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Comprehensive PALS Study - Guide

Enhance your pediatric emergency expertise with our Comprehensive PALS Study Guide. Learn to assess critically ill children, recognize life-threatening conditions, perform high-quality CPR, and apply advanced interventions confidently. This step-by-step, evidence-based guide equips healthcare providers to respond quickly, improve survival rates, and deliver expert pediatric life support with precision.

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Pediatric Advanced Life Support (PALS) is a systematic approach to assessing and treating pediatric patients in emergency situations. Developed by the American Heart Association (AHA), the PALS course equips healthcare providers with the skills to effectively recognize and manage respiratory emergencies, shock, and cardiopulmonary arrest.

For healthcare professionals working in emergency medicine, intensive care, or critical response, this certification is not just a requirement—it is a critical skillset that saves lives. According to data from the American Heart Association, pediatric out-of-hospital cardiac arrest (OHCA) survival rates remain low, emphasizing the need for high-quality, standardized training. Mastering PALS protocols ensures you are ready to intervene during those crucial first minutes.

This guide covers everything you need to know to pass your PALS exam and, more importantly, apply these skills in real-world scenarios. From the systematic approach to specific algorithms and pharmacology, we break down complex concepts into actionable knowledge.

What is the PALS Systematic Approach?

The PALS Systematic Approach is the foundation of pediatric assessment. It provides a structured method to quickly identify life-threatening conditions. The approach uses a cycle of Evaluate-Identify-Intervene.

You must constantly repeat this cycle to monitor the child’s response to your interventions.

What is the Initial Impression?

The first step is a rapid visual and auditory assessment of the child’s consciousness, breathing, and color. This “from the doorway” assessment determines if the child is unresponsive or requires immediate intervention.
  • Consciousness: Is the child unresponsive? irritable? alert?
  • Breathing: Is there increased work of breathing? absent breathing? audible sounds?
  • Color: Is the child cyanotic? pale? mottled?

What is the Primary Assessment?

If the child is responsive, you move to the Primary Assessment. This uses the ABCDE model:
  • Airway: Is the airway open? maintainable? not maintainable?
  • Breathing: Check respiratory rate, effort, tidal volume, airway sounds, and O2 saturation.
  • Circulation: Check heart rate, rhythm, pulses (central vs. peripheral), capillary refill time, skin color, temperature, and blood pressure.
  • Disability: Assess neurological status using the AVPU scale (Alert, Voice, Pain, Unresponsive) or Glasgow Coma Scale (GCS), and check pupil response and blood glucose.
  • Exposure: Undress the child to look for trauma, burns, or rashes, while maintaining thermoregulation.

What is the Secondary Assessment?

The Secondary Assessment involves a focused history and physical exam. Use the SAMPLE mnemonic to gather history:
  • Signs and Symptoms
  • Allergies
  • Medications
  • Past medical history
  • Last meal
  • Events leading to current illness

What are Diagnostic Tests?

Diagnostic tests help identify the specific cause of the emergency. These include:
  • Laboratory tests (ABG, VBG, CBC, electrolytes, glucose, lactate).
  • Imaging (Chest X-ray, CT scan).
  • Cardiac monitoring (ECG).

How Do You Recognize and Manage Respiratory Distress and Failure?

Respiratory problems are the most common cause of cardiac arrest in children. Early recognition and intervention prevent progression to respiratory failure and cardiac arrest.

What is Respiratory Distress?

Respiratory distress is characterized by increased work of breathing and adequate gas exchange. Signs include:
  • Tachypnea (fast breathing).
  • Tachycardia (fast heart rate).
  • Nasal flaring.
  • Retractions (intercostal, subcostal, suprasternal).
  • Grunting.
  • Stridor or wheezing.
  • Pale skin.

What is Respiratory Failure?

Respiratory failure occurs when oxygenation or ventilation is inadequate. Signs include:
  • Marked tachypnea (early) or bradypnea (late).
  • Apnea (late).
  • Significant or inadequate respiratory effort.
  • Tachycardia (early) or bradycardia (late).
  • Cyanosis.
  • Altered mental status (irritability, lethargy, unresponsiveness).

How Do You Treat Respiratory Emergencies?

Management depends on the type of respiratory problem:

1. Upper Airway Obstruction (Croup, Anaphylaxis, Foreign Body):

  • Croup: Dexamethasone, nebulized epinephrine.
  • Anaphylaxis: IM epinephrine, antihistamines, corticosteroids.
  • Foreign Body: Back slaps/chest thrusts (infant), abdominal thrusts (child), removal with Magill forceps if visible.

2. Lower Airway Obstruction (Asthma, Bronchiolitis):

  • Asthma: Albuterol, ipratropium, corticosteroids, magnesium sulfate.
  • Bronchiolitis: Suctioning, supportive care.

3. Lung Tissue Disease (Pneumonia, Pulmonary Edema):

  • Pneumonia: Antibiotics, oxygen.
  • Pulmonary Edema: Diuretics, ventilatory support (CPAP/BiPAP).

4. Disordered Control of Breathing (Seizures, Poisoning):

  • Treat the underlying cause (e.g., antidote for poisoning, benzodiazepines for seizures).
  • Provide ventilatory support (Bag-Mask Ventilation).

How Do You Recognize and Manage Shock?

Shock is a state where oxygen delivery does not meet metabolic demand. Pediatric shock is categorized into four types: Hypovolemic, Distributive, Cardiogenic, and Obstructive.

What are the Stages of Shock?

  • Compensated Shock: The body maintains blood pressure through compensatory mechanisms (tachycardia, vasoconstriction). Signs include cool extremities, delayed capillary refill, and weak peripheral pulses. BP remains normal.
  • Hypotensive (Decompensated) Shock: Compensatory mechanisms fail. Hypotension is a late sign and indicates imminent cardiac arrest.
Hypotension Formula (Systolic BP):
  • Neonates (0-28 days): <60 mmHg
  • Infants (1-12 months): <70 mmHg
  • Children (1-10 years): <70 + (2 x age in years) mmHg Children >10 years: <90 mmHg

How Do You Manage Hypovolemic Shock?

Hypovolemic shock results from fluid or blood loss (vomiting, diarrhea, hemorrhage).
  • Pathophysiology: Decreased preload leads to decreased stroke volume and cardiac output.
  • Treatment:
    • Give fluid bolus: 20 mL/kg of isotonic crystalloid (Normal Saline or Lactated Ringer’s) over 5-20 minutes.
    • Repeat boluses as needed based on perfusion assessment.
    • If hemorrhagic, consider packed red blood cells (PRBCs) 10 mL/kg.

How Do You Manage Distributive Shock?

Distributive shock results from inappropriate vasodilation (Septic, Anaphylactic, Neurogenic).
  • Pathophysiology: Decreased systemic vascular resistance (SVR) leads to maldistribution of blood flow.
  • Septic Shock Treatment:
    • Fluid bolus: 10-20 mL/kg (reassess frequently for fluid overload).
    • Antibiotics: Administer within 1 hour.
    • Vasoactive drugs: Epinephrine or Norepinephrine if fluid refractory.
  • Anaphylactic Shock Treatment:
    • IM Epinephrine.
    • Fluids.
    • Antihistamines/Corticosteroids.

How Do You Manage Cardiogenic Shock?

Cardiogenic shock results from pump failure (Myocarditis, Congenital Heart Disease, Arrhythmias).
  • Pathophysiology: Decreased contractility leads to decreased cardiac output.
  • Treatment:
    • Caution with fluids: Give small boluses (5-10 mL/kg) over 10-20 minutes. Monitor for pulmonary edema (crackles, hepatomegaly).
    • Vasoactive drugs: Milrinone (inodilator) or Epinephrine.
    • Consult expert consultation early.

How Do You Manage Obstructive Shock?

Obstructive shock results from physical obstruction to blood flow (Cardiac Tamponade, Tension Pneumothorax, Pulmonary Embolism).
  • Pathophysiology: Physical obstruction prevents adequate cardiac output.
  • Treatment: rapid specific intervention is required.
    • Tension Pneumothorax: Needle decompression (thoracostomy) followed by chest tube.
    • Cardiac Tamponade: Pericardiocentesis.
    • Pulmonary Embolism: Anticoagulants/Thrombolytics.

What are the Pediatric Cardiac Arrest Algorithms?

When a child has no pulse, or a pulse <60/min with signs of poor perfusion despite oxygenation and ventilation, you must start CPR.

What is the Pediatric Cardiac Arrest Algorithm?

  1. CPR: Start high-quality CPR.
    • Ratio: 15:2 (2 rescuers) or 30:2 (1 rescuer).
    • Rate: 100-120/min.
    • Depth: 1/3 AP diameter of chest (approx 1.5 inches for infants, 2 inches for children).
  2. Rhythm Check: Is the rhythm shockable?
    • Shockable: VF (Ventricular Fibrillation) / pVT (Pulseless Ventricular Tachycardia).
    • Non-Shockable: Asystole / PEA (Pulseless Electrical Activity).
Shockable Rhythm (VF/pVT):
  1. Shock: 2 J/kg.
  2. CPR: 2 minutes immediately after shock. Establish IV/IO access.
  3. Rhythm Check: If shockable?
  4. Shock: 4 J/kg.
  5. CPR: 2 minutes. Administer Epinephrine every 3-5 mins. Consider advanced airway.
  6. Rhythm Check: If shockable?
  7. Shock: >4 J/kg (Max 10 J/kg or adult dose).
  8. CPR: 2 minutes. Administer Amiodarone or Lidocaine. Treat reversible causes (H’s and T’s).
Non-Shockable Rhythm (Asystole/PEA):
  1. CPR: 2 minutes. Establish IV/IO access.
  2. Epinephrine: Administer ASAP. Repeat every 3-5 mins.
  3. Advanced Airway: Consider intubation. Once placed, continuous compressions with 1 breath every 2-3 seconds.
  4. Reversible Causes: Treat H’s and T’s.

What are the Drug Doses for Cardiac Arrest?

  • Epinephrine: 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration). Max dose 1 mg.
  • Amiodarone: 5 mg/kg bolus (may repeat up to 2 times for refractory VF/pVT).
  • Lidocaine: 1 mg/kg loading dose.

What are the H's and T's (Reversible Causes)?

  • Hypovolemia
  • Hypoxia
  • Hydrogen ion (Acidosis)
  • Hypoglycemia
  • Hypo/Hyperkalemia
  • Hypothermia
  • Tension Pneumothorax
  • Tamponade (Cardiac)
  • Toxins
  • Thrombosis (Pulmonary)
  • Thrombosis (Coronary)

How Do You Manage Pediatric Arrhythmias?

Not all arrhythmias lead to cardiac arrest, but they require prompt recognition and management to prevent deterioration.

How do you treat Bradycardia?

Defined as heart rate slower than normal for age.
  1. Assess: Maintain airway, give oxygen, cardiac monitor.
  2. Decision: Is there Cardiopulmonary Compromise? (Hypotension, altered mental status, signs of shock).
    • No: Monitor and observe.
    • Yes: Start CPR if HR <60/min despite oxygenation and ventilation.
  3. Medications:
    • Epinephrine: 0.01 mg/kg IV/IO.
    • Atropine: 0.02 mg/kg IV/IO (preferred for increased vagal tone or primary AV block).

How Do You Treat Tachycardia with a Pulse?

Assess QRS duration: Narrow (<0.09 sec) vs. Wide (>0.09 sec).

1. Narrow Complex Tachycardia:

  • Sinus Tachycardia: History compatible (fever, pain, dehydration), P waves present, variable rate. Treat underlying cause.
  • Supraventricular Tachycardia (SVT): History of abrupt onset, P waves absent/abnormal, fixed rate (>220 infant, >180 child).
    • Stable SVT: Vagal maneuvers (ice to face, Valsalva). Adenosine 0.1 mg/kg (Max 6 mg), second dose 0.2 mg/kg (Max 12 mg).
    • Unstable SVT: Synchronized Cardioversion 0.5-1 J/kg. If ineffective, increase to 2 J/kg.

2. Wide Complex Tachycardia:

  • Ventricular Tachycardia (VT):
    • Stable VT: Consider Adenosine if rhythm is regular and monomorphic. Consult expert. Amiodarone or Lidocaine.
    • Unstable VT: Synchronized Cardioversion 0.5-1 J/kg.

What is Post-Cardiac Arrest Care?

Return of Spontaneous Circulation (ROSC) is just the beginning. The goal is to preserve neurologic function and prevent secondary organ injury.

What is the Systematic Approach to Post-Cardiac Arrest Care?

  • Respiratory: Optimize ventilation and oxygenation.
    • Target PaCO2 appropriate for patient condition.
    • Target SpO2 94-99% (avoid hyperoxia).
  • Cardiovascular: Maintain hemodynamic stability.
    • Treat hypotension with fluids and vasopressors.
    • Target systolic BP >5th percentile for age.
  • Neurologic: Targeted Temperature Management (TTM).
    • Continuous monitoring of core temperature.
    • Treat seizures.
    • Avoid fever.

Why is PALS Certification Important in California?

In California, specific regulations often require healthcare providers in emergency and critical care settings to maintain current PALS certification. The state has a high volume of pediatric emergency admissions, making readiness essential.

According to a study published in the Journal of the American Heart Association, survival rates for pediatric out-of-hospital cardiac arrest vary significantly by region. While national survival to hospital discharge averages around 8-11% for OHCA, regions with integrated systems of care—including high rates of bystander CPR and highly trained EMS/hospital staff—show improved outcomes.

What are the Training Requirements?

The AHA PALS course typically involves:
  1. Didactic Learning: Understanding the science of pediatric resuscitation.
  2. Skills Stations: Practicing airway management, vascular access, and CPR.
  3. Megacode: Leading a team through simulated pediatric emergency scenarios (Cardiac, Respiratory, Shock).
  4. Written Exam: Passing a multiple-choice exam with a score of 84% or higher.
To maintain your credentials, you must renew your PALS card every two years. We at Safety Training Seminars offer flexible options to keep you compliant without disrupting your work schedule.

How to Choose the Right PALS Course Option

When selecting a PALS course, you generally have two choices approved by the American Heart Association: Traditional Classroom or Blended Learning (HeartCode PALS).

What is HeartCode PALS (Blended Learning)?

This format is increasingly popular for busy professionals.
  1. Online Portion: Complete the adaptive e-learning modules at your own pace. This includes interactive cases and the written exam.
  2. Skills Session: Visit a training center for hands-on practice and testing with an instructor or voice-assisted manikin (VAM).
Benefits:
  • Learn at your own pace.
  • Focus in-person time solely on skills.
  • Receive the same official AHA card.

What is Traditional Instructor-Led Training?

This is the classic classroom format.
  • Full-day or two-day course.
  • Video-based instruction + practice.
  • Ideal for first-time learners who want more instructor interaction.

Tips for Passing the PALS Exam

  1. Memorize the Algorithms: You must know the cardiac arrest, bradycardia, and tachycardia algorithms cold.
  2. Know your Pharmacology: Focus on Epinephrine, Amiodarone, Adenosine, and Atropine doses.
  3. Understand Shock: Be able to differentiate between Hypovolemic, Distributive, Cardiogenic, and Obstructive shock based on clinical signs.
  4. Practice Team Dynamics: PALS emphasizes effective communication (closed-loop communication, clear roles).
  5. Use Mnemonics: Remember ABCDE, SAMPLE, and H’s & T’s.

Why Choose Safety Training Seminars for PALS?

Finding a reliable training center is crucial for your certification. We offer the lowest priced American Heart Association courses in California and operate over 70 locations, making it easy to find a class near you.

Here is why thousands of California healthcare providers choose us:

  • Official AHA Certification: You receive the official card valid for two years.
  • Same Day Card: We issue your eCard immediately after you complete your skills test. No waiting.
  • Daily Availability: We offer skills sessions every day, including evenings and weekends.
  • Low Price Guarantee: We match or beat legitimate competitor pricing.
  • Convenience: With offices in San Francisco, Sacramento, San Jose, Oakland, and beyond, you are never far from a training site.
If you need to renew your PALS certification or are taking it for the first time, we make the process stress-free.
PALS Study guide

Comprehensive PALS Study Guide

The Comprehensive PALS Study Guide is designed to make learning Pediatric Advanced Life Support (PALS) simple and approachable. Using an easy-to-follow infographic format, it breaks down complex emergency procedures into clear, visual steps. Whether you’re a healthcare professional, student, or first responder, this guide helps you understand how to act quickly and confidently during pediatric emergencies.

Inside the guide, you’ll find everything from recognizing cardiac emergencies and performing CPR to airway management and life-saving medication protocols. Every section follows the latest American Heart Association (AHA) guidelines, so you can trust the information is accurate and up-to-date. Visual flowcharts, step-by-step diagrams, and quick-reference tips make it easy to see what to do next, reducing confusion in stressful situations and improving retention of critical procedures.

What makes this guide truly effective is how it combines visuals with practical learning tools. Memory aids, color-coded sections, and concise explanations ensure the information sticks, whether you’re preparing for PALS certification or refreshing your skills for real-world practice. With this Comprehensive PALS Study Guide, lifesaving knowledge is right at your fingertips—easy to understand, easy to remember, and ready to use when it matters most.

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Frequently Asked Questions

What is the passing score for the PALS written exam?

You must achieve a score of 84% or higher on the American Heart Association PALS written exam to pass. The exam consists of 33 multiple-choice questions.

No. While you can complete the cognitive portion (HeartCode PALS) online, the American Heart Association requires an in-person hands-on skills session to verify your competency. Be wary of websites offering “fully online” cards, as most employers will not accept them.

The full classroom course takes approximately 12-14 hours (often split over two days). The Blended Learning HeartCode option takes 2-6 hours online, followed by a 30-60 minute in-person skills session.

If you do not pass the Megacode skills station, your instructor will typically provide remediation and allow you to retest. The goal is to ensure you are competent, not to fail you.

PALS is typically required for nurses working in Pediatrics, PICU, NICU, Emergency Departments, and Urgent Care centers. Check your specific employer’s requirements.

AHA PALS certification is valid for two years. You must take a renewal course or complete the HeartCode skills session before your card expires.

PALS (Pediatric Advanced Life Support) is for healthcare providers who direct or participate in the management of respiratory and cardiovascular emergencies. PEARS (Pediatric Emergency Assessment, Recognition, and Stabilization) is for providers who may encounter pediatric emergencies but do not routinely provide advanced life support (e.g., school nurses, medical assistants).

You should be proficient in BLS (Basic Life Support) skills, ECG rhythm interpretation, and basic pharmacology before taking PALS.

Yes! Many training centers, including ours, allow you to schedule back-to-back skills sessions for HeartCode BLS, ACLS, and PALS, saving you a trip.

We have over 70 locations across California offering PALS skills testing. Visit our Locations Directory to find the office nearest you.