PALS Provider: Course

The Chain of Survival for Pediatrics

The Pediatric Chain of Survival outlines the essential steps necessary to maximize survival and improve neurological outcomes in children experiencing life-threatening emergencies, such as respiratory failure, shock, and cardiac arrest.

Unlike adults, where cardiac arrest is often of cardiac origin, pediatric emergencies are most commonly caused by respiratory compromise or circulatory failure—making early intervention even more critical.

Each link in the chain represents a vital opportunity for action to prevent deterioration and optimize recovery. Strengthening every step ensures the best possible outcomes for critically ill or injured children.

1. Prevention – The First Line of Defense

Most pediatric emergencies are preventable. Prevention efforts focus on reducing risk factors that contribute to respiratory failure, shock, and cardiac arrest.

Common causes of preventable pediatric emergencies include:

  • Sudden Infant Death Syndrome (SIDS) – Safe sleep practices reduce risk.
  • Drowning – Supervision, barriers, and CPR training improve outcomes.
  • Choking and Foreign Body Aspiration – Proper feeding practices and avoiding small objects in young children are crucial.
  • Trauma (e.g., falls, car accidents, abuse) – Seat belts, car seats, and fall prevention strategies save lives.
  • Sepsis and Infections – Early recognition of serious infections prevents deterioration.

Key Actions:

  • Parental and caregiver education on child safety, choking hazards, and CPR.
  • Public health initiatives like immunization programs and childproofing guidelines.
  • Early medical intervention for respiratory infections, dehydration, and trauma.

2. Early Recognition and Activation – Spotting Trouble Before It Escalates

Pediatric patients often show subtle signs of deterioration before cardiac arrest occurs. Recognizing these signs early can prevent arrest altogether.

The goal is to detect and treat respiratory distress or shock before it progresses to cardiopulmonary arrest.

Warning Signs of Impending Arrest:

  • Respiratory distress (nasal flaring, retractions, grunting, tachypnea)
  • Altered mental status (lethargy, poor responsiveness, irritability)
  • Cyanosis or pallor
  • Hypotension and poor perfusion (delayed capillary refill, weak pulses, cold extremities)
  • Bradycardia (which often indicates hypoxia in children)

Key Actions:

  • Immediate recognition of distress and prompt intervention.
  • Activating emergency medical services (EMS) early.
  • Initiating basic life support (BLS) interventions, such as oxygenation and airway management.

3. High-Quality CPR – The Lifeline

If a child suffers respiratory failure or cardiac arrest, immediate, high-quality CPR is the most important intervention.

Pediatric arrest is typically asphyxial, meaning oxygenation and ventilation are just as crucial as compressions.

Key Elements of High-Quality Pediatric CPR:

  • Start CPR immediately for unresponsive children with no breathing or only gasping.
  • Compression depth:
    • Infants: At least 1.5 inches (4 cm)
    • Children: At least 2 inches (5 cm)
  • Compression rate: 100–120 compressions per minute
  • Compression-to-ventilation ratio:
    • 30:2 (Single rescuer)
    • 15:2 (Two rescuers)
  • Minimize interruptions in compressions.
  • Allow full chest recoil to optimize circulation.

Key Actions:

  • Focus on high-quality compressions and adequate ventilation.
  • Use a bag-mask device with 100% oxygen if available.
  • If an advanced airway is placed, provide continuous compressions with 1 breath every 2–3 seconds (20–30 breaths per minute).

4. Advanced Resuscitation – Reversing the Cause

Once advanced life support providers arrive, interventions shift from BLS to ALS, addressing reversible causes of arrest and optimizing circulation, oxygenation, and perfusion.

Common Pediatric Cardiac Arrest Rhythms:

  • Asystole – Requires high-quality CPR and epinephrine.
  • Pulseless Electrical Activity (PEA) – Requires treatment of underlying causes (H’s and T’s).
  • Ventricular Fibrillation (VF)/Pulseless Ventricular Tachycardia (pVT) – Requires defibrillation.

Advanced Interventions Include:

  • Defibrillation (if indicated):
    • Initial dose: 2 J/kg
    • Subsequent doses: 4 J/kg (max 10 J/kg or adult dose)
  • Medication Administration:
    • Epinephrine: 0.01 mg/kg IV/IO every 3–5 minutes
    • Amiodarone (for refractory VF/pVT): 5 mg/kg IV bolus
  • Advanced Airway Management: Endotracheal intubation or supraglottic airway placement

Key Actions:

  • Identify and treat the underlying cause of the arrest (H’s & T’s).
  • Ensure effective oxygenation and circulation.
  • Follow PALS algorithms for rhythm-specific interventions.

5. Post-Resuscitation Care – Securing the Future

The period after resuscitation is critical to ensure the child’s survival without severe neurological damage.

This phase focuses on stabilizing the child, preventing secondary injury, and optimizing recovery.

Key Aspects of Post-Resuscitation Care:

  • Targeted temperature management to prevent hyperthermia.
  • Continuous respiratory and hemodynamic monitoring to prevent re-arrest.
  • Neuroprotection strategies (monitor for seizures, avoid hypoxia/hypotension).
  • Family support and debriefing for healthcare providers.

Key Actions:

  • Optimize oxygenation, ventilation, and perfusion.
  • Monitor for post-arrest complications (e.g., cerebral edema, organ dysfunction).
  • Support families through the recovery process.

Summary: Why Every Link Matters

  • Prevention reduces the likelihood of emergencies.
  • Early recognition and activation ensures timely intervention.
  • High-quality CPR is the foundation of successful resuscitation.
  • Advanced resuscitation targets the root cause of the arrest.
  • Post-resuscitation care helps secure long-term recovery.

Pediatric emergencies require rapid, coordinated, and effective action. By strengthening each link in the chain, healthcare providers can save lives and improve outcomes for critically ill and injured children.

Takeaway: In pediatrics, early recognition and intervention make all the difference. Every second counts.