What’s New With PALS Certification: PALS Megacodes

Children that suffer cardiac arrest have a poor survival rate. Among those that achieve a return of spontaneous circulation (ROSC), as few as 6 percent survive to hospital discharge, reports the National Library of Medicine. While the overall incidence of cardiac arrest is low, such poor outcomes indicate a need for better quality of the life-saving measures taken in Pediatric Advanced Life Support (PALS). This is part of the reason that completing a simulated, online course, such as PALS Megacodes, can help save lives.

Completing an online simulation to test your skills is an excellent way to ensure your skills will kick into action when needed. PALS Megacodes, which serve as a simulation and a test, offer anyone a fast, effortless way to review the PALS algorithm and their skills. With the International Liaison Committee on Resuscitation (ILCOR) now updating PALS recommendations annually, knowing how to apply the latest updates is essential to caring for children in distress. Those caring for children in the health care setting should consider these reasons to take part in Megacodes and follow a few tips to stay updated on the changes to the PALS algorithm.

PALS Megacodes Are an Invaluable Resource to Health Care Providers

PALS Megacodes are one of the latest resources AMC developed to help health care providers and those involved in childcare respond appropriately to a child in distress. The incidence of sudden cardiac arrest is rare in children, but trauma, allergic reactions, and other factors may lead to arrhythmia or another cause of arrest. As a result, it is important health care professionals understand the actions to take upon the presentation of a child in distress.

AMC offers six Megacodes training scenarios, focused on these key problems affecting children, including:

• Tachycardia – The tachycardia training scenario focuses on actions to take for different causes of tachycardia, including anaphylactic reactions and trauma.
• Bradycardia – The primary concern in the bradycardia scenario is knowing when to start CPR. For reference, any rhythm below 60 beats per minute warrants CPR, and it is equally important to check for a pulse throughout treatment to recognize pulseless electrical activity (PEA).
• Ventricular Fibrillation – The ventricular fibrillation (VF) simulation delves deeper into the unique concerns with administering a shock, including administration of epinephrine after giving the first shock and energy levels.
• Ventricular Tachycardia – The scenario for ventricular tachycardia (VT) is like the scenario for VF. However, it focuses on tachycardia on recognizing it on an EKG reading.
• Complex Tachycardias – The complex tachycardias simulation combines both the ventricular tachycardia and generalized tachycardia circumstances into a single situation. This is essential for recognizing unusual rhythms and when to begin CPR.
• Respiratory Distress – The final Megacodes scenario involves respiratory distress, resulting from choking, allergic reactions, and prolonged illness. This scenario supplies a thorough review of the actions to take in assessing the patient, administering oxygen properly and how to avoid unnecessary medical trauma. For example, this simulation includes a question on why health care professionals should not use an oral airway in the conscious child.

The Changes Affecting Treatment During PALS

The ILCOR has traditionally updated the PALS algorithm every five years, coinciding with the updates released by the International Liaison Committee on Resuscitation (ILCOR). While this practice worked for decades, researchers do not necessarily release study findings and information in tandem with the updates. Therefore, health care professionals would need to wait until the next five-year interval for new recommendations.

In the age of connected media, waiting unnecessarily is a poor excuse for not knowing the latest and best ways to save the lives of people, especially the most innocent—children. According to ILCOR, the updated guidelines focused on the administration of lidocaine versus amiodarone, as well as reiterating 2015 recommendations as follows.

Lidocaine or Amiodarone May Be Useful for Pediatric VF or pVT

The earlier rendition of the PALS algorithm recommended the administration of lidocaine or amiodarone for pediatric patients in VF or pulseless ventricular tachycardia (pVT). However, research from recent years would seem to suggest lidocaine increases the chances of ROSC, and in fact, the 2018 review of the literature found a “statistically significant” increase in chances of ROSC following lidocaine administration. Unfortunately, only one study showed this possibility.

Further review of studies conducted over the past three years revealed no association between lidocaine administration and survival to discharge. In other words, the use of lidocaine or amiodarone is acceptable, but lidocaine does carry potential side effects, such as the increased risk of bradycardia. It is up to each facility to determine if health care professionals should use lidocaine over amiodarone.

Early Administration of Epinephrine Is Acceptable in Exceptional Situations

Another area of focus in the updated guidelines, as explained by ECC.Guidelines.Heart.Org, involves the early administration of epinephrine. Throughout the history of PALS, recommendations aligned with the belief that early administration of high-dose epinephrine increased chances of ROSC and positive, long-term outcomes. Unfortunately, little evidence exists to support these claims. Moreover, the early administration of high-dose epinephrine carries a higher risk of adverse consequences, including tachycardia and increased risk for cardiac arrest. Therefore, the 2015 guidelines recommended against the early administration of epinephrine, as well as high-dose administration.

The guideline to avoid early administration does have an exception. In children, as well as adults, suffering from life-threatening allergic reactions, early administration of high-dose epinephrine is essential to preventing cardiac arrest, as well as reversing the causes of arrest.

For example, hypoxia is a cause of arrest, and a severe allergic reaction may result in the closure of the airway. Epinephrine acts upon receptors in the body to reverse the reaction, allowing the person to breathe. This effectively reduces the risk of cardiac arrest, but if it does occur, the PALS algorithm recommends health care providers treat the reversible causes of arrest. In other words, the algorithm would call for the administration of high-dose epinephrine.

Guidelines Advise Against Giving Atropine to Prevent Bradycardia

The use of atropine to prevent bradycardia in emergency endotracheal intubations makes up another reiteration from the 2018 update. It is really a continuation of the 2015 recommendations. Health care providers should avoid the administration of atropine as a pre-mediation to bradycardia in performing PALS with an exception.

Atropine does reduce the incidence of bradycardia. However, the guidelines recommended a minimum dose of 0.1 mg IV. Recent studies revealed that doses lower than the minimum may be more effective. Study findings suggest smaller doses reduce the incidence of bradycardia without increasing the risk of arrhythmias.

Remember to Stay on Top of Heart Rate and Blood Pressure, Checking for a Pulse Frequently

Performing CPR on children is more complex than caring for an adult through ACLS. The same complexity exists when administering PALS in health care facilities. The risk lies in the increased prevalence of PEA. In children, even those with a strong rhythm on an EKG or with a known pulse may enter PEA. Furthermore, children suffering shock may show a dramatic decline in blood pressure, resulting in poor perfusion.

The only way to truly watch a child’s blood pressure around-the-clock is by using an arterial line. Automated machines may take the blood pressure readings at set intervals, but a five-minute interval could spell tragedy if the pressure drops suddenly. Continuous monitoring via an EKG is also effective, yet it still calls for the need to physically check the child for a pulse. As noted earlier, any rhythm below 60 characterizes PEA in children. Also, PEA may occur in cases of extreme tachycardia.

Changes to Induced Hypothermia Are on the Horizon

Another core recommendation to know for the pediatric algorithm goes back to the use of induced hypothermia, also known as targeted temperature management (TTM). The 2010 guidelines called for the use of TTM in all pediatric cardiac arrest cases. Data gathered between 2010 and 2015 indicated TTM may not necessarily be as effective as believed. One study found a correlation between increased, positive outcomes, and the use of TTM after cardiac arrest.

Since hereditary illness and trauma are the most common causes of arrest in children, they are easier to find and treat. Faster treatment reduces the risk of cardiac arrest and the duration of the arrest. The primary benefit of TTM is the preservation of neural tissue. This means a shorter window of risk for brain damage may exist, so TTM may not be necessary. Of course, individual facilities may still include TTM in facility-specific PALS guidelines.

Situations warranting TTM depend on the unique causes of arrest and frequency. For example, a child that has entered arrest multiple times may benefit from TTM. In addition, health care professionals may use TTM for the aggressive treatment of fevers over 38-degrees Celsius for all patients that have achieved ROSC for a period of two days, followed by a gradual rewarming phase.

More studies on the use of TTM are underway, so this recommendation may evolve over the next year.

Tips to Stay Informed of Recent Changes to the PALS Algorithm

It is always a promising idea to follow a few tips to stay updated with the PALS algorithm, including:

1. Know who posts updates to the PALS algorithm. The ILCOR posts updates to the PALS algorithm online, but the easiest way to make sure you see the updates when released is to follow ILCOR on social media.
2. Stay on top of facility-specific recommendations. Even with the latest information at your fingertips, your facility may still adjust the PALS recommendations based on the unique needs and changes in your region. Therefore, health care professionals should stay connected with the Nurse Educator or other supervisors that oversee the credentials and continuing education of staff.
3. Practice interpreting EKG results often. Reading EKG results is a lost art, especially in an age where machines automatically interpret results and EKG technicians to interpret results. Unfortunately, this leads to a loss in the ability to interpret results when caring for a child in arrest. The smallest misinterpretation could have a disastrous impact on treatment decisions, resulting in poor outcomes and a decreased chance of survival.
4. Review the available medications in your facility. Depending on the level of your facility, different medications may be available in the crash cart for use in an emergency. Make sure your crash cart has all the medications necessary to perform PALS and treat its reversible causes. It is also important to check medications for expiration dates too.
5. Complete practice tests. Completing a practice test is another fantastic way to check your PALS skills. Practice tests supply a quick review of the core components of PALS. This helps health care professionals know when it may be time to retake a PALS course, even if it is before the certification expires.
6. Participate in simulations to test your knowledge. A pretest does have its limitations, but health care professionals can take advantage of Megacodes to truly put their skills to the test. Simulations run at timed intervals and supply immediate feedback for missed questions. Participants in Megacodes may need to interpret EKG results, consider reversible causes of arrest and much more.

Review Your Skills With Megacodes Before a Misstep Causes a Catastrophe

The worst time to start wondering about the changes to the PALS algorithm is when treating a child in distress. Time wasted increases the risk of poor outcomes and even mortality. However, health care professionals that take the time to learn what changes exist in advance can effectively reduce such risks. Put your skills to the test with these online, life-saving simulations now.

Does your facility follow any unique recommendations, or have you already completed the PALS Megacodes scenarios? Share your thoughts and experiences, along with this article, to social media now, and don’t forget, you can enroll in your life-saving skills course online too!