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The Pediatric Advanced Life Support (PALS) course is designed to help pediatric healthcare providers efficiently and effectively manage critically ill infants and children in emergency situations. The first step in managing any pediatric emergency is a thorough pediatric assessment. After the patient is assessed for obvious physical abnormalities, breathing difficulty and adequacy of circulation, PALS dictates the primary assessment procedure, which healthcare providers often remember through a simple and convenient acronym—ABCDE. 

• Airway
• Breathing
• Circulation
• Disability
• Exposure

Airway

Failure to properly manage the airway is the most common cause of preventable morbidity and death in children. The first step dictated by PALS primary assessment – an assessment of a pediatric patient’s airway – will either reveal an open airway that is clear and unobstructed for breathing or a closed airway that requires additional measures to maintain air exchange. While some measures to open an airway are simple, including easy-to-perform tasks like repositioning the patient comfortably, head-tilt/chin-lift or foreign body retrieval, other measures are more advanced and require more difficult, invasive techniques to open the airway.

Breathing

Breathing is the second area of focus in the PALS primary assessment process, and requires responders to examine key characteristics of the patient’s breathing. A normal breath rate varies by the age of the child, and respiratory rates may increase as a result of anxiety, movement, discomfort or stimulation. Breathing that is too slow is more worrisome than breathing that is too fast; a slow respiratory rate may signal the onset of respiratory failure and lead to the organs receiving insufficient oxygen. Additionally, a patient’s breath sounds can be extremely helpful in aiding diagnosis as quality, pitch, and location are often indicative of the location of the child’s problem, thereby suggesting possible causes.

Circulation

The third area of PALS primary assessment requires measuring a patient’s vital signs as a means to gauge a patient’s circulation. While core temperature and respirations do not directly correspond to cardiac function, the heart rate, pulses and blood pressure are important measures nonetheless. Normal heart rates and blood pressures vary by age. But in times of injury and stress, a child’s heart rate and blood pressure tend to be higher than normal.

Disability

PALS primary emergency assessment protocol also includes a survey of the child’s disability. Evaluation of the pupil activity is a common technique to help determine level and/or scope of disability. Further disability assessment is often reported by the AVPU Pediatric Response Scale or the Glasgow Coma Scale. The AVPU is appropriate for an initial evaluation of a child’s level of consciousness, as it examines alertness, voice quality, pain and level of consciousness. However, once the initial assessment is complete, first responders, emergency departments and intensive care units are encouraged to use the Glasgow Coma Scale for long-term monitoring and assessment of a patient’s level of consciousness.

Exposure

The final step of PALS protocol for primary pediatric emergency assessment is to perform a thorough physical examination. Everything the child is wearing should be removed, including a diaper (if applicable) so the clinician can carefully survey the entire body, noting associated injuries or abnormalities. Young children, especially infants less than one year of age, are prone to hypothermia, so while complete exposure should be undertaken, care should be taken to preserve the patient’s body temperature throughout the process.

 For more information about PALS certification, SAMPLE Pediatric Assessment or to find a Pediatric Advanced Life Support course, visit our courses.

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.