What are the updated Pediatric Advanced Life Support (PALS) guidelines for pediatric patients requiring advanced life support?

Updated PALS Guidelines 2025

The 2025 American Heart Association and American Academy of Pediatrics PALS guidelines represent the most current evidence-based approach to pediatric resuscitation, building upon the 2020 International Consensus with refined recommendations for CPR quality, drug administration, advanced airway management, and post-cardiac arrest care. 1

Core CPR Quality Metrics

High-quality chest compressions remain the cornerstone of pediatric resuscitation:

• Compression depth: Push hard to at least one-third of the anteroposterior diameter of the chest (approximately 4 cm in infants, 5 cm in children) 2, 1
• Compression rate: 100-120 compressions per minute 2
• Complete chest recoil: Allow full chest wall expansion between compressions 2
• Minimize interruptions: Limit pauses in compressions to less than 10 seconds 2
• Avoid excessive ventilation: Over-ventilation impairs venous return and cardiac output 2

Airway and Ventilation Strategy

Advanced airway management has evolved with emphasis on confirmation techniques:

• Waveform capnography or capnometry is mandatory to confirm and continuously monitor endotracheal tube placement 2, 1
• Cuffed endotracheal tubes are acceptable in infants (excluding newborns) and children when cuff pressure is maintained below 20 cm H₂O 2
• Supraglottic airways (such as laryngeal mask airways) are acceptable alternatives when placed by experienced providers 2
• Once advanced airway is secured: Deliver 1 breath every 6 seconds (10 breaths/minute) with continuous chest compressions—no longer cycling compressions and ventilations 2, 1

Vascular Access and Medication Administration

Intraosseous (IO) access is equivalent to intravenous (IV) access for drug delivery during cardiac arrest:

• Epinephrine dosing: 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration) IO/IV every 3-5 minutes 2, 1
• Endotracheal epinephrine (if IO/IV unavailable): 0.1 mg/kg (0.1 mL/kg of 1:1,000 concentration), though this route is de-emphasized 2
• High-dose epinephrine is NOT recommended routinely 2
• Weight-based dosing methods have been refined to improve accuracy and reduce medication errors 2, 1

Defibrillation for Shockable Rhythms

For ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT):

• Amiodarone: 5 mg/kg IO/IV bolus for shock-refractory VF/pVT; may repeat for persistent arrhythmia 2, 1
• Lidocaine is an alternative if amiodarone is unavailable: 1 mg/kg loading dose, with maintenance infusion of 20-50 mcg/kg/min 2
• Pad size and placement recommendations have been updated based on patient size 2
• Energy doses remain under ongoing review, with current recommendations maintained from prior guidelines 2

Physiological Monitoring During CPR

Real-time monitoring improves CPR quality and guides interventions:

• End-tidal CO₂ monitoring during CPR helps assess compression effectiveness and detect return of spontaneous circulation (ROSC) 2, 1
• Invasive blood pressure monitoring may guide CPR quality in select in-hospital settings 2
• Near-infrared spectroscopy (NIRS) is emerging as a tool to monitor cerebral perfusion during resuscitation 2
• Bedside ultrasound can help identify perfusing rhythms and guide interventions 2

Extracorporeal CPR (ECPR)

ECPR should be considered for in-hospital cardiac arrest when conventional CPR fails:

• Reasonable to consider ECPR for patients with cardiac diagnoses (including single ventricle physiology and Fontan circulation) when rapid deployment is available 2, 1
• Time to ECPR initiation is critical—outcomes deteriorate significantly beyond 30-60 minutes of conventional CPR 2

Post-Cardiac Arrest Care

Optimizing post-ROSC management directly impacts neurologic outcomes:

• Targeted temperature management: Consider therapeutic hypothermia (32-34°C for 12-24 hours) for comatose children after cardiac arrest 2, 1
• Oxygen titration: Adjust FiO₂ to maintain oxygen saturation 94-99% once ROSC is achieved to avoid hyperoxia 2, 1
• Blood pressure management: Maintain age-appropriate blood pressure targets to ensure adequate cerebral perfusion 2, 1
• Seizure monitoring: Continuous EEG monitoring is recommended for neurologic prognostication and seizure detection 2, 1
• Avoid hypocapnia: Target normocapnia as hypocapnia reduces cerebral blood flow 2

Special Resuscitation Situations

Septic Shock

• Fluid resuscitation: Evidence supports judicious fluid administration rather than unrestricted boluses in certain populations 2
• Vasoactive medications and corticosteroids have specific indications based on shock phenotype 2, 1

Congenital Heart Disease

• Single ventricle physiology: Hypoventilation may improve oxygen delivery in Fontan or hemi-Fontan/bidirectional Glenn patients 2
• ECMO consideration is particularly important for Fontan patients in cardiac arrest 2, 1

Pulmonary Hypertension

• Reinstitute pulmonary vasodilator therapy (inhaled nitric oxide or prostaglandin I₂) if previously interrupted 2, 1
• Optimize oxygenation and ventilation to prevent pulmonary hypertensive crises 2, 1

Traumatic Cardiac Arrest

• Specific resuscitation protocols address hemorrhage control, tension pneumothorax, and cardiac tamponade 2, 1

Arrhythmia Management

Updated recommendations for non-arrest arrhythmias:

• Bradycardia with poor perfusion: Epinephrine is preferred over atropine; transcutaneous pacing may be considered 2, 1
• Supraventricular tachycardia: Adenosine remains first-line for stable SVT 2, 1
• Unstable ventricular tachycardia: Synchronized cardioversion is the priority 2, 1

Family Presence During Resuscitation

The 2025 guidelines emphasize family-centered care:

• Family presence should be offered during resuscitation efforts when feasible, with dedicated staff support 1
• Communication and support for families improves psychological outcomes regardless of resuscitation success 1

Critical Pitfalls to Avoid

• Delayed chest compressions: Start compressions immediately for cardiac arrest—do not delay for pulse checks beyond 10 seconds 1
• Inadequate compression depth: Shallow compressions are ineffective; use feedback devices when available 2, 1
• Excessive ventilation: Over-ventilation increases intrathoracic pressure and reduces cardiac output 2
• Unconfirmed tube placement: Always use capnography to verify endotracheal tube position 2, 1
• Medication dosing errors: Use length-based tapes or electronic calculators to ensure accurate weight-based dosing 2, 1