A set of procedures provided by trained medical staff. In our setting, it is performed by emergency medical services; in healthcare settings, it is performed by specialist teams. It builds on PBLS.

As in ALS, the algorithm is divided into 2 branches according to the initial rhythm.

Shockable – the priority is to defibrillate using 4J/kg discharge

Nonshockable – the priority is to secure an IO access immediately and administer adrenaline 10 mcg/kg 

During PALS, we try to rule out possible reversible causes of cardiac arrest. In the PALS guidelines, hypoglycaemia is listed as a reversible cause of SCA. The risk of severe hypoglycaemia is high, especially in very young children.

The PALS issue is discussed in more detail in the available presentation.
In addition to the presentation's content, we assume detailed knowledge of the ERC algorithm.
In the text below, we provide key points on each component of PALS in children.

COMPRESSIONS

• The quality of chest compressions is defined by their depth (1/3 of anteroposterior chest diameter), frequency (100 -120/min) and minimal interruption.
• Intermittent compressions are only tolerable during rhythm control, defibrillation, ventilation and securing airway, always for the shortest time possible.
• We use both thumbs for compressions of newborns and infants and one or both hands for compressions of larger children.
• However, the priority is to achieve high-quality deep enough compressions, i.e., if 2 thumb compressions are ineffective in an infant, we can use one hand.

OXYGENATION AND VENTILATION IN PALS

• To ventilate the child during CPR, it is ideal to use an adequately sized self-expanding bag with a face mask appropriate to the size of the child. Always connect the bag to an O2 source.
• The ratio of compressions to breaths is 15:2.

DEFIBRILLATION + ECG MONITORING

• Self-adhesive electrode pads, also available in child size, are strongly recommended.
  (Usually, children's electrodes are used on children under 8.)
  
• Anterolateral placement of electrode pads can be used for larger children, and anteroposterior placement can be used for smaller children.
• We use a defibrillation discharge of 4J/kg. We select a larger one if the defibrillator does not offer an accurate value.
• After the 5th unsuccessful discharge, escalate the energy up to 8 J/kg.

VASCULAR ACCESS

• The method of choice in paediatric patients suffering from SCA is intraosseous vascular access.
• Particularly in small children, securing the IV line during SCA is very difficult, and prolonged attempts at venepuncture lead to delayed adrenaline administration.
• We use IV access if it is already present.

PHARMACOTHERAPY

Adrenaline

• we always use a standardized dosage of 1:10000 (Adrenaline 1 mg + 9 ml 0.9% NaCl)
• 
  
• nonshockable rhythm - 10 mcg/kg every 3-5 minutes

• shockable rhythm – 10 mcg/kg after 3rd shock, then every 3 - 5 minutes
• maximum single dose is 1000 mcg = 1 mg
  
• flush with a bolus of 2-10 mL of fluid (0.9% NaCl or balanced crystalloid) after each administration

Amiodarone

• dosage of 5mg/kg IV/IO
• used during shockable rhythm only – bolus of 300 mg IV/IO after 3rd and 5th shock