PALS Study Guide

The PALS Study Guide is a simple, easy-to-follow resource to help you review the key concepts learned during PALS training. Whether you’re preparing for the first time or planning to renew your PALS certification, this guide serves as an effective tool to refresh your memory.

It focuses on the core topics and skills essential for managing pediatric emergencies, such as recognizing respiratory distress, performing high-quality CPR, using an AED, and understanding shock. This guide is especially helpful for reviewing the theoretical knowledge you need to feel confident and pass the PALS exam.

1. Pediatric Advanced Life Support

Pediatric Advanced Life Support (PALS) is a critical life-saving intervention designed to help infants and children experiencing cardiac arrest, choking, suffocation, drowning, or other respiratory emergencies.

PALS is based on the latest guidelines developed by the American Heart Association (AHA) and is primarily intended for healthcare providers like doctors, nurses, paramedics, and emergency responders. However, understanding the basics of PALS can be beneficial for anyone working with children, including caregivers, teachers, and childcare providers.

Also read: Common abbreviations in PALS

2. PALS Algorithm

The PALS Algorithm is a comprehensive, step-by-step approach designed to assist healthcare professionals in recognizing and managing life-threatening emergencies in infants and children. Its primary goal is to prevent cardiopulmonary arrest through early identification, effective treatment, and team-based resuscitation.
PALS builds upon the basic life support (BLS) principles and incorporates advanced assessment, monitoring, and intervention strategies. Here is the key PALS algorithm:

1. Pediatric Cardiac Arrest Algorithm
2. Pediatric Tachycardia With Pulse
3. Pediatric Bradycardia With Pulse
4. Pediatric Septic Shock Algorithm
5. Pediatric Post-Resuscitation Care
6. Pediatric BLS Algorithm

The main algorithms are Bradycardia, Tachycardia, Cardiac Arrest, pediatric BLS algorithm, and Post-resuscitation care guide life-saving actions. Its core components are initial impression, primary assessment, and secondary assessment, which ensure rapid recognition and effective treatment.

3. Initial Assessment: Pediatric Assessment Triangle

The Pediatric Assessment Triangle (PAT) is a quick, structured tool that allows healthcare providers to identify life-threatening conditions in infants and children. It requires no equipment or physical contact, making it ideal for immediate evaluation in emergency settings. It helps to determine the severity of illness and guides in managing it effectively.
PTA categories in three parts:

Appearance

This reflects the child’s brain function and overall well-being. A normal appearance usually indicates adequate oxygenation, ventilation, perfusion, and brain function.
Use the mnemonic TICLS to assess:

1. Tone: Look carefully at the muscle tone, movement, and posture of the child
2. Interactiveness: See the responsiveness of the child around people and the environment
3. Consolability: Ability to be comforted by a caregiver or healthcare professional
4. Look: Note eye contact and visual tracking
5. Speech/Cry: Quality and strength of speech or cry

Work of Breathing

This part of the assessment helps determine whether the child is in respiratory distress or progressing toward respiratory failure. While observing the child from a distance, you can check them by looking or listening to their breathing. Here are the key signs:

1. Observe abnormal breath sounds like stridor, grunting, and wheezing
2. Visible effort, nasal flaring, head bobbing, chest retractions
3. Abnormal positioning
4. Rate and depth of breathing

Circulation of the skin

1. Analyse the skin carefully under good lighting for any signs of pallor, mottling, or bluish tint (cyanosis), especially on the lips, fingers, and toes.
2. Observe skin temperature
3. Check if the child’s skin is becoming pale. This may indicate poor blood circulation or shock.

4. Primary Assessment: ABCDE Approach

Primary assessment is the initial step that is performed by a healthcare provider or a first responder in a pediatric emergency. Here are the steps for conducting a primary assessment by using the PALS algorithm:

1. Airway: Check that the airway is open and clear, remove obstructions, and use airway maneuvers if necessary.

2. Breathing: Assess breathing rate, effort, and chest movement, and provide oxygen or support..

3. Circulation: Check pulse, skin colour, capillary refill, and control any bleeding.

4. Disability: Evaluate consciousness using AVPU ( Alert, Verbal, pain, Unresponsive) and pupil response

5. Exposure: Carefully remove the child’s clothes to identify the injuries on their body. Conduct this while preventing heat loss from the child’s body.

Also read: How long should you spend checking for a pulse and normal breathing during pediatric CPR?

5. Secondary Assessment: SAMPLE and Focused physical exam

The secondary assessment in pediatric emergencies is performed after the primary assessment and once life-threatening conditions have been addressed. It provides a more detailed evaluation of the child or infant’s condition, including focused history using SAMPLE ( Sign, Allergies, Medication, Past medical history, Last meal, Events leading to injury).

Focused History (SAMPLE)

It is a structured history to gather a patient’s health condition.

1. S: Signs and symptoms
   While checking a young patient, you need to ask the parents or caretaker for symptoms because infants and children can’t communicate their symptoms, such as difficulty breathing or other problems.
2. A: Allergies.
   Ask if the child has any known allergies to food, medicine, insects, or environmental triggers.
3. M: Mediations
   Check if the child is currently taking any prescribed, over-the-counter, or herbal medications.
4. P: Past medical history
   Ask the caretaker or parents about the child’s past medical history. Inquire about any chronic conditions (e.g., asthma, epilepsy), previous surgeries, or recent hospital visits.
5. L: Last meal or oral intake.
   It is important to know when and what type of food the last meal was. Knowing the children’s last food intake helps them manage their glucose levels.
6. E: Event leading to illness
   Understand what happened just before the symptoms started or the injury occurred (e.g., fall, choking, illness onset).

Focused physical exam

The focused physical exam is conducted after the primary assessment and focused history (SAMPLE). It is a head-to-toe examination to identify injuries or medical conditions based on the child’s symptoms and complaints.

1. Head and Neck: Look for the signs, like swelling, signs of trauma, or airway obstruction.
2. Chest: Observe the breathing effort taken by the infants or children. Listen for the abnormal breath or heat sounds.
3. Abdomen: To identify the pain, gently touch the child’s abdomen. Look for signs of internal bleeding or pain reaction.
4. Skin: Observe the colour, temperature, and moisture, rashes, or injuries on the child’s body.
5. Extremities: Check for movement, strength, sensation, and circulation (pulse, colour, warmth) and also look for fractures, bleeding, and swelling.

Diagnostic Tests

It is the most important step after completing the primary and secondary assessment. A diagnostic test helps confirm the child’s condition and guide treatment.

1. Electrocardiogram (ECG): Evaluates heart rhythm and electrical activity in cardiac concerns.
2. Blood test: Blood sugar shows if glucose is too high or too low. Electrolytes check the body’s fluid balance. CRP/ESR look for infection or inflammation. A blood culture finds germs in the blood.
3. Imaging studies: X-ray, ultrasound, MRI, or CT scan help to find out the internal injuries.

6. Pediatric vital signs

Pediatric vital signs help to determine the child’s health status. The heart rate, respiratory rate, blood pressure, and oxygen saturation vary by age. Here is the information:

7. Respiratory distress (Early warning sign)

PALS respiratory distress is an early warning sign when a child has trouble breathing but is still able to maintain oxygen levels.
Signs of Respiratory Distress:

1. Fast breathing (tachypnea)
2. Noisy breathing (wheezing, stridor, grunting)
3. Nasal flaring
4. Use of accessory muscles (chest retractions)
5. Irritability or anxiety
6. Cyanosis (late sign)

8. PALS Respiratory Failure (Late and Dangerous Stage)

Respiratory failure means the child can no longer maintain adequate oxygen or remove carbon dioxide.
Signs of Respiratory Failure:

1.  Very slow or irregular breathing
2. Poor chest rise
3. Cyanosis (bluish skin)
4. Decreased responsiveness or unresponsiveness
5. Low oxygen saturation (SpO₂ < 90%)

Types of Airway Problems

There are two types of airway problems such as upper airway obstruction and Lower airway obstruction.

General Treatment Steps

1. Position the child for comfort (e.g., sitting up).
2. Give oxygen (humidified if needed).
3. Use medications based on cause (e.g., bronchodilators, steroids).
4. Monitor vitals and SpO₂ continuously.
5. Prepare for assisted ventilation or intubation if the condition worsens.

9. Shock

Shock is a life-threatening condition where blood flow and oxygen delivery to the organs are insufficient. If it is not treated and managed on time, then it could cause severe damage and lead to organ failure. There are different types of shock, each with its own causes and signs.

its own causes and signs.

Also read: Treating shock in PALS

10. Cardiac arrest

Cardiac arrest in young children is often due to respiratory failure or shock. Infants or children can be saved from a life-threatening situation by effective Cardiopulmonary resuscitation (CPR).

Steps for Performing CPR on infants and children

1. Check responsiveness: Check if they are breathing or not by gently tapping or calling them in a clear and soft voice
2. Call for help: If the victim is unresponsive, then immediately call 911 and wait for emergency medical service. If you are trained in a PALS class, then you can perform CPR without waiting for EMS.
3. Position the child: Position the child on their back by addressing their comfort.
4. Chest compression: Perform high-quality chest compressions in infants using two fingers just below the nipple line, and in children using one or two hands based on size. Maintain a rate of 100–120 compressions per minute. Compression depth should be about 1.5 inches (4 cm) for infants and 2 inches (5 cm) for children.
5. Rescue Breaths: While giving rescue breaths, open the airway using head-tilt, chin-lift, and give 2 breaths after every 30 compressions ( 15:2 if 2 rescue). Each breath should last 1 second and make the chest rise.
6. Continue CPR: Continue CPR on infants and children until they show signs of life such as movement, breathing, or responsiveness. Use an AED and apply it effectively by following the voice instructions and continue it until professionals helps arrives.

11. PALS Bradycardia

Pediatric Bradycardia is a condition where the heart rate is slower than normal. In infants and children, the heart rate falls below the expected range for their age. The normal heart rate varies depending on the child’s age, so it’s important to know age-specific norms.

Bradycardia in pediatric patients is often a sign of serious problems, most commonly related to hypoxia, or low oxygen levels. If not recognized and treated quickly, it can rapidly progress to cardiac arrest. That’s why early identification is crucial.

The Pediatric Bradycardia Algorithm guides healthcare providers through a step-by-step response to stabilize the patient. It includes immediate actions such as:

1. Providing high-concentration oxygen.
2. Supporting the child’s breathing with bag-mask ventilation.
3. Starting CPR if the heart rate remains below 60 bpm with poor perfusion, even after adequate oxygenation and ventilation.

12. PALS Tachycardia

Pediatric Tachycardia is a condition where the heart rate is faster than normal for a child or infant. It may be a normal response to fever, pain, fear, or dehydration, but it can also signal serious issues like shock or arrhythmias.

The PALS Tachycardia Algorithm helps clinicians quickly assess and identify the type of tachycardia and guides the appropriate treatment based on the child’s condition. It begins by assessing the ABCs (Airway, Breathing, Circulation) and evaluating the ECG to determine the heart rhythm and QRS complex width.

13. PALS Post-resuscitation care

Post-resuscitation care is a vital step in supporting recovery after a child has been successfully resuscitated. It involves advanced care, continuous monitoring, and medication to stabilize the patient and prevent further complications.
Main Goals:

1. Optimize Oxygenation and Ventilation
2. Keep blood circulation stable
3. Protect the brain from injury
4. Diagnosing Hs, Ts to find out the causes
5. Provide ongoing care and family support

Also read: PALS Post resuscitation care algorithm

14. Team Dynamic

The effective team dynamic is essential for PALS treatment to coordinate high-quality care. In pediatric emergencies, a well-functioning team can make the difference between life and death. The key elements of team dynamics are:

Clear communication with the team
Clear communication with a team helps to avoid mistakes and facilitates quick decision-making with a strategy to save infants and children. It’s vital that all team members communicate clearly and concisely, especially when relaying vital information like patient status, interventions, or changes in condition.

Define team role
Each team member should have a defined role, whether it’s providing compressions, managing the airway, administering medications, or monitoring the patient. Clear roles avoid overlap and confusion and help to perform tasks efficiently and without delay.

Mutual respect and trust
While performing important tasks together, each member must be treated with respect. This fosters an environment where everyone feels valued and empowered to contribute their expertise and speak up if they notice something important. In pediatric emergencies, mutual respect ensures a collaborative and supportive team culture.

Regular training and PALS practice
Regular training and PALS practice are essential for maintaining and enhancing the skills and knowledge of healthcare team members. This includes activities like online PALS practice tests, simulation-based scenarios, team drills, and refresher courses. Consistent practice improves confidence, response time, and teamwork during real pediatric emergencies.

Review of key topic in PALS

While preparing for the PALS exam, it is essential to focus on the most important topics. Make sure to thoroughly understand the PALS algorithms, proper chest compression techniques, and the steps involved in primary and secondary assessments. These core areas form the foundation of effective pediatric emergency care.

If you also want to understand this topic in depth or ace your skills, you can join a top-tier training center in San Francisco. Heart Start CPR is the perfect choice to enroll in a PALS class. We offer hands-on practice, use advanced CPR tools, and provide updated PALS renewal courses. Our experienced team will help you gain the skills that you need to respond quickly and effectively in any emergency. Join us and be prepared for any pediatric emergencies in your way!!