides the management of pediatric patients' respiration. Normal respiratory rate by age:

Newborns: 30-60 breaths per minute

Infants: 25-50 breaths per minute

Children (2-5 years): 25-30 breaths per minute

Children (5 years+): 15-20 breaths per minute

Blood Pressure

Normal BP varies substantially based on a child's height and age. Hypotension risk thresholds correlate with patient age, weight, and clinical context. For example:

  • A 6-month-old with an SBP < 70 mm Hg would be considered hypotensive.
  • The treatment target would be to achieve an SBP >60 mm Hg through the administration of fluid boluses and/or vasoactive medications.
  • An 8 years old child will be considered hypotensive if their SBP drops below 86 mm Hg (70 + (2 x 8) years).
  • The post-resuscitation BP goal for this 8 years old would be ≥ 90 mm Hg systolic.

Oxygen Saturation

Oxygen saturation or SpO2 (%) reflects the amount of hemoglobin bound to oxygen in the arterial circulation. Normal SpO2 is > 94% at room air across pediatric age groups. Cyanosis may be present when saturation is <90%. Hypoxemia or insufficient oxygenation manifests with lower saturations.


Core body temperature is maintained within a narrow range. Normal temperature in children is 36-38°C or 96.8-100.4°F. Hypothermia (temp <36°C) increases mortality risk and complicates resuscitation. The PALS Algorithm includes an assessment for temperature abnormalities to promptly address and manage such conditions. Hyperthermia (temp >38.5°C) may reflect infection, neurological dysfunction, or heat exposure.

PALS Algorithm FAQs

Who needs PALS?

Any medical professional who provides frontline care for vital pediatric cases should pursue PALS certification and must know PALS algorithm effectively. The protocols cover crucial interventions to help save children's lives in emergency situations. Pediatric Advanced Life Support (PALS) training is most relevant for healthcare providers who regularly treat critically ill or injured children. This includes pediatricians, ER physician, nurses, paramedics and EMTs, respiratory therapists, and any other medical professionals responsible for stabilizing injured children.

What is the systematic approach algorithm in PALS?

The PALS systematic approach algorithm provides a structured framework for assessing and managing critically ill or injured children. The pediatric systematic approach enables providers to rapidly identify and respond to life threats, resuscitate if necessary, uncover underlying issues, and continually reassess to optimize management. Key aspects of PALS systematic approach algorithm include:

Primary Assessment:

  • Initial impression - quickly identifying life threats
  • Level of consciousness - AVPU scale
  • Airway - open and maintainable
  • Breathing - rate, work of breathing, oxygenation
  • Circulation - heart rate, skin perfusion, capillary refill
  • Disability - neurological status


  • Following Pediatric Basic Life Support steps if needed - airway, breathing, circulation
  • Administering medications/fluids per PALS pharmacotherapy protocols

Secondary Assessment:

  • Head-to-toe exam for additional injuries once child is stabilized
  • Review of systems to uncover any underlying conditions
  • Checking vital signs and oxygenation status


  • Integrating all findings from primary and secondary surveys
  • Identifying working diagnosis and priorities for management plan
  • Providing stabilizing interventions, treatment, and supports


  • Frequently reassessing patient and effectiveness of interventions
  • Modifying plan accordingly

What is the ABCDE approach in PALS algorithm?

The ABCDE approach in PALS algorithm stands for Airway, Breathing, Circulation, Disability, and Exposure/Environment. It guides providers to first assess and intervene on threats to airway patency, oxygenation/ventilation, circulatory inadequacy, neurological disability, and exposure issues. This systematic method facilitates rapid identification of problems that can imminently lead to cardiopulmonary arrest so providers can quickly mitigate life threats and resuscitate pediatric patients exhibiting respiratory failure, shock, or neurological deterioration.

How do you assess a child's progress?

Ongoing assessment and reevaluation of the child's condition determines if the PALS protocol is successfully improving cardiopulmonary and neurological function to guide appropriate adjustments in care. There are a few key ways to assess a child's progress in the Pediatric Advanced Life Support (PALS) protocol:

  1. Reassess vital signs - This includes heart rate, blood pressure, temperature, oxygen saturation, and respiratory rate. Improving vital signs can indicate the child is responding well to interventions.
  2. Check cardiopulmonary status - Lung sounds, capillary refill time, and pulse quality provide information on oxygenation and perfusion. Improvement suggests circulatory and respiratory function are adequate.
  3. Note neurological status - Level of consciousness, pupil reaction, and movements give insight on neurological function. A child that is more alert and responsive is showing positive progress.
  4. Review laboratory results - Trends in blood gas values, lactate, blood counts, etc. provide objective data about the child's metabolic status. Normalizing labs are reassuring.
  5. Ensure interventions are effective - Monitor how well medications, fluids, and other treatments are working to stabilize the patient. Discontinue or modify ineffective interventions.
  6. Repeat primary and secondary surveys - Serial exams uncover any new or evolving problems to address.

What is the difference between NRP and PALS?

The NRP program focuses specifically on newborns, addressing their unique critical care needs in the all-important initial minutes and hours after birth. Its protocols cover resuscitation, assessment, and stabilization interventions focused to the physiology and typical emergency presentations of neonates.

In contrast, PALS systematic approach algorithm applies to older infants, children, and adolescents, concentrating on anatomy, pathology, illnesses, and injuries relevant from 1 year of age through young adulthood. So while both involve pediatric life support principles, NRP zooms in on the newborn period alone with neonatal-specific training, while PALS covers later childhood problems requiring age-appropriate acute management approaches.

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