The Pediatric Advanced Life Support (PALS) assessment is a systematic process designed to rapidly evaluate and manage critically ill or injured children. This protocol is followed by healthcare providers to quickly identify and address life-threatening problems in pediatric patients, whose condition can change rapidly. The goal is to apply a sequence of focused evaluations to stabilize the child and prevent progression to cardiac arrest. Following the correct sequence ensures immediate threats to life are addressed first, increasing the chance of a positive outcome.
Forming the Initial Impression
The PALS assessment begins with the Initial Impression, formed using the Pediatric Assessment Triangle (PAT). This first step takes place within 30 seconds and requires no physical contact or equipment, relying purely on visual and auditory observation. The PAT consists of three sides: Appearance, Work of Breathing, and Circulation to Skin, which categorize the severity of the child’s illness.
Appearance assesses neurological function by observing muscle tone, interactivity, ability to be consoled, gaze, and quality of speech or cry. A limp or unresponsive child signals a significant problem with oxygenation, perfusion, or the central nervous system. Work of Breathing is evaluated by looking for abnormal signs like nasal flaring, retractions (sucking in of the skin between the ribs or at the neck), and unusual sounds such as grunting or wheezing. These signs indicate increased effort is required to move air effectively.
Circulation to Skin offers a quick look at the body’s perfusion status. This is evaluated by observing the child’s skin color for pallor (paleness), mottling (patchy discoloration), or cyanosis (blue or purple hue), which suggests poor blood flow or inadequate oxygen levels. The Initial Impression determines if the child is “sick” or “not sick” and directs the urgency of subsequent, detailed, hands-on evaluations.
The Primary Assessment
If the Initial Impression suggests a serious problem, the provider moves immediately to the Primary Assessment, which is a rapid, hands-on evaluation using the systematic A-B-C-D-E approach. Interventions are frequently performed immediately as problems are identified, following an “evaluate-identify-intervene” cycle to address life threats without delay.
A stands for Airway, checking for patency and stability. The provider listens for abnormal sounds like stridor, suggesting an upper airway obstruction, and determines if the airway requires immediate intervention like repositioning or suctioning. B represents Breathing, requiring a detailed assessment of the respiratory rate, the depth and symmetry of chest movement, and auscultation of lung sounds. Pulse oximetry is used to measure oxygen saturation, providing an objective measure of gas exchange effectiveness.
C is for Circulation, focusing on blood flow and heart function. This includes assessing the heart rate, the quality of central and peripheral pulses, and the capillary refill time (less than two seconds). Blood pressure is obtained, and the provider looks for signs of shock, such as poor skin perfusion or hypotension. D stands for Disability, a rapid check of neurological status, often using the AVPU scale (Alert, response to Voice, response to Pain, or Unresponsive) to assess consciousness. Pupillary response and a quick check of blood glucose levels are also commonly included to identify potential causes of altered mental status.
E is for Exposure, where the child’s clothing is removed to check for signs of injury, bleeding, rashes, or medical devices. Maintaining the child’s thermal regulation is a priority to prevent hypothermia, which can worsen a critical condition. If a life-threatening problem is discovered at any point, the provider stops the assessment to intervene before continuing the evaluation.
The Secondary Assessment and Diagnostic Testing
The Secondary Assessment is initiated only after the child has been stabilized, or when all immediate life-threatening issues identified in the Primary Assessment have been addressed and interventions are underway. This phase provides an in-depth look at the child’s history and physical condition to determine the underlying cause of the illness or injury.
The focused history is systematically gathered using the SAMPLE mnemonic, which guides the conversation with the child, parent, or caregiver:
- Signs and Symptoms (S)
- Allergies (A)
- Medications the child is currently taking (M)
- Past medical history and parental impression of the illness (P)
- Last meal or oral intake, important for anesthesia considerations (L)
- Events leading up to the current illness or injury (E)
A focused physical examination follows the history, tailored to the child’s chief complaint, or a comprehensive head-to-toe check if trauma is suspected. This exam seeks to uncover specific findings that contribute to the overall diagnosis. This investigation then guides the selection of Diagnostic Tests, which may include laboratory blood work, chest X-rays, or other imaging studies. These tests provide objective data to confirm the suspected diagnosis and formulate a definitive, long-term treatment plan, ultimately completing the systematic PALS assessment sequence.