How to Pass the Pediatric Advanced Life Support (PALS) Like A Boss in 2021

The Pediatric Advanced Life Support Certification can be very stressful whether you are taking the examination for the first time or renewing every 2 years. Here are some helpful tips in passing the PALS Certification Examination.

2020 Pediatric Advanced Life Support Update

Blood Pressure in Pediatrics

Low systolic blood pressure is a LATE sign that something is wrong. It can be difficult to memorize normal systolic blood pressure in children regarding their age.

Remember the following calculation: Low systolic blood pressure is 70 + 2 x (Age in Years of Child)

Exception to Blood Pressure rule

  • If a child is less than one years old, any blood pressure under 70 is considered hypotensive
  • If a child is a neonate, any blood pressure under 60 is considered hypotensive

Fluid Resuscitation in Pediatrics

General Fluid Resuscitation

  • 10 or 20 mL/Kg of fluid boluses with frequent reassessment (2020 AHA Guidelines Update)

Cardiac Related Fluid Resuscitation

  • 5 to 10 ML/Kg of Normal Saline or Lactated Ringers over 10 to 20 minutes

Hemorrhagic Shock

  • Transfuse Packed Red Blood Cells (PRBCs)


Shock Identification in Pediatrics

Hypovolemic Shock

  • Causes can be gastroenteritis, burns, hemorrhage, inadequate fluid intake, increased body fluid loses, osmotic diaphoresis, vomiting, diarrhea

Cardiogenic Shock

  • Causes can be congenital heart disease, myocarditis, cardiomyopathy, arrhythmia

Distributive Shock

  • Causes can be sepsis, anaphylaxis, spinal cord injuries

Obstructive Shock

  • Causes can be tension pneumothorax, cardiac tamponade, pulmonary embolism, constriction of ductus arteriosus, ductal dependent congenital heart lesions

Management of Shock

  • Oxygenation
  • Monitoring Pulse Oximetry
  • Reviewing Electrocardiogram (EKG)
  • IV/IO Access
  • Blood Glucose Monitoring
  • Basic Life Support if indicated

Sepsis in Pediatrics

Signs and Symptoms of Sepsis

  • Low Systolic Blood Pressure
  • High Heart Rate
  • Elevated White Blood Cell Count
  • Elevated Respiratory Rate
  • High or Low Temperature

Sepsis Triangle in Children

  • Evaluate the patient for signs and symptoms of sepsis
  • Identification occurs through vital signs, lab results
  • Intervene by identifying the cause and fix it
    • If the problem identified is sepsis, you start with antibiotics and move on


Respiratory Management in Pediatrics

Upper Airway Obstruction

  • Cause can be croup, anaphylaxis, foreign body aspiration
  • Assessment
    • Increased respiratory rate
    • Stridor
    • Barking cough
    • Hoarseness

Lower Airway Obstruction

  • Causes can be bronchitis, asthma
  • Assessment
    • Increased respiratory rate
    • Expiratory wheezing
    • Prolonged expiratory phase

Lung Tissue Disease

  • Causes can be pneumonia, pneumonitis, pulmonary edema, acute respiratory distress syndrome (ARDS)
  • Assessment
    • Increased respiratory rate
    • Grunting
    • Crackles
    • Decreased breath sounds

Disordered Control of Breathing

  • Causes can be neurological in nature
    • Increased intracranial pressure (ICP)
    • Poisoning, Overdose
    • Neuromuscular Disease
  • Assessment

Cardiopulmonary Resuscitation in Pediatrics

  • Chest compression should be 1/3 the AP diameter of the chest
  • One-person rescuer is 30 chest compressions to 2 breaths
  • Two-person rescuer is 15 chest compressions to 2 breaths
  • 100 to 120 chest compressions per minute
  • Provide 1 breath every 2 to 3 seconds (20 – 30/min) with or without an advanced airway (2020 AHA Guidelines Update)

Understanding the differences between Defibrillation vs Synchronized Cardioversion

Defibrillation is the treatment for immediate life-threatening arrhythmias with which the patient does not have a pulse such as ventricular fibrillation or pulseless ventricular tachycardia.

Synchronized Cardioversion is the treatment that aims to convert an arrhythmia back to sinus rhythm such as atrial fibrillation or supraventricular tachycardia.


  • Initial Shock: 2-4 Joules/Kg
  • Second Shock: > OR = 4 Joules/Kg
  • Maximum Shock: 10 Joules/Kg

Synchronized Cardioversion

  • 5 to 1 Joules/Kg

Mega Code in Pediatric Advanced Life Support Certification

Initial Impression: What you see and what you hear

  • Appearance
    • Level of consciousness
    • Is the child interacting with you?
  • Work of Breathing
    • Respiratory rate high or low
    • Effort of breathing
    • Retractions, Nasal Flaring
    • Audible irregular respiratory sounds
  • Circulation
    • Skin color
    • Capillary refill less than or more than 2 seconds
      • May not always be accurate due to body temperature

Primary Assessment Survey (A, B, C, D, E)

  • Airway
    • Is the airway patent?
    • Is there good flow in trachea?
      • Circumference in trachea is smaller than adults
  • Breathing
    • Is the respiratory rate regular, increased, decreased?
    • Is breathing effort unlabored?
    • Wheezing, Grunting?
    • Is chest expanding appropriately?
    • Adventitious breath sounds
  • Circulation
    • Is the heart rate regular, increased, decreased?
    • Is the heart rhythm regular or irregular?
    • Hypertensive blood pressure or hypotensive blood pressure?
    • Skin color
    • Capillary refill
    • Is the temperature elevated or decreased?
    • Cyanosis
    • How is the patient oxygenating?
  • Disability
    • Neurological status
      • Level of consciousness
      • Pupillary responsiveness
      • AVPU Score
        • Alert
        • Verbal to Stimuli
        • Responsive to Painful Stimuli only
        • Unresponsive
      • Blood glucose monitoring – very important
  • Exposure
    • Body temperature
    • Skin condition (bleeding, bruising, rashes)

Secondary Assessment Survey (SAMPLE mnemonic)

  • Symptoms
    • Objective information from caregiver
  • Allergies
    • Allergic to food, medications, environmental allergies
  • Medications
    • Over the counter medications
    • Vitamins
    • Supplements
    • Prescribed Medications
    • Any medications not prescribed to the child that may have been ingested or used
  • Previous Medical History
    • Illnesses
    • Hospitalizations
    • Immunizations up to date
  • Last Meal/Fluid
    • What time was their last meal/fluid intake?
    • What was the meal or fluid ingested?
  • Events
    • What lead up to the current presentation?


Pediatric Advanced Life Support Cards







6 thoughts on “How to Pass the Pediatric Advanced Life Support (PALS) Like A Boss in 2021”

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    1. Thank you Clavicle. I appreciate your support. I hope this guide was helpful in passing the Pediatric Advanced Life Support class. Here is to another two years of certification and caring for the pediatric community.

    1. Thank you Jennifer. I appreciate the support from CPR Space Coast. I am glad to see you are from my area. Keep up the great work in educating the care providers in the area and feel free to reach out anytime.

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