Pediatric Resuscitation

Aka: Pediatric Resuscitation, PALS, Pediatric Advanced Life Support

advertisement

II. Epidemiology

  1. Pediatric Cardiac ArrestIncidence: 3.3 to 8 cases per 100,000 in U.S.
    1. Out of hospital arrest ROSC: 23% (10% survival rate)
    2. Best ROSC and survival rates are for teen Cardiac Arrests (infants have the lowest rates)

III. Precautions: General

  1. See Resuscitation Precautions
  2. See Emergency Department Preparation for Resuscition
  3. See Special Circumstances When Ceasing Resuscitation Efforts

IV. Precautions: Updates based on PALS and APLS (2019, 2025 guidelines)

  1. Rapid global assessment tool
    1. See Pediatric Assessment Triangle
  2. Most pediatric Cardiac Arrests result from respiratory decompensation
    1. Rescue Breathing is an important component of Resuscitation in children
    2. Unlike adults, in whom compression only CPR may be effective, best pediatric outcomes include rescue breaths
      1. Kietlinkska (2025) Cardiol J 32(6):579-87 +PMID: 40917007 [PubMed]
  3. Foreign Body Aspiration
    1. In responsive patients, start with 5 back blocks and 5 abdominal thrusts
  4. Obtain IO Access while attempting difficult IV Access
  5. Bag-valve-mask is a reasonable alternative to Advanced Airway (LMA, Endotracheal Intubation) out of hospital
    1. ET Tube has no survival benefit over LMA, BVM when ventilating and oxygenating well
    2. With Advanced Airway or pulse, target Respiratory Rate 20-30 per minute
  6. Endotracheal Tube
    1. Use a cuffed Endotracheal Tube with cuff pressure 20-25 mmHg
  7. Lucas Chest Compression System
    1. Lucas requires distance between compressor and the anterior chest pad must be <=15 mm
  8. Chest Compressions (2025)
    1. Infants: 2 thumb encircling technique replaces other techniques (e.g. one hand or 2 finger)
  9. Attach AED as soon as available
    1. However, if single rescuer alone, perform first 2 minutes of CPR with Rescue Breathing before getting AED
    2. Use AED attenuator (if available) for infants age <1 year old
  10. Non-shockable rhythms
    1. Initiate Epinephrine as soon as possible (earlier use is associated with best outcomes)
  11. Shockable rhythms
    1. Attempt TWO shocks before Epinephrine, then Amiodarone (or Lidocaine)
    2. Lidocaine appears to have a higher rate of ROSC and 24 hours survival than Amiodarone
  12. Dosing Weight
    1. Actual body weight is preferred for dosing
    2. May use length-based or Ideal Weight, but may underestimate dose
  13. ROSC
    1. Target Blood Pressure >10th percentile for age
      1. Diastolic >=25 mmHg in infants (>=30 mmHg over age 1 year) with better survival prognosis
    2. Continuous Temperature monitoring (avoid body temp >37.5 C)
    3. Oxygen Saturation target 94-99%
    4. PCO2 target 35-45 mmHg
  14. ECMO may be considered in pediatric Cardiac Arrest patients with a cardiac diagnosis (e.g. Congenital Heart Disease)
    1. Efficacy relies on witnessed Cardiac Arrest, with early, high quality continuous CPR
  15. Targeted Temperature Management (TTM) of 36 C to 37.5 C appears equivalent to lower Temperature targets
    1. If TTM is used, may follow either target, and overall prevent fever >37.5 C (99.5 F)
  16. Pediatric pulse checks are difficult and have low accuracy (as with adults)
    1. Detecting PULSELESSNESS has a Test Sensitivity of only 76 to 86%
    2. Detecting a TRUE pulse has a Test Specificity of only 64-79%
    3. Average pulse check times are too long (20 seconds)
    4. Brachial and femoral sites have similar efficacy for pulse check
    5. Katzenschlager (2025) Resusc Plus 23:100959 +PMID: 40342519 [PubMed]
  17. References
    1. Claudius and Donofrio-Odmann (2024) Pediatric Pearls: Pediatric Cardiac Arrest, EM:Rap, 11/25/2024
    2. Claudius (2026) Pediatric Pearls: 2025 PALS Update, EM:Rap, 6/8/2026
    3. Duff (2019) Circulation 140(24):e904-14 +PMID:31722551 [PubMed]
    4. Joyner (2026) Pediatrics 157(1):e2025074350 +PMID: 41122852 [PubMed]

V. Management: Assess Responsiveness

  1. Responsive
    1. See Rapid ABC Assessment
  2. Unresponsive
    1. See Altered Level of Consciousness
    2. Call for Help
      1. Call for Defibrillator if available
      2. Activate EMS after initial ABC assessment

VI. Management: Emergency Airway

  1. See Primary Survey Airway Evaluation
  2. Position
    1. Turn on back as unit
    2. Support head and neck while positioning
    3. Place on hard firm surface
  3. Open airway
    1. Jaw Thrust (if suspected neck injury)
    2. Head Tilt-Chin Lift Maneuver

VII. Management: Emergency Breathing

  1. See Primary Survey Breathing Evaluation
  2. Breathing is assessed by medical providers concurrently with responsiveness
    1. Look Listen and feel for breathing has been removed from the ACLS and PALS sequence
  3. Rescue breaths are now started after one cycle of compressions (in Cardiac Arrest)
    1. New sequence: Compressions, open airway, give breaths
  4. Attempt 2 ventilations (each lasting 1 second) if not breathing
    1. Observe chest rise
    2. Allow deflation between breaths
    3. Reposition if first breath does not go in
  5. Airway Obstruction (if ventilations unsuccessful)
    1. No blind finger sweeps at any age
    2. Unconscious
      1. Deliver full CPR regardless of airway obstruction
    3. Conscious
      1. Perform Heimlich Maneuver
        1. Infants: 5 chest thrusts and 5 back blows
        2. Children: 5 abdominal thrusts
        3. Adults: 6-10 abdominal thrusts
      2. Attempt ventilation
      3. Repeat cycle until obstruction cleared

VIII. Management: Emergency Circulation

  1. See Primary Survey Circulation Evaluation
  2. Assess for Pulse (health care providers)
    1. Brachial Pulse in infants
    2. Carotid Pulse in children and adults
  3. Pulse Present: Perform Rescue Breathing (reassess every 2 minutes)
    1. Endotracheal Tube: 1 breath per 6-8 seconds for all ages (8 to 10 breaths per minute)
    2. Adult: 10 breaths per minute (every 6 seconds) in BLS
      1. Replaces Adult: 12 breaths/min (every 5 sec)
    3. Infant and Child breaths: 20-30 breaths/min (every 2-3 seconds) in BLS
      1. Replaces Child: 15 breaths per minute (every 4 seconds)
      2. Replaces Infant: 20 breaths per minute (every 3 seconds)
  4. Pulse Absent: Chest Compressions
    1. General
      1. Pulse check should be <10 seconds
        1. EtCO2 is a reliable marker for ROSC (if pulses are difficult to palpate)
        2. Bedside Ultrasound may prolong pulse checks (restart compressions on timer)
        3. Huis (2017) Resuscitation 119:95-98 PMID:28754527 [PubMed]
      2. Perform 5 cycles in 2 minutes
      3. Reassess pulse and rhythm every 2 minutes
      4. Focus on pressing hard and fast with minimal interruptions
      5. Connect Automatic External Defibrillator as soon as available
      6. Time interval for lone rescuer calling for help
        1. Sudden Collapse: Call immediately
          1. Minimizes time to AED application
        2. Asphyxial arrest: Perform CPR for 2 minutes
      7. Two rescuers switch places every 2 minutes
        1. Prevents rescuer Fatigue with Chest Compressions
        2. Repeat pulse and rhythm checks with the change
    2. Infants (Under 1 year old)
      1. Place 2 fingers at just below mid-nipple line
        1. Alternatively, hands encircle chest and both thumbs compress chest
      2. Compress over 100 times per minute
        1. Depth: One third of chest depth (1.5 inches or 4 cm)
        2. Compression to ventilation ratio
          1. Infant <1 month old: 3:1
          2. One rescuer: 30:2
          3. Two health care providers: 15:2
    3. Children (1-8 years old)
      1. One hand placed over Sternum at center of chest (superior to xiphoid)
      2. Compress over 100 times per minute
        1. Depth: One third of chest depth (2 inches or 5 cm)
        2. Compression to ventilation ratio
          1. One rescuer: 30:2
          2. Two health care providers: 15:2
    4. Adults (or children age over 8 years old)
      1. Two hands placed over Sternum at center of chest (superior to xiphoid)
      2. Compress 100 times per minute
        1. Depth: 2 inches or 5 cm
        2. Compression to ventilation ratio: 30:2 (one or two rescuers)

IX. Management: Rhythm - Pulse Absent in adults and children (ACLS and PALS)

  1. See Reversible Causes of Cardiopulmonary Arrest (5H5T)
  2. Shockable Rhythm: Ventricular Fibrillation or Pulseless Ventricular Tachycardia
    1. Defibrillate every 2 minutes
      1. Adult: Biphasic dose varies by device (120-200 J); Monophasic dose 360 J
      2. Children: Start at 2-4 J/kg, then 4 J/kg
      3. Start charging the Defibrillator before CPR is paused (decreases hands-off time)
        1. See above for reference
    2. CPR
      1. Performed continuously between shocks (minimal interruptions)
    3. Alpha-adrenergic agent (choose one)
      1. Epinephrine
        1. Adult: 1 mg every 3-5 minutes
        2. Child: 0.01 mg/kg (0.1 ml/kg of 1:10,000) repeated every 3-5 minutes
      2. Vasopressin (not commonly used in community EDs and removed from 2015 ACLS guidelines)
        1. Adult: 40 units for 1 dose
    4. Antiarrhythmic
      1. Amiodarone (preferred)
        1. Adult: 300 mg IV (may subsequently repeat once at dose 150 mg)
        2. Child: 5 mg/kg bolus (and may be repeated up to twice for refractory VF/VT)
      2. Lidocaine (alternative for adults, not recommended in children)
        1. Adult: 1-1.5 mg/kg IV (may subsequently repeat dose at 0.5 to 0.75 mg/kg)
        2. Prior to 2002 Alive Trial, Lidocaine had been the primary agent in VT/VF
          1. However, In 2023-2025 several studies have shown improved survival with Lidocaine
        3. Lidocaine is a cleaner drug, acting only at Sodium channels, with onset in seconds (duration <20 min)
          1. Contrast with Amiodarone which blocks multiple channels (Na+, K+, Ca++, beta) and delayed peak
        4. Lidocaine is preferred in certain scenarios
          1. Brugada Syndrome
          2. Torsades de Pointes (after Magnesium)
          3. Ischemia related Ventricular Tachycardia
        5. References
          1. Swaminathan and Hedayati (2026) Anti-Dysrhythmics in VT/VF Arrest, EM:Rap 4/6/2026
    5. Magnesium (for Torsades de Pointes)
      1. Adult: 1-2 g IV
      2. Child: 25 to 50 mg/kg IV or IO
  3. Non-shockable Rhythm: Asystole or Pulseless Electrical Activity (PEA)
    1. Key management is to identify and treat Reversible Causes of Cardiopulmonary Arrest (5H5T)
    2. Epinephrine
      1. Adult: 1 mg every 3-5 minutes
      2. Child: 0.01 mg/kg (0.1 ml/kg of 1:10,000) repeated every 3-5 minutes
    3. Vasopressin (not commonly used in community EDs and out of 2015 AHA guidelines)
      1. Adult: 40 units for 1 dose
    4. Atropine is no longer recommended as of 2010 guidelines
      1. Was previously given at 1 mg IV for Asystole or Slow PEA
  4. Other experimental measures
    1. Vasopressin 20 units
      1. No longer part of AHA pulseless algorithm guidelines as of 2015 (prior alternative to epi)
      2. Vasopressin is given in addition to Epinephrine per protocol
        1. Vasopressin may be better at maintaining brain perfusion
        2. Epinephrine appears better at achieving ROSC
      3. Consider Vasopressin when low End-Tidal CO2 (e.g. 20) despite high quality CPR
      4. Early studies suggest improved survival
      5. Orman and Weingart in Herbert (2015) EM:Rap 15(1): 14-6
      6. Mentzelopoulus (2013) JAMA 310(3): 270-9 [PubMed]
    2. Esmolol
      1. May be considered for refractory Ventricular Fibrillation in adults (based on small study)
      2. Dose: 500 mcg/kg (folllowed by infusion at 0-100 mcg/kg/min)
      3. Driver (2014) Resuscitation 85(10): 1337-41 +PMID:25033747 [PubMed]
    3. Double sequential external Defibrillation
      1. Two Defibrillators with pads right-left, front-back deliver maximal shock simultaneously
      2. May be considered in refractory Ventricular Fibrillation in adults (esp. obese)
      3. Cheskes (2023) Intensive Care Med 49(4):455-7 +PMID: 36754880 [PubMed]
  5. Other measures to avoid unless specifically indicated
    1. Empiric Calcium Administration (without specific indication)
      1. Routine Calcium administration is associated with worse outcomes in out of hospital Cardiac Arrest
      2. Messias Hirano Padrao (2022) Resusc Plus 12:100315 +PMID: 36238582 [PubMed]

X. Management: Rhythm - Pulse Present - Unstable in adults and children (ACLS and PALS)

  1. See Reversible Causes of Cardiopulmonary Arrest (5H5T)
  2. Indications for Unstable Status
    1. Chest Pain
    2. Hypotension or other signs of shock
    3. Altered Level of Consciousness
  3. Bradycardia (symptomatic with hemodynamic instability)
    1. See Unstable Bradycardia
    2. Perform CPR in children for Heart Rate <60/min with signs of hypoperfusion
    3. Atrioventricular Block (AV Block): Mobitz 2 or third degree
      1. Transcutaneous Pacing
      2. Prepare for Transvenous Pacing
    4. No AV Block (or first degree or Wenckebach)
      1. Adults
        1. Atropine 0.5 mg IV (may repeat up to a cummulative total of 3 mg)
        2. Transcutaneous Pacing
        3. Chronotropes (alternative to Transcutaneous Pacing)
          1. Epinephrine 2-10 mcg/min
          2. Dopamine 2-10 mcg/kg/min
      2. Children
        1. Epinephrine 0.01 mg/kg (0.1 ml/kg of 1:10,000) repeated every 3-5 minutes
        2. Atropine 0.02 mg/kg and may repeated once (min to max dose: 0.1 mg to 0.5 mg)
          1. Indicated if increased vagal tone or primary Atrioventricular Block
        3. Transcutaneous Pacing
  4. Tachycardia: Synchronized Cardioversion
    1. See Unstable Tachycardia
    2. Conscious Sedation if no delays
    3. Adults
      1. Atrial Arrhythmia
        1. Start at 200 joules biphasic (per ACLS 2025)
        2. Prior guidelies: 120 J biphasic for PSVT, Atrial Flutter; 120 J for Atrial Fibrillation
      2. Ventricular Arrhythmia
        1. Monomorphic Ventricular Tachycardia
          1. Synchronized Cardioversion or Defibrillation 200 J biphasic, 360 J monophasic
        2. Polymorphic Ventricular Tachycardia
          1. Immediate Defibrillation at 200 J biphasic, 360 J monophasic (ACLS 2025)
    4. Children
      1. Initial: 0.5 to 1 J/kg
      2. Refractory: 2 J/kg

XI. Management: Rhythm - Pulse Present - Stable - Bradycardia in adults and children (ACLS and PALS)

  1. Indicated if unstable criteria above not met
  2. Bradycardia
    1. Evaluate for Sinus Bradycardia causes
    2. Observe for change in status

XII. Management: Rhythm - Pulse Present - Stable - Tachycardia in Children (PALS)

  1. Indicated if unstable criteria above not met
  2. See Reversible Causes of Cardiopulmonary Arrest (5H5T)
  3. Wide Complex Tachycardia (QRS wider than 0.09 msec; contrast with 0.12 in adults)
    1. Consider Ventricular Tachycardia
    2. Unstable Wide Complex Tachycardia
      1. See Unstable Tachycardia above
      2. Synchronized Cardioversion
    3. Stable, regular Wide Complex Tachycardia
      1. Consider SVT with aberrancy if monomorphic QRS and regular rhythm
      2. Adenosine
        1. Do not use Adenosine if rhythm irregular (risk of WPW or rhythm degeneration)
        2. First: 0.1 mg/kg (maximum 6 mg)
        3. Second: 0.2 mg/kg (maximum 12 mg)
    4. Stable, irregular or refractory Wide Complex Tachycardia
      1. Precautions
        1. Consult cardiology about recommended Antiarrhythmic
        2. Avoid combining Amiodarone and Procainamide
      2. Agents
        1. Amiodarone 5 mg/kg over 20-60 minutes
        2. Procainamide 15 mg/kg IV over 30-60 minutes
  4. Narrow Complex Tachycardia (QRS 0.09 msec or less; contrast with 0.12 in adults)
    1. Sinus Tachycardia
      1. Findings
        1. Normal P Waves, variable R-R with a constant PR Interval
        2. Heart Rate <180 in children (<220 in infants)
      2. See Sinus Tachycardia
      3. Indentify and treat underlying cause
    2. Supraventricular Tachycardia
      1. Findings
        1. Abnormal or absent P Waves
        2. Constant Heart Rate >180 in children (>220 in infants)
      2. Vagal Maneuvers if no delays
      3. Adenosine (if regular rhythm)
        1. Do not use Adenosine if rhythm irregular (risk of WPW or rhythm degeneration)
        2. First: 0.1 mg/kg (maximum 6 mg)
        3. Second: 0.2 mg/kg (maximum 12 mg)
      4. Synchronized Cardioversion
        1. Indicated for irregular rapid rhythm or SVT refractory to above measures

XIII. Management: Additional measures

  1. See Reversible Causes of Cardiopulmonary Arrest
  2. See Post-Cardiac Arrest Care
  3. Post-arrest pronouncement in the emergency department
    1. Consider a moment of silence for deceased patient at end of Resuscitation attempt
    2. Strayer in Herbert (2018) EM:Rap 18(2): 3

XIV. Resources

  1. Cardiopulmonary Resuscitation Guidelines
    1. http://www.circulationaha.org

XV. References

  1. Trauma
    1. (2008) ATLS Manual, American College of Surgeons
    2. Majoewsky (2012) EMR:RAPC3 2(1): 1-2
  2. Cardiopulmonary Resuscitation Guidelines
    1. Mace (2013) Crit Dec Emerg Med 27(1): 11-20
    2. Mace (2013) Crit Dec Emerg Med 27(2): 2-10
    3. (2010) Guidelines for CPR and ECC [PubMed]
    4. (2005) Circulation 112(Suppl 112):IV [PubMed]
    5. (2000) Circulation, 102(Suppl I):86-9 [PubMed]

Images: Related links to external sites (from Bing)

These images are a random sampling from a Bing search on the term "Pediatric Resuscitation." Click on the image (or right click) to open the source website in a new browser window. Search Bing for all related images

Related Studies

Related Topics in Examination

advertisement