PALS: Initial Evaluation and Airway Management

Introduction

• The American Heart Association PALS program provides a structured approach to the assessment and treatment of critically ill pediatric patients, emphasizing the prevention of cardiac arrest by rapidly identifying and treating respiratory compromise and shock before progression to cardiopulmonary failure in infants and children up to age 18.^1,3
• In the U.S., there are more than 7000 out-of-hospital cardiac arrests (OHCA) and 20,000 in-hospital cardiac arrests (IHCA) each year among infants and children. Survival to hospital discharge rates following pediatric OHCA range from 6% to 38% while survival to hospital discharge rates for IHCA range from 38% for pulseless cardiac arrest to 66% for nonpulseless cardiac arrest.¹
• The most common cause of cardiac arrest in infants and children is progressive respiratory failure or shock. Early recognition and treatment of respiratory distress, respiratory failure, and shock, guided by the PALS algorithm, is essential to improving outcomes.³

Initial Evaluation

PAT

• The PAT is a rapid assessment that relies on three observations to quickly identify a child with respiratory or circulatory compromise who requires immediate intervention.^1,3
• Appearance^1,3
  • Tone – Vigorous movement/normal muscle tone vs. decreased muscle tone or limp and weak
  • Interactiveness – Playful/interactive vs. indifferent to distractions
  • Consolability – Easily consoled by caregiver
  • Look/gaze – Focused vs. unfocused gaze
  • Speech/Cry – Loud/strong cry vs. weak cry; hoarse or muffled voice, indicative of upper airway obstruction
• Work of breathing^1,3
  • Airway sounds – Abnormal airway sounds such as stridor, snoring, grunting, and wheezing
  • Positioning – Flexed neck with head mildly extended or tripod position
  • Accessory muscle use – Supraclavicular, intercostal, and/or substernal muscle group use and retractions from the use of accessory muscles
  • Head bobbing, nasal flaring
• Circulatory status^1,3
  • Pallor or cyanosis
  • Poor capillary refill or cool skin
• If the PAT is abnormal in two or more categories or the child appears unstable, immediate stabilization is necessary. If the PAT is abnormal in less than two categories and the child appears stable, a more detailed assessment should be performed.³

Initial Stabilization

• Children with abnormalities identified using the PAT are considered critically ill and require immediate intervention. Stabilization should begin immediately and may proceed concurrently with further assessment and examination; however, lifesaving interventions should take priority in children identified as critical.³
• Key components of initial stabilization include:
• Supplemental oxygen
  • Patients with 2 or more abnormalities in PAT categories tend to require oxygen therapy³
  • Patients with SpO₂ ≤94% should receive supplemental oxygen³
• Assisted ventilation
  • Initially provided with bag-mask ventilation (BMV) for patients with inadequate respiratory effort or weak gas exchange³
  • Endotracheal intubation or supraglottic airway placement may be necessary for patients who are not expected to improve quickly or cannot maintain a protected airway³
• Circulatory support
  • Establish vascular access via peripheral IV or intraosseous route³
  • Provide fluid resuscitation in patients with signs of poor perfusion³
• Monitoring
  • Reassess frequently³
  • Continuous monitoring of vital signs³

Airway and Breathing Management in PALS

• When assessing airway and breathing in pediatric patients, management should involve the use of the least invasive, effective intervention, with step-up interventions only when necessary. It should be done with minimal interruptions in oxygenation and ventilation.¹

Basic Management

1. Basic Airway Maneuvers and Positioning

• Perform a head tilt-chin lift to open the airway in the absence of neck injury³
• Clear the airway from visible foreign bodies and suction excessive secretions³
• Use of adjuncts such as an oropharyngeal airway or nasopharyngeal airway to assist in keeping the oral and nasal passageways patent and free of obstruction³

2. Oxygenation and BMV

• Provide supplemental oxygen if the patient is in respiratory distress, hypoxic or in shock
• Initiate BMV with 100% oxygen if the patient is unable to breathe spontaneously.²
• Ensure the mask fits properly with a tight seal using the “E-C clamp.”³
• E and C are formed by the fingers and thumb over the mask.³
• Please see the OA summary, “Pediatric Bag Mask Ventilation,” for more details. Link
• Observe chest rise over one second³

3. Noninvasive Ventilation

• May be useful as a bridge therapy in children in respiratory distress with intact airway reflexes³
• May aid in oxygenation and prevent respiratory acidosis³

Advanced Airway Placement

• Indications
  • The airway cannot be maintained with basic maneuvers³
  • Ventilation or oxygenation is inadequate despite BMV³
  • High risk of aspiration³
  • Need for a definitive airway for prolonged ventilation³
• Device types
  • Endotracheal intubation is the most common approach; it should be done with minimal interruptions in compressions or oxygenation.^1,3
  • Supraglottic airways (SGA) may be used if intubation is unsuccessful or if the placement of SGA can be done more rapidly than intubation.^2,3
• Monitoring
  • Once an advanced airway is placed, confirmation of proper placement via bilateral chest rise and auscultation³
  • Ensure reaching the ventilation rate target goal of 20-30 breaths per minute1
  • Monitor SpO₂ and hemodynamic stability^1,2

Airway Management During Cardiac Arrest

• Out-of-hospital cardiac arrest
  • BMV is recommended as the initial method of management²
  • Endotracheal intubation is not favorable, as it may cause interruptions in chest compressions¹
• In-Hospital Cardiac Arrest
  • BMV or placement of an endotracheal tube or SGA is acceptable¹
  • Decision should be based on the patient’s underlying condition, risk of aspiration, and least pauses in chest compressions.¹

Further Evaluation

Physical Examination

Following the rapid PAT, a thorough physical examination should be performed to help identify the underlying cause of distress and guide specific treatment.³

Vital Signs

• Respiratory rate, heart rate, blood pressure, pulse oximetry³
• Estimation of weight
  • Parent/primary caregiver estimation³
  • Length-based measurement³
  • Antevy formula (weight in kg)
• 1 to 9 years of age: 2.5 x (age in years) + 7.51

Key Assessments

• Respiratory evaluation³
  • Chest rise and symmetry
  • Breath sounds, wheezing, crackles, stridor
  • Use of accessory muscles, nasal flaring, intercostal/subcostal retractions
• Cardiac Examination³
  • Heart sounds, rhythm, murmurs
  • Peripheral and central pulses
  • Capillary refill time
• Neurologic Assessment
  • Level of consciousness is categorized using AVPU³
    • Alert
    • Responds to verbal commands
    • Responds to painful stimuli
    • Unresponsive
  • Skin3
    • Observe color – cyanosis vs. pallor
    • Temperature
    • Turgor
    • Rashes

Oxygenation and Ventilation Measurements

• Pulse oximetry
  • Continuous monitoring is recommended if SpO₂ is at or below 94%³
  • End-tidal carbon dioxide measurement³
  • Transcutaneous CO₂ measurement may be used in infants and children up to 16 years³
  • Arterial blood gas/venous blood gas³

Postresuscitation Airway and Ventilatory Management

• After return of spontaneous circulation (ROSC), airway management should focus on optimizing gas exchange and preventing brain and organ damage.³

ROSC Includes

• Presence of palpable central pulse³
• Organized heart rhythm³
• Increased blood pressure³

Management

• Confirm and secure advanced airway placement1
• Ensure sufficient oxygenation1
  • Initiate high FiO₂ immediately post ROSC¹
  • Titrate oxygen to maintain SpO₂ of 94 – 99%²
• Ensure sufficient ventilation¹
  • Monitor PaCO₂ and EtCO₂¹
  • Target EtCO₂ of 35-45 mmHg¹
  • Complications of hypocapnia include decreased cerebral perfusion¹
  • Complications of hypercapnia may worsen acidosis and intracranial pressure¹
  • Monitor blood gases intermittently¹
• Administer disease-dependent lung-protective tidal volumes and positive end-expiratory pressure (PEEP)³
  • Obstructive lung disease: longer expiratory time, lower respiratory rate prevents hyperinflation and air trapping³
  • Parenchymal disease or ARDS: lower tidal volume, increased PEEP³
• Provide adequate sedation and analgesia³
• Consider stepdown of ventilatory support when appropriate, with possible extubation or transition to noninvasive support¹