PALS | Systemic Approach to Critically Ill Child Extended

The PALS Systematic Approach provides a structured framework to quickly evaluate, identify, and treat life-threatening conditions in pediatric cases[1]. Applying the 80/20 principle, clinical priorities focus on rapidly recognizing respiratory failure and shock before cardiac arrest occurs[1][2].

1. Initial Impression (Pediatric Assessment Triangle)

Formed within seconds "from the doorway" without touching the child[1][3]:

• Appearance: Evaluates consciousness, interactiveness, tone, and consolability via TICLS[3].
• Work of Breathing: Identifies respiratory distress via effort (retractions, nasal flaring), position (tripod), and audible sounds (stridor, grunting, wheezing)[3][4].
• Circulation: Assesses systemic perfusion using skin color (pallor, mottling, cyanosis)[3][4].

2. Immediate Life-Threatening Interventions

• Unresponsive, No Breathing/Gasping, No Pulse: Shout for help, activate emergency response, and begin CPR (C-A-B)[5][6].
• Pulse Present, No Breathing: Provide rescue breathing (1 breath every 3-5 seconds; 12-20 breaths/min)[6].
• Pulse <60/min with Poor Perfusion (despite oxygenation): Start chest compressions[5][6].

3. Evaluate-Identify-Intervene Sequence

Care is a continuous loop: Evaluate -> Identify -> Intervene, repeated after every intervention or change in clinical condition[7][8].

4. Primary Assessment (ABCDE Framework)

Rapid hands-on evaluation of vital physiologic functions[7][8]:

• Airway (A): Assess patency (Clear, Maintainable via head tilt-chin lift/jaw thrust/OPA, or Unmaintainable requiring advanced airway)[9].
• Breathing (B): Assess rate (warning: <10 or >60/min)[11], effort, chest expansion (tidal volume 5-7 mL/kg)[12], breath sounds, and SpO2 (hypoxemia: <94%)[13]. Bradypnea and grunting signal impending arrest[14][15].
• Circulation (C): Assess HR (bradycardia is hypoxia-driven)[16], central vs peripheral pulses[17], capillary refill (<=2s)[18], skin color/temp[19], blood pressure (hypotension: infant <70, child 1-10 yrs <70 + 2xage, >10 yrs <90 mmHg)[20], and urine output (infants 1.5-2, children 1 mL/kg/h)[20]. Hypotension signals decompensated shock[20].
• Disability (D): Rapid neuro assessment using AVPU[21] or Pediatric GCS (<=8 indicates severe injury)[22][23], pupil response (PERRL)[24], and blood glucose (hypoglycemia: <=45 mg/dL in neonates, <=60 mg/dL in children)[24].
• Exposure (E): Undress to evaluate trauma, hemorrhage, or petechiae/purpura (indicative of septic shock), preventing hypothermia[24].

5. Secondary Assessment & Diagnostics

• SAMPLE History: Focused history: Signs/symptoms, Allergies, Medications, Past history, Last meal, and Events leading to illness[25].
• Diagnostic Assessments: ABG/VBG (PaO2, PaCO2, pH <7.35 acidosis)[26], blood lactate (tissue ischemia)[27], ScvO2 (normal 70-75%)[28], ECG, and CXR[29].