PALS Algorithm Quick Reference Guide: All 6 Core Algorithms

The PALS algorithms are systematic, evidence-based decision trees developed by the American Heart Association for managing pediatric emergencies. Knowing these algorithms inside and out is essential for both the written exam and the megacode skills testing. Below is a summary of each core algorithm with the key decision points and interventions.

Important: This guide is a study reference, not a substitute for the official AHA PALS Provider Manual. Always refer to the most current AHA guidelines for clinical practice.

1. Pediatric BLS Algorithm

The foundation of all PALS interventions. High-quality CPR is the single most important factor in survival from pediatric cardiac arrest.

1Verify scene safety

2Check responsiveness — tap and shout

3If unresponsive, shout for help and activate the emergency response system

4Check for breathing and pulse simultaneously (no more than 10 seconds)

5No pulse: Begin CPR — 30:2 (single rescuer) or 15:2 (two rescuers)

6Compression depth: at least 1/3 AP diameter of chest (1.5 inches infants, 2 inches children)

7Rate: 100-120 compressions per minute

8Attach AED/defibrillator as soon as available

9Shockable rhythm (VF/pVT): Deliver shock at 2 J/kg, resume CPR immediately

10Non-shockable rhythm: Continue CPR, transition to PALS Cardiac Arrest Algorithm

Key Point: In pediatric patients, always check for a pulse at the brachial artery (infants) or carotid/femoral artery (children). Minimize interruptions to chest compressions.

2. Pediatric Cardiac Arrest Algorithm

This algorithm branches based on whether the rhythm is shockable (VF/pVT) or non-shockable (asystole/PEA). Both pathways emphasize high-quality CPR with minimal interruptions.

Shockable: VF / Pulseless VT

1.Shock at 2 J/kg
2.CPR for 2 minutes
3.Check rhythm — if still shockable, shock at 4 J/kg
4.CPR for 2 minutes
5.Epinephrine 0.01 mg/kg IV/IO (every 3-5 min)
6.Shock at 4 J/kg (max 10 J/kg)
7.Amiodarone 5 mg/kg IV/IO (or lidocaine 1 mg/kg)
8.Continue cycle: CPR → rhythm check → shock if needed

Non-Shockable: Asystole / PEA

1.CPR for 2 minutes
2.Epinephrine 0.01 mg/kg IV/IO ASAP
3.Continue CPR for 2 minutes
4.Check rhythm
5.Repeat epinephrine every 3-5 minutes
6.Identify and treat reversible causes (H's and T's)
7.If rhythm becomes shockable, move to VF/pVT pathway

Remember the H's and T's: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/Hyperkalemia, Hypothermia | Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary/coronary).

3. Pediatric Bradycardia Algorithm

Bradycardia in pediatric patients is most commonly caused by hypoxia. The algorithm emphasizes addressing the underlying cause before pharmacological intervention.

1Identify bradycardia (heart rate less than normal for age) with cardiopulmonary compromise

2Support ABCs — provide oxygen, attach monitor/defibrillator

3If HR <60/min with poor perfusion despite adequate oxygenation and ventilation, start CPR

4If bradycardia persists: Epinephrine 0.01 mg/kg IV/IO (repeat every 3-5 min)

5If increased vagal tone or primary AV block: Atropine 0.02 mg/kg IV/IO (min dose 0.1 mg)

6Consider transcutaneous pacing for refractory bradycardia

7Identify and treat underlying causes

Key Point: Always address oxygenation and ventilation first. In pediatrics, the most common cause of bradycardia is hypoxia. Correcting the hypoxia often resolves the bradycardia.

4. Pediatric Tachycardia with a Pulse Algorithm

This algorithm distinguishes between narrow-complex and wide-complex tachycardias, and between stable and unstable patients. The first decision point is always: is the patient hemodynamically stable?

Narrow Complex Tachycardia (QRS ≤ 0.09 sec)

1Evaluate the QRS duration — narrow complex is most likely sinus tachycardia or SVT

2Sinus tachycardia: Treat the underlying cause (fever, dehydration, pain, anxiety)

3SVT (rate typically >220 in infants, >180 in children, no P waves or abnormal P waves)

4If hemodynamically stable: Attempt vagal maneuvers first (ice to face for infants, bearing down for children)

5If vagal maneuvers fail: Adenosine 0.1 mg/kg rapid IV push (max first dose 6 mg), may repeat at 0.2 mg/kg (max 12 mg)

6If hemodynamically unstable or adenosine fails: Synchronized cardioversion at 0.5-1 J/kg, may increase to 2 J/kg

Wide Complex Tachycardia (QRS > 0.09 sec)

1Wide complex tachycardia in children may be VT or SVT with aberrant conduction

2If hemodynamically unstable: Synchronized cardioversion at 0.5-1 J/kg

3If hemodynamically stable and rhythm is regular: Consider adenosine if rhythm may be SVT with aberrancy

4If confirmed or suspected VT: Amiodarone 5 mg/kg IV over 20-60 minutes, or procainamide 15 mg/kg IV over 30-60 minutes

5Expert consultation is recommended for wide complex tachycardia in pediatric patients

Key Point: Distinguishing sinus tachycardia from SVT is a commonly tested concept. Look for the absence of P waves, abrupt onset, and rates >220 in infants as indicators of SVT.

5. Pediatric Systematic Assessment Algorithm

The systematic approach is used for initial assessment of every pediatric patient. It follows a structured evaluate-identify-intervene sequence.

General Assessment (PAT)

The Pediatric Assessment Triangle evaluates Appearance (muscle tone, interactivity, consolability, look/gaze, speech/cry), Work of Breathing (abnormal sounds, positioning, retractions, nasal flaring), and Circulation (skin color/pallor, mottling, cyanosis).

Primary Assessment (ABCDE)

Airway (patency, maintainability), Breathing (rate, effort, breath sounds, SpO2), Circulation (HR, BP, pulses, cap refill, skin color/temp), Disability (AVPU or GCS, pupil response, blood glucose), Exposure (temperature, signs of trauma/rash).

Secondary Assessment

Focused history (SAMPLE: Signs/Symptoms, Allergies, Medications, Past medical history, Last meal, Events), focused physical exam, and ongoing reassessment.

Diagnostic Assessment

Laboratory studies, imaging, and continuous monitoring to guide definitive management and identify underlying causes.

6. Post-Resuscitation Care Algorithm

After return of spontaneous circulation (ROSC), the focus shifts to maintaining hemodynamic stability and preventing secondary injury.

1Reassess and support ABCs — maintain SpO2 94-99%, avoid hyperoxia

2Obtain 12-lead ECG and continuous monitoring

3Treat hypotension with fluid boluses (20 mL/kg NS) and/or vasopressors

4If comatose after cardiac arrest, consider targeted temperature management (TTM)

5Maintain normoglycemia — treat hypoglycemia, avoid hyperglycemia

6Monitor for seizures and treat as needed

7Obtain laboratory studies (ABG, electrolytes, lactate, glucose)

8Identify and treat the underlying cause of arrest

9Arrange transport to appropriate pediatric critical care facility

Key Point: Avoid hyperoxia after ROSC. Titrate oxygen to maintain SpO2 between 94-99%. Excessive oxygen can worsen reperfusion injury, especially in neonates and infants.

PALS Algorithm Quick Reference Guide