PALS Study Guide: Everything You Need to Pass the Exam

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.

PALS teaches recognition and treatment of life-threatening pediatric emergencies, airway/breathing problems, shock, arrhythmias, and cardiac arrest, using team-based, algorithmic care. This study guide highlights the core topics in a simple format, making it easier to recall what you have learned in class. The American Heart Association (AHA) PALS algorithms are based on the latest 2020 guidelines and updates, serve as the foundation of modern pediatric emergency practice.

What is Pediatric Advanced Life Support?

Pediatric Advanced Life Support is a set of evidence-based guidelines and a training program developed by the American Heart Association to help healthcare providers recognise and manage life-threatening pediatric emergencies. It focuses on infants and children who are critically ill or injured and require urgent medical intervention. However, understanding the basics of PALS can be beneficial for anyone working with children, including caregivers, teachers, and childcare providers.

What is the PALS Algorithm?

The Pediatric Advanced Life Support (PALS) algorithm is a structured step-by-step guide designed to help healthcare professionals manage pediatric emergencies effectively. Its primary goal is to ensure the timely delivery of cardiopulmonary resuscitation (CPR), advanced interventions, and critical decision-making that can save the lives of infants and children in life-threatening situations.

Here are the PALS Algorithm:

1. Pediatric Cardiac Arrest Algorithm

The pediatric cardiac arrest algorithm is a step-by-step guide designed to help healthcare providers effectively manage and treat children experiencing cardiac arrest. This algorithm follows evidence-based guidelines to improve survival outcomes and ensure timely interventions.

2. Pediatric Tachycardia With Pulse

Pediatric tachycardia with a pulse occurs when a child’s heart rate is abnormally fast but still has a detectable heartbeat. The first step is to assess the child’s perfusion, mental status, and signs of shock. If the child shows signs of instability, immediate synchronized cardioversion is recommended.

3. Pediatric Bradycardia With Pulse

Pediatric bradycardia with a pulse occurs when a child’s heart rate is slower than normal, but a pulse is still present. The first step is to assess the child’s perfusion, breathing, and level of consciousness. If the child shows signs of poor perfusion or shock, immediate interventions like CPR and administration of epinephrine may be required.

4. Pediatric Septic Shock Algorithm

The Pediatric Septic Shock Algorithm is a structured, step-by-step clinical guide designed to quickly recognize and treat children experiencing severe infections that cause poor perfusion, low blood pressure, and organ dysfunction. It helps healthcare providers provide timely fluid resuscitation, medications, oxygen support, and monitor responses to improve survival and outcomes.

5. Pediatric Post-Resuscitation Algorithm

The Pediatric Post-Resuscitation Algorithm is a structured, step-by-step clinical guide for managing children after successful resuscitation from cardiac arrest. It focuses on stabilizing airway, breathing, and circulation, monitoring vital signs, preventing further organ damage, supporting neurological recovery, and addressing underlying causes to optimize outcomes and improve survival.

Initial Assessment: Pediatric Assessment Triangle

The Pediatric Assessment Triangle (PAT) is a rapid evaluation tool used in PALS to assess a child’s clinical status within 30 to 60 seconds, without touching the patient. It helps healthcare providers quickly identify life-threatening conditions and prioritise interventions.
The PAT is based on three key components:

Appearance

Appearance reflects the child’s brain function and overall physiological stability. Use the mnemonic TICLS to assess:
1. Tone: Is the child moving spontaneously?
2. Interactiveness: Does the child respond to people or the environment?
3. Consolability: Can the child be comforted by caregivers?
4. Look/gaze: Are the eyes focused or glazed?
5. Speech/cry: Is it strong, weak, or absent?

Work of Breathing

This part helps to identify whether your child is in respiratory distress or progressing into respiratory failure.
1. Abnormal airway sounds (stridor, wheezing, grunting)
2. Abnormal positioning (tripod, sniffing)
3. Retractions (supraclavicular, intercostal, subcostal)
4. Nasal flaring or head bobbing

Circulation to Skin

Provides clues about perfusion and shock.
1. Pallor (pale skin)
2. Mottling (patchy discolouration)
3. Cyanosis (bluish colour around lips, fingers, or toes)

Primary Assessment: ABCDE Approach

Primary Assessment (ABCDE approach) provides a structured, hands-on method to identify and treat life-threatening problems in children. Each step should be performed systematically and simultaneously with interventions as needed.

Here are the steps of the primary assessment by using the PALS algorithm:

1. Airway: Ensure the airway is patent, clear any visible blockage, and apply basic maneuvers (head tilt–chin lift or jaw thrust) if required.
2. Breathing: Observe respiratory rate, chest expansion, and effort; provide supplemental oxygen or assisted ventilation if inadequate.
3. Circulation: Assess heart rate, pulse quality, skin temperature/colour, and capillary refill; manage shock and control external bleeding.
4. Disability: Quickly check neurological status using the AVPU scale (Alert, responds to Voice, responds to Pain, Unresponsive) and assess pupils for size and reaction.
5. Exposure: Expose the child to identify injuries, rashes, or medical alerts, while simultaneously protecting them from hypothermia.

Secondary Assessment: SAMPLE & Focused Physical Exam

Once immediate life-threatening conditions are addressed in the Primary Assessment (ABCDE), the next step in PALS is the Secondary Assessment. This stage involves gathering a focused history and performing a targeted physical exam to uncover underlying causes and guide ongoing treatment.

Focused History (SAMPLE)

Obtain a focused history using the SAMPLE acronym: Symptoms, Allergies, Medications, Past medical history, Last meal, and Events leading up to illness.

1. S – Signs & Symptoms: In emergencies, children may show changes in breathing, skin colour, level of consciousness, or behaviour that indicate serious illness or injury.
2. A – Allergies: Any known drug, food, or environmental allergies.
3. M – Medications: Current prescribed, over-the-counter, or herbal medications the child is taking.
4. P – Past Medical History: Relevant medical, surgical, or birth history, including chronic illnesses (asthma, congenital heart disease, seizures).
5. L – Last Meal: When and what the child last ate or drank (important for procedures or anesthesia).
6. E – Events Leading Up to Illness/Injury: What happened before the emergency (e.g., trauma, sudden collapse, exposure, activity).

Focused Physical Exam

A focused physical exam is performed after completing the SAMPLE history to further evaluate the child’s condition. It is not a full head-to-toe examination but rather a targeted assessment based on the child’s presenting problem and the clues gathered from history.

1. Head & Neck: Observe for trauma, swelling, deformities, or signs of infection such as meningismus or lymphadenopathy.
2. Chest: Evaluate breath sounds, chest symmetry, retractions, and listen for abnormal heart or lung sounds (wheezing, crackles, murmurs).
3. Abdomen: Inspect and palpate for distension, tenderness, rigidity, or organ enlargement.
4. Extremities: Assess capillary refill, skin temperature, peripheral pulses, and check for movement or neurological deficits.
5. Skin: Look for rashes, petechiae, cyanosis, bruising, or dehydration indicators (poor turgor, dry mucous membranes).

Diagnostic Tests & Monitoring

It is crucial to perform diagnostic tests and continuously monitor the child. This step helps evaluate the child’s condition, guide treatment, and track response. Key assessments include vital signs, ECG, oxygen saturation, blood work, and other relevant investigations.

1. ECG: For detecting arrhythmias, conduction abnormalities, and cardiac events.
2. Pulse Oximetry & Capnography: To continuously assess oxygenation and ventilation status.
3. Blood Tests: Including glucose, electrolytes, blood gases, and lactate to identify metabolic or systemic issues.
4. Imaging Studies: X-ray, ultrasound, or CT scans as needed to evaluate trauma, respiratory distress, or internal injuries.

Shock Emergency

Shock is a life-threatening condition in children where tissue perfusion and oxygen delivery are insufficient to meet the body’s metabolic needs. In PALS, rapid recognition and treatment of shock are critical to prevent progression to cardiac arrest.

Types of Shock in Children

1. Hypovolemic Shock: Caused by fluid loss from dehydration, bleeding, or burns.
2. Distributive Shock: Includes septic, anaphylactic, or neurogenic shock, where vascular tone is abnormal and blood is improperly distributed.
3. Cardiogenic Shock: Results from heart failure, myocarditis, or congenital heart defects, leading to poor cardiac output.
4. Obstructive Shock: Caused by tension pneumothorax, cardiac tamponade, or massive pulmonary embolism, which obstructs blood flow.

Key Intervention in Shock Management

1. Early recognition: Assess vital signs and perfusion to identify shock before hypotension develops.
2. Rapid vascular access: Establish IV or IO access for fluids and medications.
3. Fluid resuscitation: Administer isotonic fluids (20 mL/kg) rapidly, except in cardiogenic shock, where fluids are given cautiously.
4. Vasopressors and inotropes: Use medications such as epinephrine, norepinephrine, or dobutamine if fluid therapy is insufficient.
5. Definitive treatment: Manage the underlying cause according to the type of shock (e.g., stop bleeding, treat sepsis, relieve obstruction, or treat anaphylaxis).

Cardiac Arrest Emergency

A cardiac arrest emergency in a child occurs due to respiratory failure or shock. Infants and children can be saved in a life-threatening situation by following the AHA CPR guidelines.

Steps for Performing CPR on infants and children

1. Check Responsiveness and Call for Help:

• Tap and shout to assess responsiveness.
• If unresponsive, call emergency services and get an AED/defibrillator.

2. Assess Breathing and Pulse:

• If the child is not breathing normally or has no pulse, begin CPR immediately.

3. Chest Compressions:

• Infants (under 1 year): Use two fingers at the center of the chest.
• Children (1 year to puberty): Use one or two hands depending on the size of the child.
• Depth: About 1.5 inches (4 cm) for infants and 2 inches (5 cm) for children.
• Rate: 100–120 compressions per minute.
• Allow complete chest recoil between compressions.

4. Rescue Breaths:

• Give 2 breaths after every 30 compressions for a single rescuer, or 15:2 if two rescuers.
• Each breath should last about 1 second and make the chest visibly rise.

5. Use of AED/Defibrillator:

• Attach an AED as soon as available.
• Follow prompts and deliver a shock if indicated, then resume CPR immediately.

6. Continue CPR:

• Alternate cycles of compressions and breaths.
• Reassess pulse and rhythm every 2 minutes.
• Continue until the child shows signs of life or advanced help takes over.

Team Dynamic

Team dynamics refers to the way people in a group interact, communicate, and work together to achieve a common goal. It includes how team members share ideas, solve problems, and support one another. A positive team dynamic creates trust, cooperation, and respect, while a negative one can cause conflict and slow down progress.

Good team dynamics help everyone feel valued and motivated. When team members understand each other’s strengths and weaknesses, they can collaborate better, make decisions faster, and achieve results more effectively. In short, team dynamics shape how smoothly and successfully a group works together to save a child from cardiac emergencies and other emergencies.

Review of the key topic in PALS

Pediatric Advanced Life Support (PALS) covers essential life-saving skills designed to protect infants and children during life-threatening emergencies such as cardiac arrest, shock, choking, or other critical conditions. When reviewing, it’s important to focus on the official AHA PALS algorithm and study guide, as these form the foundation for successfully passing the PALS skills test.

If you are someone who wants to deepen their knowledge and confidently perform CPR, enrolling in professional training is the best approach. At CPRVAM, we provide hands-on practice, advanced CPR tools, and an updated PALS renewal course to ensure you are fully prepared to handle real-life emergencies with skill and confidence. Our experienced instructors help you gain confidence to handle emergencies effectively. Join us now and be prepared to handle pediatric emergencies in your own way !