What are the ACLS (Advanced Cardiovascular Life Support) guidelines for pediatric cardiac arrest?

ACLS in Pediatrics: Key Guidelines

Follow the 2025 American Heart Association/American Academy of Pediatrics Pediatric Advanced Life Support (PALS) guidelines, which emphasize high-quality CPR as the foundation, early epinephrine for non-shockable rhythms, immediate defibrillation for shockable rhythms, and comprehensive post-cardiac arrest care with strict avoidance of hyperthermia. 1

Initial Assessment and Recognition

Verify scene safety, then simultaneously assess for:

• No breathing or only gasping
• Pulse check (≤10 seconds): Brachial in infants, carotid/femoral in children
• Heart rate <60/min with poor perfusion requires CPR even if pulse present 2

If unresponsive with no pulse or HR <60/min with poor perfusion, immediately activate emergency response and begin CPR.

High-Quality CPR: Core Components

Compression technique (critical 2025 update):

• Infants: Use heel-of-1-hand OR 2-thumb-encircling hands technique
  • Eliminate 2-finger technique (proven ineffective for adequate depth) 3
• Children: Heel-of-1-hand or 2-hands technique
• Depth: At least one-third anteroposterior chest diameter
• Rate: 100-120/minute
• Allow complete chest recoil between compressions
• Minimize interruptions (<10 seconds)
• Change compressor every 2 minutes 2, 1

Compression-to-ventilation ratios:

• Single rescuer: 30:2 (all ages)
• Two or more rescuers: 15:2 (infants and children)
• Advanced airway in place: Continuous compressions with 1 breath every 2-3 seconds (20-30 breaths/minute) 2

Rhythm Recognition and Defibrillation

Shockable rhythms (VF/pulseless VT):

• Immediate defibrillation is priority
• Use AED with pediatric attenuator if available (preferred in 2025 guidelines) 3
• Give 1 shock, then immediately resume CPR for 2 minutes before rhythm check
• Administer epinephrine if defibrillation not immediately possible 1

Non-shockable rhythms (asystole/PEA):

• Administer epinephrine as soon as possible (associated with favorable outcomes) 1
• Continue high-quality CPR
• Reassess rhythm every 2 minutes

Pharmacotherapy

Epinephrine:

• Dose: 0.01 mg/kg IV/IO (0.1 mL/kg of 1:10,000 concentration)
• Maximum single dose: 1 mg
• Timing:
  • Non-shockable rhythms: As soon as possible 1
  • Shockable rhythms: After initial defibrillation attempt if ROSC not achieved
• Repeat every 3-5 minutes during arrest 2

Hemodynamic Monitoring During CPR

If invasive arterial monitoring in place, target:

• Infants: Diastolic BP ≥25 mmHg
• Children ≥1 year: Diastolic BP ≥30 mmHg 1

End-tidal CO₂ (ETCO₂):

• Use as indicator of CPR quality
• Do NOT use specific ETCO₂ cutoff values to guide termination of resuscitation (critical caveat) 1

Post-Cardiac Arrest Care

Temperature management (major emphasis in 2025):

• Strictly avoid hyperthermia: Keep core temperature ≤37.5°C
• Preventing hyperthermia improves neurological outcomes 1
• Optional: Use structured temperature control protocols

Blood pressure targets:

• Maintain systolic and mean arterial pressure >10th percentile for age and sex 1, 4

Neuroprognostication:

• Requires multiple modalities at various timepoints
• Never rely on single test in isolation (high risk of inaccurate prediction) 1

Airway Management

Rescue breathing (pulse present, inadequate breathing):

• 1 breath every 2-3 seconds (20-30 breaths/minute)
• Reassess pulse every 2 minutes 2

Foreign body airway obstruction (2025 update):

• Infants: Alternate 5 back blows with 5 chest thrusts (NO abdominal thrusts)
• Children: Alternate 5 back blows with 5 abdominal thrusts 3, 5

Team Coordination

Single rescuer:

• Witnessed collapse: Activate emergency response immediately, retrieve AED
• Unwitnessed collapse: Perform 2 minutes CPR first, then activate if alone 2

Multiple rescuers:

• First rescuer stays with child
• Second rescuer activates emergency response and retrieves AED/equipment
• Switch to 15:2 ratio when second rescuer arrives 2

Common Pitfalls

• Don't use 2-finger compressions in infants (inadequate depth)
• Don't delay epinephrine in non-shockable rhythms (early administration improves outcomes)
• Don't use ETCO₂ cutoffs alone to terminate resuscitation (unreliable in pediatrics)
• Don't allow hyperthermia post-arrest (worsens neurological outcomes)
• Don't rely on single neuroprognostication test (requires multimodal assessment)

The 2025 guidelines represent a significant shift toward evidence-based hemodynamic targets, refined compression techniques, and comprehensive post-arrest care that extends through hospital discharge and recovery 1, 4.