9.1 Pediatric Basic & Advanced Life Support

Pediatric Basic & Advanced Life Support

Pediatric cardiopulmonary arrest differs fundamentally from adult arrest: most children do not collapse suddenly from a primary cardiac event. Instead, arrest is usually the terminal event of progressive respiratory failure or shock that goes unrecognized or undertreated. This is why the Arab Board Pediatrics exam heavily tests early recognition and correct sequencing rather than pure algorithm memorization — catching a child in respiratory failure or compensated shock and intervening before arrest is the single highest-yield skill in this domain.

The pediatric Chain of Survival (out-of-hospital) is: prevention -> early high-quality CPR -> rapid activation of emergency response -> early advanced life support -> post-arrest care and rehabilitation. Note the order: prevention and early CPR precede activation of emergency response for a lone rescuer with an unwitnessed pediatric collapse, because most pediatric events are respiratory in origin and roughly 2 minutes of CPR before leaving to call for help meaningfully changes outcomes. Once initial Pediatric Basic Life Support (PBLS) steps fail to restore perfusion, providers transition to the Pediatric Advanced Life Support (PALS) algorithms, which layer rhythm-specific drug therapy and defibrillation on top of high-quality CPR.

Pediatric Basic Life Support (PBLS) Sequence

For a lone healthcare-provider rescuer who finds an unresponsive infant or child:

1. Check safety of the scene, then check responsiveness.
2. Shout for help. If a second rescuer or bystander responds, send them to activate the emergency response system and retrieve an automated external defibrillator (AED).
3. Check breathing and pulse simultaneously (maximum 10 seconds) — brachial or femoral pulse in an infant, carotid or femoral in a child.
4. If no pulse, or a pulse under 60/min with signs of poor perfusion despite adequate oxygenation and ventilation, begin chest compressions immediately.
5. If truly alone with no phone, perform 2 minutes of CPR before leaving the child to activate emergency response and retrieve an AED — the key pediatric-specific deviation from adult BLS, where a lone rescuer activates emergency medical services first for a witnessed adult collapse.

Compression Technique and Ratios

Key numeric anchors the exam expects cold:

• Compression rate: 100-120/min, regardless of ratio or age.
• Compression depth: at least one-third the anteroposterior diameter of the chest — roughly 4 cm in infants and 5 cm in children (not a fixed depth as in adults).
• Allow full chest recoil between compressions and minimize interruptions (target chest-compression fraction above 80%).
• Once an advanced airway (endotracheal tube or supraglottic airway) is placed, rescuers stop synchronizing compressions with ventilations — compressions continue uninterrupted while breaths are delivered every 2-3 seconds.

Exam trap: Post-pubertal (physically mature/adolescent) patients are managed with adult ratios (30:2 even with two rescuers) because their arrest physiology is more often primary cardiac. The 15:2 two-rescuer ratio applies only to pre-pubertal infants and children.

Pediatric Assessment Triangle (PAT)

Before ever touching the patient, the Pediatric Assessment Triangle (PAT) is a 30-60 second visual and auditory assessment across three components:

1. Appearance — tone, interactiveness, consolability, look/gaze, and speech/cry (mnemonic TICLS). Appearance reflects adequacy of ventilation, oxygenation, brain perfusion, and central nervous system (CNS) function.
2. Work of breathing — abnormal airway sounds (stridor, grunting, wheezing), abnormal positioning (sniffing, tripoding), retractions (subcostal, intercostal, suprasternal), and nasal flaring.
3. Circulation to skin — pallor, mottling, and cyanosis.

The PAT generates an immediate general impression and directs which physiologic category below the child falls into — this happens before any vital signs are measured, which is exactly why the exam favors PAT-based vignettes over lab-value vignettes for early-recognition items.

Respiratory Failure vs. Shock vs. Cardiopulmonary Failure

The single most tested concept in this section: children compensate for shock through tachycardia and vasoconstriction, keeping blood pressure normal until late. A normal blood pressure does not rule out shock in a child. Hypotension signals decompensated shock that is minutes from arrest.

PALS Algorithm Basics

Once pulseless arrest is confirmed, the PALS cardiac arrest algorithm branches on rhythm.

Shockable rhythms

• Ventricular fibrillation (VF)
• Pulseless ventricular tachycardia (pVT)
• Management: immediate CPR plus defibrillation at 2 J/kg for the first shock, 4 J/kg for the second, and at least 4 J/kg (up to 10 J/kg or the adult dose) for subsequent shocks, with 2-minute cycles of CPR between rhythm checks.

Non-shockable rhythms

• Asystole
• Pulseless electrical activity (PEA)
• Management: high-quality CPR plus epinephrine as early as feasible, with rhythm and pulse checks every 2 minutes; no defibrillation is delivered.

Weight-based epinephrine dosing

Epinephrine is the cornerstone drug for both shockable and non-shockable pediatric arrest:

• Dose: 0.01 mg/kg of the 1:10,000 concentration (0.1 mL/kg), given intravenously or intraosseously (IV/IO), maximum single dose 1 mg.
• Repeat every 3-5 minutes throughout the arrest.
• Endotracheal dosing (only if IV/IO access is not yet obtained) uses a higher dose: 0.1 mg/kg of the 1:1,000 concentration.

Worked example: A 15 kg child (roughly a 3-4-year-old) is in refractory PEA arrest. The correct IV/IO epinephrine dose is 0.01 mg/kg x 15 kg = 0.15 mg, given as 1.5 mL of the 1:10,000 (0.1 mg/mL) solution. Applying the same calculation to a 40 kg pre-adolescent gives 0.01 mg/kg x 40 kg = 0.4 mg — still well under the 1 mg adult ceiling, so no dose capping is needed at that weight.

The Broselow tape concept

Because most pediatric emergencies do not allow time to weigh the child, the Broselow tape is a color-coded, length-based resuscitation tape laid alongside the supine child. The child's length correlates with an estimated weight and a specific color zone, which cross-references pre-calculated drug doses, equipment sizes (endotracheal tube, laryngoscope blade, defibrillation pads), and fluid bolus volumes for that zone — eliminating on-the-spot calculation errors during a resuscitation. The exam tests the concept (length-based, not age-based, estimation) far more than any specific color-to-weight mapping.