| CPR |
Recommendations for initiation of CPR, components of high quality CPR, CPR techniquem, support surfaces for CPR, and for opening the airway |
High-quality cardiopulmonary resuscitation (CPR) is the foundation of pediatric advanced life support (PALS) resuscitation for health care professionals. We reaffirm the key components of high-quality CPR: providing adequate chest compression rate and depth, minimizing interruptions in CPR, allowing full chest recoil between compressions, and providing sufficient ventilation for the pediatric patient population while avoiding excessive ventilation |
| Airway management during arrest |
Advanced airway interventions, such as supraglottic airway (SGA) placement or endotracheal intubation (ETI), may improve ventilation, reduce the risk of aspiration, and enable uninterrupted compression delivery. However, airway placement may interrupt the delivery of compressions or result in a malpositioned device. Advanced airway placement requires specialized equipment and skilled providers, and it may be difficult for professionals who do not routinely intubate children. |
Advanced airway placement should not delay high-quality CPR.
In infants and children with in hospital cardiac arrest who do not have an advanced airway in place, it may be reasonable to perform bag-mask ventilation or advanced airway interventions (tracheal intubation or SGA placement) Class 2b; Level of Evidence C-LD
|
| Bag-mask ventilation (BMV) |
BMV is reasonable compared with advanced airway interventions (endotracheal intubation or SGA) in the management of children during cardiac arrest in the out-of-hospital setting (Class 2a; Level of Evidence C-LD) |
Same recommendation with new evidence added
Publications from Resuscitation between 2019 and 2022 have been incorporated as new references addressing prehospital airway management and pediatric out-of-hospital cardiac arrest.
|
| Oxygen targets after ROSC |
It may be reasonable for rescuers to target normoxemia after ROSC that is appropriate to the specific patient's underlying condition. May be reasonable to wean oxygen to target oxyhemoglobin sat between 94%-99%. Target a PaCo2 that is approrpriate to patient's underlying condition (Class 2b; Level of Evidence C-LD) |
Same recommendation with new evidence added
Additional publications from the Annals of the American Thoracic Society, JAMA, Critical Care Med, and Resuscitation have been incorporated as new references.
|
| Vasopressor use in cardiac arrest |
For pediatric patients in any setting, it is reasonable to administer the inital dose of epinephrine within 5 min from the start of chest compressions (Class 2a; Level of Evidence C-LD)
|
For infants and children with cardiac arrest with inital nonshockable rhythm, it is reasonable to administer the inital dose of epinephrine as early as possible (Class 2a; Level of Evidence C-LD)
Rapid initiation of IV or IO vascular access. For infants with initial shockable rhythm, it may be reasonable to administer epinephrine after 2 attempts at defibrillation or sooner (Class 2b; Level of Evidence C-LD)
For infants and children in cardiac arrest in any setting, it may be reasonable to administer epinephrine every 3-5 min until ROSC is achieved (Class 2b; Level of Evidence C-LD)
|
| Defibrillation energy |
Initial 2 J/kg, then it may be reasonable to attempt subsequent defibrillation doses of 4 J/kg. Not to exceed 10 J/kg. |
Same recommendation with new evidence added
Additional publications from JAMA, Resuscitation and Circulation have been incorporated as new references.
|
| Shockable rhythms |
Standard algorithm |
Added emphasis on high-performance CPR choreography and team role clarity during defibrillation |
| Extracorporeal CPR (ECPR) |
ECPR may be considered for pediatric patients with cardiac diagnoses who have IHCA in settings with existing ECMO protocols, expertise, and equipment (Class 2b; Level of Evidence C-LD) |
Same recommendation with new evidence added
Additional publications from Circulation, Critical Care Medicine, Resuscitation, Journal of Pediatric Congenital Heart Surgery, and Journal of Pedicatric Intesive Care have been incorporated as new references.
|
| Post–cardiac arrest care targeted temperature management (TTM) |
Continuous measurement of core temperature during TTM is recommended (Class 1; Level of Evidence B-NR)
For infants and children between 24 hours and 18 years of age who remain comatose after out-of-hospital cardiac arrest (OHCA) or in-hospital cardiac arrest (IHCA), it is reasonable to use either TTM 32°C to 34°C followed by TTM 36°C to 37.5°C or to use TTM 36°C to 37.5°C (Class 2a; Level of Evidence B-NR)
|
Infants and children who remain comatose following cardiac arrest, continous central temperature monitoring is recommended (Class 1; Level of Evidence A)
For infants and children who remain comatose following cardiac arrest, avoiding central temperatures >37.5°C is recommended. (Class 1; Level of Evidence B-NR)
For infants and children between 24 hours and 18 years of age who remain comatose after OHCA or IHCA, it is reasonable to use a 5-d course of TTM, either TTM 32°C to 34°C followed by TTM 36°C to 37.5°C or to use TTM 36°C to 37.5°C (Class 2a; Level of Evidence B-R)
|
| Post-cardiac arrest blood pressure management |
After ROSC, parenteral fluids and vasoactive drugs are recommended to maintain a systolic blood pressure greater than the 5th percentile for age. (Class 1; Level of Evidence C-LD)
|
After cardiac arrest in infants and children, it is recommended to maintain systolic and mean arterial blood pressure greater than the 10th percentile for age. (Class 1; Level of Evidence B-NR) |
| Sepsis and septic shock |
It is reasonable to use either epinephrine or norepinephrine as an initial vasoactive infusion (Class 2a; Level of Evidence C-LD) |
This topic was last reviewed in the 2020 AHA Guidelines for CPR and ECC. These recommendations have not been updated for this edition of the Guidelines. No studies support deviations from standard life-support algorithms to improve outcomes in patients with sepsis-associated cardiac arrest. |
| Fluid resuscitation |
It is reasonable to administer fluid in 10-20 mL/kg boluses aliquots with frequent reassessment (Class 2a; Level of Evidence C-LD) |
2020 PALS guidelines combine fluid resuscitation and management of septic shock with their recommendations. |
| Point-of-care ultrasound (POCUS) |
Point of care ultrasound, specifically echocardiography, during CPR has been considered for identification of reversible causes of arrest. |
Same recommendation with new evidence added
Additional publications from Pediatric Emergency Care have been incorporated as new references.
|
| Intubation |
It is reasonable to choose cuffed endotracheal tubes over uncuffed ETTs for intubating infants and children (Class of Recommendation 2a; Level of Evidence C-LD)
Cricoid pressure during bag-mask ventilation may be considered to reduce gastric insufflation (Class of Recommendation 2b; Level of Evidence C-LD)
|
It is reasonable to choose cuffed endotracheal tubes over uncuffed ETTs for intubating infants and children (Class of Recommendation 2a; Level of Evidence B-NR)
Cricoid pressure during bag-mask ventilation may be considered to reduce gastric insufflation (Class of Recommendation 3: No Benefit; Level of Evidence C-LD)
|
| Bradycardia |
If heart rate is <60 beats/min with cardiopulmonary compromise despite effectice ventilation with oxygen, start CPR (Class 1; Level of Evidence C-LD) |
If heart rate is <60 beats/min with cardiopulmonary compromise despite effectice ventilation with oxygen, start CPR (Class 1; Level of Evidence C-EO) |
| Tachyarrhythmias |
It is reasonable to attempt vagal stimulation first, unless the patient is hemodynamically unstable or it will delay chemical or electric synchronized cardioversion (Class 2a; Level of Evidence C-LD) |
In infants and children with SVT without cardiopulmonary compromise, it is useful to attempt vagal stimulation first (Class 1, Level of Evidence C-LD)
New Addition: In infants and children with wide-complex tachycardia with regular and monomorphic QRS without cardiopulmonary compromise, adenosine administration can be useful in conjunction with expert consultation. (Class 2a; Level of Evidence C-EO)
|
| Myocarditis and Cardiomyopathy |
Given the high risk of cardiac arrest in children with acute myocarditis who demonstrate arrhythmias, heart block, ST-segment changes, and/or low cardiac output, early consideration of transfer to ICU monitoring and therapy is recommended (Class 1, Level of Evidence C-LD) |
Given the high risk of cardiac arrest in children with acute myocarditis who demonstrate arrhythmias, heart block, ST-segment changes, and/or low cardiac output, early consideration of transfer to ICU monitoring and therapy is recommended (Class 1, Level of Evidence B-NR)
ECMO included for refractory low cardiac output
For infants and children with myocarditis or cardiomyopathy and refractory low cardiac output, when feasible, early transfer to a center with ECMO/MCS capability is reasonable (Class 2a; Level of Evidence C-LD)
|
| Patient with a Single Ventricle Congential Heart Disease |
Recommendations for the Treatment of Preoperative Stage 1 and Postoperative Stage 1, 2, and 3 Palliation |
Collapses the guidance into generalized Single Ventricle Congential Heart Disease. Contents have been changed and updated and it is less specific regarding specific heart diseases.
|
| Pulmonary Hypertension |
Recommendations for Treatment of Pulmonary Hypertension with five different recommendations in treatment |
Recommendations split with three recommendations for infants and children at risk for pulmonary hypertensive crises, three recommendations for infants and children with pulmonary hypertensive crises, and one recommendation for pulmonary hypertension specific therapies and interventions during cardiac arrest. This totals seven recommendations. |