AHA PALS Provider common mistakes
AHA PALS Provider · Understand the traps and how to avoid them.
Waits for a rhythm check or for the heart rate to fall further before starting chest compressions in an infant with a heart rate of 50/min, poor perfusion, and no improvement after effective oxygenation and ventilation.
The team anchors on the rhythm and treats bradycardia as a 'rhythm problem' rather than recognizing it as arrest-equivalent when perfusion is inadequate.
What to do instead
Treat a heart rate <60/min with poor perfusion unresponsive to oxygenation/ventilation as cardiac arrest: start high-quality CPR immediately and follow the bradycardia-with-poor-perfusion pathway.
Documents a 'normal blood pressure' and continues observation in a child with cool extremities, capillary refill >3 seconds, mottling, and tachycardia, delaying fluid bolus and vasoactive support.
Hypotension is a late finding in pediatric shock; the team uses adult blood pressure thresholds and waits for a drop before acting.
What to do instead
Assess perfusion (mental status, pulses, capillary refill, skin, urine output, lactate) and treat compensated shock before hypotension develops; reassess after each 10-20 mL/kg bolus.
Squeezes the self-inflating bag rapidly and fully at >40 breaths/min during bag-mask ventilation, producing little chest rise and increasing gastric distension.
Under stress, providers equate faster and larger breaths with more oxygen delivery and do not watch the chest for adequate rise.
What to do instead
Deliver each breath over about 1 second with just enough volume for visible chest rise; without an advanced airway, provide 1 breath every 2-3 seconds and monitor for gastric inflation.
Inserts an oropharyngeal airway chosen by eyeballing, leaves the head in a neutral position, and continues ventilation attempts without repositioning or suctioning secretions.
Airway equipment is selected without length-based measurement, and obstruction from positioning or secretions is not addressed before repeated attempts.
What to do instead
Use a length-based tape or landmarks (corner of mouth to angle of mandible), position the head in a sniffing position, suction as needed, and confirm effective ventilation with chest rise and capnography.
Discharges an unsynchronized shock in a child with a pulse and unstable SVT, or forgets to press 'sync' before cardioversion.
Panic and unfamiliarity with defibrillator modes cause the team to conflate pulseless rhythms with tachyarrhythmias that still have a pulse.
What to do instead
Check the pulse first; use synchronized cardioversion for an unstable tachyarrhythmia with a pulse and unsynchronized defibrillation only for VF/pulseless VT; confirm sync markers before shock delivery.
Selects 200 J (adult default) for defibrillation or repeats the same 2 J/kg dose for subsequent shocks in a child.
The device defaults to adult energy and the team does not recalculate weight-based energy doses during the resuscitation.
What to do instead
Use 2 J/kg for the first shock, 4 J/kg for the second, and at least 4 J/kg (maximum 10 J/kg or adult dose) for subsequent shocks; for cardioversion use 0.5-1 J/kg then 2 J/kg.
Draws up 1:1000 epinephrine and gives 0.1 mL/kg IV/IO during cardiac arrest.
Both concentrations are stocked, the label is not checked, and the endotracheal dose is confused with the IV/IO dose.
What to do instead
For IV/IO arrest use 0.01 mg/kg (0.1 mL/kg of 1:10,000); for endotracheal use 0.1 mg/kg (0.1 mL/kg of 1:1000). Read the concentration aloud and double-check before administration.
Gives the first epinephrine dose and then continues compressions and rhythm checks without a timer, so the next dose is given more than 5 minutes later or omitted in PEA/asystole.
Cognitive load is high and no dedicated timer or recorder is assigned; epinephrine is treated as a one-time drug rather than a repeated intervention.
What to do instead
Assign a timekeeper/recorder; repeat epinephrine every 3-5 minutes and give it as early as possible in nonshockable rhythms.
After return of spontaneous circulation, continues 100% oxygen and high-minute ventilation without a blood gas, driving SpO2 to 100% and PaCO2 below normal.
The team carries the arrest ventilation strategy into post-arrest care and fears hypoxia more than hyperoxia or hypocapnia.
What to do instead
Titrate oxygen to SpO2 94-99% and ventilation to normocapnia (PaCO2 35-45 mm Hg), obtain a blood gas, and avoid both hyperoxia and hypocapnia.
During a simulated resuscitation, team members speak simultaneously without directed orders or confirmation, and no one states when the next epinephrine dose is due or who is doing compressions.
No team leader or roles are designated, and communication is assumed rather than closed-loop.
What to do instead
Assign explicit roles, use closed-loop communication (name, order, confirm), and have the leader summarize the rhythm, interventions, and next steps aloud.