Pediatric Advanced Life Support (PALS) is a systematic approach healthcare providers use to evaluate and manage critically ill or injured children. This framework relies on a structured sequence of assessments and interventions to maximize the chance of a positive outcome. The PALS approach begins with a rapid initial stabilization phase, known as the Primary Assessment, which addresses immediate life threats. Once the child’s most pressing concerns are managed and stabilized, the Secondary Assessment begins, shifting the focus toward uncovering the root cause of the child’s distress.
Purpose and Context of Secondary Assessment
The Secondary Assessment is initiated only after the Primary Assessment has been completed and immediate life-threatening issues have been addressed. This phase moves beyond initial resuscitation to gather detailed information necessary for formulating a definitive diagnosis. The primary purpose is to collect comprehensive data that will guide subsequent targeted treatment. This evaluation is a focused, hands-on process driven by the findings of the initial assessment. For example, if the Primary Assessment indicated severe respiratory difficulty, the Secondary Assessment focuses heavily on the respiratory system. Successfully completing this step is a bridge between immediate stabilization and the long-term management of the child’s illness or injury.
Obtaining Patient History
A structured history is one of the first components of the Secondary Assessment, providing essential context for the child’s current condition. Because young children cannot always communicate their symptoms, this history is often obtained from parents or caregivers. PALS uses the SAMPLE mnemonic to ensure all pertinent details are collected systematically and efficiently. This detailed historical information is instrumental in narrowing down the possible causes of the child’s emergency.
SAMPLE Mnemonic
- Signs and Symptoms: Objective findings observed by the provider and subjective complaints reported by the child or family.
- Allergies: Drug sensitivities and food allergies, which could influence medication choices.
- Medications: Prescription drugs, over-the-counter remedies, and supplements the child is currently taking.
- Past Medical History: Previous illnesses, hospitalizations, surgeries, and underlying chronic conditions.
- Last Meal or Last Intake: Important for determining the risk of aspiration and for planning potential procedures.
- Events: Circumstances leading up to the illness or injury, providing insight into the mechanism or timeline of symptom development.
Focused Physical Examination and Diagnostics
Following the history, a focused physical examination is performed, concentrating on the body systems suggested by the chief complaint and the Primary Assessment findings. This is a targeted evaluation that helps providers confirm or rule out specific diagnoses. For a child with circulatory compromise, the examination prioritizes assessing capillary refill time, skin color and temperature, and the quality of central and peripheral pulses.
Monitoring devices are deployed during this phase to obtain precise physiological measurements, including continuous pulse oximetry to track oxygen saturation and frequent blood pressure readings. Core temperature measurement is also performed to identify extremes of hypothermia or hyperthermia. These objective measurements provide a quantifiable baseline and allow the healthcare team to monitor the effectiveness of interventions.
Immediate diagnostics are often ordered to support the clinical findings and move toward a definitive diagnosis. Point-of-care testing, such as a rapid bedside blood glucose check, is common because hypoglycemia is a treatable cause of altered mental status. Other diagnostics may include a 12-lead electrocardiogram (ECG) or a portable chest X-ray to evaluate for conditions like a tension pneumothorax or pneumonia. Blood gas analysis, which provides data on oxygenation, ventilation, and acid-base status, is another diagnostic tool utilized during this detailed assessment phase.
Identifying Treatable Underlying Causes
The goal of the Secondary Assessment is to identify the underlying physiological derangements causing the child’s severe condition. This process is streamlined by considering the H’s and T’s, a mnemonic for reversible causes of cardiac arrest, shock, or respiratory failure. The data collected from the history and physical examination directly informs the search for these specific issues.
The H’s
The “H’s” include Hypovolemia (low blood volume), Hypoxia (inadequate oxygenation), Hydrogen ion excess (acidosis), Hypo-/Hyperkalemia (abnormal potassium levels), and Hypothermia (low body temperature). Treating these conditions involves targeted actions, such as administering intravenous fluids for hypovolemia or improving ventilation for hypoxia.
The T’s
The “T’s” refer to mechanical or toxicological causes: Toxins, Tamponade (fluid around the heart), Tension pneumothorax (collapsed lung with pressure), and Thrombosis (blood clots in the coronary or pulmonary arteries). Recognizing and correcting these reversible causes is a fundamental component of the PALS approach that transitions care to targeted, life-saving intervention.