Important 2015 Updates to PALS

• The routine use of atropine as premedication for emergency tracheal intubation in infants and children (not
neonates) is controversial. No evidence supports its routine use, however, it can be considered if there is an
increased risk of bradycardia.
• It is reasonable to give epinephrine during cardiac arrest.
• If invasive hemodynamic monitoring is already in place at the time of a cardiac arrest, it can be used to assess
the quality of CPR.
• Rapid intravenous administration of isotonic fluids is an important treatment for shock; however, children with
shock due to a febrile illness should be given fluids cautiously in resource limited settings (i.e., limited or no ICU
support). Excessive fluid administration can be hazardous. An initial fluid bolus of 20 mL per kilogram is
reasonable, but children should be monitored closely.
• Comatose children who were resuscitated after cardiac arrest should not be allowed to develop a fever. In other
words, fever should be treated aggressively in the first several days after cardiac arrest.
• For comatose children who had a cardiac arrest within the hospital, there is insufficient data to recommend
targeted temperature management.
• For comatose children who have a cardiac arrest outside of a hospital, it is reasonable to institute some form of
targeted temperature management:
o Five days of normothermia (36°C to 37.5°C),or
o Two days of continuous hypothermia (32°C to 34°C) followed by 3 days of normothermia
• In infants or children with ventricular fibrillation or pulseless ventricular tachycardia that did not respond to
shock, amiodarone and lidocaine are equally effective. Either amiodarone or lidocaine is appropriate.
• After cardiac arrest and return of spontaneous circulation, caretakers should use fluids, inotropes, and
vasopressors to keep systolic blood pressure above the fifth percentile for the patient’s age. It is also
recommended to use intra-arterial pressure monitoring to monitor and titrate blood pressure.
• After return of spontaneous circulation in children, it is reasonable for arterial oxygen levels to be kept between
94% and 99%. Essentially, hypoxemia should be strictly avoided and normoxemia is the goal. Also, the partial
pressure of arterial carbon dioxide should be appropriate for the patient’s age, avoiding both extreme
hypercapnia and hypocapnia.