PALS (Pediatric Advanced Life Support) 2026: Essential Guide for Nursing Officers

Introduction

Pediatric Advanced Life Support (PALS) focuses on a systematic approach to assess, recognize, and treat critically ill infants and children. As a Nursing Officer in the Pediatric ICU or Emergency, you must understand that “Children are not small adults”—their physiology requires specialized care.

The Systematic Approach Algorithm

The PALS assessment follows a specific pattern to identify life-threatening conditions early:
Initial Assessment (Evaluate): Use the Pediatric Assessment Triangle (PAT).
Appearance: Tone, interactiveness, and look.
Work of Breathing: Check for retractions, grunting, or nasal flaring.
Circulation to Skin: Check for pallor, mottling, or cyanosis.
Primary Assessment (ABCDE):
A – Airway: Clear or maintainable?
B – Breathing: Respiratory rate and effort.
C – Circulation: Heart rate, BP, and capillary refill (Normal is <2 sec).
D – Disability: Level of consciousness (AVPU scale).
E – Exposure: Check for rashes, trauma, or fever.

Pediatric Vital Signs (Normal Ranges)

Nursing Officers must memorize these to identify “Respiratory Failure” or “Shock” in children.

Age Group Heart Rate (BPM) Respiratory Rate
Infant (<1 year) 100 – 160 30 – 60
Toddler (1-3 yrs) 90 – 150 24 – 40
Preschooler (4-5 yrs) 80 – 140 22 – 34
School-age (6-12 yrs) 70 – 120 18 – 30

Management of Respiratory Emergencies

Most pediatric cardiac arrests are caused by respiratory failure, not heart issues.
Upper Airway Obstruction: Common in Croup or Foreign body.
Lower Airway Obstruction: Seen in Asthma or Bronchiolitis.
Nursing Action: Provide high-flow oxygen, assist with nebulization, and prepare for Endotracheal Intubation if breathing effort decreases.

Pediatric Cardiac Arrest Management (Shockable vs Non-Shockable)

Energy Dose for Defibrillation: * First Shock: 2 J/kg
Second Shock: 4 J/kg
Subsequent Shocks: Max 10 J/kg
Drug Dosages:
Adrenaline (Epinephrine): 0.01 mg/kg (Repeat every 3-5 mins).
Amiodarone: 5 mg/kg bolus (for VF/pVT).
Hindi Note: बच्चों में शॉक की डोज उनके वजन (Weight) पर आधारित होती है, इसलिए PALS में वजन का सही होना बहुत जरूरी है।

Fluid Resuscitation in Shock

If a child is in Hypovolemic or Septic shock:
Action: Give an IV/IO Bolus of 20 ml/kg of Isotonic Crystalloid (Normal Saline).
Caution: In cases of Cardiogenic shock, use smaller boluses (5-10 ml/kg).

The “Broselow Tape” Hack

In an emergency, it is hard to calculate doses for children.
The Pro-Tip: Use the Broselow Pediatric Emergency Tape. It is a color-coded tape measure that helps you determine the correct drug doses and equipment sizes (ET Tube, Laryngoscope) based on the child’s height.
Conclusion
PALS requires quick thinking and precise dosing. For a nursing professional, identifying the “Compensated Shock” stage is the key to preventing cardiac arrest in pediatric patients.

Pediatric Arrhythmias: Recognition and Management

As a Nursing Officer, you must distinguish between Bradycardia, Tachycardia, and Arrest rhythms in children.
Pediatric Bradycardia (Heart Rate < 60 bpm): Clinical Sign: If the child has poor perfusion (pallor, altered consciousness). Action: Start CPR if the heart rate is <60 despite oxygenation and ventilation. Drug:

Administer Atropine (0.02 mg/kg) if bradycardia is due to increased vagal tone or primary AV block. SVTs (Supraventricular Tachycardia): Infants: HR > 220 bpm.
Children: HR > 180 bpm.
Treatment: Vagal maneuvers (ice to the face for infants) or Adenosine (0.1 mg/kg rapid IV push).

Intraosseous (IO) Access: The Lifesaver in Pediatrics

In pediatric emergencies, if you cannot get an IV line within 90 seconds or 3 attempts, you must proceed to IO access.
Site: Proximal Tibia (just below the knee) is the preferred site.
Nursing Responsibility: * Ensure the limb is supported.
After inserting the IO needle, flush with Normal Saline to confirm placement.
Remember: Any medication that can be given IV can also be given IO.

Post-Resuscitation Care in Children

Once the heart starts beating again (ROSC), the goal is to protect the brain and other organs.
Oxygenation: Avoid hyperoxia. Aim for SpO_2 94% – 99%.
Blood Pressure: Maintain Systolic BP at least above the 5th percentile for the child’s age. Use Adrenaline or Dopamine infusions if needed.
Glucose Monitoring: Children have low glycogen stores. Check for Hypoglycemia and treat with Dextrose (D10 or D25) if necessary.
Targeted Temperature Management (TTM): Prevent fever. Maintain a core temperature of 36°C to 37.5°C.

The H’s and T’s of Pediatric Cardiac Arrest

Identify why the child’s heart stopped. These are similar to ACLS but more focused on respiratory and fluid issues:
Hypovolemia: (Most common cause due to diarrhea/vomiting).
Hypoxia: (Respiratory failure).
Hydrogen Ion: (Acidosis).
Hypoglycemia: (Critical in infants).
Hypo/Hyperkalemia: (Electrolyte imbalance).
Hypothermia: (Babies lose heat quickly).
Tension Pneumothorax.
Tamponade (Cardiac).
Toxins: (Accidental ingestion).
Thrombosis.

Essential PALS Medications Table (The “Pro-Nurse” Reference)

Drug Pediatric Dose Indication
Epinephrine 0.01 mg/kg (0.1 ml/kg of 1:10,000) Cardiac Arrest / Bradycardia
Adenosine 0.1 mg/kg (Max 6mg first dose) SVT
Amiodarone 5 mg/kg bolus VF / Pulseless VT
Magnesium Sulfate 25-50 mg/kg Torsades de Pointes
Sodium Bicarbonate 1 mEq/kg Metabolic Acidosis

Author’s Note for PALS:

“At BexyHub, our PALS guide is designed to bridge the gap between theory and clinical practice. This content is curated by nursing professionals for nursing professionals, following the latest AHA 2026 Pediatric Guidelines. We prioritize accuracy and patient safety in every note we provide.”

Pediatric Equipment Selection: The “Rule of Thumb”

Choosing the right size of equipment is the most critical part of PALS. A wrong-sized ET tube can cause airway trauma or inadequate ventilation.
Endotracheal (ET) Tube Size Calculation:
Uncuffed Tube: (Age / 4) + 4
Cuffed Tube: (Age / 4) + 3.5
NG/OG Tube & Suction Catheters: Usually, double the ET tube size (e.g., if ET tube is 4.0, use an 8F suction catheter).
Defibrillation Paddles: * Use Large (Adult) paddles for children >10 kg.
Use Small (Infant) paddles for infants <10 kg.

Shock Management in Pediatrics (A Quick Summary)

In PALS, you must identify the Type of Shock to give the right treatment:
Hypovolemic Shock: Most common (Dehydration/Trauma). Treat with 20 ml/kg NS/RL bolus.

Distributive Shock: Sepsis or Anaphylaxis. Treat with fluids and Vasopressors (Noradrenaline).
Cardiogenic Shock: Heart failure/Congenital issues. Treat with 5-10 ml/kg cautious fluids and Inotropes (Dobutamine).
Obstructive Shock: Tension pneumothorax or Tamponade. Requires immediate procedure (Needle Decompression).

End-Tidal CO_2 (EtCO_2) in PALS

Monitoring EtCO_2 (Capnography) is now a “Gold Standard” in 2026 PALS guidelines:
Effectiveness of CPR: If EtCO_2 is persistently below 10-15 mmHg, you need to improve the quality of chest compressions.

ROSC Identification: A sudden jump in EtCO_2 (to 35-40 mmHg) is a sign that the child’s heart has started beating again.
Final Summary for Nursing Officers
Ratio (1 Rescuer): 30:2
Ratio (2 Rescuers): 15:2 (Professional Standard)
Compression Depth: 1/3rd of the chest diameter.
First Action: Always check for Respiratory Effort first, as most pediatric arrests are respiratory-led.