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Trauma—or injury—is the leading cause of death in children aged 1-17 years. Of all pediatric injuries, head injuries are the most common and severe, accounting for the highest incidence of injury-related deaths (80%) and post-injury disability in children. While pediatric trauma in itself can sometimes be deadly, these injuries commonly progress into circulatory or respiratory problems which pose significant risk for cardiac arrest in infants and children. While infants and children are not immune to cardiac events including heart attacks, progression from respiratory failure or shock into cardiac arrest is far more likely than primary cardiac events.

The stress of managing any emergency situation can be enormous for healthcare professionals, and is even more pronounced when children are involved. High-stress situations tend to lead to greater probability of error, which is one reason a systematic approach to emergency management in the pediatric patient is so important. The pediatric advanced life support (PALS) protocol ensures that all healthcare providers can work together to take necessary steps efficiently and effectively when managing critically ill infants and children in emergencies, resulting in the best chance for survival.

PALS also provides healthcare professionals with critical knowledge about the physiological differences between adults and children and how emergency life support for children must be tailored to the individual patient. When approaching pediatric patients, it’s important for clinicians to remember that they are not simply “miniature adults.” Rather, children’s bones are much more likely to bend than break, their tongues take up a larger percentage of their oral cavities, and their airways are sufficiently narrow that even slight inflammation can cause distress. Children’s blood volume—which is significantly smaller than that of adults—is another differentiator. For infants or children, seemingly insignificant blood loss may actually be critical, and necessitate blood volume replacement.

The PALS protocol calls for a four-stage, sequential approach to pediatric emergency assessment, including general, primary, secondary and tertiary assessment.

1. General pediatric assessment: This assessment stage occurs first, and is completed within seconds of reaching the patient. Clinicians look at and listen to the child, focusing on overall appearance, the nature of breathing and obvious signs of circulation.
2. Primary pediatric assessment: Following general assessment, this stage involves checking the pulse, vital signs and blood glucose of the child or infant. Clinicians generally leverage the “ABCDE” process by addressing airway, breathing, circulatory, disability and exposure.
3. Secondary pediatric assessment: This assessment stage is lengthier and more deliberate, incorporating a complete physical exam. Clinicians generally leverage the “SAMPLE” mnemonic, asking the child or infant or his or her parents questions regarding symptoms, allergies, medicines, past medical history, last oral intake and events leading to the injury or illness.
4. Tertiary pediatric assessment: This assessment phase is completed as required depending on the child or infant’s injuries and condition. Clinicians will often order advanced tests or laboratory imaging to determine a physiologic condition and establish a diagnosis.

While these four pediatric emergency assessment stages outlined by PALS serve as a helpful tool for ensuring healthcare providers address all areas of concern when responding to a pediatric emergency, it’s important to remember that the organization of this approach may not always be possible in emergency situations involving infants and children. If a life-threatening abnormality is found at any point during any phase of the patient assessment process, it should be addressed immediately before completing subsequent assessment stages.

Contact us for more information about the Pediatric Advanced Life Support course for PALS certification or PALS recertification.

The information included in this article is based on the 2020 guidelines for CPR, first aid and advanced cardiovascular care. Read more about the 2020 changes to the online PALS course.