Pediatric Advanced Life Support

New Provider Course Remodel

Instructor Guidance for Breakout Learning Stations

Developed by Advanced Life Support (ALS) Program Staff
Effective 1 January 2013

Table of Contents
I. Purpose ........................................................................................................................... 2
II. Respiratory Emergencies Learning Station ................................................................ 2
PALS Core Cases 1-4 ..................................................................................................... 2
Airway Management...................................................................................................... 2
Respiratory Specific Flowcharts .................................................................................... 3
III. Shock and Fluid Resuscitation Learning Station ....................................................... 3
PALS Core Cases 5-8 ..................................................................................................... 3
Vascular Access............................................................................................................. 3
Shock Specific Flowcharts............................................................................................. 4
IV. Cardiovascular Emergencies Learning Station .......................................................... 4
Technology Review ........................................................................................................ 4
Rhythm Disturbances .................................................................................................... 5
Simulation Scenarios .................................................................................................... 5
Electrical Therapy .......................................................................................................... 6
Cardiac Specific Treatment Algorithms ......................................................................... 6

Attachment A: Recognition of Respiratory Problems Flowchart

Attachment B: Management of Respiratory Emergencies Flowchart
Attachment C: Recognition of Shock Flowchart
Attachment D: Management of Shock Flowchart
Attachment E: EZ-IO G3 Product Fact Sheet
Attachment F: EZ-IO Infusion System Needle Insertion Guide
Attachment G: Zoll M-Series Technology Review Guide
Attachment H: Pediatric Tachycardia Treatment Algorithm
Attachment I: Pediatric Bradycardia Treatment Algorithm
Attachment J: Pediatric Cardiac Arrest Treatment Algorithm

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I.

Purpose
This outline was developed in conjunction with the 2013 Pediatric Advanced Life Support
(PALS) course remodel. It was designed to establish a standard of training and to be a
uniform training approach for Instructors aligned with the UNC-Community Training Center
(CTC).
The course outlines will be specific to New Provider and Renewal courses and will consist
of three combined Breakout learning stations: (1) Respiratory Emergencies, (2) Shock
and Fluid Resuscitation and (3) Cardiac Emergencies. Instructors will be presenting
clinically related material within each of the learning stations, and in a video
driven/scenario-based format. We believe this approach will enhance the learning
process through practice and realistic hands-on simulation.

II.

Respiratory Emergencies Learning Station

The Respiratory Emergencies station is a 70-minute rotation consisting of three
segments, all of which combine respiratory and airway management related content. This
station will be conducted in a video-driven/scenario-based format by utilizing the
respiratory core case videos, while integrating clinical skills, simulation and hands-on
practice.
Reference: PALS Provider Manual Parts 4 and 5; Pages 37-67
A. PALS Core Cases 1-4
1. In this segment, Instructors should progress through individual core case
scenarios, pausing during respiratory and airway related conditions and
demonstrating respiratory and airway related interventions.
B. Airway Management
1. During each core case scenario pause, Instructors should verbalize and
demonstrate step-by-step basic and advanced treatment options, while
allowing time for hands-on practice.
2. Instructors should meet all of the following objectives during the course of
the rotation station:
Demonstrate head-tilt, chin-lift method to open the airway;
Demonstrate modified jaw thrust method to open the airway;
Demonstrate insertion of the OPA and NPA airway and their
indications;
Demonstrate the correct process of orally suctioning a patient;
Demonstrate oxygen delivery methods using nasal cannula and nonrebreather mask devices;
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Demonstrate using a Bag Valve Mask to effectively manage a

simulated respiratory arrest case for one minute;
Review waveform capnography and ETCO2 measurement and its
importance during cardiac arrest resuscitation; and
Identify advanced airway devices and their indications
Note: Endotracheal Intubation (ETI) is no longer a priority in this station, as
this advanced skill does not typically fall within the Scope of Practice for
many students. Instructors may demonstrate the skill or answer treatment
related questions specific to ETI ONLY if time permits. ETI training
equipment will remain available in this station for special situations.

C. Respiratory Specific Flowcharts

1. Instructors should incorporate the respiratory recognition and treatment
flowcharts into stations, which may be introduced and explained during the
core case scenarios (recommended) or at the completion of the station.
See Attachments A & B.
2. Instructors should place emphasis on first-line medications and dosages
during this station.

III.

Shock and Fluid Resuscitation Learning Station

The Shock and Fluid Resuscitation station is a 70-minute rotation consisting of three
segments, all of which combine shock related content. This station will be conducted in a
video-driven/scenario-based format by utilizing the shock core case videos, while
integrating clinical skills, simulation and hands-on practice.
Reference: PALS Provider Manual Parts 6 and 7; Pages 69-111
A. PALS Core Cases 5-8
1. In this segment, Instructors should progress through individual core case
scenarios, pausing during shock related conditions and demonstrating
related interventions.
B. Vascular Access
1. During each core case scenario pause, Instructors should verbalize and
demonstrate step-by-step vascular access treatment options, while allowing
time for hands-on IV/IO skills practice. For EZ-IO reference material, See
Attachments E & F.

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2. Instructors should meet all of the following objectives during the course of
the rotation station:
Identify indications for Intraosseous (IO) device insertion;
Identify correct landmarks for IO device insertion;
Identify contraindications for IO device placement;
Demonstrate the IO device placement process;
Identify ways to confirm placement and then how to secure the IO
device;
Identify steps for proper Intravenous (IV) placement; and
Demonstrate how to select correct drug doses by using a colorcoded length-based tape or other resource.
C. Shock Specific Flowcharts
1. Instructors should incorporate the shock recognition and treatment
flowcharts into learning stations, which may be introduced and explained
during the core case scenarios (recommended) or at the completion of the
station. See Attachments C & D.
2. Instructors should place emphasis on first-line medications and dosages
during this station.

IV.

Cardiovascular Emergencies Learning Station

The Cardiovascular Emergencies station is a 70-minute rotation consisting of three
segments, all of which combine cardiovascular related content. This station will be
conducted in a scenario-based only format, while integrating clinical skills, simulation and
hands-on practice. Unlike other stations within this course, the core case videos are not
utilized in this station. Instructors should utilize pre-written simulation scenarios.
Reference: PALS Provider Manual Parts 8, 9 and 10; Pages 113-167
A. Technology Review
1. In this segment, Instructors should first conduct an in-depth review of the
Zoll M-Series CCT Monitor, incorporating the Monitor function, Defibrillation
function, and Synchronized Cardioversion function.
Note: Non-Invasive Transcutaneous/Transthoracic Pacing (NTP) is not a
priority in this station, as Pediatric Bradycardia is commonly related to
Hypoxia. However, a small percentage of the Pediatric population suffers
from congenital AV Blocks and Bradyarrythmias, requiring NTP. Instructors
may review NTP function ONLY if time permits.

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2. Instructors may utilize the Zoll M-Series Technology Review Guide found
as Attachment G.
3. At this point in the station, students should have a basic understanding of
monitor related functions, as they will receive hands-on electrical therapy
skills throughout the scenarios.

B. Rhythm Disturbances
1. It is recommended that this segment be completed prior to beginning the
PALS simulation segment, however may be integrated into simulation
scenarios. Instructors should review the basics of rhythm identification (i.e.
rate, regularity, QRS width) and review the following rhythms related to
PALS cardiac algorithms:
Regular Sinus Rhythm;
Sinus Tachycardia;
Sinus Bradycardia;
First Degree AV Block;
High and Low Degree AV Blocks;
Tachyarrhythmias (Narrow Complex);
Tachyarrhythmias (Wide Complex);
Ventricular Fibrillation (VF);
Pulseless Ventricular Tachycardia (VT); and
Asystole
C. Simulation Scenarios
1. In this segment, Instructors should choose one or more of the scenarios
from the list below. Once selected, the Instructor will progress through the
scenario, while pausing for cardiovascular related conditions and
demonstrating associated interventions. The direction of scenario
progression will be based upon each Instructors expertise and experience.
Ventricular Fibrillation: While charting, you are frantically called to
assist another co-worker performing chest compressions on a 9
year old child admitted for Syncope
Tachycardia: You are evaluating a 4 year old child presenting with
weakness, lethargy and mild shortness of breath

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PEA: You are evaluating an 8 year old child admitted for severe
Hypotension secondary to Dehydration. During your assessment,
the child becomes unresponsive, pulseless and apneic
Bradycardia: You are evaluating a 2 year old child presenting with
an Altered Mental Status following an MRI
D. Electrical Therapy
1. During each scenario pause, Instructors should verbalize and demonstrate
step-by-step electrical therapy treatment options, while allowing time for
hands-on skills practice.
2. Instructors should meet all of the following objectives during the course of
the rotation station:
Proper application of ECG leads and pediatric multi-function pads;
Review of rhythm-based electrical therapy with correct interpretation
of life threatening cardiac rhythms;
Demonstration of Synchronized Cardioversion with emphasis on
age-appropriate energy levels, pathway to and application of the
Sync soft key, purpose of synchronizing to R-wave, as well as safe
and timely shock delivery; and
Demonstration of manual defibrillation with emphasis on ageappropriate energy levels, charging and clearing, as well as safe and
timely shock delivery.
E. Cardiac Specific Treatment Algorithms
1. Instructors should incorporate the cardiac specific treatment algorithms
into learning stations, which may be introduced and explained during the
core case videos (recommended) or at the completion of the station. See
Attachments H-J.
2. Instructors should place emphasis on first-line medications and dosages
during this station.

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Attachment A
Recognition of Respiratory Problems
Flowchart

Attachment B
Management of Respiratory
Emergencies Flowchart

Attachment C
Recognition of Shock Flowchart

Attachment D
Management of Shock Flowchart

Attachment E
EZ-IO G3 Product Fact Sheet

Immediate Vascular Access... When You Nee

EC REP
Emerge Europe
Molenstraat 15
2513 BH, The Hague
The Netherlands

Vidacare.com

Vidacare.com

Vidacare Declaration Electromagnetic Emissions

The G3 Power Driver is intended for use in the electromagnetic environment specified below. The customer or the user
of the Vidacare Driver should assure that it is issued in such an environment.
Emission Test

Compliance

Compliance

RF Emissions CISPR 11

Group 1

The G3 Power Driver uses RF energy only for its internal

function. Therefore, its RF Emissions are very low and are not
likely to cause interference in nearby electronic equipment.

RF Emissions CISPR 11

Class B

The G3 Power Driver is suitable for use in all establishments,

including domestic establishments and those directly
connected to the public low voltage power supply network that
supplies buildings used for domestic purposes.

Harmonic emissions IEC 61000-3-2

Not applicable

Voltage fluctuations/flicker
emissions IEC 61000-3-3

Not applicable

Guidance and Manufacturers Declaration

Electromagnetic Immunity
The G3 Power Driver is intended for use in the electromagnetic environment specified below. The customer or the user of the
G3 Power Driver should assure that it is used in such an environment.
Immunity test

IEC 60601 test level

Compliance Level

Electromagnetic environment guidance

Portable and mobile RF communications equipment
should be used no closer to any part of the Power Driver
including cables, than the recommended separation
distance calculated from the equation applicable to the
frequency of the transmitter.

The G3 Power Driver is intended for use in the electromagnetic environment specified below. The customer or the user of
the Vidacare Driver should assure that it is used in such an environment.

Conducted RF
IEC 61000-4-6

3 Vrms
150 kHz to 80 MHz

Not applicable
(battery powered)

d = 3,5
V1

Radiated RF
IEC 61000-4-3

3 V/m
80 MHz to 2,5 GHz

3 V/m

d = 3,5
E1

P
P

Immunity test

IEC 60601 test level

Compliance Level

Electromagnetic environment
guidance

d=

Electrostatic discharge
(ESD)
IEC 61000-4-2

+/- 6 kV Contact

+/- 6 kV Contact

+/- 8 kV air

+/- 8 kV air

Floors should be wood, concrete

or ceramic tile. If floors are
covered with synthetic material
the relative humidity should be
at least 30%

Where P is the maximum output power rating of the

transmitter in watts (W) according to the transmitter
manufacturer and d is the recommended separation
distance in meters (m).

Electrical fast
Transient/burst
IEC 61000-4-4

+/- 2 kV for power

supply lines

Not applicable (battery

powered)

Mains power quality should be

that of a typical commercial or
hospital environment

Field strengths from fixed RF transmitters as determined

by an electromagnetic site survey, a should be less than
the compliance level in each frequency range.b

+/- 1 kV for input.

output lines

Not applicable (no I/O

lines)

Surge

+/- 1 kV differential mode

Not applicable (battery

powered)

IEC 61000-4-5

+/- 2 kV common mode

Mains power quality should be

that of a typical commercial or
hospital environment

Voltage dips, short

interruptions and voltage
variations on power supply
input lines

< 5% Ur (>95% dip in

Ur) for 0.5 cycles

Not applicable (battery

powered)

Mains power quality should be

that of a typical commercial
or hospital environment.
If the user of the G3 Power
Driver requires continued
operation during power mains
interruptions, it is recommended
that the Power Driver be
powered from an uninterruptible
power supply or a battery.

40% Ur (60% dip in Ur)

for 5 cycles

IEC 61000-4-11
70% Ur (30% dip in Ur)
for 25 cycles
<5% Ur (95% dip in Ur)
for 5 sec
3 A/m

The G3 Power Driver is intended for use in an electromagnetic environment in which radiated RF disturbances
are controlled. The customer or the user of the G3 Power Driver can help prevent electromagnetic interference by
maintaining a minimum distance between portable and mobile RF communications equipment (transmitters) and the
EZ-IO Power Driver recommended below, according to the maximum output power of the communications equipment.
Rated maximum output
power of transmitter
W

Recommended separation distance

Vidcares Declarations Electromagnetic Immunity

Power frequency (50/60Hz)

magnetic field IEC
61000-4-8

Recommended separation distances between portable and mobile

RF communications equipment and the [EQUIPMENT or SYSTEM]

3 A/m

Power frequency magnetic

fields should be at levels
characteristic of typical
location in typical

7
E1

Interference may occur in the vicinity of equipment

marked with the following symbol:
NOTE 1 At 80 MHz and 800 MHz, the higher frequency range applies.
NOTE 2 These guidelines may not apply in all situations. Electromagnetic propagation is affected by absorption and
reflection from structures, objects and people.
a Field strengths from fixed transmitters, such as base stations for radio (cellular/cordless) telephones and land mobile
radios, amateur radio , Am and FM radio broadcast and TV broadcast cannot be predicted theoretically with accuracy. To
assess the electromagnetic environment due to fixed RF transmitters an electromagnetic site survey should be considered. If
the measured filed strength in the location in which the G3 Power Driver is used exceeds the applicable RF compliance level
above, the G3 Power Driver should be observed to verify normal operation, If abnormal performance is observed, additional
measures may be necessary, such as re-orienting or relocating the G3 Power Driver.
b Over the frequency range 150 kHz to 80 MHz, field strengths should be less than 3 V/m.

Separation distance according to frequency of transmitter

m
150 kHz to 80 MHz

80 MHz to 800 MHz

800 MHz to 2,5 GHz

d = 3,5
V1

d = 3,5
E1

d=

7
E1

.01

0.12

0.12

0.23

.1

0.38

0.38

0.73

1.2

1.2

2.3

10

3.8

3.8

7.3

100

12

12

23

For transmitters rated at a maximum output power not listed above, the recommended separation distance d in meters (m)
can be estimated using the equation applicable to the frequency of the transmitter; where P is the maximum output power
rating of the transmitter in watts (W) according to the transmitter manufacturer.
NOTE 1 At 80 MHz and 800 MHz, the separation distance for the higher frequency range applies.
NOTE 2 These guidelines may not apply in all situations. Electromagnetic propagation is affected by absorption and reflection
from structures, objects and people.
Medical Electrical Equipment needs special precautions regarding EMC and needs to be installed and put into service according
to the EMC information provided in this manual.
Portable and mobile RF communications equipment can affect Medical Electrical Equipment.
The use of Accessories, transducers and cables other than those specified by the manufacturer, may result in increased
Emissions or decreased Immunity of the Power Driver.
The G3 Power Driver should be observed to verify normal operation in the configuration in which it will be used.
The G3 Power Driver is designed and tested to run intermittently with a duty cycle of 30 seconds on 1 minute off cycle.

Equipment Classification
Type of protection against electric shock

NA internal powered equipment

Degree of protection against electric shock

Type BF applied part

Degree of protection against ingress of water

LPX0 or ordinary protection

Degree of safety or application in the presence of a

flammable anesthetic mixture

Equipment not suitable for use in the presence of a flammable

anesthetic Mixture with air or with oxygen or nitrous oxide

Mode of operation

Continuous

NOTE Ur is the a.c. mains voltage prior to application of the test level.
At the completion of the G3 Power Drivers service life, proper disposal is the responsibility of the institution or
service (directive 2002/96/EC).
Degree of protection against electric shock BF Applied part.

Attachment F
EZ-IO Infusion System Needle Insertion
Guide

Intraosseous Infusion System

1

To Insert Needle Set:

Locate landmarks.................................. 1
Clean site................................................ 2

Insert EZ-IO Needle Set ....................... 3

Remove stylet from catheter .................. 4

Attach primed EZ-Connect
Consider IO 2% lidocaine without preservatives

or epinephrine (cardiac lidocaine) for patients

responsive to pain prior to flush

Follow institutional protocols/policy

Medications intended to remain in the medullary

space, such as a local anesthetic, must be

administered very slowly until the desired
anesthetic effect is achieved
Syringe bolus (flush) IO with 10 ml

normal saline........................................ 5
Start infusion under pressure ................. 6

A Medical Director or qualified prescriber

must authorize .appropriate dosage range.

Do Not Leave the EZ-IO catheter in for more than 24 hours.

To Remove Catheter:
Stabilize patients extremity
Connect sterile Luer lock syringe to hub of catheter
Rotate catheter clockwise while pulling straight back
When catheter has been removed, immediately place
in appropriate biohazard container.

DO NOT ROCK the catheter while removing. Rocking or bending

the catheter may cause the catheter to separate from the hub.

Emergency contact in US or Canada call: 1-800-680-4911

For international assistance contact your local Vidacare Distributor
T427 REV C

Vidacare.com

Attachment G
Zoll M-Series Technology Review Guide

ZOLL DEFIBRILLATOR/CARDIOVERSION/PACING
Biphasic Defibrillator uses less energy restricts electricity to core- max is 200 joules
A.

Defibrillation1. Describe proper pad placement

-Place anterior/anterior
*Rectangular Pad under right Clavicle (near square shoulder)
*Round Pad left Mid-axillary line (near round stomach)
-may also place Anterior/Posterior
-takes longer to place (due to having to turn/roll patient)
-If used think of two pieces of white bread (myocardial sandwich)

INSTRUCTOR TURN SIMULATOR ON AND TO V-FIB

2. Turn machine On to 1Defib
-Heathers suggestion: In emergency situation, never turn selector dial to monitor.
In emergency the question is whether defib is needed.
3. Adjust energy level to 200 joules, per UNC standing orders
4. Select # 2 Charge
-Wait for the red light and the continuous alarm
5. Call out- All clear and confirm with eye contact
6. Press # 3 Shock
-If energy is adjusted to different joules, the energy level will not automatically
change
B.

Synchronized Cardioversion

INSTRUCTOR SETS SIMULATOR TO SVT

1. Describe proper pad placement
- Anterior/posterior (heart sandwich) is preferred
- May use anterior/anterior in emergency
2. Turn machine On to 1Defib
3. Turn on SYNC. Located on the bottom right-hand corner of the screen
4. Look for an arrow on each QRS
5. If do not see arrow, then
a. Increase amplitude of QRS
b. Change to a different lead
c. Change electrode patches
INSTRUCTOR REQUESTS ENERGY LEVEL TO BE AT 75 joules
6. Adjust energy level to ordered joules (NO standing order for cardioversion)
7. Select # 2 Charge
-Wait for the red light and the continuous alarm
8. Call out- All clear and confirm with eye contact
9. Press # 3 Shock
10. Recognize that SYNC turns off after each shock

Note: -For safety, someone must be depressing the shock button in order for shock to be
delivered. During cardioversion, Zoll monitor must find the correct place to fire (on the Rwave). So sometimes need to press and HOLD shock button to get cardioversion.
C.

Pacing

INSTRUCTOR SET SIMULATOR TO 3RD DEGREE HEART BLOCK or CHB

NOTES:-Pace only if patient is unstable (pacing hurts)
*unstable is: low BP, decrease LOC, chest pain, SOBr
-Asynchronous pacing never used without physician order
1. Describe proper pad placement to pace
a. Pads MUST be anterior/posterior (myocardial sandwich)
b. AND must have the EKG leads attached to patient and to back of the Zoll
c. If pacing 100% of the time, change pads every 8 hours (Pads dry out; then do not
conduct as well)
2. Select Pacer Mode ( Green) (Turn selector switch counterclockwise)
a. pace at a rate of 70, per UNC Standing order
i. Machine automatically turns on at 70 pulses per minute
b. Pacing consists of two parts
i. Electrical capture
ii. Mechanical capture
3. Turn mA (milliamps) knob and looking for capture
a. Capture - a pacer spike before each wide bizarre QRS
i. This represents electrical capture
b. Also check radial or femoral pulse instead of carotid pulse
i. Youre checking for mechanical capture
ii. Carotid pulse could reflect muscle contraction rather than a pulse
iii. If no pulse, increase mAs
c. Assess need for pain medication (pacing is painful)
d. Once calm, Check threshold
i. Decrease mAs until lose capture
ii. Slowly increase mAs until get 100% capture. The EXACT energy
required to get 100% capture is the THRESHOLD.
iii. Increase mAs by 2, as safety measure
iv. Machine only does mAs in even numbers
NOTES in general:
- If patient in v-tach and rate is < 150, AED will not shock
- defibrillation for Peds patients
-2 joules/kilo initially, then
-4 joules/kilo for each subsequent shock
Remember: an additional resource can be found on the Zolls website: there are several
PPT presentations that you may find helpful:
http://www.zoll.com.au/products/m_series/

Attachment H
Pediatric Tachycardia Treatment
Algorithm

Attachment I
Pediatric Bradycardia Treatment
Algorithm

Attachment J
Pediatric Cardiac Arrest Treatment
Algorithm