Part 4: Pediatric Basic and Advanced Life Support

These guidelines are intended to be a resource for lay rescuers and healthcare providers to identify and treat infants and children in the prearrest, intra-arrest, and postarrest states. These apply to infants and children in multiple settings; the community, prehospital, and the hospital environment. Prearrest, intra-arrest, and postarrest topics are reviewed, including cardiac arrest in special circumstances, such as in patients with congenital heart disease.

For the purposes of the pediatric advanced life support guidelines, pediatric patients are infants, children, and adolescents up to 18 years of age, excluding newborns. For pediatric basic life support (BLS), guidelines apply as follows:

• Infant guidelines apply to infants younger than approximately 1 year of age.
• Child guidelines apply to children approximately 1 year of age until puberty. For teaching purposes, puberty is defined as breast development in females and the presence of axillary hair in males.
• For those with signs of puberty and beyond, adult basic life support guidelines should be followed.

Resuscitation of the neonate is addressed in “Part 5: Neonatal Resuscitation” and applies to the newborn typically only during the first hospitalization following birth. Pediatric basic and advanced life support guidelines apply to neonates (less than 30 days old) after hospital discharge.

COVID-19 Guidance

Together with other professional societies, the AHA has provided interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed coronavirus disease 2019 (COVID-19). Because evidence and guidance are evolving with the COVID-19 situation, this interim guidance is maintained separately from the emergency cardiovascular care (ECC) guidelines. Readers are directed to the American Heart Association (AHA) website for the most recent guidance.⁸

The Pediatric Writing Group consisted of pediatric clinicians including intensivists, cardiac intensivists, cardiologists, emergency medicine physicians, medical toxicologists, and nurses. Volunteers with recognized expertise in resuscitation are nominated by the writing group chair and selected by the AHA ECC Committee. The AHA has rigorous conflict of interest policies and procedures to minimize the risk of bias or improper influence during development of the guidelines.⁹ Prior to appointment, writing group members and peer reviewers disclosed all commercial relationships and other potential (including intellectual) conflicts. Writing group members whose research led to changes in guidelines were required to declare those conflicts during discussions and abstain from voting on those specific recommendations. This process is described more fully in “Part 2: Evidence Evaluation and Guidelines Development.” Disclosure information for writing group members is listed in Appendix 1.

These pediatric guidelines are based on the extensive evidence evaluation performed in conjunction with the ILCOR and affiliated ILCOR member councils. Three different types of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2020 process.^10,11 After review by the ILCOR Science Advisory Committee Chair, the evidence update worksheets were included in Appendix C of the 2020 ILCOR Consensus on CPR and ECC Science With Treatment Recommendations.^11a Each of these resulted in a description of the literature that facilitated guideline development. This process is described more fully in “Part 2: Evidence Evaluation and Guidelines Development.”¹²

The writing group reviewed all relevant and current AHA Guidelines for Cardiopulmonary Resuscitation (CPR) and ECC and all relevant 2020 ILCOR Consensus on CPR and ECC Science With Treatment Recommendations evidence and recommendations to determine if current guidelines should be reaffirmed, revised, or retired or if new recommendations were needed. The writing group then drafted, reviewed, and approved recommendations, assigning to each a Class of Recommendation (COR; ie, strength) and Level of Evidence (LOE; ie, quality, certainty). Criteria for each COR and LOE are described in Table 1.

The 2020 Guidelines are organized in discrete modules of information on specific topics or management issues.¹³ Each modular “knowledge chunk” includes a table of recommendations using standard AHA nomenclature of COR and LOE. Recommendations are presented in order of COR: most potential benefit (Class 1), followed by lesser certainty of benefit (Class 2), and finally potential for harm or no benefit (Class 3). Following the COR, recommendations are ordered by the certainty of supporting LOE: Level A (high-quality randomized controlled trials) to Level C-EO (expert opinion). This order does not reflect the order in which care should be provided.

A brief introduction or short synopsis is provided to contextualize the recommendations with important background information and overarching management or treatment concepts. Recommendation-specific supportive text clarifies the rationale and key study data supporting the recommendations. When appropriate, flow diagrams or additional tables are included. Hyperlinked references are provided to facilitate quick access and review.

The guideline was submitted for blinded peer review to 5 subject matter experts nominated by the AHA. Peer reviewer feedback was provided for guidelines in draft format and again in final format. The guideline was also reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and AHA Executive Committee. Disclosure information for peer reviewers is listed in Appendix 2.

Historically, cardiac arrest care has largely focused on the management of the cardiac arrest itself, highlighting high-quality CPR, early defibrillation, and effective teamwork. However, there are aspects of prearrest and postarrest care that are critical to improve outcomes. As pediatric cardiac arrest survival rates have plateaued, the prevention of cardiac arrest becomes even more important. In the out-of-hospital environment, this includes safety initiatives (eg, bike helmet laws), sudden infant death syndrome prevention, lay rescuer CPR training, and early access to emergency care. When OHCA occurs, early bystander CPR is critical in improving outcomes. In the in-hospital environment, cardiac arrest prevention includes early recognition and treatment of patients at risk for cardiac arrest such as neonates undergoing cardiac surgical procedures, patients presenting with acute fulminant myocarditis, acute decompensated heart failure, or pulmonary hypertension.

Following resuscitation from cardiac arrest, management of the post–cardiac arrest syndrome (which may include brain dysfunction, myocardial dysfunction with low cardiac output, and ischemia or reperfusion injury) is important to avoid known contributors to secondary injury, such as hypotension.^8,9 Accurate neuroprognostication is important to guide caregiver discussions and decision-making. Finally, given the high risk of neurodevelopmental impairment in cardiac arrest survivors, early referral for rehabilitation assessment and intervention is key.

To highlight these different aspects of cardiac arrest management, the Pediatric Chain of Survival has been updated (Figure 1). A separate OHCA Chain of Survival has been created to distinguish the differences between OHCA and IHCA. In both the OHCA and IHCA chains, a sixth link has been added to stress the importance of recovery, which focuses on short- and long-term treatment evaluation, and support for survivors and their families. For both chains of survival, activating the emergency response is followed immediately by the initiation of high-quality CPR. If help is nearby or a cell phone is available, activating the emergency response and starting CPR can be nearly simultaneous. However, in the out-of-hospital setting, a single rescuer who does not have access to a cell phone should begin CPR (compressions-airway-breathing) for infants and children before calling for help because respiratory arrest is the most common cause of cardiac arrest and help may not be nearby. In the event of sudden witnessed collapse, rescuers should use an available automatic external defibrillator (AED), because early defibrillation can be lifesaving.

Recommendation-Specific Supportive Text

1. Lay rescuers are unable to reliably determine the presence or absence of a pulse.^6–20
   
   
2. No clinical trials have compared manual pulse checks with observations of “signs of life.” However, adult and pediatric studies have identified a high error rate and harmful CPR pauses during manual pulse checks by trained rescuers.^21–23 In 1 study, healthcare provider pulse palpation accuracy was 78%²¹ compared with lay rescuer pulse palpation accuracy of 47% at 5 seconds and 73% at 10 seconds.⁶
   
   
3. One pediatric study demonstrated only a small delay (5.74 seconds) in commencement of rescue breathing with compressions-airway-breathing compared with airway-breathing-compressions.²⁴ Although the evidence is of low certainty, continuing to recommend compressions-airway-breathing likely results in minimal delays in rescue breathing and allows for a consistent approach to cardiac arrest treatment in adults and children.

Recommendation-Specific Supportive Text

1. Large observational studies of children with OHCA show the best outcomes with compression-ventilation CPR, though outcomes for infants with OHCA are often poor regardless of resuscitation strategy.^25–29
   
   
2. Large observational studies of children with OHCA show that compression-only CPR is superior to no bystander CPR, though outcomes for infants with OHCA are often poor.^27,28
   
   
3. Allowing complete chest re-expansion improves the flow of blood returning to the heart and thereby blood flow to the body during CPR. There are no pediatric studies evaluating the effect of residual leaning during CPR, although leaning during pediatric CPR is common.^2,3 In 1 observational study of invasively monitored and anesthetized children, leaning was associated with elevated cardiac filling pressures, leading to decreased coronary perfusion pressures during sinus rhythm.³⁰
   
   
4. A small observational study found that a compression rate of at least 100/min was associated with improved systolic and diastolic blood pressures during CPR for pediatric IHCA.³¹ One multicenter, observational study of pediatric IHCA demonstrated increased systolic blood pressures with chest compression rates between 100 and 120/min when compared with rates exceeding 120/min.³² Rates less than 100/min were associated with improved survival compared to rates of 100 to 120/min; however, the median rate in this slower category was approximately 95/min (ie, very close to 100/min).³²
   
   
5. Three anthropometric studies have shown that the pediatric chest can be compressed to one third of the anterior-posterior chest diameter without damaging intrathoracic organs.^33–35 An observational study found an improvement in rates of ROSC and 24-hour survival, when at least 60% of 30-second epochs of CPR achieve an average chest compression depth greater than 5 cm for pediatric IHCA.³⁶
   
   
6. Current recommendations include a brief rhythm check every 2 minutes when a monitor or AED is available.
   
   
7. There are no human studies addressing the effect of varying inhaled oxygen concentrations during CPR on outcomes in infants and children.
   
   
8. The optimum compression-to-ventilation ratio is uncertain. Large observational studies of children with OHCA demonstrated better outcomes with compression-ventilation CPR with ratios of either 15:2 or 30:2 compared with compression-only CPR.²⁵
   
   
9. One small, multicenter observational study of intubated pediatric patients found that ventilation rates (at least 30 breaths/min in children less than 1 year of age, at least 25 breaths/min in older children) were associated with improved rates of ROSC and survival.⁵ However, increasing ventilation rates are associated with decreased systolic blood pressure in children. The optimum ventilation rate during continuous chest compressions in children with an advanced airway is based on limited data and requires further study.

Recommendations 1 and 2 were reviewed in the “2017 American Heart Association Focused Update on Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.”³⁷

Recommendation-Specific Supportive Text

1. One anthropometric³⁸ and 3 radiological studies^39–41 found that optimal cardiac compressions occur when fingers are placed just below the intermammary line. One observational pediatric study found that blood pressure was higher when compressions were performed over the lower third of the sternum compared to the midsternum.⁴¹ See Figure 2 for the 2-finger technique.
   
   
2. Systematic reviews suggest that the 2-thumb– encircling hands technique may improve CPR quality when compared with 2-finger compressions, particularly for depth.^42,43 However, recent manikin studies suggest that the 2-thumb–encircling hands technique may be associated with lower chest compression fractions (percent of cardiac arrest time that chest compression are provided)⁴⁴ and incomplete chest recoil,^45,46 especially when performed by single rescuers. See Figure 3 for the 2-thumb–encircling hands technique.
   
   
3. There are no pediatric-specific clinical data to determine if the 1-hand or 2-hand technique produces better outcomes for children receiving CPR. In manikin studies, the 2-hand technique has been associated with improved compression depth,⁴⁷ compression force,⁴⁸ and less rescuer fatigue.⁴⁹
   
   
4. There were no human studies comparing the 1-hand compression versus the 2-thumb–encircling hands technique in infants.

Recommendation-Specific Supportive Text

1. “CPR mode” is available on some hospital beds to stiffen the mattress during CPR. Manikin models indicate that mattress compression ranges between 12% and 57% of total compression depth, with softer mattresses being compressed the most.^50–53 This can lead to reduced sternal displacement and a reduction in effective chest compression depth.
   
   
2. Manikin studies and 1 pediatric case series show that effective compression depth can be achieved even on a soft surface, providing the CPR provider increases overall compression depth to compensate for mattress compression.^53–59
   
   
3. Meta-analysis of 6 studies^{53,56,60–63} showed a 3-mm (95% CI 1–4 mm) improvement in chest compression depth associated with backboard use when CPR was performed on a manikin placed on a mattress or bed.

Recommendation-Specific Supportive Text

1. No data directly address the ideal method to open or maintain airway patency. One retrospective cohort study evaluated various head-tilt angles in neonates and young infants undergoing diagnostic MRI and found that the highest proportion of patent airways was at a head-tilt angle of 144 to 150 degrees based on a regression analysis.⁶⁴
   
   
2. While no pediatric studies evaluate jaw thrust versus head tilt–chin lift to open the airway, the jaw thrust is widely accepted as an effective way to open the airway, and this maneuver theoretically limits cervical motion compared with the head tilt–chin lift.
   
   
3. There are no pediatric studies evaluating the impact of a head tilt–chin lift maneuver to open the airway in a trauma patient with suspected cervical spine injury. However, if providers are unable to open the airway and deliver effective ventilations using a jaw thrust, given the importance of a patent airway, using a head tilt–chin lift maneuver is recommended.

Figures 4, 5, 6, and 7 show, respectively, an infographic for pediatric BLS for lay rescuers, the current pediatric BLS algorithms for healthcare provider, single-rescuer CPR and 2-rescuer CPR, and the current algorithm for pediatric cardiac arrest.

Recommendation-Specific Supportive Text

1. There are limited data in pediatrics comparing epinephrine administration to no epinephrine administration in any setting. In an OHCA study of 65 children, 12 patients did not receive epinephrine due to lack of a route of administration, and only 1 child had ROSC.² An OHCA study of 9 children who had cardiac arrest during sport or exertion noted a survival rate of 67%, of whom 83% did not receive epinephrine. All survivors received early chest compressions (within 5 minutes) and early defibrillation (within 10 minutes), and the initial cardiac arrest rhythm was a shockable rhythm.⁹ Intravenous/intraosseous (IV/IO) administration of epinephrine is preferred over ETT administration when possible.^10,11
   
   
2. One retrospective observational study of children with IHCA who received epinephrine for an initial nonshockable rhythm demonstrated that, for every minute delay in administration of epinephrine, there was a significant decrease in ROSC, survival at 24 hours, survival to discharge, and survival with favorable neurological outcome.¹² Patients who received epinephrine within 5 minutes of CPR compared to those who received epinephrine more than 5 minutes after CPR initiation were more likely to survive to discharge.¹² Four observational studies of pediatric OHCA demonstrated that earlier epinephrine administration increased rates of ROSC,^13,14 survival to ICU admission,¹⁴ survival to discharge,^14,16 and 30-day survival.¹⁵
   
   
3. One observational study demonstrated an increased survival rate at 1 year in the group that was administered epinephrine at an interval of less than 5 minutes.¹⁷ One observational study of pediatric IHCA demonstrated that an average epinephrine administration interval of 5 to 8 minutes and of 8 to 10 minutes was associated with increased odds of survival compared with an epinephrine interval of 1 to 5 minutes.¹⁸ Both studies^17,18 calculated the average interval of epinephrine doses by averaging all doses over total arrest time, which does not account for potential differences in dosing intervals throughout resuscitations of varying duration. No studies of pediatric OHCA on frequency of epinephrine dosing were identified.
   
   
4. Two studies examined drug therapy of VF/pVT in infants and children.^19,20 In Valdes et al, administration of lidocaine, but not amiodarone, was associated with higher rates of ROSC and survival to hospital admission.¹⁹ Neither lidocaine nor amiodarone significantly affected the odds of survival to hospital discharge; neurological outcome was not assessed. A propensity-matched study of an IHCA registry demonstrated no difference in outcomes for patients receiving lidocaine compared with amiodarone.²⁰
   
   
5. A recent evidence review identified 8 observational studies of sodium bicarbonate administration during cardiac arrest.^{5–7,21–25} Bicarbonate administration was associated with worse survival outcomes for both IHCA and OHCA. There are special circumstances in which bicarbonate is used, such as the treatment of hyperkalemia and sodium channel blocker toxicity, including from tricyclic antidepressants.
   
   
6. Two observational studies examining the administration of calcium during cardiac arrest demonstrated worse survival and ROSC with calcium administration.^4,23 There are special circumstances in which calcium administration is used, such as hypocalcemia, calcium channel blocker overdose, hypermagnesemia, and hyperkalemia.³

Recommendation 4 was reviewed in “2018 American Heart Association Focused Update on Pediatric Advanced Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.”²⁶

Weight-Based Dosing of Resuscitation Medications

1. There are many theoretical concerns about the use of actual body weight (especially in overweight or obese patients).^27–29 However, there are no data about the safety and efficacy of adjusting medication dosing in obese patients. Such adjustments could result in inaccurate dosing of medications.^30,31
   
   
2. Several studies suggest that inclusion of body habitus or anthropometric measurements further refines and improves weight estimations using length-based measures.⁸ However, there is considerable variation in these methods, and the training required to use these measures may not be practical in every context.
   
   
3. Cognitive aids can assist in the accurate approximation of body weight (described as being within 10% to 20% of measured total body weight). Several recent studies demonstrated high variability of weight estimates, with a tendency toward underestimation of total body weight yet closely approximating ideal body weight.^29,32,33

Recommendation-Specific Supportive Text

1. 2, and 3. A systematic review¹ demonstrated no relationship between energy dose and any outcome. No randomized controlled trials were available, and most studies only evaluated the first shock. An IHCA case series of 71 shocks in 27 patients concluded that 2 J/kg terminated VF, but neither the subsequent rhythm nor the outcome of the resuscitation was reported.² A small case series of prolonged OHCA observed that 2 to 4 J/kg shock terminated VF 14 times in 11 patients, resulting in asystole or pulseless electric activity, with no survivors to hospital discharge.³ In 1 observational study of IHCA,⁴ a higher initial energy dose of more than 3 to 5 J/kg was less effective than 1 to 3 J/kg in achieving ROSC. Three small, observational studies of pediatric IHCA^3,5 and OHCA⁶ found no specific initial energy dose that was associated with successful defibrillation. One study suggested that 2 J/kg was an ineffective dose, especially for secondary VF.⁷

Recommendation-Specific Supportive Text

1. There are currently no pediatric data available regarding the optimal timing of CPR prior to defibrillation. Adult studies demonstrate no benefit of a prolonged period of CPR prior to initial defibrillation.^8–12
   
   
2. There are currently no pediatric data concerning the best sequence for coordination of shocks and CPR. Adult studies comparing a 1-shock protocol versus a 3-shock protocol for treatment of VF suggest significant survival benefit with the single-shock protocol.^13,14
   
   
3. Prolonged pauses in chest compressions decrease blood flow and oxygen delivery to vital organs, such as the brain and heart, and are associated with lower survival.^13,15

Recommendation-Specific Supportive Text

1. Larger pad or paddle size decreases transthoracic impedance, which is a major determinant of current delivery.^16–18
   
   
2. One human and 1 porcine study demonstrated no significant difference in shock success or ROSC when comparing anterior-lateral with anterior-posterior position.^7,19
   
   
3. One study demonstrated no significant difference in median time to shock with paddles compared with self-adhesive pads.²⁰

Recommendation-Specific Supportive Text

1. Shockable rhythms are infrequent in infants.^21,22 Studies of rhythm identification algorithms have demonstrated high specificity for shockable rhythms in infants and children.^23–25 Although there are no direct comparisons between pediatric attenuator and nonattenuator AED-delivered shocks, multiple case reports and case series document shock success with survival when a pediatric attenuator was used.^26–32
   
   
2. There are no specific studies comparing manual defibrillators with AEDs in infants or children. Manual defibrillators are preferred for in-hospital use because the energy dose can be titrated to the patient’s weight. In adults, use of an AED in hospitals did not improve survival,³³ and the perishock pauses needed for rhythm analysis were prolonged.³⁴
   
   
3. AEDs without pediatric modifications deliver 120 to 360 Joules, exceeding the recommended dose for children weighing less than 25 kg. However, there are reports of safe and effective AED use in infants and young children when the dose exceeded 2 to 4 J/kg.^{26–28,30,35} Because defibrillation is the only effective therapy for VF, an AED without a dose attenuator may be lifesaving.

Recommendation-Specific Supportive Text

1. and 2. Two pediatric randomized clinical trials of TTM (32°C–34°C for 48 hours followed by 3 days of TTM 36°C–37.5°C versus TTM 36°C–37.5°C for a total of 5 days) after IHCA or OHCA in children with coma following ROSC found no difference in 1-year survival with a favorable neurological outcome.^3,4 Hyperthermia was actively prevented with TTM. Continuous core temperature monitoring was used for the 5 days of TTM in both trials.

Recommendations 1 and 2 were reviewed in the “2019 American Heart Association Focused Update on Pediatric Advanced Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.”⁵

Recommendation-Specific Supportive Text

1. and 2. Two observational studies demonstrated that systolic hypotension (below 5th percentile for age and sex) at approximately 6 to 12 hours following cardiac arrest is associated with decreased survival to discharge.^6,7 Another observational study found that patients who had longer periods of hypotension within the first 72 hours of ICU post–cardiac arrest care had decreased survival to discharge.⁸ In an observational study of patients with arterial monitoring during and immediately after cardiac arrest, diastolic hypertension (above 90th percentile) in the first 20 minutes after ROSC was associated with an increased likelihood of survival to discharge.⁹ Because blood pressure is often labile in the post–cardiac arrest period, continuous arterial pressure monitoring is recommended.

Recommendation-Specific Supportive Text

1. and 2. Because an arterial oxyhemoglobin saturation of 100% may correspond to a Pao₂ between 80 and approximately 500 mm Hg, it is reasonable to target an oxyhemoglobin saturation between 94% and 99%. Three small observational studies of pediatric IHCA and OHCA did not show an association between hyperoxemia and outcome.^10,11,13 In a larger observational study of pediatric IHCA and OHCA patients, the presence of normoxemia compared with hyperoxemia after ROSC was associated with improved survival to pediatric ICU discharge.¹²

3. One observational study demonstrated that both hypercapnia and hypocapnia after ROSC were associated with increased mortality.¹¹ One small observational study demonstrated no association between hypercapnia (Paco₂ greater than 50 mm Hg) or hypocapnia (Paco₂ less than 30 mm Hg) and outcome.¹⁰ Another observational study of pediatric IHCA, showed hypercapnia (Paco₂ 50 mm Hg or greater) was associated with decreased survival to hospital discharge.¹⁴ Because hypercapnia and hypocapnia impact cerebral blood flow, normocapnia should be the focus after ROSC while accounting for patients who have chronic hypercapnia.

Recommendation-Specific Supportive Text

1. Nonconvulsive seizures and nonconvulsive status epilepticus are common after pediatric cardiac arrest.^15–18 The American Clinical Neurophysiology Society recommends continuous EEG monitoring for encephalopathic patients after pediatric cardiac arrest.¹⁵ Nonconvulsive seizures and nonconvulsive status epilepticus cannot be detected without EEG monitoring.¹⁵
   
   
2. and 3. There is insufficient evidence to determine whether treatment of convulsive or nonconvulsive seizures improves neurological and/or functional outcomes after pediatric cardiac arrest. Both convulsive and nonconvulsive status epilepticus are associated with worse outcomes.¹⁷ The Neurocritical Care Society recommends treating status epilepticus with the goal of stopping convulsive and electrographic seizure activity.¹⁹

Figure 8 shows the checklist for post–cardiac arrest care.

Recommendation-Specific Supportive Text

1. Although fluids remain the mainstay initial therapy for infants and children in shock, especially in hypovolemic and septic shock, fluid overload can lead to increased morbidity.³ In 2 randomized trials of patients with septic shock, those who received higher fluid volumes⁴ or faster fluid resuscitation⁵ were more likely to develop clinically significant fluid overload characterized by increased rates of mechanical ventilation and worsening oxygenation.
   
   
2. In a systematic review, 12 relevant studies were identified, though 11 assessed colloid or crystalloid fluid resuscitation in patients with malaria, dengue shock syndrome, or “febrile illness” in sub-Saharan Africa.⁶ There was no clear benefit to crystalloid or colloid solutions as first-line fluid therapy in any of the identified studies.
   
   
3. One pragmatic, randomized controlled trial compared the use of balanced (lactated Ringer’s solution) to unbalanced (0.9% saline) crystalloid solutions as the initial resuscitation fluid and showed no difference in relevant clinical outcomes.⁷ A matched retrospective cohort study of pediatric patients with septic shock showed no difference in outcomes,⁸ though a propensity-matched database study showed an association with increased 72-hour mortality and vasoactive infusion days with unbalanced crystalloid fluid resuscitation.⁹
   
   
4. In a small, randomized controlled study, there were no significant differences in outcomes with the use of 20 mL/kg as the initial fluid bolus volume (compared with 10 mL/kg); however, the study was limited by a small sample size.⁴

Recommendation-Specific Supportive Text

1. Two randomized controlled trials comparing escalating doses of dopamine or epinephrine demonstrated improvement in timing of resolution of shock¹⁰ and 28-day mortality¹¹ with the use of epinephrine over dopamine. Both studies were conducted in resource-limited settings, and the doses of inotropes used may not have been directly comparable, limiting conclusions from the studies. Medications that increase systemic vascular resistance, such as norepinephrine, may also be a reasonable initial vasopressor therapy in septic shock patients.^1,12–14 Recent international sepsis guidelines recommend the choice of the medications to be guided by patient physiology and clinician preferences.¹
   
   
2. No studies support deviations from standard life-support algorithms to improve outcomes in patients with sepsis-associated cardiac arrest. Sepsis-associated cardiac arrest is associated with worse outcomes than other causes of cardiac arrest.¹⁵
   
   
3. A meta-analysis²⁰ showed no change in survival with corticosteroid use in pediatric septic shock, though a more recent randomized controlled trial suggested a shorter time to reversal of shock with steroid use.¹⁷ Two observational studies^18,19 suggested there may be specific subpopulations, based on genomics, that would either benefit or experience harm from steroid administration, though these subpopulations are difficult to identify clinically. Patients at risk for adrenal insufficiency (eg, those on chronic steroids, patients with purpura fulminans) are more likely to benefit from steroid therapy.¹²
   
   
4. In situations when epinephrine or norepinephrine are not available, dopamine is a reasonable alternative initial vasoactive infusion in patients with fluid-refractory septic shock.^10,11 Patients with vasodilatory shock may require a higher dose of dopamine.¹²

Recommendation-Specific Supportive Text

1. and 2. Cardiogenic shock in infants and children is uncommon and associated with high mortality rates. No studies were identified comparing outcomes between vasoactive medications. For patients with hypotension, medications such as epinephrine may be more appropriate as an initial inotropic therapy. Because of the rarity and complexity of these presentations, expert consultation is recommended when managing infants and children in cardiogenic shock.

Recommendation-Specific Supportive Text

1. There are no prospective pediatric data comparing the administration of early blood products versus early crystalloid for traumatic hemorrhagic shock. A scoping review identified 6 recent retrospective studies that compared patient outcomes with the total volume of crystalloid resuscitation received in the first 24 to 48 hours among children with hemorrhagic shock.^21–25,28 Four studies reported no differences in survival to 24 hours, survival at 30 days with good neurological outcome, or survival to discharge.^21,24,25,28 Large-volume resuscitation was associated with increased hospital/ICU length of stay in 5 of the 6 studies.^22–25,28 One study reported lower survival to hospital discharge among children who received more than 60 mL/kg crystalloid compared to lower volume groups.²² Despite limited pediatric data, recent guidelines for adults from the Eastern Association for the Surgery of Trauma,²⁶ the American College of Surgeons, and the National Institute for Health and Care Excellence²⁷ suggest the early use of balanced ratios of packed red blood cells, fresh frozen plasma, and platelets for trauma-related hemorrhagic shock.²⁹

Recommendation-Specific Supportive Text

1. and 2. There are no pediatric-specific clinical studies evaluating the effect of different ventilation rates on outcomes in inadequate breathing with a pulse. One multicenter observational study found that high ventilation rates (at least 30/min in children younger than 1 year of age, at least 25/min in children older than 1 year) during CPR with an advanced airway for cardiac arrest were associated with improved ROSC and survival.⁷ For the ease of training, the suggested respiratory rate for the patient with inadequate breathing and a pulse has been increased from 1 breath every 3 to 5 seconds to 1 breath every 2 to 3 seconds to be consistent with the new CPR guideline recommendation for ventilation in patients with an advanced airway.

Recommendation-Specific Supportive Text

1. and 2. There are no high-quality data to support recommendations regarding FBAO in children. Many FBAOs are relieved by allowing the patient to cough or, if severe, are treated by bystanders using abdominal thrusts.^4,8,9

3. Observational data primarily from case series support the use of back blows^4,9,10 or chest compressions^10,11 for infants. Abdominal thrusts are not recommended for infants given the potential to cause abdominal organ injury.¹²
   
   
4. Once the victim is unconscious, observational data support immediate provision of chest compressions whether or not the patient has a pulse.¹¹
   
   
5. and 6. Observational data suggest that the risk of blind finger sweeps outweighs any potential benefit in the management of FBAO.^13–15

Recommendation-Specific Supportive Text

1. Initial management should focus on support of the patient’s airway and breathing. This begins with opening the airway followed by delivery of rescue breaths, ideally with the use of a bag-mask or barrier device.^17,18 Provision of life support should continue if return of spontaneous breathing does not occur.
   
   
2. Because there are no studies demonstrating improvement in patient outcomes from administration of naloxone during cardiac arrest, provision of CPR should be the focus of initial care.²⁰ Naloxone can be administered along with standard advanced cardiovascular life support care if it does not delay components of high-quality CPR.
   
   
3. Early activation of the emergency response system is critical for patients with suspected opioid overdose. Rescuers cannot be certain that the person’s clinical condition is due to opioid-induced respiratory depression alone. This is particularly true in first aid and BLS, where determination of the presence of a pulse is unreliable.^21,22 Naloxone is ineffective in other medical conditions, including overdose involving nonopioids and cardiac arrest from any cause. Patients who respond to naloxone administration may develop recurrent central nervous system and/or respiratory depression and require longer periods of observation before safe discharge.^37–40
   
   
4. Twelve studies examined the use of naloxone in respiratory arrest, of which 5 compared intramuscular, intravenous, and/or intranasal routes of naloxone administration (2 RCT^23,24 and 3 non-RCT^25–27) and 9 assessed the safety of naloxone use or were observational studies of naloxone use.^28–36 These studies report that naloxone is safe and effective in treatment of opioid-induced respiratory depression and that complications are rare and dose related.

These recommendations were taken from Part 3: Adult Basic and Advanced Life Support⁴¹ and further supported by a 2020 ILCOR evidence update.⁴² There were no pediatric data supporting these recommendations; however, due to the urgency of the opioid crisis, the adult recommendations should be applied to children.

Figures 10 and 11 are algorithms for opioid-associated emergencies for lay responders and healthcare providers.

Recommendation-Specific Supportive Text

1. A retrospective study including 2953 children noted that, with 25 cm H₂O of pressure to the airway and a slight leak around the ETT, there were no cases of clinically significant subglottic stenosis, and the incidence of stridor requiring reintubation was less than 1%.³
   
   
2. Three systematic reviews, 2 randomized controlled trials, and 2 retrospective reviews support the safety of cuffed ETTs and the decreased need for ETT changes.^4–10 These studies were almost entirely performed in the perioperative patient population, and intubation was performed by highly skilled airway providers. Thus, ETT duration may have been shorter than in critically ill patients. The use of cuffed ETTs is associated with lower reintubation rates, more successful ventilation, and improved accuracy of capnography without increased risk of complications.^7,9–13 Cuffed ETTs may decrease the risk of aspiration.^14,15

Recommendation-Specific Supportive Text

1. 2, and 3. A retrospective, propensity score–matched study from a large pediatric ICU intubation registry showed that cricoid pressure during induction and bag-mask ventilation before tracheal intubation was not associated with lower rates of regurgitation.¹⁷ A study from the same pediatric ICU database reported external laryngeal manipulation was associated with lower initial tracheal intubation success.¹⁶

Recommendation-Specific Supportive Text

1. The 2019 French Society of Anesthesia and Intensive Care Medicine guidelines state that atropine “should probably” be used as a preintubation drug in children 28 days to 8 years with septic shock, with hypovolemia, or with succinylcholine administration.^18,19
   
   
2. One nonrandomized, single-center intervention study did not identify an association between atropine dosing less than 0.1 mg and bradycardia or arrhythmias.²⁰

Recommendation-Specific Supportive Text

1. Although there are no randomized controlled trials linking use of ETCO₂ detection with clinical outcomes, the Fourth National Audit Project of the Royal College of Anesthetists and Difficult Airway Society concluded that the failure to use or inability to properly interpret capnography contributed to adverse events, including ICU-related deaths (mixed adult and pediatric data).^21,22 One small randomized study showed that capnography was faster than clinical assessment in premature newborns intubated in the delivery room.²³ There was no difference in patient outcomes between qualitative (colorimetric) and quantitative (capnography or numeric display) ETCO₂ detectors.^24–27
   
   
2. Adult literature suggests monitoring and correct interpretation of capnography in intubated patients may prevent adverse events.^21,22,28 This has been demonstrated in simulated pediatric scenarios, in which capnography increased provider recognition of possible ETT dislodgement.^29,30

Recommendation-Specific Supportive Text

1. Intravenous adenosine remains generally effective for terminating re-entrant SVT within the first 2 doses.^3–6 Of 5 retrospective observational studies on the management of tachyarrhythmias (4 single center, 1 multicenter), none directly compared adenosine to other drugs.^6–9,17
   
   
2. For patients with hemodynamically stable SVT that is refractory to vagal maneuvers or adenosine, consideration of alternative second-line agents should be guided by expert consultation, given potential proarrhythmic and life-threatening hemodynamic collapse with the administration of multiple antiarrhythmic agents. Multiple medications have been used as second-line agents for the management of adenosine-refractory SVT, including intravenous verapamil, β-blockers, amiodarone, procainamide, and sotalol.^5–15,17 Few comparative studies exist.
   
   
3. Vagal maneuvers are noninvasive, have few adverse effects, and effectively terminate SVT in many cases; exact success rates for each type of maneuver (ie, ice water to face, postural modification) are unknown.⁴ Although improved success rates have been reported with a postural modification to the standard Valsalva maneuver in adults,¹ published pediatric experience with this technique is very limited. Upside-down positioning may be an additional form of a vagal maneuver that is effective in children.²
   
   
4. Direct current synchronized cardioversion remains the treatment of choice for patients with hemodynamically unstable SVT (ie, with cardiovascular compromise characterized by altered mental status, signs of shock, or hypotension) and those with SVT unresponsive to standard measures. However, these cases are uncommon, and there are few data reporting outcomes from cardioversion of SVT.^5,8,15 Consider administering sedation prior to synchronized cardioversion if resources are available and definitive therapy is not delayed.
   
   
5. Procainamide and amiodarone are moderately effective treatments for adenosine-resistant SVT.¹² There may be a small efficacy advantage favoring procainamide; adverse effects are frequent with both therapies. Intravenous sotalol was approved by the US Food and Drug Administration for the treatment of SVT in 2009. Only 3 reports describe its use in acute or subacute supraventricular tachyarrhythmias, with a 60% to 100% termination rate of SVT and atrial tachyarrhythmias.^9,13,14 In the aforementioned studies, IV sotalol was administered under the guidance of pediatric electrophysiologists in the critical care or pediatric cardiology unit. Due to its potential proarrhythmic properties, it is unknown whether IV sotalol can be safely given in other settings. There is currently insufficient evidence in support for or against the use of IV sotalol for refractory SVT.

Recommendation-Specific Supportive Text

1. The occurrence of wide-complex tachycardia (QRS duration more than 0.09 s) with a pulse is rare in children and may originate from either the ventricle (ventricular tachycardia) or atria (SVT with aberrant conduction).¹⁸ Both pediatric and adult studies have identified potential populations at risk of proarrhythmic complications from antiarrhythmic therapies, including patients with underlying cardiomyopathies, long-QT syndrome, Brugada syndrome, and Wolff-Parkinson-White syndrome.^19–23
   
   
2. Electric direct current synchronized cardioversion should be provided urgently for the treatment of children with wide-complex tachycardia of either atrial or ventricular origin who are hemodynamically unstable with a pulse. Cardiovascular compromise is a key factor in determining the use of electric therapy instead of primary pharmacological management. There is insufficient evidence describing the incidence of wide-complex tachycardias with a pulse and hemodynamic stability, and there is no support for or against the use of specific antiarrhythmic drugs in the management of children with wide-complex tachycardia with a pulse.

Figure 13 shows the algorithm for pediatric tachycardia with a pulse.

Recommendation-Specific Supportive Text

1. In the early postoperative period, noninvasively measured regional cerebral and somatic saturations, via near infrared spectroscopy, can predict outcomes of early mortality and ECLS use following stage I Norwood palliation. There are retrospective data that postoperative near infrared spectroscopy measures may be targets for goal-directed interventions.³
   
   
2. Afterload reduction using vasodilators (sodium nitroprusside or phentolamine), with or without a phosphodiesterase type III inhibitor (eg, milrinone), reduces systemic vascular resistance, serum lactate, arterial venous oxygen difference, and the need for ECPR in the postoperative period for shunt-dependent single-ventricle patients.^4,5
   
   
3. In the period before single-ventricle palliation, cautious use of controlled hypoventilation can reduce Qp:Qs by increasing pulmonary vascular resistance, narrowing the arterial-venous oxygen difference, and increasing cerebral oxygen delivery. Simple hypoventilation can also increase the pulmonary vascular resistance but can be associated with unwanted atelectasis or respiratory acidosis.^6,7
   
   
4. For cardiac arrest before or after Stage I palliation repair, the use of ECPR is associated with improved survival. In 2 observational studies, 32% to 54% of neonates requiring ECPR survived, and, in 1 study, the odds of survival improved in cardiac arrest patients managed with ECPR.^8,9
   
   
5. Treatment of acute shunt obstruction can include administration of oxygen, vasoactive agents (eg, phenylephrine, norepinephrine, epinephrine) to maximize shunt perfusion pressure, anticoagulation with heparin (50–100 U/kg bolus), shunt intervention by catheterization or surgery, and ECLS.²

Recommendation-Specific Supportive Text

1. In patients immediately following bidirectional Glenn placement, a ventilation strategy with higher Paco₂ improved oxygenation.¹⁰
   
   
2. In 1 retrospective analysis of the Extracorporeal Life Support Organization database, among infants in whom a bidirectional Glenn had been placed and in whom ECLS was required, survival was similar in patients who had cardiac arrest before ECLS (16/39, 41%) and those who did not (26/64, 41%).¹¹

These topics were reviewed previously in “Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association.”¹²

• Alexis A. Topjian, MD, MSCE, Chair
• Tia T. Raymond, MD, Vice-Chair
• Dianne Atkins, MD
• Melissa Chan, MD
• Jonathan P. Duff, MD, MEd
• Benny L. Joyner Jr, MD, MPH
• Javier J. Lasa, MD
• Eric J. Lavonas, MD, MS
• Arielle Levy, MD, MEd
• Melissa Mahgoub, PhD
• Garth D. Meckler, MD, MSHS
• Kathryn E. Roberts, MSN, RN
• Robert M. Sutton, MD, MSCE
• Stephen M. Schexnayder, MD

On behalf of the Pediatric Basic and Advanced Life Support Collaborators

The authors thank the following individuals (the Pediatric Basic and Advanced Life Support Collaborators) for their contributions: Ronald A. Bronicki, MD; Allan R. de Caen, MD; Anne Marie Guerguerian, MD, PhD; Kelly D. Kadlec, MD, MEd; Monica E. Kleinman, MD; Lynda J. Knight, MSN, RN; Taylor N. McCormick, MD, MSc; Ryan W. Morgan, MD, MTR; Joan S. Roberts, MD; Barnaby R. Scholefield, MBBS, PhD; Sarah Tabbutt, MD, PhD; Ravi Thiagarajan, MBBS, MPH; Janice Tijssen, MD, MSc; Brian Walsh, PhD, RRT, RRT-NPS; and Arno Zaritsky, MD.