AMERICAN HEART ASSOCIATION PALS
(PEDIATRIC ADVANCED LIFE SUPPORT)
2025/2026 UPDATED
COMPREHENSIVE EXAM AND STUDY GUIDE
Capillary refill
Capillary refill time is the time it takes for blood to return to tissue blanched by pressure. It
increases as skin perfusion decreases. Note that normal capillary refill time is 2 seconds or less,
and a prolonged capillary refill time may indicate low cardiac output
Evaluate capillary refill in a neutral thermal environment (ie, room temperature) by
• Lifting the extremity slightly above the level of the heart
• Pressing on the skin
• Rapidly releasing the pressure
BGL in pediatrics
Hypoglycemia refers to blood glucose 45 mg/dL or less in the newly born and 60 mg/dL or less
in a child. It may result in brain injury if not recognized and effectively treated. Base treatment
decisions on patient symptoms, and potentially include oral glucose. Monitor the blood glucose
concentration of any seriously ill infant or child. A low blood glucose concentration may cause
altered level of consciousness or even brain injury if it is not quickly identified and adequately
treated. Measure the blood glucose concentration with a point-of-care glucose test.
Important factors associated with increased work of breathing:
• Increased airway resistance (upper and lower)
• Decreased lung compliance
• Use of accessory muscles of respiration
• Disordered central nervous system control of breathing
Airway resistance
• Airway resistance, or the impedance to airflow within the airways, is primarily increased by
reducing the size of the conducting airways, either by airway constriction or inflammation.
Turbulent airflow also causes increased airway resistance. Airflow may become turbulent when
the flow rate increases, even if the airway size remains unchanged. When airway resistance
increases, work of breathing increases in an attempt to maintain airflow despite the increase in
airway resistance.
,• Larger airways provide lower resistance to airflow than smaller. Airway resistance decreases as
lung volume increases (inflation) because airway dilation accompanies lung inflation.
• Conditions such as edema, bronchoconstriction, secretions, mucus, or a mediastinal mass
impinging on large or small airways can decrease airway size, thereby increasing airway
resistance.
• Resistance in the upper airway, particularly in the nasal or nasopharyngeal passages, can
represent a significant portion of tot
Lung compliance
• Compliance refers to the distensibility of the lung, chest wall, or both. Specifically, lung
compliance is defined as the change in lung volume produced by a change in driving pressure
across the lung. When lung compliance is high, the lungs easily inflate, a large change in volume
produced by a slight change in driving pressure.
• The lungs are stiffer in a child with low lung compliance, so it takes more effort to inflate them.
To create a significant pressure gradient to produce air flow into the stiff lung, the diaphragm
contracts more forcefully, increasing intrathoracic volume and reducing intrathoracic pressure.
Poorly compliant lungs will also lead to increased work of breathing. During mechanical
ventilation, increased positive airway pressure is needed to achieve adequate ventilation when
lung compliance decreases.
Decreased lung compliance
• The chest wall in infants and young children is compliant. Therefore, relatively small pressure
changes can move the chest wall. During normal breathing, diaphragm contraction in infants
pulls the lower ribs slightly inward but does not cause significant chest retraction. However,
forcefully contracting the diaphragm results in a large drop in pressure within the chest, pulling
the chest inward (ie, retracting it) during inspiration.
• When lung compliance is reduced, maximum inspiratory effort may not produce adequate tidal
volume because marked retractions of the chest wall limit lung expansion during inspiration.
Breathing is controlled by complex mechanisms involving...
• Brainstem respiratory centers
• Central and peripheral chemoreceptors
• Voluntary control
Respiratory center
A group of respiratory centers located in the brainstem controls spontaneous breathing. Voluntary
control from the cerebral cortex, such as breath holding, panting, and sighing, can also override
breathing. Conditions like infection of the central nervous system, traumatic brain injury, and
drug overdose can impair respiratory drive, resulting in hypoventilation or even apnea.
Chemoreceptors
, Note that central chemoreceptors respond to changes in the hydrogen ion concentration of
cerebrospinal fluid, which is largely determined by the arterial CO2 tension (Paco,). Peripheral
chemoreceptors (eg, the carotid body) respond primarily to a decrease in arterial oxygen (Pa02);
some receptors also respond to an increase in Paco2
Healthcare providers often deliver excessive ventilation during CPR, which is harmful
because it...
• Increases intrathoracic pressure and impedes venous return, thus decreasing filling of the heart
between compressions, reducing blood flow generated by the next compression, and reducing
coronary perfusion and cerebral blood flow
• Causes air trapping and barotrauma in children with small airway obstruction
• Increases the risk of regurgitation and aspiration in children without an advanced airway
Awareness of Lung Compliance
• When performing bag-mask ventilation, be aware of the child's lung compliance. A poorly
compliant lung is "stiff" or difficult to inflate. A sudden increase in lung stiffness during
ventilation with a bag may indicate airway obstruction, decreased lung compliance, or
development of a pneumothorax.
• Lung distention from excessive inflating pressures, positive end-expiratory pressure, or rapid
assisted respiratory rates with short exhalation time may also cause the feel of "stiff lungs"
during ventilation.
Stomach inflation or distention frequently develops during bag-mask ventilation. Gastric
inflation is more likely to develop during assisted ventilation if...
• A partial airway obstruction is present
• High airway pressures are needed, such as in a child with poor lung compliance
• The bag-mask ventilation rate is too fast
• The tidal volume delivered is excessive
• The peak inspiratory pressure created is excessive (eg, >30 cm H20)
• The child is unconscious or is in cardiac arrest (because the gastro-esophageal sphincter opens
at a lower than normal pressure)
To minimize gastric inflation
• Ventilate at a rate of 1 breath every 2 to 3 seconds (about 20-30 breaths per minute)
• Use a manometer (if available) and avoid, if at all possible, generating excessive peak
inspiratory pressures (eg, >30 cm H20) by delivering each breath over about 1 second
• Deliver enough volume and pressure to produce visible chest rise
• Advanced providers may perform gastric decompression by inserting a nasogastric or
orogastric tube
• Consider administering cricoid pressure; although cricoid pressure is not routinely
(PEDIATRIC ADVANCED LIFE SUPPORT)
2025/2026 UPDATED
COMPREHENSIVE EXAM AND STUDY GUIDE
Capillary refill
Capillary refill time is the time it takes for blood to return to tissue blanched by pressure. It
increases as skin perfusion decreases. Note that normal capillary refill time is 2 seconds or less,
and a prolonged capillary refill time may indicate low cardiac output
Evaluate capillary refill in a neutral thermal environment (ie, room temperature) by
• Lifting the extremity slightly above the level of the heart
• Pressing on the skin
• Rapidly releasing the pressure
BGL in pediatrics
Hypoglycemia refers to blood glucose 45 mg/dL or less in the newly born and 60 mg/dL or less
in a child. It may result in brain injury if not recognized and effectively treated. Base treatment
decisions on patient symptoms, and potentially include oral glucose. Monitor the blood glucose
concentration of any seriously ill infant or child. A low blood glucose concentration may cause
altered level of consciousness or even brain injury if it is not quickly identified and adequately
treated. Measure the blood glucose concentration with a point-of-care glucose test.
Important factors associated with increased work of breathing:
• Increased airway resistance (upper and lower)
• Decreased lung compliance
• Use of accessory muscles of respiration
• Disordered central nervous system control of breathing
Airway resistance
• Airway resistance, or the impedance to airflow within the airways, is primarily increased by
reducing the size of the conducting airways, either by airway constriction or inflammation.
Turbulent airflow also causes increased airway resistance. Airflow may become turbulent when
the flow rate increases, even if the airway size remains unchanged. When airway resistance
increases, work of breathing increases in an attempt to maintain airflow despite the increase in
airway resistance.
,• Larger airways provide lower resistance to airflow than smaller. Airway resistance decreases as
lung volume increases (inflation) because airway dilation accompanies lung inflation.
• Conditions such as edema, bronchoconstriction, secretions, mucus, or a mediastinal mass
impinging on large or small airways can decrease airway size, thereby increasing airway
resistance.
• Resistance in the upper airway, particularly in the nasal or nasopharyngeal passages, can
represent a significant portion of tot
Lung compliance
• Compliance refers to the distensibility of the lung, chest wall, or both. Specifically, lung
compliance is defined as the change in lung volume produced by a change in driving pressure
across the lung. When lung compliance is high, the lungs easily inflate, a large change in volume
produced by a slight change in driving pressure.
• The lungs are stiffer in a child with low lung compliance, so it takes more effort to inflate them.
To create a significant pressure gradient to produce air flow into the stiff lung, the diaphragm
contracts more forcefully, increasing intrathoracic volume and reducing intrathoracic pressure.
Poorly compliant lungs will also lead to increased work of breathing. During mechanical
ventilation, increased positive airway pressure is needed to achieve adequate ventilation when
lung compliance decreases.
Decreased lung compliance
• The chest wall in infants and young children is compliant. Therefore, relatively small pressure
changes can move the chest wall. During normal breathing, diaphragm contraction in infants
pulls the lower ribs slightly inward but does not cause significant chest retraction. However,
forcefully contracting the diaphragm results in a large drop in pressure within the chest, pulling
the chest inward (ie, retracting it) during inspiration.
• When lung compliance is reduced, maximum inspiratory effort may not produce adequate tidal
volume because marked retractions of the chest wall limit lung expansion during inspiration.
Breathing is controlled by complex mechanisms involving...
• Brainstem respiratory centers
• Central and peripheral chemoreceptors
• Voluntary control
Respiratory center
A group of respiratory centers located in the brainstem controls spontaneous breathing. Voluntary
control from the cerebral cortex, such as breath holding, panting, and sighing, can also override
breathing. Conditions like infection of the central nervous system, traumatic brain injury, and
drug overdose can impair respiratory drive, resulting in hypoventilation or even apnea.
Chemoreceptors
, Note that central chemoreceptors respond to changes in the hydrogen ion concentration of
cerebrospinal fluid, which is largely determined by the arterial CO2 tension (Paco,). Peripheral
chemoreceptors (eg, the carotid body) respond primarily to a decrease in arterial oxygen (Pa02);
some receptors also respond to an increase in Paco2
Healthcare providers often deliver excessive ventilation during CPR, which is harmful
because it...
• Increases intrathoracic pressure and impedes venous return, thus decreasing filling of the heart
between compressions, reducing blood flow generated by the next compression, and reducing
coronary perfusion and cerebral blood flow
• Causes air trapping and barotrauma in children with small airway obstruction
• Increases the risk of regurgitation and aspiration in children without an advanced airway
Awareness of Lung Compliance
• When performing bag-mask ventilation, be aware of the child's lung compliance. A poorly
compliant lung is "stiff" or difficult to inflate. A sudden increase in lung stiffness during
ventilation with a bag may indicate airway obstruction, decreased lung compliance, or
development of a pneumothorax.
• Lung distention from excessive inflating pressures, positive end-expiratory pressure, or rapid
assisted respiratory rates with short exhalation time may also cause the feel of "stiff lungs"
during ventilation.
Stomach inflation or distention frequently develops during bag-mask ventilation. Gastric
inflation is more likely to develop during assisted ventilation if...
• A partial airway obstruction is present
• High airway pressures are needed, such as in a child with poor lung compliance
• The bag-mask ventilation rate is too fast
• The tidal volume delivered is excessive
• The peak inspiratory pressure created is excessive (eg, >30 cm H20)
• The child is unconscious or is in cardiac arrest (because the gastro-esophageal sphincter opens
at a lower than normal pressure)
To minimize gastric inflation
• Ventilate at a rate of 1 breath every 2 to 3 seconds (about 20-30 breaths per minute)
• Use a manometer (if available) and avoid, if at all possible, generating excessive peak
inspiratory pressures (eg, >30 cm H20) by delivering each breath over about 1 second
• Deliver enough volume and pressure to produce visible chest rise
• Advanced providers may perform gastric decompression by inserting a nasogastric or
orogastric tube
• Consider administering cricoid pressure; although cricoid pressure is not routinely
