1. High-quality cardiopulmonary resuscitation (CPR) is the foundation of resuscitation. New data 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 avoiding excessive ventilation.

  2. A respiratory rate of 20 to 30 breaths per minute is new for infants and children who are (a) receiving CPR with an advanced airway in place or (b) receiving rescue breathing and have a pulse.

  3. For patients with nonshockable rhythms, the earlier epinephrine is administered after CPR initiation, the more likely the patient is to survive.

  4. Using a cuffed endotracheal tube decreases the need for endotracheal tube changes.

  5. The routine use of cricoid pressure does not reduce the risk ofd regurgitation during bag-mask ventilation and may impede intubation success.

  6. For out-of-hospital cardiac arrest, bag-mask ventilation results in the same resuscitation outcomes as advanced airway interventions such as endotracheal intubation.

  7. Resuscitation does not end with return of spontaneous circulation (ROSC). Excellent post–cardiac arrest care is critically important to achieving the best patient outcomes. For children who do not regain consciousness after ROSC, this care includes targeted temperature management and continuous electroencephalography monitoring. The prevention and/or treatment of hypotension, hyperoxia or hypoxia, and hypercapnia or hypocapnia is important.

  8. After discharge from the hospital, cardiac arrest survivors can have physical, cognitive, and emotional challenges and may need ongoing therapies and interventions.

  9. Naloxone can reverse respiratory arrest due to opioid overdose, but there is no evidence that it benefits patients in cardiac arrest.

  10. Fluid resuscitation in sepsis is based on patient response and requires frequent reassessment. Balanced crystalloid, unbalanced crystalloid, and colloid fluids are all acceptable for sepsis resuscitation. Epinephrine or norepinephrine infusions are used for fluid-refractory septic shock.

More than 20 000 infants and children have a cardiac arrest per year in the United States.1–4 In 2015, emergency medical service–documented out-of-hospital cardiac arrest (OHCA) occurred in more than 7000 infants and children.4

Approximately 11.4% of pediatric OHCA patients survived to hospital discharge, but outcomes varied by age, with survival rates of 17.1% in adolescents, 13.2% in children, and 4.9% in infants. In the same year, pediatric in-hospital cardiac arrest (IHCA) incidence was 12.66 events per 1000 infant and child hospital admissions, with an overall survival to hospital discharge rate of 41.1%.4 Neurological outcomes remain difficult to assess across the pediatric age spectrum, with variability in reporting metrics and time to follow-up across studies of both OHCA and IHCA. Favorable neurological outcome has been reported in up to 47% of survivors to discharge.5 Despite increases in survival from IHCA, there is more to be done to improve both survival and neurological outcomes.6

The International Liaison Committee on Resuscitation (ILCOR) Formula for Survival emphasizes 3 essential components for good resuscitation outcomes: guidelines based on sound resuscitation science, effective education of the lay public and resuscitation providers, and implementation of a well-functioning Chain of Survival.7

These guidelines contain recommendations for pediatric basic and advanced life support, excluding the newborn period, and are based on the best available resuscitation science. The Chain of Survival (Section 2), which is now expanded to include recovery from cardiac arrest, requires coordinated efforts from medical professionals in a variety of disciplines and, in the case of OHCA, from bystanders, emergency dispatchers, and first responders. In addition, specific recommendations about the training of resuscitation providers are provided in Part 6: Resuscitation Education Science, and recommendations about systems of care are provided in Part 7.

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.

Coronavirus Disease 2019 Guidance

Together with other professional societies, the American Heart Association (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 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.

Table 1

Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*

 
 

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.

AbbreviationMeaning/Phrase
ACLS advanced cardiovascular life support 
AED automated external defibrillator 
ALS advanced life support 
AHA American Heart Association 
BLS basic life support 
COI conflict of interest 
COR Class of Recommendation 
CPR cardiopulmonary resuscitation 
ECC emergency cardiovascular care 
ECLS extracorporeal life support 
ECMO extracorporeal membrane oxygenation 
ECPR extracorporeal cardiopulmonary resuscitation 
EO Expert Opinion 
ETI endotracheal intubation 
FBAO foreign body airway obstruction 
IHCA in-hospital cardiac arrest 
ILCOR International Liaison Committee on Resuscitation 
LD limited data 
LOE Level of Evidence 
MCS mechanical circulatory support 
NR nonrandomized 
OHCA out-of-hospital cardiac arrest 
PALS pediatric advanced life support 
PICO population, intervention, comparator, outcome 
pVT pulseless ventricular tachycardia 
RCT randomized clinical trial 
ROSC return of spontaneous circulation 
SGA supraglottic airway 
TTM targeted temperature management 
VF ventricular fibrillation 
AbbreviationMeaning/Phrase
ACLS advanced cardiovascular life support 
AED automated external defibrillator 
ALS advanced life support 
AHA American Heart Association 
BLS basic life support 
COI conflict of interest 
COR Class of Recommendation 
CPR cardiopulmonary resuscitation 
ECC emergency cardiovascular care 
ECLS extracorporeal life support 
ECMO extracorporeal membrane oxygenation 
ECPR extracorporeal cardiopulmonary resuscitation 
EO Expert Opinion 
ETI endotracheal intubation 
FBAO foreign body airway obstruction 
IHCA in-hospital cardiac arrest 
ILCOR International Liaison Committee on Resuscitation 
LD limited data 
LOE Level of Evidence 
MCS mechanical circulatory support 
NR nonrandomized 
OHCA out-of-hospital cardiac arrest 
PALS pediatric advanced life support 
PICO population, intervention, comparator, outcome 
pVT pulseless ventricular tachycardia 
RCT randomized clinical trial 
ROSC return of spontaneous circulation 
SGA supraglottic airway 
TTM targeted temperature management 
VF ventricular fibrillation 
  • 1. Holmberg MJ, Ross CE, Fitzmaurice GM, Chan PS, Duval-Arnould J, Grossestreuer AV, Yankama T, Donnino MW, Andersen LW; American Heart Association’s Get With The Guidelines–Resuscitation Investigators. Annual Incidence of Adult and Pediatric In-Hospital Cardiac Arrest in the United States. Circ Cardiovasc Qual Outcomes. 2019;12:e005580.

  • 2. Atkins DL, Everson-Stewart S, Sears GK, Daya M, Osmond MH, Warden CR, Berg RA; Resuscitation Outcomes Consortium Investigators. Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest. Circulation. 2009;119:1484–1491. doi: 10.1161/CIRCULATIONAHA.108.802678

  • 3. Knudson JD, Neish SR, Cabrera AG, Lowry AW, Shamszad P, Morales DL, Graves DE, Williams EA, Rossano JW. Prevalence and outcomes of pediatric in-hospital cardiopulmonary resuscitation in the United States: an analysis of the Kids’ Inpatient Database*. Crit Care Med. 2012;40:2940–2944. doi: 10.1097/CCM.0b013e31825feb3f

  • 4. Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Delling FN, et al: on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2020 update: a report from the American Heart Association. Circulation. 2020;141:e139–e596. doi: 10.1161/CIR.0000000000000757

  • 5. Matos RI, Watson RS, Nadkarni VM, Huang HH, Berg RA, Meaney PA, Carroll CL, Berens RJ, Praestgaard A, Weissfeld L, Spinella PC; American Heart Association’s Get With The Guidelines–Resuscitation (Formerly the National Registry of Cardiopulmonary Resuscitation) Investigators. Duration of cardiopulmonary resuscitation and illness category impact survival and neurologic outcomes for in-hospital pediatric cardiac arrests. Circulation. 2013;127:442–451. doi: 10.1161/CIRCULATIONAHA.112.125625

  • 6. Girotra S, Spertus JA, Li Y, Berg RA, Nadkarni VM, Chan PS; American Heart Association Get With the Guidelines–Resuscitation Investigators. Survival trends in pediatric in-hospital cardiac arrests: an analysis from Get With the Guidelines-Resuscitation. Circ Cardiovasc Qual Outcomes. 2013;6:42–49. doi: 10.1161/CIRCOUTCOMES.112.967968

  • 7. Søreide E, Morrison L, Hillman K, Monsieurs K, Sunde K, Zideman D, Eisenberg M, Sterz F, Nadkarni VM, Soar J, Nolan JP; Utstein Formula for Survival Collaborators. The formula for survival in resuscitation. Resuscitation. 2013;84:1487–1493. doi: 10.1016/j.resuscitation.2013.07.020

  • 8. American Heart Association. CPR & ECC. https://cpr.heart.org/.Accessed June 19, 2020.

  • 9. American Heart Association. Conflict of interest policy. https://www. heart.org/en/about-us/statements-and-policies/conflict-of-interest-policy. Accessed December 31, 2019.

  • 10. International Liaison Committee on Resuscitation (ILCOR). Continuous evidence evaluation guidance and templates: 2020 evidence update process final. https://www.ilcor.org/documents/continuous-evidence-evaluation-guidance-and-templatesAccessed December 31, 2019.

  • 11. Institute of Medicine (US) Committee of Standards for Systematic Reviews of Comparative Effectiveness Research. Finding What Works in Health Care: Standards for Systematic Reviews. Eden J, Levit L, Berg A, Morton S, eds. Washington, DC: The National Academies Press; 2011.

  • 11a. Maconochie IK, Aickin R, Hazinski MF, Atkins DL, Bingham R, Couto TB, Guerguerian A-M, Nadkarni VM, Ng K-C, Nuthall GA, et al; on behalf of the Pediatric Life Support Collaborators. Pediatric life support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142(suppl 1):S140–S184. doi: 10.1161/CIR.0000000000000894

  • 12. Magid DJ, Aziz K, Cheng A, Hazinski MF, Hoover AV, Mahgoub M, Panchal AR, Sasson C, Topjian AA, Rodriguez AJ, et al. Part 2: evidence evaluation and guidelines development: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(suppl 2):S358–S365. doi: 10.1161/CIR.0000000000000898

  • 13. Levine GN, O’Gara PT, Beckman JA, Al-Khatib SM, Birtcher KK, Cigarroa JE, de Las Fuentes L, Deswal A, Fleisher LA, Gentile F, Goldberger ZD, Hlatky MA, Joglar JA, Piano MR, Wijeysundera DN. Recent Innovations, Modifications, and Evolution of ACC/AHA Clinical Practice Guidelines: An Update for Our Constituencies: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;139:e879–e886. doi: 10.1161/CIR.0000000000000651

The epidemiology, pathophysiology, and common etiologies of pediatric cardiac arrest are distinct from adult and neonatal cardiac arrest. Cardiac arrest in infants and children does not usually result from a primary cardiac cause; rather, it is the end result of progressive respiratory failure or shock. In these patients, cardiac arrest is preceded by a variable period of deterioration, which eventually results in cardiopulmonary failure, bradycardia, and cardiac arrest. In children with congenital heart disease, cardiac arrest is often due to a primary cardiac cause, although the etiology is distinct from adults.

Outcomes for pediatric IHCA have improved over the past 20 years, in part because of early recognition, high-quality CPR, postarrest care, and extracorporeal cardiopulmonary resuscitation (ECPR).1,2 In a recent analysis of the Get With The Guidelines Resuscitation Registry, a large multicenter, hospital-based cardiac arrest registry, pediatric cardiac arrest survival to hospital discharge was 19% in 2000 and 38% in 2018.2 Survival has increased on average by 0.67% per year, though that increase has plateaued since 2010.2 New directions of research and therapy may be required to improve cardiac arrest survival. More cardiac arrest events now occur in an intensive care unit (ICU) setting, suggesting that patients at risk for cardiac arrest are being identified sooner and transferred to a higher level of care.3

Survival rates from OHCA remain less encouraging. In a recent analysis of the Resuscitation Outcomes Consortium Epidemiological Registry, a multicenter OHCA registry, annual survival to hospital discharge of pediatric OHCA between 2007 and 2012 ranged from 6.7% to 10.2% depending on region and patient age.4 There was no significant change in these rates over time, consistent with other national registries from Japan and from Australia and New Zealand.5,6 In the Resuscitation Outcomes Consortium Epidemiological Registry, survival of OHCA was higher in regions with more arrests that were witnessed by emergency medical services and with higher bystander CPR rates, stressing the importance of early recognition and treatment of these patients.4

As survival rates from pediatric cardiac arrest increase, there has been a shift with more focus on neurodevelopmental, physical, and emotional outcomes of survivors. Recent studies demonstrate that a quarter of patients with favorable outcomes have global cognitive impairment and that 85% of older children who were reported to have favorable outcomes have selective neuropsychological deficits.7

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 shortand 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.

Figure 1

Pediatric Chains of Survival for in-hospital (top) and out-of-hospital (bottom) cardiac arrest. CPR indicates cardiopulmonary resuscitation.

Figure 1

Pediatric Chains of Survival for in-hospital (top) and out-of-hospital (bottom) cardiac arrest. CPR indicates cardiopulmonary resuscitation.

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  1. Girotra S, Spertus JA, Li Y, Berg RA, Nadkarni VM, Chan PS; American Heart Association Get With the Guidelines–Resuscitation Investigators. Survival trends in pediatric in-hospital cardiac arrests: an analysis from Get With the Guidelines-Resuscitation. Circ Cardiovasc Qual Outcomes. 2013;6:42–49. doi: 10.1161/CIRCOUTCOMES.112.967968

  2. Holmberg MJ, Wiberg S, Ross CE, Kleinman M, Hoeyer-Nielsen AK, Donnino MW, Andersen LW. Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States. Circulation. 2019;140:1398–1408. doi: 10.1161/CIRCULATIONAHA.119.041667

  3. Berg RA, Sutton RM, Holubkov R, Nicholson CE, Dean JM, Harrison R, Heidemann S, Meert K, Newth C, Moler F, Pollack M, Dalton H, Doctor A, Wessel D, Berger J, Shanley T, Carcillo J, Nadkarni VM; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network and for the American Heart Association’s Get With the Guidelines-Resuscitation (formerly the National Registry of Cardiopulmonary Resuscitation) Investigators. Ratio of PICU versus ward cardiopulmonary resuscitation events is increasing. Crit Care Med. 2013;41:2292–2297. doi: 10.1097/CCM.0b013e31828cf0c0

  4. Fink EL, Prince DK, Kaltman JR, Atkins DL, Austin M, Warden C, Hutchison J, Daya M, Goldberg S, Herren H, Tijssen JA, Christenson J, Vaillancourt C, Miller R, Schmicker RH, Callaway CW; Resuscitation Outcomes Consortium. Unchanged pediatric out-of-hospital cardiac arrest incidence and survival rates with regional variation in North America. Resuscitation. 2016;107:121–128. doi: 10.1016/j.resuscitation.2016.07.244

  5. Kitamura T, Iwami T, Kawamura T, Nitta M, Nagao K, Nonogi H, Yonemoto N, Kimura T; Japanese Circulation Society Resuscitation Science Study Group. Nationwide improvements in survival from out-of-hospital cardiac arrest in Japan. Circulation. 2012;126:2834–2843. doi: 10.1161/CIRCULATIONAHA.112.109496

  6. Straney LD, Schlapbach LJ, Yong G, Bray JE, Millar J, Slater A, Alexander J, Finn J; Australian and New Zealand Intensive Care Society Paediatric Study Group. Trends in PICU Admission and Survival Rates in Children in Australia and New Zealand Following Cardiac Arrest. Pediatr Crit Care Med. 2015;16:613–620. doi: 10.1097/PCC.0000000000000425

  7. Slomine BS, Silverstein FS, Christensen JR, Page K, Holubkov R, Dean JM, Moler FW. Neuropsychological Outcomes of Children 1 Year After Pediatric Cardiac Arrest: Secondary Analysis of 2 Randomized Clinical Trials. JAMA Neurol. 2018;75:1502–1510. doi: 10.1001/jamaneurol.2018.2628

  8. Topjian AA, de Caen A, Wainwright MS, Abella BS, Abend NS, Atkins DL, Bembea MM, Fink EL, Guerguerian AM, Haskell SE, Kilgannon JH, Lasa JJ, Hazinski MF. Pediatric Post-Cardiac Arrest Care: A Scientific Statement From the American Heart Association. Circulation. 2019;140:e194–e233. doi: 10.1161/CIR.0000000000000697

  9. Laverriere EK, Polansky M, French B, Nadkarni VM, Berg RA, Topjian AA. Association of Duration of Hypotension With Survival After Pediatric Cardiac Arrest. Pediatr Crit Care Med. 2020;21:143–149. doi: 10.1097/PCC.0000000000002119

Rapid recognition of cardiac arrest, immediate initiation of high-quality chest compressions, and delivery of effective ventilations are critical to improve outcomes from cardiac arrest. Lay rescuers should not delay starting CPR in a child with no “signs of life.” Healthcare providers may consider assessing the presence of a pulse as long as the initiation of CPR is not delayed more than 10 seconds. Palpation for the presence or absence of a pulse is not reliable as the sole determinant of cardiac arrest and the need for chest compressions. In infants and children, asphyxial cardiac arrest is more common than cardiac arrest from a primary cardiac event; therefore, effective ventilation is important during resuscitation of children. When CPR is initiated, the sequence is compressions-airway-breathing.

High-quality CPR generates blood flow to vital organs and increases the likelihood of return of spontaneous circulation (ROSC). The 5 main components of high-quality CPR are (1) adequate chest compression depth, (2) optimal chest compression rate, (3) minimizing interruptions in CPR (ie, maximizing chest compression fraction or the proportion of time that chest compressions are provided for cardiac arrest), (4) allowing full chest recoil between compressions, and (5) avoiding excessive ventilation. Compressions of inadequate depth and rate,1,2 incomplete chest recoil,3 and high ventilation rates4,5 are common during pediatric resuscitation.

  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.

  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

Figure 2

2-Finger compressions.

Figure 2

2-Finger compressions.

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Figure 3

2-Thumb–encircling hands compressions.

Figure 3

2-Thumb–encircling hands compressions.

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  1. One anthropometric38 and 3 radiological studies39–41 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.

  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 studies53,56,60–63 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.

  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.

Figure 4

Pediatric BLS for lay rescuers. AED indicates automated external defibrillator; BLS, basic life support; CPR, cardiopulmonary resuscitation; and EMS, emergency medical services.

Figure 4

Pediatric BLS for lay rescuers. AED indicates automated external defibrillator; BLS, basic life support; CPR, cardiopulmonary resuscitation; and EMS, emergency medical services.

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Figure 5

Pediatric Basic Life Support Algorithm for Healthcare Providers—Single Rescuer. AED indicates automated external defibrillator; ALS, advanced life support; CPR, cardiopulmonary resuscitation; and HR, heart rate.

Figure 5

Pediatric Basic Life Support Algorithm for Healthcare Providers—Single Rescuer. AED indicates automated external defibrillator; ALS, advanced life support; CPR, cardiopulmonary resuscitation; and HR, heart rate.

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Figure 6

Pediatric Basic Life Support Algorithm for Healthcare Providers—2 or More Rescuers. AED indicates automated external defibrillator; ALS, advanced life support; CPR, cardiopulmonary resuscitation; and HR, heart rate.

Figure 6

Pediatric Basic Life Support Algorithm for Healthcare Providers—2 or More Rescuers. AED indicates automated external defibrillator; ALS, advanced life support; CPR, cardiopulmonary resuscitation; and HR, heart rate.

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Figure 7

Pediatric Cardiac Arrest Algorithm. ASAP indicates as soon as possible; CPR, cardiopulmonary resuscitation; ET, endotracheal; HR, heart rate; IO, intraosseous; IV, intravenous; PEA, pulseless electrical activity; and VF/pVT, ventricular fibrillation/pulseless ventricular tachycardia.

Figure 7

Pediatric Cardiac Arrest Algorithm. ASAP indicates as soon as possible; CPR, cardiopulmonary resuscitation; ET, endotracheal; HR, heart rate; IO, intraosseous; IV, intravenous; PEA, pulseless electrical activity; and VF/pVT, ventricular fibrillation/pulseless ventricular tachycardia.

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  1. Niles DE, Duval-Arnould J, Skellett S, Knight L, Su F, Raymond TT, Sweberg T, Sen AI, Atkins DL, Friess SH, de Caen AR, Kurosawa H, Sutton RM, Wolfe H, Berg RA, Silver A, Hunt EA, Nadkarni VM; pediatric Resuscitation Quality (pediRESQ) Collaborative Investigators. Characterization of Pediatric In Hospital Cardiopulmonary Resuscitation Quality Metrics Across an International Resuscitation Collaborative. Pediatr Crit Care Med. 2018;19:421–432. doi: 10.1097/PCC.0000000000001520

  2. Sutton RM, Niles D, Nysaether J, Abella BS, Arbogast KB, Nishisaki A, Maltese MR, Donoghue A, Bishnoi R, Helfaer MA, Myklebust H, Nadkarni V. Quantitative analysis of CPR quality during in-hospital resuscitation of older children and adolescents. Pediatrics. 2009;124:494–499. doi: 10.1542/ peds.2008-1930

  3. Niles D, Nysaether J, Sutton R, Nishisaki A, Abella BS, Arbogast K, Maltese MR, Berg RA, Helfaer M, Nadkarni V. Leaning is common during in-hospital pediatric CPR, and decreased with automated corrective feedback. Resuscitation. 2009;80:553–557. doi: 10.1016/j.resuscitation.2009.02.012

  4. McInnes AD, Sutton RM, Orioles A, Nishisaki A, Niles D, Abella BS, Maltese MR, Berg RA, Nadkarni V. The first quantitative report of ventilation rate during in-hospital resuscitation of older children and adolescents. Resuscitation. 2011;82:1025–1029. doi: 10.1016/j. resuscitation.2011.03.020

  5. Sutton RM, Reeder RW, Landis WP, Meert KL, Yates AR, Morgan RW, Berger JT, Newth CJ, Carcillo JA, McQuillen PS, Harrison RE, Moler FW, Pollack MM, Carpenter TC, Notterman DA, Holubkov R, Dean JM, Nadkarni VM, Berg RA; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN). Ventilation Rates and Pediatric In-Hospital Cardiac Arrest Survival Outcomes. Crit Care Med. 2019;47:1627–1636. doi: 10.1097/CCM.0000000000003898

  6. Bahr J, Klingler H, Panzer W, Rode H, Kettler D. Skills of lay people in checking the carotid pulse. Resuscitation. 1997;35:23–26. doi: 10.1016/s0300-9572(9601092-1)

  7. Brearley S, Shearman CP, Simms MH. Peripheral pulse palpation: an unreliable physical sign. Ann R Coll Surg Engl. 1992;74:169–171.

  8. Cavallaro DL, Melker RJ. Comparison of two techniques for detecting cardiac activity in infants. Crit Care Med. 1983;11:189–190. doi: 10.1097/00003246-198303000-00009

  9. Inagawa G, Morimura N, Miwa T, Okuda K, Hirata M, Hiroki K. A comparison of five techniques for detecting cardiac activity in infants. Paediatr Anaesth. 2003;13:141–146. doi: 10.1046/j.1460-9592.2003.00970.x

  10. Kamlin CO, O’Donnell CP, Everest NJ, Davis PG, Morley CJ. Accuracy of clinical assessment of infant heart rate in the delivery room. Resuscitation. 2006;71:319–321. doi: 10.1016/j.resuscitation.2006.04.015

  11. Lee CJ, Bullock LJ. Determining the pulse for infant CPR: time for a change? Mil Med. 1991;156:190–193.

  12. Mather C, O’Kelly S. The palpation of pulses. Anaesthesia. 1996;51:189–191. doi: 10.1111/j.1365-2044.1996.tb07713.x

  13. Ochoa FJ, Ramalle-Gómara E, Carpintero JM, García A, Saralegui I. Competence of health professionals to check the carotid pulse. Resuscitation. 1998;37:173–175. doi: 10.1016/s0300-9572(9800055-0)

  14. Owen CJ, Wyllie JP. Determination of heart rate in the baby at birth. Resuscitation. 2004;60:213–217. doi: 10.1016/j.resuscitation.2003.10.002

  15. Sarti A, Savron F, Casotto V, Cuttini M. Heartbeat assessment in infants: a comparison of four clinical methods. Pediatr Crit Care Med. 2005;6:212–215. doi: 10.1097/01.PCC.0000154952.59176.E0

  16. Sarti A, Savron F, Ronfani L, Pelizzo G, Barbi E. Comparison of three sites to check the pulse and count heart rate in hypotensive infants. Paediatr Anaesth. 2006;16:394–398. doi: 10.1111/j.1460-9592.2005.01803.x

  17. Tanner M, Nagy S, Peat JK. Detection of infant’s heart beat/pulse by caregivers: a comparison of 4 methods. J Pediatr. 2000;137:429–430. doi: 10.1067/mpd.2000.107188

  18. Whitelaw CC, Goldsmith LJ. Comparison of two techniques for determining the presence of a pulse in an infant. Acad Emerg Med. 1997;4:153–154. doi: 10.1111/j.1553-2712.1997.tb03725.x

  19. Dick WF, Eberle B, Wisser G, Schneider T. The carotid pulse check revisited: what if there is no pulse? Crit Care Med. 2000;28(suppl):N183–N185. doi: 10.1097/00003246-200011001-00002

  20. Eberle B, Dick WF, Schneider T, Wisser G, Doetsch S, Tzanova I. Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse. Resuscitation. 1996;33:107–116. doi: 10.1016/s0300-9572(9601016-7)

  21. Tibballs J, Russell P. Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest. Resuscitation. 2009;80:61–64. doi: 10.1016/j.resuscitation.2008.10.002

  22. Tibballs J, Weeranatna C. The influence of time on the accuracy of healthcare personnel to diagnose paediatric cardiac arrest by pulse palpation. Resuscitation. 2010;81:671–675. doi: 10.1016/j.resuscitation.2010.01.030

  23. O’Connell KJ, Keane RR, Cochrane NH, Sandler AB, Donoghue AJ, Kerrey BT, Myers SR, Vazifedan T, Mullan PC. Pauses in compressions during pediatric CPR: Opportunities for improving CPR quality. Resuscitation. 2019;145:158–165. doi: 10.1016/j.resuscitation.2019.08.015

  24. Lubrano R, Cecchetti C, Bellelli E, Gentile I, Loayza Levano H, Orsini F, Bertazzoni G, Messi G, Rugolotto S, Pirozzi N, Elli M. Comparison of times of intervention during pediatric CPR maneuvers using ABC and CAB sequences: a randomized trial. Resuscitation. 2012;83:1473–1477. doi: 10.1016/j.resuscitation.2012.04.011

  25. Kitamura T, Iwami T, Kawamura T, Nagao K, Tanaka H, Nadkarni VM, Berg RA, Hiraide A; implementation working group for All-Japan Utstein Registry of the Fire and Disaster Management Agency. Conventional and chest-compression only cardiopulmonary resuscitation by bystanders for children who have out-of-hospital cardiac arrests: a prospective, nationwide, population-based cohort study. Lancet. 2010;375:1347–1354. doi: 10.1016/S0140-6736(1060064-5)

  26. Goto Y, Maeda T, Goto Y. Impact of dispatcher-assisted bystander cardiopulmonary resuscitation on neurological outcomes in children with out-of-hospital cardiac arrests: a prospective, nationwide, population-based cohort study. J Am Heart Assoc. 2014;3:e000499. doi: 10.1161/JAHA.113.000499

  27. Naim MY, Burke RV, McNally BF, Song L, Griffis HM, Berg RA, Vellano K, Markenson D, Bradley RN, Rossano JW. Association of Bystander Cardiopulmonary Resuscitation With Overall and Neurologically Favorable Survival After Pediatric Out-of-Hospital Cardiac Arrest in the United States: A Report From the Cardiac Arrest Registry to Enhance Survival Surveillance Registry. JAMA Pediatr. 2017;171:133–141. doi: 10.1001/jamapediatrics.2016.3643

  28. Fukuda T, Ohashi-Fukuda N, Kobayashi H, Gunshin M, Sera T, Kondo Y, Yahagi N. Conventional Versus Compression-Only Versus No-Bystander Cardiopulmonary Resuscitation for Pediatric Out-of-Hospital Cardiac Arrest. Circulation. 2016;134:2060–2070. doi: 10.1161/CIRCULATIONAHA.116.023831

  29. Ashoor HM, Lillie E, Zarin W, Pham B, Khan PA, Nincic V, Yazdi F, Ghassemi M, Ivory J, Cardoso R, Perkins GD, de Caen AR, Tricco AC; ILCOR Basic Life Support Task Force. Effectiveness of different compression-to-ventilation methods for cardiopulmonary resuscitation: A systematic review. Resuscitation. 2017;118:112–125. doi: 10.1016/j.resuscitation.2017.05.032

  30. Glatz AC, Nishisaki A, Niles DE, Hanna BD, Eilevstjonn J, Diaz LK, Gillespie MJ, Rome JJ, Sutton RM, Berg RA, Nadkarni VM. Sternal wall pressure comparable to leaning during CPR impacts intrathoracic pressure and haemodynamics in anaesthetized children during cardiac catheterization. Resuscitation. 2013;84:1674–1679. doi: 10.1016/j.resuscitation.2013.07.010

  31. Sutton RM, French B, Nishisaki A, Niles DE, Maltese MR, Boyle L, Stavland M, Eilevstjønn J, Arbogast KB, Berg RA, et al. American Heart Association cardiopulmonary resuscitation quality targets are associated with improved arterial blood pressure during pediatric cardiac arrest. Resuscitation. 2013;84:168–172. doi: 10.1016/j.resuscitation.2012.08.335

  32. Sutton RM, Reeder RW, Landis W, Meert KL, Yates AR, Berger JT, Newth CJ, Carcillo JA, McQuillen PS, Harrison RE, Moler FW, Pollack MM, Carpenter TC, Notterman DA, Holubkov R, Dean JM, Nadkarni VM, Berg RA; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN) Investigators. Chest compression rates and pediatric in-hospital cardiac arrest survival outcomes. Resuscitation. 2018;130:159–166. doi: 10.1016/j.resuscitation.2018.07.015

  33. Kao PC, Chiang WC, Yang CW, Chen SJ, Liu YP, Lee CC, Hsidh MJ, Ko PC, Chen SC, Ma MH. What is the correct depth of chest compression for infants and children? A radiological study. Pediatrics. 2009;124:49–55. doi: 10.1542/peds.2008-2536

  34. Sutton RM, Niles D, Nysaether J, Arbogast KB, Nishisaki A, Maltese MR, Bishnoi R, Helfaer MA, Nadkarni V, Donoghue A. Pediatric CPR quality monitoring: analysis of thoracic anthropometric data. Resuscitation. 2009;80:1137–1141. doi: 10.1016/j.resuscitation. 2009.06.031

  35. Braga MS, Dominguez TE, Pollock AN, Niles D, Meyer A, Myklebust H, Nysaether J, Nadkarni V. Estimation of optimal CPR chest compression depth in children by using computer tomography. Pediatrics. 2009;124:e69–e74. doi: 10.1542/peds.2009-0153

  36. Sutton RM, French B, Niles DE, Donoghue A, Topjian AA, Nishisaki A, Leffelman J, Wolfe H, Berg RA, Nadkarni VM, et al. 2010 American Heart Association recommended compression depths during pediatric in-hospital resuscitations are associated with survival. Resuscitation. 2014;85:1179–1184. doi: 10.1016/j.resuscitation.2014.05.007

  37. Atkins DL, de Caen AR, Berger S, Samson RA, Schexnayder SM, Joyner BL Jr, Bigham BL, Niles DE, Duff JP, Hunt EA, Meaney PA. 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. Circulation. 2018;137:e1–e6. doi: 10.1161/CIR.0000000000000540

  38. Clements F, McGowan J. Finger position for chest compressions in cardiac arrest in infants. Resuscitation. 2000;44:43–46. doi: 10.1016/s0300-9572(9900165-3)

  39. Finholt DA, Kettrick RG, Wagner HR, Swedlow DB. The heart is under the lower third of the sternum. Implications for external cardiac massage. Am J Dis Child. 1986;140:646–649. doi: 10.1001/archpedi.1986.02140210044022

  40. Phillips GW, Zideman DA. Relation of infant heart to sternum: its significance in cardiopulmonary resuscitation. Lancet. 1986;1:1024–1025. doi: 10.1016/s0140-6736(8691284-5)

  41. Orlowski JP. Optimum position for external cardiac compression in infants and young children. Ann Emerg Med. 1986;15:667–673. doi: 10.1016/s0196-0644(8680423-1)

  42. Douvanas A, Koulouglioti C, Kalafati M. A comparison between the two methods of chest compression in infant and neonatal resuscitation: a review according to 2010 CPR guidelines. J Matern Fetal Neonatal Med. 2018;31:805–816. doi: 10.1080/14767058.2017.1295953

  43. Lee JE, Lee J, Oh J, Park CH, Kang H, Lim TH, Yoo KH. Comparison of two-thumb encircling and two-finger technique during infant cardiopulmonary resuscitation with single rescuer in simulation studies: a systematic review and meta-analysis. Medicine (Baltimore). 2019;98:e17853. doi: 10.1097/MD.0000000000017853

  44. Lee SY, Hong JY, Oh JH, Son SH. The superiority of the two-thumb over the two-finger technique for single-rescuer infant cardiopulmonary resuscitation. Eur J Emerg Med. 2018;25:372–376. doi: 10.1097/MEJ.0000000000000461

  45. Tsou JY, Kao CL, Chang CJ, Tu YF, Su FC, Chi CH. Biomechanics of two-thumb versus two-finger chest compression for cardiopulmonary resuscitation in an infant manikin model. Eur J Emerg Med. 2020;27:132–136. doi: 10.1097/MEJ.0000000000000631

  46. Pellegrino JL, Bogumil D, Epstein JL, Burke RV. Two-thumb-encircling advantageous for lay responder infant CPR: a randomised manikin study. Arch Dis Child. 2019;104:530–534. doi: 10.1136/archdischild-2018-314893

  47. Kim MJ, Lee HS, Kim S, Park YS. Optimal chest compression technique for paediatric cardiac arrest victims. Scand J Trauma Resusc Emerg Med. 2015;23:36. doi: 10.1186/s13049-015-0118-y

  48. Stevenson AG, McGowan J, Evans AL, Graham CA. CPR for children: one hand or two? Resuscitation. 2005;64:205–208. doi: 10.1016/j.resuscitation.2004.07.012

  49. Peska E, Kelly AM, Kerr D, Green D. One-handed versus two-handed chest compressions in paediatric cardio-pulmonary resuscitation. Resuscitation. 2006;71:65–69. doi: 10.1016/j.resuscitation.2006.02.007

  50. Lin Y, Wan B, Belanger C, Hecker K, Gilfoyle E, Davidson J, Cheng A. Reducing the impact of intensive care unit mattress compressibility during CPR: a simulation-based study. Adv Simul (Lond). 2017;2:22. doi: 10.1186/s41077-017-0057-y

  51. Noordergraaf GJ, Paulussen IW, Venema A, van Berkom PF, Woerlee PH, Scheffer GJ, Noordergraaf A. The impact of compliant surfaces on in-hospital chest compressions: effects of common mattresses and a backboard. Resuscitation. 2009;80:546–552. doi: 10.1016/j. resuscitation.2009.03.023

  52. Oh J, Chee Y, Song Y, Lim T, Kang H, Cho Y. A novel method to decrease mattress compression during CPR using a mattress compression cover and a vacuum pump. Resuscitation. 2013;84:987–991. doi: 10.1016/j.resuscitation.2012.12.027

  53. Song Y, Oh J, Lim T, Chee Y. A new method to increase the quality of cardiopulmonary resuscitation in hospital. Conf Proc IEEE Eng Med Biol Soc. 2013;2013:469–472. doi: 10.1109/EMBC.2013.6609538

  54. Beesems SG, Koster RW. Accurate feedback of chest compression depth on a manikin on a soft surface with correction for total body displacement. Resuscitation. 2014;85:1439–1443. doi: 10.1016/j. resuscitation.2014.08.005

  55. Nishisaki A, Maltese MR, Niles DE, Sutton RM, Urbano J, Berg RA, Nadkarni VM. Backboards are important when chest compressions are provided on a soft mattress. Resuscitation. 2012;83:1013–1020. doi: 10.1016/j.resuscitation.2012.01.016

  56. Sato H, Komasawa N, Ueki R, Yamamoto N, Fujii A, Nishi S, Kaminoh Y. Backboard insertion in the operating table increases chest compression depth: a manikin study. J Anesth. 2011;25:770–772. doi: 10.1007/s00540-011-1196-2

  57. Lee S, Oh J, Kang H, Lim T, Kim W, Chee Y, Song Y, Ahn C, Cho JH. Proper target depth of an accelerometer-based feedback device during CPR performed on a hospital bed: a randomized simulation study. Am J Emerg Med. 2015;33:1425–1429. doi: 10.1016/j.ajem.2015.07.010

  58. Oh J, Song Y, Kang B, Kang H, Lim T, Suh Y, Chee Y. The use of dual accelerometers improves measurement of chest compression depth. Resuscitation. 2012;83:500–504. doi: 10.1016/j.resuscitation.2011.09.028

  59. Ruiz de Gauna S, González-Otero DM, Ruiz J, Gutiérrez JJ, Russell JK. A feasibility study for measuring accurate chest compression depth and rate on soft surfaces using two accelerometers and spectral analysis. Biomed Res Int. 2016;2016:6596040. doi: 10.1155/2016/6596040

  60. Andersen LØ, Isbye DL, Rasmussen LS. Increasing compression depth during manikin CPR using a simple backboard. Acta Anaesthesiol Scand. 2007;51:747–750. doi: 10.1111/j.1399-6576.2007.01304.x

  61. Fischer EJ, Mayrand K, Ten Eyck RP. Effect of a backboard on compression depth during cardiac arrest in the ED: a simulation study. Am J Emerg Med. 2016;34:274–277. doi: 10.1016/j.ajem.2015.10.035

  62. Perkins GD, Smith CM, Augre C, Allan M, Rogers H, Stephenson B, Thickett DR. Effects of a backboard, bed height, and operator position on compression depth during simulated resuscitation. Intensive Care Med. 2006;32:1632–1635. doi: 10.1007/s00134-006-0273-8

  63. Sanri E, Karacabey S. The Impact of Backboard Placement on Chest Compression Quality: A Mannequin Study. Prehosp Disaster Med. 2019;34:182–187. doi: 10.1017/S1049023X19000153

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Most pediatric cardiac arrests are triggered by respiratory deterioration. Airway management and effective ventilation are fundamental to pediatric resuscitation. Although the majority of patients can be successfully ventilated with bag-mask ventilation, this method requires interruptions in chest compressions and is associated with risk of aspiration and barotrauma.

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.

  1. A clinical trial and 2 propensity-matched retrospective studies show that ETI and bag-mask ventilation achieve similar rates of survival with good neurological function and survival to hospital discharge in pediatric patients with OHCA.1–3 Propensity-matched retrospective studies also show similar rates of survival with good neurological function and survival to discharge when comparing SGA with bag-mask ventilation in pediatric OHCA.2,3 No difference was observed in outcomes between SGA and ETI.2,3 There are limited data to compare outcomes between bagmask ventilation versus ETI in the management of IHCA,4 and there are no hospital-based studies of SGA. The data are not sufficient to support a recommendation for advanced airway use in IHCA. There may be specific circumstances or populations in which early advanced airway interventions are beneficial.

This recommendation was 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

  1. Gausche M, Lewis RJ, Stratton SJ, Haynes BE, Gunter CS, Goodrich SM, Poore PD, McCollough MD, Henderson DP, Pratt FD, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA. 2000;283:783–790.

  2. Hansen ML, Lin A, Eriksson C, Daya M, McNally B, Fu R, Yanez D, Zive D, Newgard C; CARES surveillance group. A comparison of pediatric airway management techniques during out-of-hospital cardiac arrest using the CARES database. Resuscitation. 2017;120:51–56. doi: 10.1016/j.resuscitation.2017.08.015

  3. Ohashi-Fukuda N, Fukuda T, Doi K, Morimura N. Effect of prehospital advanced airway management for pediatric out-of-hospital cardiac arrest. Resuscitation. 2017;114:66–72. doi: 10.1016/j.resuscitation.2017.03.002

  4. Andersen LW, Raymond TT, Berg RA, Nadkarni VM, Grossestreuer AV, Kurth T, Donnino MW; American Heart Association’s Get With The Guidelines–Resuscitation Investigators. Association Between Tracheal Intubation During Pediatric In-Hospital Cardiac Arrest and Survival. JAMA. 2016;316:1786–1797. doi: 10.1001/jama.2016.14486

  5. Duff JP, Topjian AA, Berg MD, Chan M, Haskell SE, Joyner BL Jr, Lasa JJ, Ley SJ, Raymond TT, Sutton RM, Hazinski MF, Atkins DL. 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. Circulation. 2019;140:e904–e914. doi: 10.1161/CIR.0000000000000731

Vasoactive agents, such as epinephrine, are used during cardiac arrest to restore spontaneous circulation by optimizing coronary perfusion and maintaining cerebral perfusion, but the benefit and optimal timing of administration remain unclear.1,2 Antiarrhythmics reduce the risk of recurrent ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT) following defibrillation and may improve defibrillation success. Routine use of sodium bicarbonate and calcium is not supported by current data.3–7 However, there are specific circumstances when their administration is indicated, such as electrolyte imbalances and certain drug toxicities.

Medication dosing for children is based on weight, which is often difficult to obtain in an emergency setting. There are numerous approaches to estimating weight when an actual weight cannot be obtained.8

  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 studies17,18 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

  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

  1. Campbell ME, Byrne PJ. Cardiopulmonary resuscitation and epinephrine infusion in extremely low birth weight infants in the neonatal intensive care unit. J Perinatol. 2004;24:691–695. doi: 10.1038/sj.jp.7211174

  2. Dieckmann RA, Vardis R. High-dose epinephrine in pediatric out-of-hospital cardiopulmonary arrest. Pediatrics. 1995;95:901–913.

  3. Kette F, Ghuman J, Parr M. Calcium administration during cardiac arrest: a systematic review. Eur J Emerg Med. 2013;20:72–78. doi: 10.1097/MEJ.0b013e328358e336

  4. Lasa JJ, Alali A, Minard CG, Parekh D, Kutty S, Gaies M, Raymond TT, Guerguerian AM, Atkins D, Foglia E, et al; on behalf of the American Heart Association’s Get With the Guidelines-Resuscitation Investigators. Cardiopulmonary resuscitation in the pediatric cardiac catheterization laboratory: A report from the American Heart Association’s Get With the Guidelines-Resuscitation Registry. Pediatr Crit Care Med. 2019;20:1040–1047. doi: 10.1097/PCC.0000000000002038

  5. Matamoros M, Rodriguez R, Callejas A, Carranza D, Zeron H, Sánchez C, Del Castillo J, López-Herce J; Iberoamerican Pediatric Cardiac Arrest Study Network (RIBEPCI). In-hospital pediatric cardiac arrest in Honduras. Pediatr Emerg Care. 2015;31:31–35. doi: 10.1097/PEC.0000000000000323

  6. Nehme Z, Namachivayam S, Forrest A, Butt W, Bernard S, Smith K. Trends in the incidence and outcome of paediatric out-of-hospital cardiac arrest: A 17-year observational study. Resuscitation. 2018;128:43–50. doi: 10.1016/j.resuscitation.2018.04.030

  7. Raymond TT, Stromberg D, Stigall W, Burton G, Zaritsky A; American Heart Association’s Get With The Guidelines-Resuscitation Investigators. Sodium bicarbonate use during in-hospital pediatric pulseless cardiac arrest a report from the American Heart Association Get With The Guidelines®-Resuscitation. Resuscitation. 2015;89:106–113. doi: 10.1016/j.resuscitation.2015.01.007

  8. Young KD, Korotzer NC. Weight Estimation Methods in Children: A Systematic Review. Ann Emerg Med. 2016;68:441–451.e10. doi: 10.1016/j.annemergmed.2016.02.043

  9. Enright K, Turner C, Roberts P, Cheng N, Browne G. Primary cardiac arrest following sport or exertion in children presenting to an emergency department: chest compressions and early defibrillation can save lives, but is intravenous epinephrine always appropriate? Pediatr Emerg Care. 2012;28:336–339. doi: 10.1097/PEC.0b013e31824d8c78

  10. Niemann JT, Stratton SJ, Cruz B, Lewis RJ. Endotracheal drug administration during out-of-hospital resuscitation: where are the survivors? Resuscitation. 2002;53:153–157. doi: 10.1016/s0300-9572(0200004-7)

  11. Niemann JT, Stratton SJ. Endotracheal versus intravenous epinephrine and atropine in out-of-hospital “primary” and postcountershock asystole. Crit Care Med. 2000;28:1815–1819. doi: 10.1097/00003246-200006000-00022

  12. Andersen LW, Berg KM, Saindon BZ, Massaro JM, Raymond TT, Berg RA, Nadkarni VM, Donnino MW; American Heart Association Get With the Guidelines–Resuscitation Investigators. Time to Epinephrine and Survival After Pediatric In-Hospital Cardiac Arrest. JAMA. 2015;314:802–810. doi: 10.1001/jama.2015.9678

  13. Lin YR, Wu MH, Chen TY, Syue YJ, Yang MC, Lee TH, Lin CM, Chou CC, Chang CF, Li CJ. Time to epinephrine treatment is associated with the risk of mortality in children who achieve sustained ROSC after traumatic out-of-hospital cardiac arrest. Crit Care. 2019;23:101. doi: 10.1186/s13054-019-2391-z

  14. Lin YR, Li CJ, Huang CC, Lee TH, Chen TY, Yang MC, Chou CC, Chang CF, Huang HW, Hsu HY, Chen WL. Early Epinephrine Improves the Stabilization of Initial Post-resuscitation Hemodynamics in Children With Nonshockable Out-of-Hospital Cardiac Arrest. Front Pediatr. 2019;7:220. doi: 10.3389/fped.2019.00220

  15. Fukuda T, Kondo Y, Hayashida K, Sekiguchi H, Kukita I. Time to epinephrine and survival after paediatric out-of-hospital cardiac arrest. Eur Heart J Cardiovasc Pharmacother. 2018;4:144–151. doi: 10.1093/ehjcvp/pvx023

  16. Hansen M, Schmicker RH, Newgard CD, Grunau B, Scheuermeyer F, Cheskes S, Vithalani V, Alnaji F, Rea T, Idris AH, Herren H, Hutchison J, Austin M, Egan D, Daya M; Resuscitation Outcomes Consortium Investigators. Time to Epinephrine Administration and Survival From Nonshockable Out-of-Hospital Cardiac Arrest Among Children and Adults. Circulation. 2018;137:2032–2040. doi: 10.1161/CIRCULATIONAHA.117.033067

  17. Meert K, Telford R, Holubkov R, Slomine BS, Christensen JR, Berger J, Ofori-Amanfo G, Newth CJL, Dean JM, Moler FW. Paediatric in-hospital cardiac arrest: factors associated with survival and neurobehavioural outcome one year later. Resuscitation. 2018;124:96–105. doi: 10.1016/j.resuscitation.2018.01.013

  18. Hoyme DB, Patel SS, Samson RA, Raymond TT, Nadkarni VM, Gaies MG, Atkins DL; American Heart Association Get With The Guidelines–Resuscitation Investigators. Epinephrine dosing interval and survival outcomes during pediatric in-hospital cardiac arrest. Resuscitation. 2017;117:18–23. doi: 10.1016/j.resuscitation.2017.05.023

  19. Valdes SO, Donoghue AJ, Hoyme DB, Hammond R, Berg MD, Berg RA, Samson RA; American Heart Association Get With The Guidelines-Resuscitation Investigators. Outcomes associated with amiodarone and lidocaine in the treatment of in-hospital pediatric cardiac arrest with pulseless ventricular tachycardia or ventricular fibrillation. Resuscitation. 2014;85:381–386. doi: 10.1016/j.resuscitation.2013.12.008

  20. Holmberg MJ, Ross CE, Atkins DL, Valdes SO, Donnino MW, Andersen LW; on behalf of the American Heart Association’s Get With The Guidelines Resuscitation Pediatric Research Task Force. Lidocaine versus amiodarone for pediatric in-hospital cardiac arrest: an observational study. Resuscitation. 2020:Epub ahead of print. doi: 10.1016/j.resuscitation.2019.12.033

  21. López-Herce J, del Castillo J, Cañadas S, Rodríguez-Núñez A, Carrillo A; Spanish Study Group of Cardiopulmonary Arrest in Children. In-hospital pediatric cardiac arrest in Spain. Rev Esp Cardiol (Engl Ed). 2014;67:189–195. doi: 10.1016/j.rec.2013.07.017

  22. Wolfe HA, Sutton RM, Reeder RW, Meert KL, Pollack MM, Yates AR, Berger JT, Newth CJ, Carcillo JA, McQuillen PS, Harrison RE, Moler FW, Carpenter TC, Notterman DA, Holubkov R, Dean JM, Nadkarni VM, Berg RA; Eunice Kennedy Shriver National Institute of Child Health; Human Development Collaborative Pediatric Critical Care Research Network; Pediatric Intensive Care Quality of Cardiopulmonary Resuscitation Investigators. Functional outcomes among survivors of pediatric in-hospital cardiac arrest are associated with baseline neurologic and functional status, but not with diastolic blood pressure during CPR. Resuscitation. 2019;143:57–65. doi: 10.1016/j.resuscitation.2019.08.006

  23. Mok YH, Loke AP, Loh TF, Lee JH. Characteristics and Risk Factors for Mortality in Paediatric In-Hospital Cardiac Events in Singapore: Retrospective Single Centre Experience. Ann Acad Med Singapore. 2016;45:534–541.

  24. Del Castillo J, López-Herce J, Cañadas S, Matamoros M, RodríguezNúnez A, Rodríguez-Calvo A, Carrillo A; Iberoamerican Pediatric Cardiac Arrest Study Network RIBEPCI. Cardiac arrest and resuscitation in the pediatric intensive care unit: a prospective multicenter multinational study. Resuscitation. 2014;85:1380–1386. doi: 10.1016/j. resuscitation.2014.06.024

  25. Wu ET, Li MJ, Huang SC, Wang CC, Liu YP, Lu FL, Ko WJ, Wang MJ, Wang JK, Wu MH. Survey of outcome of CPR in pediatric in-hospital cardiac arrest in a medical center in Taiwan. Resuscitation. 2009;80:443–448. doi: 10.1016/j.resuscitation.2009.01.006

  26. Duff JP, Topjian A, Berg MD, Chan M, Haskell SE, Joyner BL Jr, Lasa JJ, Ley SJ, Raymond TT, Sutton RM, Hazinski MF, Atkins DL. 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. Circulation. 2018;138:e731–e739. doi: 10.1161/CIR.0000000000000612

  27. Wells M, Goldstein LN, Bentley A. It is time to abandon age-based emergency weight estimation in children! A failed validation of 20 different age-based formulas. Resuscitation. 2017;116:73–83. doi: 10.1016/j.resuscitation.2017.05.018

  28. Tanner D, Negaard A, Huang R, Evans N, Hennes H. A Prospective Evaluation of the Accuracy of Weight Estimation Using the Broselow Tape in Overweight and Obese Pediatric Patients in the Emergency Department. Pediatr Emerg Care. 2017;33:675–678. doi: 10.1097/PEC.0000000000000894

  29. Waseem M, Chen J, Leber M, Giambrone AE, Gerber LM. A reexamination of the accuracy of the Broselow tape as an instrument for weight estimation. Pediatr Emerg Care. 2019;35:112–116. doi: 10.1097/PEC.0000000000000982

  30. van Rongen A, Brill MJE, Vaughns JD, Välitalo PAJ, van Dongen EPA, van Ramshorst B, Barrett JS, van den Anker JN, Knibbe CAJ. Higher midazolam clearance in obese adolescents compared with morbidly obese adults. Clin Pharmacokinet. 2018;57:601–611. doi: 10.1007/s40262-017-0579-4

  31. Vaughns JD, Ziesenitz VC, Williams EF, Mushtaq A, Bachmann R, Skopp G, Weiss J, Mikus G, van den Anker JN. Use of fentanyl in adolescents with clinically severe obesity undergoing bariatric surgery: a pilot study. Paediatr Drugs. 2017;19:251–257. doi: 10.1007/s40272-017-0216-6

  32. Shrestha K, Subedi P, Pandey O, Shakya L, Chhetri K, House DR. Estimating the weight of children in Nepal by Broselow, PAWPER XL and Mercy method. World J Emerg Med. 2018;9:276–281. doi: 10.5847/wjem.j. 1920-8642.2018.04.007

  33. Wells M, Goldstein LN, Bentley A. The accuracy of paediatric weight estimation during simulated emergencies: the effects of patient position, patient cooperation, and human errors. Afr J Emerg Med. 2018;8:43–50. doi: 10.1016/j.afjem.2017.12.003

The risk of VF/pVT steadily increases throughout childhood and adolescence but remains less frequent than in adults. Cardiac arrest due to an initial rhythm of VF/pVT has better rates of survival to hospital discharge with favorable neurological function than cardiac arrests due to an initial nonshockable rhythm. Shockable rhythms may be the initial rhythm of the cardiac arrest (primary VF/ pVT) or may develop during the resuscitation (secondary VF/pVT). Defibrillation is the definitive treatment for VF/ pVT. The shorter the duration of VF/pVT, the more likely that the shock will result in a perfusing rhythm. Both manual defibrillators and AEDs can be used to treat VF/pVT in children. Manual defibrillators are preferred when a shockable rhythm is identified by a healthcare provider because the energy dose can be titrated to the patient’s weight. AEDs have high specificity in recognizing pediatric shockable rhythms. Biphasic, instead of monophasic, defibrillators are recommended because less energy is required to achieve termination of VF/pVT, with fewer side effects. Many AEDs are equipped to attenuate (reduce) the energy dose to make them suitable for infants and children younger than 8 years of age.

  1. 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 IHCA3,5 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

  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

  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 anteriorposterior position.7,19

  3. One study demonstrated no significant difference in median time to shock with paddles compared with self-adhesive pads.20

  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.

  1. Mercier E, Laroche E, Beck B, Le Sage N, Cameron PA, Émond M, Berthelot S, Mitra B, Ouellet-Pelletier J. Defibrillation energy dose during pediatric cardiac arrest: Systematic review of human and animal model studies. Resuscitation. 2019;139:241–252. doi: 10.1016/j.resuscitation.2019.04.028

  2. Gutgesell HP, Tacker WA, Geddes LA, Davis S, Lie JT, McNamara DG. Energy dose for ventricular defibrillation of children. Pediatrics. 1976;58:898–901.

  3. Berg MD, Samson RA, Meyer RJ, Clark LL, Valenzuela TD, Berg RA. Pediatric defibrillation doses often fail to terminate prolonged out-of-hospital ventricular fibrillation in children. Resuscitation. 2005;67:63–67. doi: 10.1016/j.resuscitation.2005.04.018

  4. Meaney PA, Nadkarni VM, Atkins DL, Berg MD, Samson RA, Hazinski MF, Berg RA; American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators. Effect of defibrillation energy dose during in-hospital pediatric cardiac arrest. Pediatrics. 2011;127:e16–e23. doi: 10.1542/peds.2010-1617

  5. Rodríguez-Núñez A, López-Herce J, del Castillo J, Bellón JM; and the Iberian-American Paediatric Cardiac Arrest Study Network RIBEPCI. Shockable rhythms and defibrillation during in-hospital pediatric cardiac arrest. Resuscitation. 2014;85:387–391. doi: 10.1016/j.resuscitation.2013.11.015

  6. Rossano JW, Quan L, Kenney MA, Rea TD, Atkins DL. Energy doses for treatment of out-of-hospital pediatric ventricular fibrillation. Resuscitation. 2006;70:80–89. doi: 10.1016/j.resuscitation.2005.10.031

  7. Tibballs J, Carter B, Kiraly NJ, Ragg P, Clifford M. External and internal biphasic direct current shock doses for pediatric ventricular fibrillation and pulseless ventricular tachycardia. Pediatr Crit Care Med. 2011;12:14–20. doi: 10.1097/PCC.0b013e3181dbb4fc

  8. Baker PW, Conway J, Cotton C, Ashby DT, Smyth J, Woodman RJ, Grantham H; Clinical Investigators. Defibrillation or cardiopulmonary resuscitation first for patients with out-of-hospital cardiac arrests found by paramedics to be in ventricular fibrillation? A randomised control trial. Resuscitation. 2008;79:424–431. doi: 10.1016/j.resuscitation.2008.07.017

  9. Jacobs IG, Finn JC, Oxer HF, Jelinek GA. CPR before defibrillation in out-of-hospital cardiac arrest: a randomized trial. Emerg Med Australas. 2005;17:39–45. doi: 10.1111/j.1742-6723.2005.00694.x

  10. Ma MH, Chiang WC, Ko PC, Yang CW, Wang HC, Chen SY, Chang WT, Huang CH, Chou HC, Lai MS, Chien KL, Lee BC, Hwang CH, Wang YC, Hsiung GH, Hsiao YW, Chang AM, Chen WJ, Chen SC. A randomized trial of compression first or analyze first strategies in patients with outof-hospital cardiac arrest: results from an Asian community. Resuscitation. 2012;83:806–812. doi: 10.1016/j.resuscitation.2012.01.009

  11. Stiell IG, Nichol G, Leroux BG, Rea TD, Ornato JP, Powell J, Christenson J, Callaway CW, Kudenchuk PJ, Aufderheide TP, Idris AH, Daya MR, Wang HE, Morrison LJ, Davis D, Andrusiek D, Stephens S, Cheskes S, Schmicker RH, Fowler R, Vaillancourt C, Hostler D, Zive D, Pirrallo RG, Vilke GM, Sopko G, Weisfeldt M; ROC Investigators. Early versus later rhythm analysis in patients with out-of-hospital cardiac arrest. N Engl J Med. 2011;365:787–797. doi: 10.1056/NEJMoa1010076

  12. Wik L, Hansen TB, Fylling F, Steen T, Vaagenes P, Auestad BH, Steen PA. Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-of-hospital ventricular fibrillation: a randomized trial. JAMA. 2003;289:1389–1395. doi: 10.1001/jama.289.11.1389

  13. Bobrow BJ, Clark LL, Ewy GA, Chikani V, Sanders AB, Berg RA, Richman PB, Kern KB. Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA. 2008;299:1158–1165. doi: 10.1001/jama.299.10.1158

  14. Rea TD, Helbock M, Perry S, Garcia M, Cloyd D, Becker L, Eisenberg M. Increasing use of cardiopulmonary resuscitation during out-of-hospital ventricular fibrillation arrest: survival implications of guideline changes. Circulation. 2006;114:2760–2765. doi: 10.1161/CIRCULATIONAHA.106.654715

  15. Sutton RM, Case E, Brown SP, Atkins DL, Nadkarni VM, Kaltman J, Callaway C, Idris A, Nichol G, Hutchison J, Drennan IR, Austin M, Daya M, Cheskes S, Nuttall J, Herren H, Christenson J, Andrusiek D, Vaillancourt C, Menegazzi JJ, Rea TD, Berg RA; ROC Investigators. A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality–A report from the ROC epistry-cardiac arrest. Resuscitation. 2015;93:150–157. doi: 10.1016/j.resuscitation.2015.04.010

  16. Atkins DL, Kerber RE. Pediatric defibrillation: current flow is improved by using “adult” electrode paddles. Pediatrics. 1994;94:90–93.

  17. Samson RA, Atkins DL, Kerber RE. Optimal size of self-adhesive preapplied electrode pads in pediatric defibrillation. Am J Cardiol. 1995;75:544–545. doi: 10.1016/s0002-9149(9980606-7)

  18. Atkins DL, Sirna S, Kieso R, Charbonnier F, Kerber RE. Pediatric defibrillation: importance of paddle size in determining transthoracic impedance. Pediatrics. 1988;82:914–918.

  19. Ristagno G, Yu T, Quan W, Freeman G, Li Y. Comparison of defibrillation efficacy between two pads placements in a pediatric porcine model of cardiac arrest. Resuscitation. 2012;83:755–759. doi: 10.1016/j.resuscitation.2011.12.010

  20. Bhalala US, Balakumar N, Zamora M, Appachi E. Hands-On Defibrillation Skills of Pediatric Acute Care Providers During a Simulated Ventricular Fibrillation Cardiac Arrest Scenario. Front Pediatr. 2018;6:107. doi: 10.3389/fped.2018.00107

  21. Atkins DL, Everson-Stewart S, Sears GK, Daya M, Osmond MH, Warden CR, Berg RA; Resuscitation Outcomes Consortium Investigators. Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest. Circulation. 2009;119:1484–1491. doi: 10.1161/CIRCULATIONAHA.108.802678

  22. Samson RA, Nadkarni VM, Meaney PA, Carey SM, Berg MD, Berg RA; American Heart Association National Registry of CPR Investigators. Outcomes of in-hospital ventricular fibrillation in children. N Engl J Med. 2006;354:2328–2339. doi: 10.1056/NEJMoa052917

  23. Cecchin F, Jorgenson DB, Berul CI, Perry JC, Zimmerman AA, Duncan BW, Lupinetti FM, Snyder D, Lyster TD, Rosenthal GL, Cross B, Atkins DL. Is arrhythmia detection by automatic external defibrillator accurate for children?: sensitivity and specificity of an automatic external defibrillator algorithm in 696 pediatric arrhythmias. Circulation. 2001;103:2483–2488. doi: 10.1161/01.cir.103.20.2483

  24. Atkinson E, Mikysa B, Conway JA, Parker M, Christian K, Deshpande J, Knilans TK, Smith J, Walker C, Stickney RE, Hampton DR, Hazinski MF. Specificity and sensitivity of automated external defibrillator rhythm analysis in infants and children. Ann Emerg Med. 2003;42:185–196. doi: 10.1067/mem.2003.287

  25. Atkins DL, Scott WA, Blaufox AD, Law IH, Dick M II, Geheb F, Sobh J, Brewer JE. Sensitivity and specificity of an automated external defibrillator algorithm designed for pediatric patients. Resuscitation. 2008;76:168–174. doi: 10.1016/j.resuscitation.2007.06.032

  26. Atkins DL, Jorgenson DB. Attenuated pediatric electrode pads for automated external defibrillator use in children. Resuscitation. 2005;66:31–37. doi: 10.1016/j.resuscitation.2004.12.025

  27. Bar-Cohen Y, Walsh EP, Love BA, Cecchin F. First appropriate use of automated external defibrillator in an infant. Resuscitation. 2005;67:135–137. doi: 10.1016/j.resuscitation.2005.05.003

  28. Divekar A, Soni R. Successful parental use of an automated external defibrillator for an infant with long-QT syndrome. Pediatrics. 2006;118:e526–e529. doi: 10.1542/peds.2006-0129

  29. Hoyt WJ Jr, Fish FA, Kannankeril PJ. Automated external defibrillator use in a previously healthy 31-day-old infant with out-of-hospital cardiac arrest due to ventricular fibrillation. J Cardiovasc Electrophysiol. 2019;30:2599–2602. doi: 10.1111/jce.14125

  30. Gurnett CA, Atkins DL. Successful use of a biphasic waveform automated external defibrillator in a high-risk child. Am J Cardiol. 2000;86:1051–1053. doi: 10.1016/s0002-9149(0001151-6)

  31. Mitani Y, Ohta K, Yodoya N, Otsuki S, Ohashi H, Sawada H, Nagashima M, Sumitomo N, Komada Y. Public access defibrillation improved the outcome after out-of-hospital cardiac arrest in school-age children: a nationwide, population-based, Utstein registry study in Japan. Europace. 2013;15:1259–1266. doi: 10.1093/europace/eut053

  32. Pundi KN, Bos JM, Cannon BC, Ackerman MJ. Automated external defibrillator rescues among children with diagnosed and treated long QT syndrome. Heart Rhythm. 2015;12:776–781. doi: 10.1016/j.hrthm.2015.01.002

  33. Chan PS, Krumholz HM, Spertus JA, Jones PG, Cram P, Berg RA, Peberdy MA, Nadkarni V, Mancini ME, Nallamothu BK. Automated external defibrillators and survival after in-hospital cardiac arrest. JAMA. 2010;304:2129–2136. doi: 10.1001/jama.2010.1576

  34. Cheskes S, Schmicker RH, Christenson J, Salcido DD, Rea T, Powell J, Edelson DP, Sell R, May S, Menegazzi JJ, Van Ottingham L, Olsufka M, Pennington S, Simonini J, Berg RA, Stiell I, Idris A, Bigham B, Morrison L; Resuscitation Outcomes Consortium (ROC) Investigators. Perishock pause: an independent predictor of survival from out-of-hospital shockable cardiac arrest. Circulation. 2011;124:58–66. doi: 10.1161/CIRCULATIONAHA.110.010736

  35. König B, Benger J, Goldsworthy L. Automatic external defibrillation in a 6 year old. Arch Dis Child. 2005;90:310–311. doi: 10.1136/adc.2004.054981

Initiating and maintaining high-quality CPR is associated with improved rates of ROSC, survival, and favorable neurological outcome, yet measured CPR quality is often suboptimal.1–3 Noninvasive and invasive monitoring techniques may be used to assess and guide the quality of CPR. Invasive arterial blood pressure monitoring during CPR provides insight to blood pressures generated with compressions and medications.4 End-tidal CO2 (ETCO2) reflects both the cardiac output produced and ventilation efficacy and may provide feedback on the quality of CPR.5

A sudden rise in ETCO2 may be an early sign of ROSC.6 CPR feedback devices (ie, coaching, audio, and audiovisual devices) may improve compression rate, depth, and recoil within a system of training and quality assurance for high-quality CPR. Point of care ultrasound, specifically echocardiography, during CPR has been considered for identification of reversible causes of arrest. Technologies that are under evaluation to assess resuscitation quality include noninvasive measures of cerebral oxygenation, such as using near infrared spectroscopy during CPR.

  1. A prospective observational study of pediatric patients with invasive arterial blood pressure monitoring during the first 10 minutes of CPR demonstrated higher rates of favorable neurological outcome if the diastolic blood pressure was at least 25 mm Hg in infants and at least 30 mm Hg in children.4 Of note, the cut points for diastolic blood pressure tracings were analyzed using post hoc waveform analysis; therefore, prospective evaluation is needed.

  2. A single-center, retrospective study of in-hospital CPR in infants found that ETCO2 values between 17 and 18 mm Hg had a positive predictive value for ROSC of 0.885.7 A prospective, multicenter observational study of IHCA did not find an association between mean ETCO2 and outcomes.8

  3. A simulation trial of pediatric healthcare providers demonstrated a significant improvement in chest compression depth and rate compliance when they received visual feedback (compared to no feedback), although overall compression quality remained poor.9 One small observational study of 8 children with IHCA did not find an association between CPR with or without audiovisual feedback and survival to discharge, although feedback decreased excessive compression rates.10

  4. Several case series evaluated the use of bedside echocardiography to identify reversible causes of cardiac arrest, including pulmonary embolism.11,12 One prospective observational study of children (without cardiac arrest) admitted to an ICU reported good agreement of estimates of shortening fraction and inferior vena cava volume between emergency physicians using bedside limited echocardiography and cardiologists performing formal echocardiography.13

  1. Niles DE, Duval-Arnould J, Skellett S, Knight L, Su F, Raymond TT, Sweberg T, Sen AI, Atkins DL, Friess SH, de Caen AR, Kurosawa H, Sutton RM, Wolfe H, Berg RA, Silver A, Hunt EA, Nadkarni VM; pediatric Resuscitation Quality (pediRESQ) Collaborative Investigators. Characterization of Pediatric InHospital Cardiopulmonary Resuscitation Quality Metrics Across an International Resuscitation Collaborative. Pediatr Crit Care Med. 2018;19:421–432. doi: 10.1097/PCC.0000000000001520

  2. Sutton RM, Case E, Brown SP, Atkins DL, Nadkarni VM, Kaltman J, Callaway C, Idris A, Nichol G, Hutchison J, Drennan IR, Austin M, Daya M, Cheskes S, Nuttall J, Herren H, Christenson J, Andrusiek D, Vaillancourt C, Menegazzi JJ, Rea TD, Berg RA; ROC Investigators. A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality–A report from the ROC epistry-cardiac arrest. Resuscitation. 2015;93:150–157. doi: 10.1016/j.resuscitation.2015.04.010

  3. Wolfe H, Zebuhr C, Topjian AA, Nishisaki A, Niles DE, Meaney PA, Boyle L, Giordano RT, Davis D, Priestley M, Apkon M, Berg RA, Nadkarni VM, Sutton RM. Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes*. Crit Care Med. 2014;42:1688–1695. doi: 10.1097/CCM. 0000000000000327

  4. Berg RA, Sutton RM, Reeder RW, Berger JT, Newth CJ, Carcillo JA, McQuillen PS, Meert KL, Yates AR, Harrison RE, Moler FW, Pollack MM, Carpenter TC, Wessel DL, Jenkins TL, Notterman DA, Holubkov R, Tamburro RF, Dean JM, Nadkarni VM; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN) PICqCPR (Pediatric Intensive Care Quality of Cardio-Pulmonary Resuscitation) Investigators. Association Between Diastolic Blood Pressure During Pediatric In-Hospital Cardiopulmonary Resuscitation and Survival. Circulation. 2018;137:1784–1795. doi: 10.1161/CIRCULATIONAHA.117.032270

  5. Hamrick JL, Hamrick JT, Lee JK, Lee BH, Koehler RC, Shaffner DH. Efficacy of chest compressions directed by end-tidal CO2 feedback in a pediatric resuscitation model of basic life support. J Am Heart Assoc. 2014;3:e000450. doi: 10.1161/JAHA.113.000450

  6. Hartmann SM, Farris RW, Di Gennaro JL, Roberts JS. Systematic Review and Meta-Analysis of End-Tidal Carbon Dioxide Values Associated With Return of Spontaneous Circulation During Cardiopulmonary Resuscitation. J Intensive Care Med. 2015;30:426–435. doi: 10.1177/0885066614530839

  7. Stine CN, Koch J, Brown LS, Chalak L, Kapadia V, Wyckoff MH. Quantitative end-tidal CO2 can predict increase in heart rate during infant cardiopulmonary resuscitation. Heliyon. 2019;5:e01871. doi: 10.1016/j. heliyon.2019.e01871

  8. Berg RA, Reeder RW, Meert KL, Yates AR, Berger JT, Newth CJ, Carcillo JA, McQuillen PS, Harrison RE, Moler FW, Pollack MM, Carpenter TC, Notterman DA, Holubkov R, Dean JM, Nadkarni VM, Sutton RM; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN) Pediatric Intensive Care Quality of Cardio-Pulmonary Resuscitation (PICqCPR) investigators. End-tidal carbon dioxide during pediatric in-hospital cardiopulmonary resuscitation. Resuscitation. 2018;133:173–179. doi: 10.1016/j.resuscitation.2018.08.013

  9. Cheng A, Brown LL, Duff JP, Davidson J, Overly F, Tofil NM, Peterson DT, White ML, Bhanji F, Bank I, et al; on behalf of the International Network for Simulation-Based Pediatric Innovation, Research, & Education (INSPIRE) CPR Investigators. Improving cardiopulmonary resuscitation with a CPR feedback device and refresher simulations (CPR CARES Study): a randomized clinical trial. JAMA Pediatr. 2015;169:137–144. doi: 10.1001/jamapediatrics.2014.2616

  10. Sutton RM, Niles D, French B, Maltese MR, Leffelman J, Eilevstjonn J, Wolfe H, Nishisaki A, Meaney PA, Berg RA, et al. First quantitative analysis of cardiopulmonary resuscitation quality during in-hospital cardiac arrests of young children. Resuscitation. 2014;85:70–74. doi: 10.1016/j. resuscitation.2013.08.014

  11. Steffen K, Thompson WR, Pustavoitau A, Su E. Return of Viable Cardiac Function After Sonographic Cardiac Standstill in Pediatric Cardiac Arrest. Pediatr Emerg Care. 2017;33:58–59. doi: 10.1097/PEC.0000000000001002

  12. Morgan RW, Stinson HR, Wolfe H, Lindell RB, Topjian AA, Nadkarni VM, Sutton RM, Berg RA, Kilbaugh TJ. Pediatric In-Hospital Cardiac Arrest Secondary to Acute Pulmonary Embolism. Crit Care Med. 2018;46:e229–e234. doi: 10.1097/CCM.0000000000002921

  13. Pershad J, Myers S, Plouman C, Rosson C, Elam K, Wan J, Chin T. Bedside limited echocardiography by the emergency physician is accurate during evaluation of the critically ill patient. Pediatrics. 2004;114:e667–e671. doi: 10.1542/peds.2004-0881

Extracorporeal cardiopulmonary resuscitation (ECPR) is defined as the rapid deployment of venoarterial extracorporeal membrane oxygenation (ECMO) for patients who do not achieve sustained ROSC. It is a resource-intense, complex, multidisciplinary therapy that traditionally has been limited to large pediatric medical centers with providers who have expertise in the management of children with cardiac disease. Judicious use of ECPR for specific patient populations and within dedicated and highly practiced environments has proved successful, especially for IHCA with reversible causes.1 ECPR use rates have increased, with single-center reports in both adults and children suggesting that application of this therapy across broader patient populations may improve survival after cardiac arrest.2–4

There are no studies of ECPR demonstrating improved outcomes following pediatric OHCA.

  1. One observational registry study of ECPR for pediatric IHCA after cardiac surgery demonstrated that ECPR was associated with higher rates of survival to hospital discharge than conventional CPR.5 A propensity-matched analysis of ECPR compared with conventional CPR using the same registry found that ECPR was associated with favorable neurological outcome in patients with IHCA of any etiology.6 There is insufficient evidence to suggest for or against the use of ECPR for pediatric patients experiencing OHCA or pediatric patients with noncardiac disease experiencing IHCA refractory to conventional CPR.

This recommendation was 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.”7

  1. Brunetti MA, Gaynor JW, Retzloff LB, Lehrich JL, Banerjee M, Amula V, Bailly D, Klugman D, Koch J, Lasa J, Pasquali SK, Gaies M. Characteristics, Risk Factors, and Outcomes of Extracorporeal Membrane Oxygenation Use in Pediatric Cardiac ICUs: A Report From the Pediatric Cardiac Critical Care Consortium Registry. Pediatr Crit Care Med. 2018;19:544–552. doi: 10.1097/PCC.0000000000001571

  2. Sakamoto T, Morimura N, Nagao K, Asai Y, Yokota H, Nara S, Hase M, Tahara Y, Atsumi T; SAVE-J Study Group. Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest: a prospective observational study. Resuscitation. 2014;85:762–768. doi: 10.1016/j.resuscitation.2014.01.031

  3. Stub D, Bernard S, Pellegrino V, Smith K, Walker T, Sheldrake J, Hockings L, Shaw J, Duffy SJ, Burrell A, Cameron P, Smit de V, Kaye DM. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation. 2015;86:88–94. doi: 10.1016/j.resuscitation.2014.09.010

  4. Conrad SJ, Bridges BC, Kalra Y, Pietsch JB, Smith AH. Extracorporeal Cardiopulmonary Resuscitation Among Patients with Structurally Normal Hearts. ASAIO J. 2017;63:781–786. doi: 10.1097/MAT.0000000000000568

  5. Ortmann L, Prodhan P, Gossett J, Schexnayder S, Berg R, Nadkarni V, Bhutta A; American Heart Association’s Get With the Guidelines–Resuscitation Investigators. Outcomes after in-hospital cardiac arrest in children with cardiac disease: a report from Get With the Guidelines–Resuscitation. Circulation. 2011;124:2329–2337. doi: 10.1161/CIRCULATIONAHA.110.013466

  6. Lasa JJ, Rogers RS, Localio R, Shults J, Raymond T, Gaies M, Thiagarajan R, Laussen PC, Kilbaugh T, Berg RA, Nadkarni V, Topjian A. Extracorporeal Cardiopulmonary Resuscitation (E-CPR) During Pediatric In-Hospital Cardiopulmonary Arrest Is Associated With Improved Survival to Discharge: A Report from the American Heart Association’s Get With The GuidelinesResuscitation (GWTG-R) Registry. Circulation. 2016;133:165–176. doi: 10.1161/CIRCULATIONAHA.115.016082

  7. Duff JP, Topjian AA, Berg MD, Chan M, Haskell SE, Joyner BL Jr, Lasa JJ, Ley SJ, Raymond TT, Sutton RM, Hazinski MF, Atkins DL. 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. Circulation. 2019;140:e904–e914. doi: 10.1161/CIR.0000000000000731

Successful resuscitation from cardiac arrest results in a post–cardiac arrest syndrome that can evolve in the days after ROSC. The components of post–cardiac arrest syndrome are (1) brain injury, (2) myocardial dysfunction, (3) systemic ischemia and reperfusion response, and (4) persistent precipitating pathophysiology.1,2 Post–cardiac arrest brain injury remains a leading cause of morbidity and mortality in adults and children because the brain has limited tolerance of ischemia, hyperemia, or edema. Pediatric post–cardiac arrest care focuses on anticipating, identifying, and treating this complex physiology to improve survival and neurological outcomes.

Targeted temperature management (TTM) refers to continuous maintenance of patient temperature within a narrowly prescribed range while continuously monitoring temperature. All forms of TTM avoid fever, and hypothermic TTM attempts to treat reperfusion syndrome by decreasing metabolic demand, reducing free radical production, and decreasing apoptosis.2

Identification and treatment of derangements—such as hypotension, fever, seizures, acute kidney injury, and abnormalities of oxygenation, ventilation, and electrolytes—are important because they may impact outcomes.

  • 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

  • 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.

  • 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.

  • 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.

Figure 8

Post–cardiac arrest care checklist.

Figure 8

Post–cardiac arrest care checklist.

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  1. Neumar RW, Nolan JP, Adrie C, Aibiki M, Berg RA, Böttiger BW, Callaway C, Clark RS, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth WT Jr, Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Vanden Hoek T. Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A consensus statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian and New Zealand Council on Resuscitation, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Asia, and the Resuscitation Council of Southern Africa); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the Stroke Council. Circulation. 2008;118:2452–2483. doi: 10.1161/CIRCULATIONAHA.108.190652

  2. Topjian AA, de Caen A, Wainwright MS, Abella BS, Abend NS, Atkins DL, Bembea MM, Fink EL, Guerguerian AM, Haskell SE, Kilgannon JH, Lasa JJ, Hazinski MF. Pediatric post-cardiac arrest care: a scientific statement from the American Heart Association. Circulation. 2019;140:e194–e233. doi: 10.1161/CIR.0000000000000697

  3. Moler FW, Silverstein FS, Holubkov R, Slomine BS, Christensen JR, Nadkarni VM, Meert KL, Browning B, Pemberton VL, Page K, et al; on behalf of the THAPCA Trial Investigators. Therapeutic hypothermia after in-hospital cardiac arrest in children. N Engl J Med. 2017;376:318–329. doi: 10.1056/NEJMoa1610493

  4. Moler FW, Silverstein FS, Holubkov R, Slomine BS, Christensen JR, Nadkarni VM, Meert KL, Clark AE, Browning B, Pemberton VL, Page K, Shankaran S, Hutchison JS, Newth CJ, Bennett KS, Berger JT, Topjian A, Pineda JA, Koch JD, Schleien CL, Dalton HJ, Ofori-Amanfo G, Goodman DM, Fink EL, McQuillen P, Zimmerman JJ, Thomas NJ, van der Jagt EW, Porter MB, Meyer MT, Harrison R, Pham N, Schwarz AJ, Nowak JE, Alten J, Wheeler DS, Bhalala US, Lidsky K, Lloyd E, Mathur M, Shah S, Wu T, Theodorou AA, Sanders RC Jr, Dean JM; THAPCA Trial Investigators. Therapeutic hypothermia after out-of-hospital cardiac arrest in children. N Engl J Med. 2015;372:1898–1908. doi: 10.1056/NEJMoa1411480

  5. Duff JP, Topjian AA, Berg MD, Chan M, Haskell SE, Joyner BL Jr, Lasa JJ, Ley SJ, Raymond TT, Sutton RM, Hazinski MF, Atkins DL. 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. Circulation. 2019;140:e904–e914. doi: 10.1161/CIR.0000000000000731

  6. Topjian AA, Telford R, Holubkov R, Nadkarni VM, Berg RA, Dean JM, Moler FW; on behalf of the Therapeutic Hypothermia after Pediatric Cardiac Arrest (THAPCA) Trial Investigators. The association of early postresuscitation hypotension with discharge survival following targeted temperature management for pediatric in-hospital cardiac arrest. Resuscitation. 2019;141:24–34. doi: 10.1016/j.resuscitation.2019.05.032

  7. Topjian AA, Telford R, Holubkov R, Nadkarni VM, Berg RA, Dean JM, Moler FW; Therapeutic Hypothermia After Pediatric Cardiac Arrest (THAPCA) Trial Investigators. Association of Early Postresuscitation Hypotension With Survival to Discharge After Targeted Temperature Management for Pediatric Out-of-Hospital Cardiac Arrest: Secondary Analysis of a Randomized Clinical Trial. JAMA Pediatr. 2018;172:143–153. doi: 10.1001/jamapediatrics.2017.4043

  8. Laverriere EK, Polansky M, French B, Nadkarni VM, Berg RA, Topjian AA. Association of Duration of Hypotension With Survival After Pediatric Cardiac Arrest. Pediatr Crit Care Med. 2020;21:143–149. doi: 10.1097/PCC.0000000000002119

  9. Topjian AA, Sutton RM, Reeder RW, Telford R, Meert KL, Yates AR, Morgan RW, Berger JT, Newth CJ, Carcillo JA, McQuillen PS, Harrison RE, Moler FW, Pollack MM, Carpenter TC, Notterman DA, Holubkov R, Dean JM, Nadkarni VM, Berg RA, Zuppa AF, Graham K, Twelves C, Diliberto MA, Landis WP, Tomanio E, Kwok J, Bell MJ, Abraham A, Sapru A, Alkhouli MF, Heidemann S, Pawluszka A, Hall MW, Steele L, Shanley TP, Weber M, Dalton HJ, Bell A, Mourani PM, Malone K, Locandro C, Coleman W, Peterson A, Thelen J, Doctor A; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN) Investigators. The association of immediate post cardiac arrest diastolic hypertension and survival following pediatric cardiac arrest. Resuscitation. 2019;141:88–95. doi: 10.1016/j.resuscitation.2019.05.033

  10. Bennett KS, Clark AE, Meert KL, Topjian AA, Schleien CL, Shaffner DH, Dean JM, Moler FW; Pediatric Emergency Care Medicine Applied Research Network. Early oxygenation and ventilation measurements after pediatric cardiac arrest: lack of association with outcome. Crit Care Med. 2013;41:1534–1542. doi: 10.1097/CCM.0b013e318287f54c

  11. López-Herce J, del Castillo J, Matamoros M, Canadas S, Rodriguez-Calvo A, Cecchetti C, Rodríguez-Núnez A, Carrillo Á; Iberoamerican Pediatric Cardiac Arrest Study Network RIBEPCI. Post return of spontaneous circulation factors associated with mortality in pediatric in-hospital cardiac arrest: a prospective multicenter multinational observational study. Crit Care. 2014;18:607. doi: 10.1186/s13054-014-0607-9

  12. Ferguson LP, Durward A, Tibby SM. Relationship between arterial partial oxygen pressure after resuscitation from cardiac arrest and mortality in children. Circulation. 2012;126:335–342. doi: 10.1161/ CIRCULATIONAHA.111.085100

  13. van Zellem L, de Jonge R, van Rosmalen J, Reiss I, Tibboel D, Buysse C. High cumulative oxygen levels are associated with improved survival of children treated with mild therapeutic hypothermia after cardiac arrest. Resuscitation. 2015;90:150–157. doi: 10.1016/j.resuscitation.2014.12.013

  14. Del Castillo J, López-Herce J, Matamoros M, Cañadas S, Rodriguez-Calvo A, Cechetti C, Rodriguez-Núñez A, Alvarez AC; Iberoamerican Pediatric Cardiac Arrest Study Network RIBEPCI. Hyperoxia, hypocapnia and hypercapnia as outcome factors after cardiac arrest in children. Resuscitation. 2012;83:1456–1461. doi: 10.1016/j.resuscitation.2012.07.019

  15. Herman ST, Abend NS, Bleck TP, Chapman KE, Drislane FW, Emerson RG, Gerard EE, Hahn CD, Husain AM, Kaplan PW, et al. Consensus statement on continuous EEG in critically ill adults and children, part I: indications. J Clin Neurophysiol. 2015;32:87–95. doi: 10.1097/wnp.0000000000000166

  16. Abend NS, Topjian A, Ichord R, Herman ST, Helfaer M, Donnelly M, Nadkarni V, Dlugos DJ, Clancy RR. Electroencephalographic monitoring during hypothermia after pediatric cardiac arrest. Neurology. 2009;72:1931–1940. doi: 10.1212/WNL.0b013e3181a82687

  17. Topjian AA, Gutierrez-Colina AM, Sanchez SM, Berg RA, Friess SH, Dlugos DJ, Abend NS. Electrographic status epilepticus is associated with mortality and worse short-term outcome in critically ill children. Crit Care Med. 2013;41:215–223. doi: 10.1097/CCM.0b013e3182668035

  18. Ostendorf AP, Hartman ME, Friess SH. Early Electroencephalographic Findings Correlate With Neurologic Outcome in Children Following Cardiac Arrest. Pediatr Crit Care Med. 2016;17:667–676. doi: 10.1097/PCC.0000000000000791

  19. Brophy GM, Bell R, Claassen J, Alldredge B, Bleck TP, Glauser T, Laroche SM, Riviello JJ Jr, Shutter L, Sperling MR, Treiman DM, Vespa PM; Neurocritical Care Society Status Epilepticus Guideline Writing Committee. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012;17:3–23. doi: 10.1007/s12028-012-9695-z

  20. Topjian AA, Sánchez SM, Shults J, Berg RA, Dlugos DJ, Abend NS. Early Electroencephalographic Background Features Predict Outcomes in Children Resuscitated From Cardiac Arrest. Pediatr Crit Care Med. 2016;17:547–557. doi: 10.1097/PCC.0000000000000740

Early and reliable prognostication of neurological outcome in pediatric survivors of cardiac arrest is essential to guide treatment, enable effective planning, and provide family support. Clinicians use patient and cardiac arrest characteristics, postarrest neurological examination, laboratory results, neurological imaging (eg, brain computed tomography and MRI), and EEG to guide prognostication. At this time, no single factor or validated decision rule has been identified to reliably predict either favorable or unfavorable outcome within 24 to 48 hours of ROSC. EEG, neuroimaging, and serum biomarkers when used alone predict outcome with only moderate accuracy, and more data are needed before applying these to individual patients.

  • 1. Eight retrospective observational studies demonstrate that EEG background patterns are associated with neurological outcomes at discharge.1–8 The presence of sleep spindles,3,4,8 normal background,2 and reactivity7,8 is associated with favorable outcomes. Burst suppression and flat or attenuated EEG patterns are associated with unfavorable neurological outcome.1,2,5,8 However, these associations do not reach the high degrees of sensitivity and specificity needed to use EEG as a stand-alone modality for neuroprognostication.

  • 2. Several studies demonstrate the association of clinical history, patient characteristics, physical examination, imaging, and biomarker data with neurological outcome following cardiac arrest.1,7,9–19 To date, no single factor has demonstrated sufficient accuracy to prognosticate outcome. Elevated serum lactate, pH, or base deficit measured within the first 24 hours after cardiac arrest are associated with unfavorable outcome;9,11,12,16–18,20,21 however, specific cutoff values are unknown.

  • 3. Shorter submersion times are associated with better outcomes after pediatric nonfatal drowning.22–25 There is no clear association between patient age,23,26–31,38water type,30,32,33 water temperature,23,25,34,35 emergency medical services response times35,36 or witnessed status,36–39 and neurological outcome following nonfatal drowning. No single factor accurately predicts prognosis after nonfatal drowning.

  1. Brooks GA, Park JT. Clinical and Electroencephalographic Correlates in Pediatric Cardiac Arrest: Experience at a Tertiary Care Center. Neuropediatrics. 2018;49:324–329. doi: 10.1055/s-0038-1657757

  2. Topjian AA, Sánchez SM, Shults J, Berg RA, Dlugos DJ, Abend NS. Early Electroencephalographic Background Features Predict Outcomes in Children Resuscitated From Cardiac Arrest. Pediatr Crit Care Med. 2016;17:547–557. doi: 10.1097/PCC.0000000000000740

  3. Ostendorf AP, Hartman ME, Friess SH. Early Electroencephalographic Findings Correlate With Neurologic Outcome in Children Following Cardiac Arrest. Pediatr Crit Care Med. 2016;17:667–676. doi: 10.1097/PCC.0000000000000791

  4. Ducharme-Crevier L, Press CA, Kurz JE, Mills MG, Goldstein JL, Wainwright MS. Early Presence of Sleep Spindles on Electroencephalography Is Associated With Good Outcome After Pediatric Cardiac Arrest. Pediatr Crit Care Med. 2017;18:452–460. doi: 10.1097/PCC.0000000000001137

  5. Bourgoin P, Barrault V, Joram N, Leclair Visonneau L, Toulgoat F, Anthoine E, Loron G, Chenouard A. The Prognostic Value of Early Amplitude-Integrated Electroencephalography Monitoring After Pediatric Cardiac Arrest. Pediatr Crit Care Med. 2020;21:248–255. doi: 10.1097/PCC.0000000000002171

  6. Lee S, Zhao X, Davis KA, Topjian AA, Litt B, Abend NS. Quantitative EEG predicts outcomes in children after cardiac arrest. Neurology. 2019;92:e2329–e2338. doi: 10.1212/WNL.0000000000007504

  7. Yang D, Ryoo E, Kim HJ. Combination of Early EEG, Brain CT, and Ammonia Level Is Useful to Predict Neurologic Outcome in Children Resuscitated From Cardiac Arrest. Front Pediatr. 2019;7:223. doi: 10.3389/fped.2019.00223

  8. Fung FW, Topjian AA, Xiao R, Abend NS. Early EEG Features for Outcome Prediction After Cardiac Arrest in Children. J Clin Neurophysiol. 2019;36:349–357. doi: 10.1097/WNP.0000000000000591

  9. Meert K, Telford R, Holubkov R, Slomine BS, Christensen JR, Berger J, Ofori-Amanfo G, Newth CJL, Dean JM, Moler FW. Paediatric in-hospital cardiac arrest: Factors associated with survival and neurobehavioural outcome one year later. Resuscitation. 2018;124:96–105. doi: 10.1016/j. resuscitation.2018.01.013

  10. Ichord R, Silverstein FS, Slomine BS, Telford R, Christensen J, Holubkov R, Dean JM, Moler FW; THAPCA Trial Group. Neurologic outcomes in pediatric cardiac arrest survivors enrolled in the THAPCA trials. Neurology. 2018;91:e123–e131. doi: 10.1212/WNL.0000000000005773

  11. Meert KL, Telford R, Holubkov R, Slomine BS, Christensen JR, Dean JM, Moler FW; Therapeutic Hypothermia after Pediatric Cardiac Arrest (THAPCA) Trial Investigators. Pediatric Out-of-Hospital Cardiac Arrest Characteristics and Their Association With Survival and Neurobehavioral Outcome. Pediatr Crit Care Med. 2016;17:e543–e550. doi: 10.1097/PCC. 0000000000000969

  12. Del Castillo J, López-Herce J, Matamoros M, Cañadas S, Rodríguez-Calvo A, Cecchetti C, Rodriguez-Núñez A, Álvarez AC; Iberoamerican Pediatric Cardiac Arrest Study Network RIBEPCI. Long-term evolution after in-hospital cardiac arrest in children: Prospective multicenter multinational study. Resuscitation. 2015;96:126–134. doi: 10.1016/j.resuscitation.2015.07.037

  13. Topjian AA, Telford R, Holubkov R, Nadkarni VM, Berg RA, Dean JM, Moler FW; Therapeutic Hypothermia After Pediatric Cardiac Arrest (THAPCA) Trial Investigators. Association of Early Postresuscitation Hypotension With Survival to Discharge After Targeted Temperature Management for Pediatric Out-of-Hospital Cardiac Arrest: Secondary Analysis of a Randomized Clinical Trial. JAMA Pediatr. 2018;172:143–153. doi: 10.1001/jamapediatrics.2017.4043

  14. Conlon TW, Falkensammer CB, Hammond RS, Nadkarni VM, Berg RA, Topjian AA. Association of left ventricular systolic function and vasopressor support with survival following pediatric out-of-hospital cardiac arrest. Pediatr Crit Care Med. 2015;16:146–154. doi: 10.1097/pcc. 0000000000000305

  15. Starling RM, Shekdar K, Licht D, Nadkarni VM, Berg RA, Topjian AA. Early Head CT Findings Are Associated With Outcomes After Pediatric Out-of-Hospital Cardiac Arrest. Pediatr Crit Care Med. 2015;16:542–548. doi: 10.1097/PCC.0000000000000404

  16. Alsoufi B, Awan A, Manlhiot C, Guechef A, Al-Halees Z, Al-Ahmadi M, McCrindle BW, Kalloghlian A. Results of rapid-response extracorporeal cardiopulmonary resuscitation in children with refractory cardiac arrest following cardiac surgery. Eur J Cardiothorac Surg. 2014;45:268–275. doi: 10.1093/ejcts/ezt319

  17. Polimenakos AC, Rizzo V, El-Zein CF, Ilbawi MN. Post-cardiotomy Rescue Extracorporeal Cardiopulmonary Resuscitation in Neonates with Single Ventricle After Intractable Cardiac Arrest: Attrition After Hospital Discharge and Predictors of Outcome. Pediatr Cardiol. 2017;38:314–323. doi: 10.1007/s00246-016-1515-3

  18. Scholefield BR, Gao F, Duncan HP, Tasker RC, Parslow RC, Draper ES, McShane P, Davies P, Morris KP. Observational study of children admitted to United Kingdom and Republic of Ireland Paediatric Intensive Care Units after out-of-hospital cardiac arrest. Resuscitation. 2015;97:122–128. doi: 10.1016/j.resuscitation.2015.07.011

  19. Kramer P, Miera O, Berger F, Schmitt K. Prognostic value of serum biomarkers of cerebral injury in classifying neurological outcome after paediatric resuscitation. Resuscitation. 2018;122:113–120. doi: 10.1016/j.resuscitation.2017.09.012

  20. López-Herce J, del Castillo J, Matamoros M, Canadas S, RodriguezCalvo A, Cecchetti C, Rodríguez-Núnez A, Carrillo Á; Iberoamerican Pediatric Cardiac Arrest Study Network RIBEPCI. Post return of spontaneous circulation factors associated with mortality in pediatric in-hospital cardiac arrest: a prospective multicenter multinational observational study. Crit Care. 2014;18:607. doi: 10.1186/s13054-014-0607-9

  21. Topjian AA, Clark AE, Casper TC, Berger JT, Schleien CL, Dean JM, Moler FW; Pediatric Emergency Care Applied Research Network. Early lactate elevations following resuscitation from pediatric cardiac arrest are associated with increased mortality*. Pediatr Crit Care Med. 2013;14:e380–e387. doi: 10.1097/PCC.0b013e3182976402

  22. Kyriacou DN, Arcinue EL, Peek C, Kraus JF. Effect of immediate resuscitation on children with submersion injury. Pediatrics. 1994;94(2 Pt 1):137–142.

  23. Suominen P, Baillie C, Korpela R, Rautanen S, Ranta S, Olkkola KT. Impact of age, submersion time and water temperature on outcome in near-drowning. Resuscitation. 2002;52:247–254. doi: 10.1016/s0300-9572(01)00478-6

  24. Panzino F, Quintillá JM, Luaces C, Pou J. [Unintentional drowning by immersion. Epidemiological profile of victims attended in 21 Spanish emergency departments]. An Pediatr (Barc). 2013;78:178–184. doi: 10.1016/j.anpedi.2012.06.014

  25. Quan L, Mack CD, Schiff MA. Association of water temperature and submersion duration and drowning outcome. Resuscitation. 2014;85:790–794. doi: 10.1016/j.resuscitation.2014.02.024

  26. Frates RC Jr. Analysis of predictive factors in the assessment of warmwater near-drowning in children. Am J Dis Child. 1981;135:1006–1008. doi: 10.1001/archpedi.1981.02130350010004

  27. Nagel FO, Kibel SM, Beatty DW. Childhood near-drowning–factors associated with poor outcome. S Afr Med J. 1990;78:422–425.

  28. Quan L, Wentz KR, Gore EJ, Copass MK. Outcome and predictors of outcome in pediatric submersion victims receiving prehospital care in King County, Washington. Pediatrics. 1990;86:586–593.

  29. Niu YW, Cherng WS, Lin MT, Tsao LY. An analysis of prognostic factors for submersion accidents in children. Zhonghua Min Guo Xiao Er Ke Yi Xue Hui Za Zhi. 1992;33:81–88.

  30. Mizuta R, Fujita H, Osamura T, Kidowaki T, Kiyosawa N. Childhood drownings and near-drownings in Japan. Acta Paediatr Jpn. 1993;35:186–192. doi: 10.1111/j.1442-200x.1993.tb03036.x

  31. Al-Mofadda SM, Nassar A, Al-Turki A, Al-Sallounm AA. Pediatric near drowning: the experience of King Khalid University Hospital. Ann Saudi Med. 2001;21:300–303. doi: 10.5144/0256-4947.2001.300

  32. Forler J, Carsin A, Arlaud K, Bosdure E, Viard L, Paut O, Camboulives J, Dubus JC. [Respiratory complications of accidental drownings in children]. Arch Pediatr. 2010;17:14–18. doi: 10.1016/j.arcped.2009.09.021

  33. Al-Qurashi FO, Yousef AA, Aljoudi A, Alzahrani SM, Al-Jawder NY, Al-Ahmar AK, Al-Majed MS, Abouollo HM. A Review of Nonfatal Drowning in the Pediatric-Age Group: A 10-Year Experience at a University Hospital in Saudi Arabia. Pediatr Emerg Care. 2019;35:782–786. doi: 10.1097/PEC.0000000000001232

  34. Kieboom JK, Verkade HJ, Burgerhof JG, Bierens JJ, Rheenen PF, Kneyber MC, Albers MJ. Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide retrospective cohort study. BMJ. 2015;350:h418. doi: 10.1136/bmj.h418

  35. Claesson A, Lindqvist J, Ortenwall P, Herlitz J. Characteristics of lifesaving from drowning as reported by the Swedish Fire and Rescue Services 1996–2010. Resuscitation. 2012;83:1072–1077. doi: 10.1016/j.resuscitation.2012.05.025

  36. Claesson A, Svensson L, Silfverstolpe J, Herlitz J. Characteristics and outcome among patients suffering out-of-hospital cardiac arrest due to drowning. Resuscitation. 2008;76:381–387. doi: 10.1016/j.resuscitation.2007.09.003

  37. Dyson K, Morgans A, Bray J, Matthews B, Smith K. Drowning related out-of-hospital cardiac arrests: characteristics and outcomes. Resuscitation. 2013;84:1114–1118. doi: 10.1016/j.resuscitation.2013.01.020

  38. Nitta M, Kitamura T, Iwami T, Nadkarni VM, Berg RA, Topjian AA, Okamoto Y, Nishiyama C, Nishiuchi T, Hayashi Y, Nishimoto Y, Takasu A. Out-of-hospital cardiac arrest due to drowning among children and adults from the Utstein Osaka Project. Resuscitation. 2013;84:1568–1573. doi: 10.1016/j.resuscitation.2013.06.017

  39. Claesson A, Lindqvist J, Herlitz J. Cardiac arrest due to drowning– changes over time and factors of importance for survival. Resuscitation. 2014;85:644–648. doi: 10.1016/j.resuscitation.2014.02.006

Survivors are at significant risk for both short-term and long-term physical, neurological, cognitive, emotional, and social morbidity.3 Many children who survive a cardiac arrest with a grossly “favorable outcome” have more subtle and sustained neuropsychological impairment.4 The full impact of brain injury on children’s development may not be fully appreciated until months to years after the cardiac arrest. Furthermore, because children are raised by caregivers, the impact of morbidity following cardiac arrest affects not only the child but also the family. Recovery has been introduced as the sixth link in the Chain of Survival to acknowledge that survivors of cardiac arrest may require ongoing integrated medical, rehabilitative, caregiver, and community support in the months to years after their cardiac arrest (see Figure 9).3 Recent scientific statements from the AHA and ILCOR highlight the importance of studying long-term neurological and health-related quality-of-life outcomes.5,6

Figure 9

Road map to recovery.3

Figure 9

Road map to recovery.3

Close modal
  1. Two randomized controlled trials of TTM for comatose children after IHCA or OHCA with a primary outcome of neurobehavioral outcome at 1 year7,8 showed that new morbidity is common.9–11 Many children who survived to 1 year with a favorable neurobehavioral outcome on Vineland Adaptive Behavior Scales-II (VABS-II) had global cognitive impairment or selective neuropsychological deficits.4

  2. Two randomized controlled trials of TTM for pediatric cardiac arrest demonstrated that neurological function improves for some survivors during the first year after cardiac arrest.10,11 Several case series of longer-term outcomes (more than 1 year after cardiac arrest) demonstrate ongoing cognitive, physical, and neuropsychological impairments.12–14 Recent statements from the AHA highlight the importance of follow-up after discharge, because patient recovery continues during the first year after cardiac arrest.3,5,6,15 It is unclear what impact ongoing childhood development has on recovery following pediatric cardiac arrest.

  1. Deleted in proof.

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  3. Sawyer KN, Camp-Rogers TR, Kotini-Shah P, Del Rios M, Gossip MR, pediatric cardiac arrest trials. Resuscitation. 2019;139:329–336. doi: 10.1016/j.resuscitation.2019.03.020 Moitra VK, Haywood KL, Dougherty CM, Lubitz SA, Rabinstein AA, Rittenberger JC, Callaway CW, Abella BS, Geocadin RG, Kurz MC; American Heart Association Emergency Cardiovascular Care Committee; Council on Cardiovascular and Stroke Nursing; Council on Genomic and Precision Medicine; Council on Quality of Care and Outcomes Research; and Stroke Council. Sudden Cardiac Arrest Survivorship: A Scientific Statement From the American Heart Association. Circulation. 2020;141:e654–e685. doi: 10.1161/CIR.0000000000000747

  4. Slomine BS, Silverstein FS, Christensen JR, Page K, Holubkov R, Dean JM, Moler FW. Neuropsychological Outcomes of Children 1 Year After Pediatric Cardiac Arrest: Secondary Analysis of 2 Randomized Clinical Trials. JAMA Neurol. 2018;75:1502–1510. doi: 10.1001/jamaneurol.2018.2628

  5. Geocadin RG, Callaway CW, Fink EL, Golan E, Greer DM, Ko NU, Lang E, Licht DJ, Marino BS, McNair ND, Peberdy MA, Perman SM, Sims DB, Soar J, Sandroni C; American Heart Association Emergency Cardiovascular Care Committee. Standards for Studies of Neurological Prognostication in Comatose Survivors of Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation. 2019;140:e517–e542. doi: 10.1161/CIR.0000000000000702

  6. Topjian AA, Scholefield BR, Pinto NP, Fink EL, Buysse CMP, Haywood K, Maconochie I, Nadkarni VM, de Caen A, Escalante-Kanashiro R, Ng K-C, Nuthall G, Reis AG, Van de Voorde P, Suskauer SJ, Schexnayder SM, Hazinski MF, Slomine BS. P-COSCA (Pediatric Core Outcome Set for Cardiac Arrest) in children: an advisory statement from the International Liaison Committee on Resuscitation. Circulation. 2020;142:e000–e000. doi: 10.1161/CIR.0000000000000911

  7. Moler FW, Silverstein FS, Holubkov R, Slomine BS, Christensen JR, Nadkarni VM, Meert KL, Clark AE, Browning B, Pemberton VL, Page K, Shankaran S, Hutchison JS, Newth CJ, Bennett KS, Berger JT, Topjian A, Pineda JA, Koch JD, Schleien CL, Dalton HJ, Ofori-Amanfo G, Goodman DM, Fink EL, McQuillen P, Zimmerman JJ, Thomas NJ, van der Jagt EW, Porter MB, Meyer MT, Harrison R, Pham N, Schwarz AJ, Nowak JE, Alten J, Wheeler DS, Bhalala US, Lidsky K, Lloyd E, Mathur M, Shah S, Wu T, Theodorou AA, Sanders RC Jr, Dean JM; THAPCA Trial Investigators. Therapeutic hypothermia after out-of-hospital cardiac arrest in children. N Engl J Med. 2015;372:1898–1908. doi: 10.1056/NEJMoa1411480

  8. Moler FW, Silverstein FS, Holubkov R, Slomine BS, Christensen JR, Nadkarni VM, Meert KL, Browning B, Pemberton VL, Page K, et al; on behalf of the THAPCA Trial Investigators. Therapeutic hypothermia after in-hospital cardiac arrest in children. N Engl J Med. 2017;376:318–329. doi: 10.1056/NEJMoa1610493

  9. Slomine BS, Silverstein FS, Page K, Holubkov R, Christensen JR, Dean JM, Moler FW; Therapeutic Hypothermia after Pediatric Cardiac Arrest (THAPCA) Trial Investigators. Relationships between three and twelve month outcomes in children enrolled in the therapeutic hypothermia after

  10. Slomine BS, Silverstein FS, Christensen JR, Holubkov R, Telford R, Dean JM, Moler FW; Therapeutic Hypothermia after Paediatric Cardiac Arrest (THAPCA) Trial Investigators. Neurobehavioural outcomes in children after In-Hospital cardiac arrest. Resuscitation. 2018;124:80–89. doi: 10.1016/j.resuscitation.2018.01.002

  11. Slomine BS, Silverstein FS, Christensen JR, Holubkov R, Page K, Dean JM, Moler FW; on behalf of the THAPCA Trial Group. Neurobehavioral outcomes in children after out-of-hospital cardiac arrest. Pediatrics. 2016;137:e20153412. doi: 10.1542/peds.2015–3412

  12. van Zellem L, Buysse C, Madderom M, Legerstee JS, Aarsen F, Tibboel D, Utens EM. Long-term neuropsychological outcomes in children and adolescents after cardiac arrest. Intensive Care Med. 2015;41:1057–1066. doi: 10.1007/s00134-015-3789-y

  13. van Zellem L, Utens EM, Legerstee JS, Cransberg K, Hulst JM, Tibboel D, Buysse C. Cardiac Arrest in Children: Long-Term Health Status and HealthRelated Quality of Life. Pediatr Crit Care Med. 2015;16:693–702. doi: 10.1097/PCC.0000000000000452

  14. van Zellem L, Utens EM, Madderom M, Legerstee JS, Aarsen F, Tibboel D, Buysse C. Cardiac arrest in infants, children, and adolescents: long-term emotional and behavioral functioning. Eur J Pediatr. 2016;175:977–986. doi: 10.1007/s00431-016-2728-4

  15. Topjian AA, de Caen A, Wainwright MS, Abella BS, Abend NS, Atkins DL, Bembea MM, Fink EL, Guerguerian AM, Haskell SE, Kilgannon JH, Lasa JJ, Hazinski MF. Pediatric Post-Cardiac Arrest Care: A Scientific Statement From the American Heart Association. Circulation. 2019;140:e194–e233. doi: 10.1161/CIR.0000000000000697

Over the past 20 years, the practice of maintaining family presence during resuscitation has increased. Most parents surveyed indicate that they would desire to be present during their child’s resuscitation. Older data suggest a lower incidence of anxiety and depression and more constructive grief behaviors among parents who were present when their child died.1

  1. Qualitative studies generally show that there can be benefits for families if they are permitted to be present during the resuscitation of their children. Parents stated that they believed their presence brought their child comfort and that it helped them to adjust to the loss of their child.2 Other surveys of parents reported that they desired to be present to understand what was happening, to know that all that could be done was being done, and to keep physical contact with their child.3,4 However, not all parents who were present for their child’s resuscitation would choose to do so again.5 Some concerns have been raised about family presence during resuscitation, such as trauma for the family, interference with procedures, impact on technical performance, and concern for teaching and clinical decision-making, but these have not been supported by the available evidence.6–8 Experienced providers are more likely than trainees to support family presence.9,10

  2. The presence of a facilitator to support the family is helpful.11,12 It is important that the family have a dedicated team member during the resuscitation to help process the traumatic event, but this is not always feasible. Lack of an available facilitator should not prevent family presence at the resuscitation.

  3. Most surveys indicate family presence is not disruptive during resuscitation, although some providers feel increased stress.13 Providers with significant experience with family presence acknowledge occasional negative experiences.14

  1. Robinson SM, Mackenzie-Ross S, Campbell Hewson GL, Egleston CV, Prevost AT. Psychological effect of witnessed resuscitation on bereaved relatives. Lancet. 1998;352:614–617. doi: 10.1016/s0140- 6736(97)12179-1

  2. Tinsley C, Hill JB, Shah J, Zimmerman G, Wilson M, Freier K, Abd-Allah S. Experience of families during cardiopulmonary resuscitation in a pediatric intensive care unit. Pediatrics. 2008;122:e799–e804. doi: 10.1542/peds.2007-3650

  3. Maxton FJ. Parental presence during resuscitation in the PICU: the parents’ experience. Sharing and surviving the resuscitation: a phenomenological study. J Clin Nurs. 2008;17:3168–3176. doi: 10.1111/j.1365- 2702.2008.02525.x

  4. Stewart SA. Parents’ Experience During a Child’s Resuscitation: Getting Through It. J Pediatr Nurs. 2019;47:58–67. doi: 10.1016/j.pedn. 2019.04.019

  5. Curley MA, Meyer EC, Scoppettuolo LA, McGann EA, Trainor BP, Rachwal CM, Hickey PA. Parent presence during invasive procedures and resuscitation: evaluating a clinical practice change. Am J Respir Crit Care Med. 2012;186:1133–1139. doi: 10.1164/rccm.201205-0915OC

  6. McClenathan BM, Torrington KG, Uyehara CF. Family member presence during cardiopulmonary resuscitation: a survey of US and international critical care professionals. Chest. 2002;122:2204–2211. doi: 10.1378/chest.122.6.2204

  7. Vavarouta A, Xanthos T, Papadimitriou L, Kouskouni E, Iacovidou N. Family presence during resuscitation and invasive procedures: physicians’ and nurses’ attitudes working in pediatric departments in Greece. Resuscitation. 2011;82:713–716. doi: 10.1016/j.resuscitation.2011.02.011

  8. Pasek TA, Licata J. Parent Advocacy Group for Events of Resuscitation. Crit Care Nurse. 2016;36:58–64. doi: 10.4037/ccn2016759

  9. Fein JA, Ganesh J, Alpern ER. Medical staff attitudes toward family presence during pediatric procedures. Pediatr Emerg Care. 2004;20:224–227. doi: 10.1097/01.pec.0000121241.99242.3b

  10. Bradford KK, Kost S, Selbst SM, Renwick AE, Pratt A. Family member presence for procedures: the resident’s perspective. Ambul Pediatr. 2005;5:294–297. doi: 10.1367/A04-024R1.1

  11. Jarvis AS. Parental presence during resuscitation: attitudes of staff on a paediatric intensive care unit. Intensive Crit Care Nurs. 1998;14:3–7. doi: 10.1016/s0964-3397(9880029-3)

  12. Zavotsky KE, McCoy J, Bell G, Haussman K, Joiner J, Marcoux KK, Magarelli K, Mahoney K, Maldonado L, Mastro KA, Milloria A, Tamburri LM, Tortajada D.Resuscitation team perceptions of family presence during CPR. Adv Emerg Nurs J. 2014;36:325–334. doi: 10.1097/TME.0000000000000027

  13. Kuzin JK, Yborra JG, Taylor MD, Chang AC, Altman CA, Whitney GM, Mott AR. Family-member presence during interventions in the intensive care unit: perceptions of pediatric cardiac intensive care providers. Pediatrics. 2007;120:e895–e901. doi: 10.1542/peds.2006-2943

  14. Fulbrook P, Latour JM, Albarran JW. Paediatric critical care nurses’ attitudes and experiences of parental presence during cardiopulmonary resuscitation: a European survey. Int J Nurs Stud. 2007;44:1238–1249. doi: 10.1016/j.ijnurstu.2006.05.006

Hypertrophic cardiomyopathy, coronary artery anomalies, and arrhythmias are common causes of sudden unexplained cardiac arrest in infants and children. Up to one third of young patients who do not survive sudden unexplained cardiac arrest have no abnormalities found on gross and microscopic autopsy.1–4 Postmortem genetic evaluation (“molecular autopsy”) is increasingly used to inform etiology of sudden unexplained cardiac arrest.5 In addition to providing an explanation for the arrest, genetic diagnosis can identify inheritable cardiac disease, such as channelopathy and cardiomyopathy, enabling screening and preventive measures for relatives.

  1. In 7 cohort studies, mutations causing channelopathies were identified in 2% to 10% of infants with sudden infant death syndrome.6–12 Among children and adolescents with sudden unexplained cardiac arrest and a normal autopsy, 9 cohort studies report identification of genetic mutations associated with channelopathy or cardiomyopathy.13–21

  2. In 7 cohort studies17,18,20,22–25 and 1 population-based study21 of screening using clinical and laboratory (electrocardiographic, molecular genetic screening) investigations, 14% to 53% of first- and second-degree relatives of patients with sudden unexplained cardiac arrest had inherited, arrhythmogenic disorders. In 7 cohort studies, mutations causing channelopathies were identified in 2% to 10% of infants with sudden infant death syndrome.6–12

  3. Several cohort studies report the utility of obtaining a complete past medical and family history after sudden unexplained cardiac arrest as well as review of prior electrocardiograms. A small case series suggested that specific genetic screening of family members was directed by the clinical history.20 Three small cohort studies and 1 population-based study reported relevant clinical symptoms or medical comorbidities, such as seizure, syncope, palpitations, chest pain, left arm pain, and shortness of breath, among patients who had a sudden unexplained cardiac arrest and their family members.16,17,19,21

  1. Doolan A, Langlois N, Semsarian C. Causes of sudden cardiac death in young Australians. Med J Aust. 2004;180:110–112.

  2. Eckart RE, Scoville SL, Campbell CL, Shry EA, Stajduhar KC, Potter RN, Pearse LA, Virmani R. Sudden death in young adults: a 25-year review of autopsies in military recruits. Ann Intern Med. 2004;141:829–834. doi: 10.7326/0003-4819-141-11-200412070-00005

  3. Ong ME, Stiell I, Osmond MH, Nesbitt L, Gerein R, Campbell S, McLellan B; OPALS Study Group. Etiology of pediatric out-of-hospital cardiac arrest by coroner’s diagnosis. Resuscitation. 2006;68:335–342. doi: 10.1016/j.resuscitation.2005.05.026

  4. Puranik R, Chow CK, Duflou JA, Kilborn MJ, McGuire MA. Sudden death in the young. Heart Rhythm. 2005;2:1277–1282. doi: 10.1016/j.hrthm.2005.09.008

  5. Torkamani A, Muse ED, Spencer EG, Rueda M, Wagner GN, Lucas JR, Topol EJ. Molecular Autopsy for Sudden Unexpected Death. JAMA. 2016; 316:1492–1494. doi: 10.1001/jama.2016.11445

  6. Ackerman MJ, Siu BL, Sturner WQ, Tester DJ, Valdivia CR, Makielski JC, Towbin JA. Postmortem molecular analysis of SCN5A defects in sudden infant death syndrome. JAMA. 2001;286:2264–2269. doi: 10.1001/jama. 286.18.2264

  7. Arnestad M, Crotti L, Rognum TO, Insolia R, Pedrazzini M, Ferrandi C, Vege A, Wang DW, Rhodes TE, George AL Jr, Schwartz PJ. Prevalence of long-QT syndrome gene variants in sudden infant death syndrome. Circulation. 2007;115:361–367. doi: 10.1161/CIRCULATIONAHA.106.658021

  8. Cronk LB, Ye B, Kaku T, Tester DJ, Vatta M, Makielski JC, Ackerman MJ. Novel mechanism for sudden infant death syndrome: persistent late sodium current secondary to mutations in caveolin-3. Heart Rhythm. 2007;4:161–166. doi: 10.1016/j.hrthm.2006.11.030

  9. Millat G, Kugener B, Chevalier P, Chahine M, Huang H, Malicier D, Rodriguez-Lafrasse C, Rousson R. Contribution of long-QT syndrome genetic variants in sudden infant death syndrome. Pediatr Cardiol. 2009;30:502–509. doi: 10.1007/s00246-009-9417-2

  10. Otagiri T, Kijima K, Osawa M, Ishii K, Makita N, Matoba R, Umetsu K, Hayasaka K. Cardiac ion channel gene mutations in sudden infant death syndrome. Pediatr Res. 2008;64:482–487. doi: 10.1203/PDR. 0b013e3181841eca

  11. Plant LD, Bowers PN, Liu Q, Morgan T, Zhang T, State MW, Chen W, Kittles RA, Goldstein SA. A common cardiac sodium channel variant associated with sudden infant death in African Americans, SCN5A S1103Y. J Clin Invest. 2006;116:430–435. doi: 10.1172/JCI25618

  12. Tester DJ, Dura M, Carturan E, Reiken S, Wronska A, Marks AR, Ackerman MJ. A mechanism for sudden infant death syndrome (SIDS): stress-induced leak via ryanodine receptors. Heart Rhythm. 2007;4:733–739. doi: 10.1016/j.hrthm.2007.02.026

  13. Albert CM, Nam EG, Rimm EB, Jin HW, Hajjar RJ, Hunter DJ, MacRae CA, Ellinor PT. Cardiac sodium channel gene variants and sudden cardiac death in women. Circulation. 2008;117:16–23. doi: 10.1161/ CIRCULATIONAHA.107.736330

  14. Chugh SS, Senashova O, Watts A, Tran PT, Zhou Z, Gong Q, Titus JL, Hayflick SJ. Postmortem molecular screening in unexplained sudden death. J Am Coll Cardiol. 2004;43:1625–1629. doi: 10.1016/j.jacc.2003.11.052

  15. Tester DJ, Spoon DB, Valdivia HH, Makielski JC, Ackerman MJ. Targeted mutational analysis of the RyR2-encoded cardiac ryanodine receptor in sudden unexplained death: a molecular autopsy of 49 medical examiner/coroner’s cases. Mayo Clin Proc. 2004;79:1380–1384. doi: 10.4065/79.11.1380

  16. Scheiper S, Ramos-Luis E, Blanco-Verea A, Niess C, Beckmann BM, Schmidt U, Kettner M, Geisen C, Verhoff MA, Brion M, Kauferstein S. Sudden unexpected death in the young Value of massive parallel sequencing in postmortem genetic analyses. Forensic Sci Int. 2018;293:70–76. doi: 10.1016/j.forsciint.2018.09.034

  17. Hellenthal N, Gaertner-Rommel A, Klauke B, Paluszkiewicz L, Stuhr M, Kerner T, Farr M, Püschel K, Milting H. Molecular autopsy of sudden unexplained deaths reveals genetic predispositions for cardiac diseases among young forensic cases. Europace. 2017;19:1881–1890. doi: 10.1093/europace/euw247

  18. Jiménez-Jáimez J, Alcalde Martínez V, Jiménez Fernández M, Bermúdez Jiménez F, Rodríguez Vázquez Del Rey MDM, Perin F, Oyonarte Ramírez JM, López Fernández S, de la Torre I, García Orta R, González Molina M, Cabrerizo EM, Álvarez Abril B, Álvarez M, Macías Ruiz R, Correa C, Tercedor L. Clinical and Genetic Diagnosis of Nonischemic Sudden Cardiac Death. Rev Esp Cardiol (Engl Ed). 2017;70:808–816. doi: 10.1016/j.rec. 2017.04.024

  19. Lahrouchi N, Raju H, Lodder EM, Papatheodorou E, Ware JS, Papadakis M, Tadros R, Cole D, Skinner JR, Crawford J, Love DR, Pua CJ, Soh BY, Bhalshankar JD, Govind R, Tfelt-Hansen J, Winkel BG, van der Werf C, Wijeyeratne YD, Mellor G, Till J, Cohen MC, Tome-Esteban M, Sharma S, Wilde AAM, Cook SA, Bezzina CR, Sheppard MN, Behr ER. Utility of PostMortem Genetic Testing in Cases of Sudden Arrhythmic Death Syndrome. J Am Coll Cardiol. 2017;69:2134–2145. doi: 10.1016/j.jacc.2017.02.046

  20. Anastasakis A, Papatheodorou E, Ritsatos K, Protonotarios N, Rentoumi V, Gatzoulis K, Antoniades L, Agapitos E, Koutsaftis P, SpiliopoulouC, Tousoulis D. Sudden unexplained death in the young: epidemiology, aetiology and value of the clinically guided genetic screening. Europace. 2018;20:472–480. doi: 10.1093/europace/euw362

  21. Hendrix A, Borleffs CJ, Vink A, Doevendans PA, Wilde AA, van Langen IM, van der Smagt JJ, Bots ML, Mosterd A. Cardiogenetic screening of first-degree relatives after sudden cardiac death in the young: a population-based approach. Europace. 2011;13:716–722. doi: 10.1093/europace/euq460

  22. Behr E, Wood DA, Wright M, Syrris P, Sheppard MN, Casey A, Davies MJ, McKenna W; Sudden Arrhythmic Death Syndrome Steering Group. Cardiological assessment of first-degree relatives in sudden arrhythmic death syndrome. Lancet. 2003;362:1457–1459. doi: 10.1016/s0140- 6736(03)14692-2

  23. Behr ER, Dalageorgou C, Christiansen M, Syrris P, Hughes S, Tome Esteban MT, Rowland E, Jeffery S, McKenna WJ. Sudden arrhythmic death syndrome: familial evaluation identifies inheritable heart disease in the majority of families. Eur Heart J. 2008;29:1670–1680. doi: 10.1093/eurheartj/ehn219

  24. Hofman N, Tan HL, Clur SA, Alders M, van Langen IM, Wilde AA. Contribution of inherited heart disease to sudden cardiac death in childhood. Pediatrics. 2007;120:e967–e973. doi: 10.1542/peds.2006-3751

  25. Tan HL, Hofman N, van Langen IM, van der Wal AC, Wilde AA. Sudden unexplained death: heritability and diagnostic yield of cardiological and genetic examination in surviving relatives. Circulation. 2005;112:207–213. doi: 10.1161/CIRCULATIONAHA.104.522581

Shock is the failure of oxygen delivery to meet tissue metabolic demands and can be life threatening. The most common type of pediatric shock is hypovolemic, including shock due to hemorrhage. Distributive, cardiogenic, and obstructive shock occur less frequently. Often, multiple types of shock can occur simultaneously; thus, providers should be vigilant. Cardiogenic shock in its early stages can be difficult to diagnose, so a high index of suspicion is warranted.

Shock progresses over a continuum of severity, from a compensated to a decompensated (hypotensive) state. Compensatory mechanisms include tachycardia and increased systemic vascular resistance (vasoconstriction) in an effort to maintain cardiac output and end-organ perfusion. As compensatory mechanisms fail, hypotension and signs of inadequate end-organ perfusion develop, such as depressed mental status, decreased urine output, lactic acidosis, and weak central pulses.

Early administration of intravenous fluids to treat septic shock has been widely accepted based on limited evidence. Mortality from pediatric sepsis has declined in recent years, concurrent with implementation of guidelines emphasizing the role of early antibiotic and fluid administration.1 Controversies in the management of septic shock include volume of fluid administration and how to assess the patient’s response, the timing and choice of vasopressor agents, the use of corticosteroids, and modifications to treatment algorithms for patients in sepsis-related cardiac arrest. Previous AHA guidelines2 have considered large studies of patients with malaria, sickle cell anemia, and dengue shock syndrome; however, these patients require special consideration that make generalization of results from these studies problematic. Resuscitation guidance for children with hemorrhagic shock is evolving, as crystalloid-then-blood paradigms are being challenged by resuscitation protocols using blood products early in resuscitation. However, the ideal resuscitation strategy for a given type of injury is often unknown.

  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

  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 studies18,19 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 fluidrefractory septic shock.10,11 Patients with vasodilatory shock may require a higher dose of dopamine.12

  • 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.

  • 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 traumarelated hemorrhagic shock.29

  1. Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, Nadel S, Schlapbach LJ, Tasker RC, Argent AC, Brierley J, Carcillo J, Carrol ED, Carroll CL, Cheifetz IM, Choong K, Cies JJ, Cruz AT, De Luca D, Deep A, Faust SN, De Oliveira CF, Hall MW, Ishimine P, Javouhey E, Joosten KFM, Joshi P, Karam O, Kneyber MCJ, Lemson J, MacLaren G, Mehta NM, Møller MH, Newth CJL, Nguyen TC, Nishisaki A, Nunnally ME, Parker MM, Paul RM, Randolph AG, Ranjit S, Romer LH, Scott HF, Tume LN, Verger JT, Williams EA, Wolf J, Wong HR, Zimmerman JJ, Kissoon N, Tissieres P. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med. 2020;21:e52–e106. doi: 10.1097/PCC.0000000000002198

  2. de Caen AR, Berg MD, Chameides L, Gooden CK, Hickey RW, Scott HF, Sutton RM, Tijssen JA, Topjian A, van der Jagt EW, et al. Part 12: pediatric advanced life support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S526–S542. doi: 10.1161/CIR.0000000000000266

  3. van Paridon BM, Sheppard C, Garcia Guerra G, Joffe AR; on behalf of the Alberta Sepsis Network. Timing of antibiotics, volume, and vasoactive infusions in children with sepsis admitted to intensive care. Crit Care. 2015;19:293. doi: 10.1186/s13054-015-1010-x

  4. Inwald DP, Canter R, Woolfall K, Mouncey P, Zenasni Z, O’Hara C, Carter A, Jones N, Lyttle MD, Nadel S, et al; on behalf of PERUKI (Paediatric Emergency Research in the UK and Ireland) and PICS SG (Paediatric Intensive Care Society Study Group). Restricted fluid bolus volume in early septic shock: results of the Fluids in Shock pilot trial. Arch Dis Child. 2019;104:426–431. doi: 10.1136/archdischild-2018–314924

  5. Sankar J, Ismail J, Sankar MJ, C P S, Meena RS. Fluid Bolus Over 15-20 Versus 5-10 Minutes Each in the First Hour of Resuscitation in Children With Septic Shock: A Randomized Controlled Trial. Pediatr Crit Care Med. 2017;18:e435–e445. doi: 10.1097/PCC.0000000000001269

  6. Medeiros DN, Ferranti JF, Delgado AF, de Carvalho WB. Colloids for the Initial Management of Severe Sepsis and Septic Shock in Pediatric Patients: A Systematic Review. Pediatr Emerg Care. 2015;31:e11–e16. doi: 10.1097/PEC.0000000000000601

  7. Balamuth F, Kittick M, McBride P, Woodford AL, Vestal N, Casper TC, Metheney M, Smith K, Atkin NJ, Baren JM, Dean JM, Kuppermann N, Weiss SL. Pragmatic Pediatric Trial of Balanced Versus Normal Saline Fluid in Sepsis: The PRoMPT BOLUS Randomized Controlled Trial Pilot Feasibility Study. Acad Emerg Med. 2019;26:1346–1356. doi: 10.1111/acem.13815

  8. Weiss SL, Keele L, Balamuth F, Vendetti N, Ross R, Fitzgerald JC, Gerber JS. Crystalloid Fluid Choice and Clinical Outcomes in Pediatric Sepsis: A Matched Retrospective Cohort Study. J Pediatr. 2017;182:304–310. e10. doi: 10.1016/j.jpeds.2016.11.075

  9. Emrath ET, Fortenberry JD, Travers C, McCracken CE, Hebbar KB. Resuscitation With Balanced Fluids Is Associated With Improved Survival in Pediatric Severe Sepsis. Crit Care Med. 2017;45:1177–1183. doi: 10.1097/CCM.0000000000002365

  10. Ventura AM, Shieh HH, Bousso A, Góes PF, de Cássia F O Fernandes I, de Souza DC, Paulo RL, Chagas F, Gilio AE. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock. Crit Care Med. 2015;43:2292–2302. doi: 10.1097/CCM.0000000000001260

  11. Ramaswamy KN, Singhi S, Jayashree M, Bansal A, Nallasamy K. DoubleBlind Randomized Clinical Trial Comparing Dopamine and Epinephrine in Pediatric Fluid-Refractory Hypotensive Septic Shock. Pediatr Crit Care Med. 2016;17:e502–e512. doi: 10.1097/PCC.0000000000000954

  12. Davis AL, Carcillo JA, Aneja RK, Deymann AJ, Lin JC, Nguyen TC, Okhuysen-Cawley RS, Relvas MS, Rozenfeld RA, Skippen PW, Stojadinovic BJ, Williams EA, Yeh TS, Balamuth F, Brierley J, deCaen AR, Cheifetz IM, Choong K, Conway E Jr, Cornell T, Doctor A, Dugas MA, Feldman JD, Fitzgerald JC, Flori HR, Fortenberry JD, Graciano AL, Greenwald BM, Hall MW, Han YY, Hernan LJ, Irazuzta JE, Iselin E, van der Jagt EW, Jeffries HE, Kache S, Katyal C, Kissoon N, Kon AA, Kutko MC, MacLaren G, Maul T, Mehta R, Odetola F, Parbuoni K, Paul R, Peters MJ, Ranjit S, Reuter-Rice KE, Schnitzler EJ, Scott HF, Torres A Jr, Weingarten-Arams J, Weiss SL, Zimmerman JJ, Zuckerberg AL. American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock. Crit Care Med. 2017;45:1061–1093. doi: 10.1097/CCM.0000000000002425

  13. Lampin ME, Rousseaux J, Botte A, Sadik A, Cremer R, Leclerc F. Noradrenaline use for septic shock in children: doses, routes of administration and complications. Acta Paediatr. 2012;101:e426–e430. doi: 10.1111/j.1651-2227.2012.02725.x

  14. Deep A, Goonasekera CD, Wang Y, Brierley J. Evolution of haemodynamics and outcome of fluid-refractory septic shock in children. Intensive Care Med. 2013;39:1602–1609. doi: 10.1007/s00134-013-3003-z

  15. Del Castillo J, López-Herce J, Cañadas S, Matamoros M, Rodríguez-Núnez A, Rodríguez-Calvo A, Carrillo A; Iberoamerican Pediatric Cardiac Arrest Study Network RIBEPCI. Cardiac arrest and resuscitation in the pediatric intensive care unit: a prospective multicenter multinational study. Resuscitation. 2014;85:1380–1386. doi: 10.1016/j.resuscitation.2014.06.024

  16. Menon K, Ward RE, Lawson ML, Gaboury I, Hutchison JS, Hébert PC; Canadian Critical Care Trials Group. A prospective multicenter study of adrenal function in critically ill children. Am J Respir Crit Care Med. 2010;182:246–251. doi: 10.1164/rccm.200911-1738OC

  17. El-Nawawy A, Khater D, Omar H, Wali Y. Evaluation of Early Corticosteroid Therapy in Management of Pediatric Septic Shock in Pediatric Intensive Care Patients: A Randomized Clinical Study. Pediatr Infect Dis J. 2017;36:155–159. doi: 10.1097/INF.0000000000001380

  18. Wong HR, Atkinson SJ, Cvijanovich NZ, Anas N, Allen GL, Thomas NJ, Bigham MT, Weiss SL, Fitzgerald JC, Checchia PA, et al. Combining prognostic and predictive enrichment strategies to identify children with septic shock responsive to corticosteroids. Crit Care Med. 2016;44:e1000–e1003. doi: 10.1097/CCM.0000000000001833

  19. Wong HR, Cvijanovich NZ, Anas N, Allen GL, Thomas NJ, Bigham MT, Weiss SL, Fitzgerald JC, Checchia PA, Meyer K, et al. Endotype transitions during the acute phase of pediatric septic shock reflect changing risk and treatment response. Crit Care Med. 2018;46:e242–e249. doi: 10.1097/CCM.0000000000002932

  20. Menon K, McNally D, Choong K, Sampson M. A systematic review and meta-analysis on the effect of steroids in pediatric shock. Pediatr Crit Care Med. 2013;14:474–480. doi: 10.1097/PCC.0b013e31828a8125

  21. Hussmann B, Lefering R, Kauther MD, Ruchholtz S, Moldzio P, Lendemans S; and the TraumaRegister DGU. Influence of prehospital volume replacement on outcome in polytraumatized children. Crit Care. 2012;16:R201. doi: 10.1186/cc11809

  22. Acker SN, Ross JT, Partrick DA, DeWitt P, Bensard DD. Injured children are resistant to the adverse effects of early high volume crystalloid resuscitation. J Pediatr Surg. 2014;49:1852–1855. doi: 10.1016/j.jpedsurg.2014.09.034

  23. Edwards MJ, Lustik MB, Clark ME, Creamer KM, Tuggle D. The effects of balanced blood component resuscitation and crystalloid administration in pediatric trauma patients requiring transfusion in Afghanistan and Iraq 2002 to 2012. J Trauma Acute Care Surg. 2015;78:330–335. doi: 10.1097/TA.0000000000000469

  24. Coons BE, Tam S, Rubsam J, Stylianos S, Duron V. High volume crystalloid resuscitation adversely affects pediatric trauma patients. J Pediatr Surg. 2018;53:2202–2208. doi: 10.1016/j.jpedsurg.2018.07.009

  25. Elkbuli A, Zajd S, Ehrhardt JD Jr, McKenney M, Boneva D. Aggressive crystalloid resuscitation outcomes in low-severity pediatric trauma. J Surg Res. 2020;247:350–355. doi: 10.1016/j.jss.2019.10.009

  26. Cannon JW, Khan MA, Raja AS, Cohen MJ, Como JJ, Cotton BA, Dubose JJ, Fox EE, Inaba K, Rodriguez CJ, Holcomb JB, Duchesne JC. Damage control resuscitation in patients with severe traumatic hemorrhage: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2017;82:605–617. doi: 10.1097/TA.0000000000001333

  27. Kanani AN, Hartshorn S. NICE clinical guideline NG39: Major trauma: assessment and initial management. Arch Dis Child Educ Pract Ed. 2017;102:20–23. doi: 10.1136/archdischild-2016-310869

  28. Zhu H, Chen B, Guo C. Aggressive crystalloid adversely affects outcomes in a pediatric trauma population. Eur J Trauma Emerg Surg. 2019:Epub ahead of print. doi: 10.1007/s00068-019-01134-0

  29. Henry S. ATLS Advanced Trauma Life Support. 10th Edition Student Course Manual. Chicago, IL: American College of Surgeons; 2018.

Respiratory failure occurs when a patient’s breathing becomes inadequate and results in ineffective oxygenation and ventilation. This can occur due to disordered control of breathing, upper airway obstruction, lower airway obstruction, respiratory muscle failure, or parenchymal lung disease. Providing assisted ventilation when breathing is absent or inadequate, relieving foreign body airway obstruction (FBAO), and administering naloxone in opioid overdose can be lifesaving.

Suffocation (eg, FBAO) and poisoning are leading causes of death in infants and children. Balloons, foods (eg, hot dogs, nuts, grapes), and small household objects are the most common causes of FBAO in children,1–3 whereas liquids are common among infants.4 It is important to differentiate between mild FBAO (the patient is coughing and making sounds) and severe FBAO (the patient cannot make sounds). Patients with mild FBAO can attempt to clear the obstruction by coughing, but intervention is required in severe obstruction.

In the United States in 2017, opioid overdose caused 79 deaths in children less than 15 years old and 4094 deaths in people age 15 to 24 years.5 Naloxone reverses the respiratory depression of narcotic overdose,6 and, in 2014, the US Food and Drug Administration approved the use of a naloxone autoinjector by lay rescuers and healthcare providers. Naloxone intranasal delivery devices are also available.

  • 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.

  • 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 blows4,9,10 or chest compressions10,11 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

  • 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 RCT23,24 and 3 non-RCT25–27) 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.

Figure 10

Opioid-Associated Emergency for Lay Responders Algorithm. AED indicates automated external defibrillator; CPR, cardiopulmonary resuscitation; and EMS, emergency medical services.

Figure 10

Opioid-Associated Emergency for Lay Responders Algorithm. AED indicates automated external defibrillator; CPR, cardiopulmonary resuscitation; and EMS, emergency medical services.

Close modal
Figure 11

Opioid-Associated Emergency for Healthcare Providers Algorithm. AED indicates automated external defibrillator; BLS, basic life support; and CPR, cardiopulmonary resuscitation.

Figure 11

Opioid-Associated Emergency for Healthcare Providers Algorithm. AED indicates automated external defibrillator; BLS, basic life support; and CPR, cardiopulmonary resuscitation.

Close modal
  1. Morley RE, Ludemann JP, Moxham JP, Kozak FK, Riding KH. Foreign body aspiration in infants and toddlers: recent trends in British Columbia. J Otolaryngol. 2004;33:37–41. doi: 10.2310/7070.2004.00310

  2. Harris CS, Baker SP, Smith GA, Harris RM. Childhood asphyxiation by food. A national analysis and overview. JAMA. 1984;251:2231–2235.

  3. Rimell FL, Thome A Jr, Stool S, Reilly JS, Rider G, Stool D, Wilson CL. Characteristics of objects that cause choking in children. JAMA. 1995;274:1763–1766.

  4. Vilke GM, Smith AM, Ray LU, Steen PJ, Murrin PA, Chan TC. Airway obstruction in children aged less than 5 years: the prehospital experience. Prehosp Emerg Care. 2004;8:196–199. doi: 10.1016/j.prehos.2003.12.014

  5. Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and opioid-involved overdose deaths—United States, 2013–2017. MMWR Morb Mortal Wkly Rep. 2018;67:1419–1427. doi: 10.15585/mmwr.mm675152e1

  6. Fischer CG, Cook DR. The respiratory and narcotic antagonistic effects of naloxone in infants. Anesth Analg. 1974;53:849–852. doi: 10.1213/00000539-197453060-00007

  7. Sutton RM, Reeder RW, Landis WP, Meert KL, Yates AR, Morgan RW, Berger JT, Newth CJ, Carcillo JA, McQuillen PS, Harrison RE, Moler FW, Pollack MM, Carpenter TC, Notterman DA, Holubkov R, Dean JM, Nadkarni VM, Berg RA; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN). Ventilation Rates and Pediatric In-Hospital Cardiac Arrest Survival Outcomes. Crit Care Med. 2019;47:1627–1636. doi: 10.1097/CCM.0000000000003898

  8. Heimlich HJ. A life-saving maneuver to prevent food-choking. JAMA. 1975;234:398–401.

  9. Sternbach G, Kiskaddon RT. Henry Heimlich: a life-saving maneuver for food choking. J Emerg Med. 1985;3:143–148. doi: 10.1016/0736-4679(8590047-2)

  10. Redding JS. The choking controversy: critique of evidence on the Heimlich maneuver. Crit Care Med. 1979;7:475–479.

  11. Kinoshita K, Azuhata T, Kawano D, Kawahara Y. Relationships between pre-hospital characteristics and outcome in victims of foreign body airway obstruction during meals. Resuscitation. 2015;88:63–67. doi: 10.1016/j.resuscitation.2014.12.018

  12. Lee SL, Kim SS, Shekherdimian S, Ledbetter DJ. Complications as a result of the Heimlich maneuver. J Trauma. 2009;66:E34–E35. doi: 10.1097/01.ta.0000219291.27245.90

  13. Abder-Rahman HA. Infants choking following blind finger sweep. J Pediatr (Rio J). 2009;85:273–275. doi: 10.2223/JPED.1892

  14. Hartrey R, Bingham RM. Pharyngeal trauma as a result of blind finger sweeps in the choking child. J Accid Emerg Med. 1995;12:52–54. doi: 10.1136/emj.12.1.52

  15. Kabbani M, Goodwin SR. Traumatic epiglottis following blind finger sweep to remove a pharyngeal foreign body. Clin Pediatr (Phila). 1995;34:495–497. doi: 10.1177/000992289503400908

  16. Deleted in proof.

  17. Guildner CW. Resuscitation—opening the airway: a comparative study of techniques for opening an airway obstructed by the tongue. JACEP. 1976;5:588–590. doi: 10.1016/s0361-1124(7680217-1)

  18. Wenzel V, Keller C, Idris AH, Dörges V, Lindner KH, Brimacombe JR. Effects of smaller tidal volumes during basic life support ventilation in patients with respiratory arrest: good ventilation, less risk? Resuscitation. 1999;43:25–29. doi: 10.1016/s0300-9572(9900118-5)

  19. Saybolt MD, Alter SM, Dos Santos F, Calello DP, Rynn KO, Nelson DA, Merlin MA. Naloxone in cardiac arrest with suspected opioid overdoses. Resuscitation. 2010;81:42–46. doi: 10.1016/j.resuscitation.2009.09.016

  20. Dezfulian C, Orkin AM, Maron BA, Elmer J, Girota S, Gladwin MT, Merchant RM, Panchal AR, Perman SM, Starks M, et al; on behalf of the American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; and Council on Clinical Cardiology. Opioid-associated out-of-hospital cardiac arrest: distinctive clinical features and implications for healthcare and public responses: a scientific statement from the American Heart Association. Circulation. In press.

  21. Bahr J, Klingler H, Panzer W, Rode H, Kettler D. Skills of lay people in checking the carotid pulse. Resuscitation. 1997;35:23–26. doi: 10.1016/s0300-9572(9601092-1)

  22. Eberle B, Dick WF, Schneider T, Wisser G, Doetsch S, Tzanova I. Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse. Resuscitation. 1996;33:107–116. doi: 10.1016/s0300-9572(9601016-7)

  23. Kelly AM, Kerr D, Dietze P, Patrick I, Walker T, Koutsogiannis Z. Randomised trial of intranasal versus intramuscular naloxone in prehospital treatment for suspected opioid overdose. Med J Aust. 2005;182:24–27.

  24. Kerr D, Kelly AM, Dietze P, Jolley D, Barger B. Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose. Addiction. 2009;104:2067–2074. doi: 10.1111/j.1360-0443.2009.02724.x

  25. Wanger K, Brough L, Macmillan I, Goulding J, MacPhail I, Christenson JM. Intravenous vs subcutaneous naloxone for out-of-hospital management of presumed opioid overdose. Acad Emerg Med. 1998;5:293–299. doi: 10.1111/j.1553-2712.1998.tb02707.x

  26. Barton ED, Colwell CB, Wolfe T, Fosnocht D, Gravitz C, Bryan T, Dunn W, Benson J, Bailey J. Efficacy of intranasal naloxone as a needleless alternative for treatment of opioid overdose in the prehospital setting. J Emerg Med. 2005;29:265–271. doi: 10.1016/j.jemermed.2005.03.007

  27. Robertson TM, Hendey GW, Stroh G, Shalit M. Intranasal naloxone is a viable alternative to intravenous naloxone for prehospital narcotic overdose. Prehosp Emerg Care. 2009;13:512–515. doi: 10.1080/10903120903144866

  28. Cetrullo C, Di Nino GF, Melloni C, Pieri C, Zanoni A. [Naloxone antagonism toward opiate analgesic drugs. Clinical experimental study]. Minerva Anestesiol. 1983;49:199–204.

  29. Osterwalder JJ. Naloxone–for intoxications with intravenous heroin and heroin mixtures–harmless or hazardous? A prospective clinical study. J Toxicol Clin Toxicol. 1996;34:409–416. doi: 10.3109/15563659609013811

  30. Sporer KA, Firestone J, Isaacs SM. Out-of-hospital treatment of opioid overdoses in an urban setting. Acad Emerg Med. 1996;3:660–667. doi: 10.1111/j.1553-2712.1996.tb03487.x

  31. Stokland O, Hansen TB, Nilsen JE. [Prehospital treatment of heroin intoxication in Oslo in 1996]. Tidsskr Nor Laegeforen. 1998;118:3144–3146.

  32. Buajordet I, Naess AC, Jacobsen D, Brørs O. Adverse events after naloxone treatment of episodes of suspected acute opioid overdose. Eur J Emerg Med. 2004;11:19–23. doi: 10.1097/00063110-200402000-00004

  33. Cantwell K, Dietze P, Flander L. The relationship between naloxone dose and key patient variables in the treatment of non-fatal heroin overdose in the prehospital setting. Resuscitation. 2005;65:315–319. doi: 10.1016/j.resuscitation.2004.12.012

  34. Boyd JJ, Kuisma MJ, Alaspää AO, Vuori E, Repo JV, Randell TT. Recurrent opioid toxicity after pre-hospital care of presumed heroin overdose patients. Acta Anaesthesiol Scand. 2006;50:1266–1270. doi: 10.1111/j.1399- 6576.2006.01172.x

  35. Nielsen K, Nielsen SL, Siersma V, Rasmussen LS. Treatment of opioid overdose in a physician-based prehospital EMS: frequency and long-term prognosis. Resuscitation. 2011;82:1410–1413. doi: 10.1016/j.resuscitation.2011.05.027

  36. Wampler DA, Molina DK, McManus J, Laws P, Manifold CA. No deaths associated with patient refusal of transport after naloxonereversed opioid overdose. Prehosp Emerg Care. 2011;15:320–324. doi: 10.3109/10903127.2011.569854

  37. Clarke SF, Dargan PI, Jones AL. Naloxone in opioid poisoning: walking the tightrope. Emerg Med J. 2005;22:612–616. doi: 10.1136/emj. 2003.009613

  38. Etherington J, Christenson J, Innes G, Grafstein E, Pennington S, Spinelli JJ, Gao M, Lahiffe B, Wanger K, Fernandes C. Is early discharge safe after naloxone reversal of presumed opioid overdose? CJEM. 2000;2:156–162. doi: 10.1017/s1481803500004863

  39. Zuckerman M, Weisberg SN, Boyer EW. Pitfalls of intranasal naloxone.Prehosp Emerg Care. 2014;18:550–554. doi: 10.3109/10903127. 2014.896961

  40. Heaton JD, Bhandari B, Faryar KA, Huecker MR. Retrospective Review of Need for Delayed Naloxone or Oxygen in Emergency Department Patients Receiving Naloxone for Heroin Reversal. J Emerg Med. 2019;56:642–651. doi: 10.1016/j.jemermed.2019.02.015

  41. Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, et al; on behalf of the Adult Basic and Advanced Life Support Writing Group. Part 3: adult basic and advanced life support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(suppl 2):S366–S468 doi: 10.1161/ CIR.0000000000000916

  42. Olasveengen TM, Mancini ME, Perkins GD, Avis S, Brooks S, Castrén M, Chung SP, Considine J, Couper K, Escalante R, et al; on behalf of the Adult Basic Life Support Collaborators. Adult basic life support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142(suppl 1):S41–S91. doi: 10.1161/CIR.0000000000000892

It is important to select appropriate equipment and medications for pediatric intubation. Uncuffed ETTs were historically preferred for young children because the normal pediatric airway narrows below the vocal cords, creating an anatomic seal around the distal tube. In the acute setting and with poor pulmonary compliance, uncuffed ETTs may need to be changed to cuffed ETTs. Cuffed tubes improve capnography accuracy, reduce the need for ETT changes (resulting in high-risk reintubations or delayed compressions), and improve pressure and tidal volume delivery. However, high pressure in the cuff can cause airway mucosal damage. Although several studies have identified that cuffed tube use may actually decrease airway trauma by decreasing tube changes, attention must be made to selecting the correct tube size and cuff inflation pressure.1 ETT cuff pressures are dynamic during transport at altitude2 and with increasing airway edema.

Intubation is a high-risk procedure. Depending on the patient’s hemodynamics, respiratory mechanics, and airway status, the patient can be at increased risk for cardiac arrest during intubation. Therefore, it is important to provide adequate resuscitation before intubation.

Cricoid pressure during bag-mask ventilation and intubation has historically been used to minimize the risk of gastric contents refluxing into the airway, but there are concerns that tracheal compression may impede effective bag-mask ventilation and intubation success.

Confirmation of ETT placement in patients with a perfusing rhythm is not reliably achieved by auscultation of breath sounds, mist in the tube, or chest rise. Either colorimetric detector or capnography (ETCO2) can be used to assess initial ETT placement. In patients with decreased pulmonary blood flow from low cardiac output or cardiac arrest, ETCO2 may not be as reliable.

  • 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

  • 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

  • 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

  • 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

  1. Tobias JD. Pediatric airway anatomy may not be what we thought: implications for clinical practice and the use of cuffed endotracheal tubes. Paediatr Anaesth. 2015;25:9–19. doi: 10.1111/pan.12528

  2. Orsborn J, Graham J, Moss M, Melguizo M, Nick T, Stroud M. Pediatric Endotracheal Tube Cuff Pressures During Aeromedical Transport. Pediatr Emerg Care. 2016;32:20–22. doi: 10.1097/PEC.0000000000000365

  3. Black AE, Hatch DJ, Nauth-Misir N. Complications of nasotracheal intubation in neonates, infants and children: a review of 4 years’ experience in a children’s hospital. Br J Anaesth. 1990;65:461–467. doi: 10.1093/bja/65.4.461

  4. Chen L, Zhang J, Pan G, Li X, Shi T, He W. Cuffed versus uncuffed endotracheal tubes in pediatrics: a meta-analysis. Open Med (Wars). 2018;13:366–373. doi: 10.1515/med-2018-0055

  5. Shi F, Xiao Y, Xiong W, Zhou Q, Huang X. Cuffed versus uncuffed endotracheal tubes in children: a meta-analysis. J Anesth. 2016;30:3–11. doi: 10.1007/s00540-015-2062-4

  6. De Orange FA, Andrade RG, Lemos A, Borges PS, Figueiroa JN, Kovatsis PG. Cuffed versus uncuffed endotracheal tubes for general anaesthesia in children aged eight years and under. Cochrane Database Syst Rev. 2017;11:CD011954. doi: 10.1002/14651858.CD011954.pub2

  7. Chambers NA, Ramgolam A, Sommerfield D, Zhang G, Ledowski T, Thurm M, Lethbridge M, Hegarty M, von Ungern-Sternberg BS. Cuffed vs. uncuffed tracheal tubes in children: a randomised controlled trial comparing leak, tidal volume and complications. Anaesthesia. 2018;73:160–168. doi: 10.1111/anae.14113

  8. de Wit M, Peelen LM, van Wolfswinkel L, de Graaff JC. The incidence of postoperative respiratory complications: A retrospective analysis of cuffed vs uncuffed tracheal tubes in children 0-7 years of age. Paediatr Anaesth. 2018;28:210–217. doi: 10.1111/pan.13340

  9. Schweiger C, Marostica PJ, Smith MM, Manica D, Carvalho PR, Kuhl G. Incidence of post-intubation subglottic stenosis in children: prospective study. J Laryngol Otol. 2013;127:399–403. doi: 10.1017/S002221511300025X

  10. Dorsey DP, Bowman SM, Klein MB, Archer D, Sharar SR. Perioperative use of cuffed endotracheal tubes is advantageous in young pediatric burn patients. Burns. 2010;36:856–860. doi: 10.1016/j.burns.2009.11.011

  11. Khine HH, Corddry DH, Kettrick RG, Martin TM, McCloskey JJ, Rose JB, Theroux MC, Zagnoev M. Comparison of cuffed and uncuffed endotracheal tubes in young children during general anesthesia. Anesthesiology. 1997;86:627–31; discussion 27A. doi: 10.1097/00000542-199703000-00015

  12. Weiss M, Dullenkopf A, Fischer JE, Keller C, Gerber AC; European Paediatric Endotracheal Intubation Study Group. Prospective randomized controlled multi-centre trial of cuffed or uncuffed endotracheal tubes in small children. Br J Anaesth. 2009;103:867–873. doi: 10.1093/bja/aep290

  13. James I. Cuffed tubes in children. Paediatr Anaesth. 2001;11:259–263. doi: 10.1046/j.1460-9592.2001.00675.x

  14. Gopalareddy V, He Z, Soundar S, Bolling L, Shah M, Penfil S, McCloskey JJ, Mehta DI. Assessment of the prevalence of microaspiration by gastric pepsin in the airway of ventilated children. Acta Paediatr. 2008;97:55–60. doi: 10.1111/j.1651-2227.2007.00578.x

  15. Browning DH, Graves SA. Incidence of aspiration with endotracheal tubes in children. J Pediatr. 1983;102:582–584. doi: 10.1016/s0022-3476(83)801917

  16. Kojima T, Laverriere EK, Owen EB, Harwayne-Gidansky I, Shenoi AN, Napolitano N, Rehder KJ, Adu-Darko MA, Nett ST, Spear D, et al; and the National Emergency Airway Registry for Children (NEAR4KIDS) Collaborators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI). Clinical impact of external laryngeal manipulation during laryngoscopy on tracheal intubation success in critically ill children. Pediatr Crit Care Med. 2018;19:106–114. doi: 10.1097/PCC.0000000000001373

  17. Kojima T, Harwayne-Gidansky I, Shenoi AN, Owen EB, Napolitano N, Rehder KJ, Adu-Darko MA, Nett ST, Spear D, Meyer K, Giuliano JS Jr, Tarquinio KM, Sanders RC Jr, Lee JH, Simon DW, Vanderford PA, Lee AY, Brown CA III, Skippen PW, Breuer RK, Toedt-Pingel I, Parsons SJ, Gradidge EA, Glater LB, Culver K, Nadkarni VM, Nishisaki A; National Emergency Airway Registry for Children (NEAR4KIDS) and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI). Cricoid Pressure During Induction for Tracheal Intubation in Critically Ill Children: A Report From National Emergency Airway Registry for Children. Pediatr Crit Care Med. 2018;19:528–537. doi: 10.1097/PCC.0000000000001531

  18. Quintard H, l’Her E, Pottecher J, Adnet F, Constantin JM, De Jong A, Diemunsch P, Fesseau R, Freynet A, Girault C, Guitton C, Hamonic Y, Maury E, Mekontso-Dessap A, Michel F, Nolent P, Perbet S, Prat G, Roquilly A, Tazarourte K, Terzi N, Thille AW, Alves M, Gayat E, Donetti L. Experts’ guidelines of intubation and extubation of the ICU patient of French Society of Anaesthesia and Intensive Care Medicine (SFAR) and French-speaking Intensive Care Society (SRLF): In collaboration with the pediatric Association of French-speaking Anaesthetists and Intensivists (ADARPEF), French-speaking Group of Intensive Care and Paediatric emergencies (GFRUP) and Intensive Care physiotherapy society (SKR). Ann Intensive Care. 2019;9:13. doi: 10.1186/s13613-019-0483-1

  19. Jones P, Ovenden N, Dauger S, Peters MJ. Estimating ‘lost heart beats’ rather than reductions in heart rate during the intubation of critically-ill children. PLoS One. 2014;9:e86766. doi: 10.1371/journal.pone.0086766

  20. Eisa L, Passi Y, Lerman J, Raczka M, Heard C. Do small doses of atropine (<0.1 mg) cause bradycardia in young children? Arch Dis Child. 2015;100:684–688. doi: 10.1136/archdischild-2014-307868

  21. Cook TM, Woodall N, Harper J, Benger J; on behalf of the Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society, part 2: intensive care and emergency departments. Br J Anaesth. 2011;106:632–642. doi: 10.1093/bja/aer059

  22. Cook TM. Strategies for the prevention of airway complications a narrative review. Anaesthesia. 2018;73:93–111. doi: 10.1111/anae.14123

  23. Hosono S, Inami I, Fujita H, Minato M, Takahashi S, Mugishima H. A role of end-tidal CO(2) monitoring for assessment of tracheal intubations in very low birth weight infants during neonatal resuscitation at birth. J Perinat Med. 2009;37:79–84. doi: 10.1515/JPM.2009.017

  24. Hawkes GA, Finn D, Kenosi M, Livingstone V, O’Toole JM, Boylan GB, O’Halloran KD, Ryan AC, Dempsey EM. A Randomized Controlled Trial of End-Tidal Carbon Dioxide Detection of Preterm Infants in the Delivery Room. J Pediatr. 2017;182:74–78.e2. doi: 10.1016/j.jpeds.2016.11.006

  25. Hunt KA, Yamada Y, Murthy V, Srihari Bhat P, Campbell M, Fox GF, Milner AD, Greenough A. Detection of exhaled carbon dioxide following intubation during resuscitation at delivery. Arch Dis Child Fetal Neonatal Ed. 2019;104:F187–F191. doi: 10.1136/archdischild-2017-313982

  26. Langhan ML, Emerson BL, Nett S, Pinto M, Harwayne-Gidansky I, Rehder KJ, Krawiec C, Meyer K, Giuliano JS Jr, Owen EB, Tarquinio KM, Sanders RC Jr, Shepherd M, Bysani GK, Shenoi AN, Napolitano N, Gangadharan S, Parsons SJ, Simon DW, Nadkarni VM, Nishisaki A; for Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) and National Emergency Airway Registry for Children (NEAR4KIDS) Investigators. End-Tidal Carbon Dioxide Use for Tracheal Intubation: Analysis From the National Emergency Airway Registry for Children (NEAR4KIDS) Registry. Pediatr Crit Care Med. 2018;19:98–105. doi: 10.1097/PCC.0000000000001372

  27. Hawkes GA, Kenosi M, Ryan CA, Dempsey EM. Quantitative or qualitative carbon dioxide monitoring for manual ventilation: a mannequin study. Acta Paediatr. 2015;104:e148–e151. doi: 10.1111/apa.12868

  28. Fanara B, Manzon C, Barbot O, Desmettre T, Capellier G. Recommendations for the intra-hospital transport of critically ill patients. Crit Care. 2010;14:R87. doi: 10.1186/cc9018

  29. Langhan ML, Ching K, Northrup V, Alletag M, Kadia P, Santucci K, Chen L. A randomized controlled trial of capnography in the correction of simulated endotracheal tube dislodgement. Acad Emerg Med. 2011;18:590–596. doi: 10.1111/j.1553-2712.2011.01090.x

  30. Langhan ML, Auerbach M, Smith AN, Chen L. Improving detection by pediatric residents of endotracheal tube dislodgement with capnography: a randomized controlled trial. J Pediatr. 2012;160:1009–14.e1. doi: 10.1016/j.jpeds.2011.12.012

Bradycardia associated with hemodynamic compromise, even with a palpable pulse, may be a harbinger for cardiac arrest. As such, bradycardia with a heart rate of less than 60 beats per minute requires emergent evaluation for cardiopulmonary compromise. If cardiopulmonary compromise is present, the initial management in the pediatric patient requires simultaneous assessment of the etiology and treatment by supporting airway, ventilation, and oxygenation. If bradycardia with cardiopulmonary compromise is present despite effective oxygenation and ventilation, CPR should be initiated immediately. Outcomes are better for children who receive CPR for bradycardia before progressing to pulseless arrest.1 Correctable factors that contribute to bradycardia (ie, hypoxia, hypotension, hypoglycemia, hypothermia, acidosis, or toxic ingestions) should be identified and treated immediately.

  • 1. Two adult studies2,4 and 2 pediatric studies6,7 demonstrate that atropine is effective to treat bradycardia due to vagal stimulation, atrioventricular block, and intoxication. There is no evidence that atropine should be used for bradycardia due to other causes.

  • 2. Two retrospective analyses from the same database showed children who received CPR for bradycardia and poor perfusion had better outcomes than children who suffered pulseless cardiac arrest and received CPR.1,10 The longer the time between the initiation of CPR for bradycardia and the loss of a pulse, the lower the chance of survival.

  • 3. There are limited pediatric data regarding the treatment of bradycardia. A recent retrospective, propensity-matched study of pediatric patients with bradycardia with a pulse found that patients who received epinephrine had worse outcomes than patients who did not receive epinephrine.11 However, due to limitations of the study, further research on the impact of epinephrine on patients with bradycardia and a pulse is required.

  • 4. There are limited data about transcutaneous pacing for refractory bradycardia in children.12–16 In patients with complete heart block or sinus node dysfunction, especially when caused by congenital or acquired heart disease, emergency transcutaneous pacing may be considered. Pacing is not useful for asystole or bradycardia due to postarrest hypoxic or ischemic myocardial insult or respiratory failure.

Figure 12 shows the algorithm for pediatric bradycardia with a pulse.

Figure 12

Pediatric Bradycardia With a Pulse Algorithm. ABC indicates airway, breathing, and circulation; AV, atrioventricular; BP, blood pressure; CPR, cardiopulmonary resuscitation; ECG, electrocardiogram; HR, heart rate; IO, intraosseous; and IV, intravenous.

Figure 12

Pediatric Bradycardia With a Pulse Algorithm. ABC indicates airway, breathing, and circulation; AV, atrioventricular; BP, blood pressure; CPR, cardiopulmonary resuscitation; ECG, electrocardiogram; HR, heart rate; IO, intraosseous; and IV, intravenous.

Close modal
  1. Khera R, Tang Y, Girotra S, Nadkarni VM, Link MS, Raymond TT, Guerguerian AM, Berg RA, Chan PS; on behalf of the American Heart Association’s Get With the Guidelines-Resuscitation Investigators. Pulselessness after initiation of cardiopulmonary resuscitation for bradycardia in hospitalized children. Circulation. 2019;140:370–378. doi: 10.1161/CIRCULATIONAHA.118.039048

  2. Smith I, Monk TG, White PF. Comparison of transesophageal atrial pacing with anticholinergic drugs for the treatment of intraoperative bradycardia. Anesth Analg. 1994;78:245–252. doi: 10.1213/00000539-199402000-00009

  3. Deleted in proof.

  4. Brady WJ, Swart G, DeBehnke DJ, Ma OJ, Aufderheide TP. The efficacy of atropine in the treatment of hemodynamically unstable bradycardia and atrioventricular block: prehospital and emergency department considerations. Resuscitation. 1999;41:47–55. doi: 10.1016/s0300-9572(9900032-5)

  5. Deleted in proof.

  6. Zimmerman G, Steward DJ. Bradycardia delays the onset of action of intravenous atropine in infants. Anesthesiology. 1986;65:320–322.

  7. Fullerton DA, St Cyr JA, Clarke DR, Campbell DN, Toews WH, See WM. Bezold-Jarisch reflex in postoperative pediatric cardiac surgical patients. Ann Thorac Surg. 1991;52:534–536. doi: 10.1016/0003-4975(9190919-h)

  8. Deleted in proof.

  9. Deleted in proof.

  10. Donoghue A, Berg RA, Hazinski MF, Praestgaard AH, Roberts K, Nadkarni VM; American Heart Association National Registry of CPR Investigators. Cardiopulmonary resuscitation for bradycardia with poor perfusion versus pulseless cardiac arrest. Pediatrics. 2009;124:1541–1548. doi: 10.1542/peds.2009-0727

  11. Holmberg MJ, Ross CE, Yankama T, Roberts JS, Andersen LW; on behalf of the American Heart Association’s Get With The Guidelines-Resuscitation Investigators. Epinephrine in children receiving cardiopulmonary resuscitation for bradycardia with poor perfusion. Resuscitation. 2020:180–190. doi: 10.1016/j.resuscitation.2019.12.032

  12. Pirasath S, Arulnithy K. Yellow oleander poisoning in eastern province: an analysis of admission and outcome. Indian J Med Sci. 2013;67:178–183. doi: 10.4103/0019-5359.125879

  13. Singh HR, Batra AS, Balaji S. Pacing in children. Ann Pediatr Cardiol. 2013;6:46–51. doi: 10.4103/0974-2069.107234

  14. Kugler JD, Danford DA. Pacemakers in children: an update. Am Heart J. 1989;117:665–679. doi: 10.1016/0002-8703(8990743-6)

  15. Bolourchi M, Silver ES, Liberman L. Advanced heart block in children with Lyme disease. Pediatr Cardiol. 2019;40:513–517. doi: 10.1007/s00246- 018-2003-8

  16. Nazif TM, Vazquez J, Honig LS, Dizon JM. Anti-N-methyl-D-aspartate receptor encephalitis: an emerging cause of centrally mediated sinus node dysfunction. Europace. 2012;14:1188–1194. doi: 10.1093/europace/eus014

Regular, narrow-complex tachyarrhythmias (QRS duration 0.09 seconds or less) are most commonly caused by re-entrant circuits, although other mechanisms (eg, ectopic atrial tachycardia, atrial fibrillation) sometimes occur. Regular, wide-complex tachyarrhythmias (greater than 0.09 seconds) can have multiple mechanisms, including supraventricular tachycardia (SVT) with aberrant conduction or ventricular tachycardia.

The hemodynamic impact of SVT in the pediatric patient can be variable, with cardiovascular compromise (ie, altered mental status, signs of shock, hypotension) occurring in the minority of patients. In hemodynamically stable patients, re-entrant SVT can often be terminated with vagal maneuvers.1,2 Adenosine remains the preferred medication to treat SVT in infants and children with a palpable pulse who do not respond to vagal maneuvers. For patients with hemodynamically stable widecomplex tachycardia and those in whom SVT recurs after initial successful treatment, expert consultation is important to diagnose etiology and customize treatment.

In hemodynamically unstable patients with SVT or wide-complex tachycardia, synchronized cardioversion should be considered.

  • 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. 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.

  • 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.

Figure 13

Pediatric Tachycardia With a Pulse Algorithm. CPR indicates cardiopulmonary resuscitation; ECG, electrocardiogram; IO, intraosseous; and IV, intravenous.

Figure 13

Pediatric Tachycardia With a Pulse Algorithm. CPR indicates cardiopulmonary resuscitation; ECG, electrocardiogram; IO, intraosseous; and IV, intravenous.

Close modal
  1. Appelboam A, Reuben A, Mann C, Gagg J, Ewings P, Barton A, Lobban T, Dayer M, Vickery J, Benger J; REVERT trial collaborators. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet. 2015;386:1747–1753. doi: 10.1016/S0140-6736(1561485-4)

  2. Bronzetti G, Brighenti M, Mariucci E, Fabi M, Lanari M, Bonvicini M, Gargiulo G, Pession A. Upside-down position for the out of hospital management of children with supraventricular tachycardia. Int J Cardiol. 2018;252:106–109. doi: 10.1016/j.ijcard.2017.10.120

  3. Losek JD, Endom E, Dietrich A, Stewart G, Zempsky W, Smith K. Adenosine and pediatric supraventricular tachycardia in the emergency department: multicenter study and review. Ann Emerg Med. 1999;33:185–191. doi: 10.1016/s0196-0644(9970392-6)

  4. Campbell M, Buitrago SR. BET 2: Ice water immersion, other vagal manoeuvres or adenosine for SVT in children. Emerg Med J. 2017;34:58–60. doi: 10.1136/emermed-2016–206487.2

  5. Clausen H, Theophilos T, Jackno K, Babl FE. Paediatric arrhythmias in the emergency department. Emerg Med J. 2012;29:732–737. doi: 10.1136/emermed-2011-200242

  6. Díaz-Parra S, Sánchez-Yañez P, Zabala-Argüelles I, Picazo-Angelin B, Conejo-Muñoz L, Cuenca-Peiró V, Durán-Hidalgo I, García-Soler P. Use of adenosine in the treatment of supraventricular tachycardia in a pediatric emergency department. Pediatr Emerg Care. 2014;30:388–393. doi: 10.1097/PEC.0000000000000144

  7. Chu PY, Hill KD, Clark RH, Smith PB, Hornik CP. Treatment of supraventricular tachycardia in infants: Analysis of a large multicenter database. Early Hum Dev. 2015;91:345–350. doi: 10.1016/j.earlhumdev.2015.04.001

  8. Lewis J, Arora G, Tudorascu DL, Hickey RW, Saladino RA, Manole MD. Acute management of refractory and unstable pediatric supraventricular tachycardia. J Pediatr. 2017;181;177.e2–182.e2. doi: 10.1016/j.jpeds.2016.10.051

  9. Borquez AA, Aljohani OA, Williams MR, Perry JC. Intravenous sotalol in the young. J Am Coll Cardiol EP. 2020;6:425–432. doi: 10.1016/j.ja-cep.2019.11.019

  10. Lim SH, Anantharaman V, Teo WS, Chan YH. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency-treatment of supraventricular tachycardia. Resuscitation. 2009;80:523–528. doi: 10.1016/j.resuscitation.2009.01.017

  11. Lapage MJ, Bradley DJ, Dick M II. Verapamil in infants: an exaggerated fear? Pediatr Cardiol. 2013;34:1532–1534. doi: 10.1007/s00246-013-0739-8

  12. Chang PM, Silka MJ, Moromisato DY, Bar-Cohen Y. Amiodarone versus procainamide for the acute treatment of recurrent supraventricular tachycardia in pediatric patients. Circ Arrhythm Electrophysiol. 2010;3:134–140. doi: 10.1161/CIRCEP.109.901629

  13. Li X, Zhang Y, Liu H, Jiang H, Ge H, Zhang Y. Efficacy of intravenous sotalol for treatment of incessant tachyarrhythmias in children. Am J Cardiol. 2017;119:1366–1370. doi: 10.1016/j.amjcard.2017.01.034

  14. Valdés SO, Landstrom AP, Schneider AE, Miyake CY, de la Uz CM, Kim JJ. Intravenous sotalol for the management of postoperative junctional ectopic tachycardia. HeartRhythm Case Rep. 2018;4:375–377. doi: 10.1016/j. hrcr.2018.05.007

  15. Sacchetti A, Moyer V, Baricella R, Cameron J, Moakes ME. Primary cardiac arrhythmias in children. Pediatr Emerg Care. 1999;15:95–98. doi: 10.1097/00006565-199904000-00004

  16. Deleted in proof.

  17. Chandler SF, Chu E, Whitehill RD, Bevilacqua LM, Bezzerides VJ, DeWitt ES, Alexander ME, Abrams DJ, Triedman JK, Walsh EP, et al. Adverse event rate during inpatient sotalol initiation for the management of supraventricular and ventricular tachycardia in the pediatric and young adult population. Heart Rhythm. 2020;17:984-990. doi: 10.1016/j.hrthm.2020.01.022

  18. Brady WJ, Mattu A, Tabas J, Ferguson JD. The differential diagnosis of wide QRS complex tachycardia. Am J Emerg Med. 2017;35:1525–1529. doi: 10.1016/j.ajem.2017.07.056

  19. Ramusovic S, Läer S, Meibohm B, Lagler FB, Paul T. Pharmacokinetics of intravenous amiodarone in children. Arch Dis Child. 2013;98:989–993. doi: 10.1136/archdischild-2013-304483

  20. Sarganas G, Garbe E, Klimpel A, Hering RC, Bronder E, Haverkamp W. Epidemiology of symptomatic drug-induced long QT syndrome and Torsade de Pointes in Germany. Europace. 2014;16:101–108. doi: 10.1093/europace/eut214

  21. Chen S, Motonaga KS, Hollander SA, Almond CS, Rosenthal DN, Kaufman BD, May LJ, Avasarala K, Dao DT, Dubin AM, Ceresnak SR. Electrocardiographic repolarization abnormalities and increased risk of lifethreatening arrhythmias in children with dilated cardiomyopathy. Heart Rhythm. 2016;13:1289–1296. doi: 10.1016/j.hrthm.2016.02.014

  22. Coughtrie AL, Behr ER, Layton D, Marshall V, Camm AJ, Shakir SAW. Drugs and life-threatening ventricular arrhythmia risk: results from the DARE study cohort. BMJ Open. 2017;7:e016627. doi: 10.1136/bmjopen-2017-016627

  23. Ortiz M, Martín A, Arribas F, Coll-Vinent B, Del Arco C, Peinado R, Almendral J; PROCAMIO Study Investigators. Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. Eur Heart J. 2017;38:1329–1335. doi: 10.1093/eurheartj/ehw230

Fulminant myocarditis can result in decreased cardiac output with end-organ compromise; conduction system disease, including complete heart block; and persistent supraventricular or ventricular arrhythmias, which can ultimately result in cardiac arrest.1 Because patients can present with nonspecific symptoms such as abdominal pain, diarrhea, vomiting, or fatigue, myocarditis can be confused with other, more common disease presentations. Outcomes can be optimized by early diagnosis and prompt intervention, including ICU monitoring and therapy. Sudden onset of heart block and multifocal ventricular ectopy in the patient with fulminant myocarditis should be considered a prearrest state. Treatment with external or intracardiac pacing or antiarrhythmic drugs may not be successful, and early transfer to a center capable of providing extracorporeal life support (ECLS) or mechanical circulatory support (MCS), such as temporary or implanted ventricular assist devices, is recommended.2,3

Noninfectious causes of cardiomyopathy in children include dilated cardiomyopathy, hypertrophic cardiomyopathy, restrictive cardiomyopathy, and miscellaneous (rare) forms of cardiomyopathy that include arrhythmogenic right ventricular dysplasia and mitochondrial and left ventricular noncompaction cardiomyopathies. Cardiomyopathy patients who present in acute decompensated heart failure refractory to mechanical ventilation and vasoactive administration have undergone preemptive MCS in the form of ECMO, short-term percutaneous ventricular assist device, or long-term implantable ventricular assist device prior to or during cardiac arrest.4,5

For patients who have worsening clinical status or incessant ventricular arrhythmias, ECLS can be lifesaving when initiated prior to cardiac arrest. ECLS also offers an opportunity to wean inotropic support, assist myocardial recovery, and serve as a bridge to cardiac transplantation if needed. The use of ECLS and MCS have improved outcomes from acute myocarditis, with a high possibility of partial or complete recovery of myocardial function.2,6

  • 1. Three retrospective studies have evaluated predictors of worse outcome in fulminant myocarditis, noting increased incidence of cardiac arrest and the need for ECLS in this high-risk population.1,7,8 In 1 study, nearly half of fulminant myocarditis patients required CPR, and nearly one third received MCS.7 Even modest decreases in left ventricular ejection fraction are associated with the need for invasive circulatory support.8

  • 2. The prognosis for patients with fulminant myocarditis who receive ECLS or MCS can be good. In 1 study, 13 (46%) of 28 children requiring MCS survived without transplant.9 One study noted that outcomes for ECPR patients cannulated with a diagnosis of myocarditis are superior to other arrest and illness categories leading to ECPR (ie, patients without congenital heart disease), noting myocarditis as a precannulation factor associated with improved survival.10 In the pre–cardiac arrest cardiomyopathy patient, newer forms of temporary circulatory support devices provide alternate and potentially improved support for decompensated heart failure requiring bridge to transplantation. These devices may provide a survival benefit over ECMO.4,5

  • 3. In 1 study, 95% of children with myocarditis who were placed on ECLS (n=15) or MCS (n=1) after cardiac arrest were alive 6 months later.9

  1. Miyake CY, Teele SA, Chen L, Motonaga KS, Dubin AM, Balasubramanian S, Balise RR, Rosenthal DN, Alexander ME, Walsh EP, Mah DY. In-hospital arrhythmia development and outcomes in pediatric patients with acute myocarditis. Am J Cardiol. 2014;113:535–540. doi: 10.1016/j.amjcard.2013.10.021

  2. Wilmot I, Morales DL, Price JF, Rossano JW, Kim JJ, Decker JA, McGarry MC, Denfield SW, Dreyer WJ, Towbin JA, Jefferies JL. Effectiveness of mechanical circulatory support in children with acute fulminant and persistent myocarditis. J Card Fail. 2011;17:487–494. doi: 10.1016/j.cardfail.2011.02.008

  3. Teele SA, Allan CK, Laussen PC, Newburger JW, Gauvreau K, Thiagarajan RR. Management and outcomes in pediatric patients presenting with acute fulminant myocarditis. J Pediatr. 2011;158:638–643.e1. doi: 10.1016/j.jpeds.2010.10.015

  4. Lorts A, Eghtesady P, Mehegan M, Adachi I, Villa C, Davies R, Gossett JG, Kanter K, Alejos J, Koehl D, Cantor RS, Morales DLS. Outcomes of children supported with devices labeled as “temporary” or short term: A report from the Pediatric Interagency Registry for Mechanical Circulatory Support. J Heart Lung Transplant. 2018;37:54–60. doi: 10.1016/j.healun.2017.10.023

  5. Yarlagadda VV, Maeda K, Zhang Y, Chen S, Dykes JC, Gowen MA, Shuttleworth P, Murray JM, Shin AY, Reinhartz O, Rosenthal DN, McElhinney DB, Almond CS. Temporary Circulatory Support in U.S. Children Awaiting Heart Transplantation. JAm Coll Cardiol. 2017;70:2250–2260. doi: 10.1016/j.jacc. 2017.08.072

  6. Rajagopal SK, Almond CS, Laussen PC, Rycus PT, Wypij D, Thiagarajan RR. Extracorporeal membrane oxygenation for the support of infants, children, and young adults with acute myocarditis: a review of the Extracorporeal Life Support Organization registry. Crit Care Med. 2010;38:382–387. doi: 10.1097/CCM.0b013e3181bc8293

  7. Casadonte JR, Mazwi ML, Gambetta KE, Palac HL, McBride ME, Eltayeb OM, Monge MC, Backer CL, Costello JM. Risk Factors for Cardiac Arrest or Mechanical Circulatory Support in Children with Fulminant Myocarditis. Pediatr Cardiol. 2017;38:128–134. doi: 10.1007/s00246-016-1493-5

  8. Wu HP, Lin MJ, Yang WC, Wu KH, Chen CY. Predictors of Extracorporeal Membrane Oxygenation Support for Children with Acute Myocarditis. Biomed Res Int. 2017;2017:2510695. doi: 10.1155/2017/2510695

  9. Schubert S, Opgen-Rhein B, Boehne M, Weigelt A, Wagner R, Müller G, Rentzsch A, Zu Knyphausen E, Fischer M, Papakostas K, Wiegand G, Ruf B, Hannes T, Reineker K, Kiski D, Khalil M, Steinmetz M, Fischer G, Pickardt T, Klingel K, Messroghli DR, Degener F; MYKKE consortium. Severe heart failure and the need for mechanical circulatory support and heart transplantation in pediatric patients with myocarditis: Results from the prospective multicenter registry “MYKKE”. Pediatr Transplant. 2019;23:e13548. doi: 10.1111/petr.13548

  10. Conrad SJ, Bridges BC, Kalra Y, Pietsch JB, Smith AH. Extracorporeal Cardiopulmonary Resuscitation Among Patients with Structurally Normal Hearts. ASAIO J. 2017;63:781–786. doi: 10.1097/MAT.0000000000000568

The complexity and variability in pediatric congenital heart disease pose unique challenges during resuscitation. Children with single-ventricle heart disease typically undergo a series of staged palliative operations. The objectives of the first palliative procedure, typically performed during the neonatal period, are (1) to create unobstructed systemic blood flow, (2) to create an effective atrial communication to allow for atrial level mixing, and (3) to regulate pulmonary blood flow to prevent overcirculation and decrease the volume load on the systemic ventricle (Figure 14). During the second stage of palliation, a superior cavopulmonary anastomosis, or bidirectional Glenn/hemi-Fontan operation, is performed to create an anastomosis, which aids in the redistribution of systemic venous return directly to the pulmonary circulation (Figure 15). The Fontan is the final palliation, in which inferior vena caval blood flow is baffled directly to the pulmonary circulation, thereby making the single (systemic) ventricle preload dependent on passive flow across the pulmonary vascular bed (Figure 16).

Figure 14

Stage I palliation for single ventricle with a Norwood repair and either a Blalock-Taussig Shunt from the right subclavian artery to the right pulmonary artery or a Sano shunt from the right ventricle to pulmonary artery.

Figure 14

Stage I palliation for single ventricle with a Norwood repair and either a Blalock-Taussig Shunt from the right subclavian artery to the right pulmonary artery or a Sano shunt from the right ventricle to pulmonary artery.

Close modal
Figure 15

Stage II palliation for single ventricle with a bidirectional Glenn shunt connecting the superior vena cava to the right pulmonary artery.

Figure 15

Stage II palliation for single ventricle with a bidirectional Glenn shunt connecting the superior vena cava to the right pulmonary artery.

Close modal
Figure 16

Stage III Fontan single ventricle palliation with an extracardiac conduit connecting the inferior vena cava to the right pulmonary artery.

Figure 16

Stage III Fontan single ventricle palliation with an extracardiac conduit connecting the inferior vena cava to the right pulmonary artery.

Close modal

Neonates and infants with single-ventricle physiology have an increased risk of cardiac arrest as a result of (1) increased myocardial work as a consequence of volume overload, (2) imbalances in relative systemic (Qs) and pulmonary (Qp) blood flow, and (3) potential shunt occlusion.1,2 Depending on the stage of repair, resuscitation may require control of pulmonary vascular resistance, oxygenation, systemic vascular resistance, or ECLS.

  • 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

  • 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

  1. Feinstein JA, Benson DW, Dubin AM, Cohen MS, Maxey DM, Mahle WT, Pahl E, Villafañe J, Bhatt AB, Peng LF, et al. Hypoplastic left heart syndrome: current considerations and expectations. J Am Coll Cardiol. 2012;59(suppl 1):S1–S42. doi: 10.1016/j.jacc.2011.09.022

  2. Marino BS, Tibby SM, Hoffman GM. Resuscitation of the patient with the functionally univentricular heart. Curr Pediatr Rev. 2013;9:148–157. doi: 10.2174/1573396311309020008

  3. Hoffman GM, Ghanayem NS, Scott JP, Tweddell JS, Mitchell ME, Mussatto KA. Postoperative Cerebral and Somatic Near-Infrared Spectroscopy Saturations and Outcome in Hypoplastic Left Heart Syndrome. Ann Thorac Surg. 2017;103:1527–1535. doi: 10.1016/j.athoracsur.2016.09.100

  4. Mills KI, Kaza AK, Walsh BK, Bond HC, Ford M, Wypij D, Thiagarajan RR, Almodovar MC, Quinonez LG, Baird CW, et al. Phosphodiesterase inhibitor-based vasodilation improves oxygen delivery and clinical outcomes following stage 1 palliation. J Am Heart Assoc. 2016;5 doi: 10.1161/JAHA.116.003554

  5. Hansen JH, Schlangen J, Voges I, Jung O, Wegmann A, Scheewe J, Kramer HH. Impact of afterload reduction strategies on regional tissue oxygenation after the Norwood procedure for hypoplastic left heart syndrome. Eur J Cardiothorac Surg. 2014;45:e13–e19. doi: 10.1093/ejcts/ezt538

  6. Ramamoorthy C, Tabbutt S, Kurth CD, Steven JM, Montenegro LM, Durning S, Wernovsky G, Gaynor JW, Spray TL, Nicolson SC. Effects of inspired hypoxic and hypercapnic gas mixtures on cerebral oxygen saturation in neonates with univentricular heart defects. Anesthesiology. 2002;96:283–288. doi: 10.1097/00000542-200202000-00010

  7. Tabbutt S, Ramamoorthy C, Montenegro LM, Durning SM, Kurth CD, Steven JM, Godinez RI, Spray TL, Wernovsky G, Nicolson SC. Impact of inspired gas mixtures on preoperative infants with hypoplastic left heart syndrome during controlled ventilation. Circulation. 2001;104(suppl 1):I159–I164. doi: 10.1161/hc37t1.094818

  8. Alsoufi B, Awan A, Manlhiot C, Guechef A, Al-Halees Z, Al-Ahmadi M, McCrindle BW, Kalloghlian A. Results of rapid-response extracorporeal cardiopulmonary resuscitation in children with refractory cardiac arrest following cardiac surgery. Eur J Cardiothorac Surg. 2014;45:268–275. doi: 10.1093/ejcts/ezt319

  9. Alsoufi B, Awan A, Manlhiot C, Al-Halees Z, Al-Ahmadi M, McCrindle BW, Alwadai A. Does single ventricle physiology affect survival of children requiring extracorporeal membrane oxygenation support following cardiac surgery? World J Pediatr Congenit Heart Surg. 2014;5:7–15. doi: 10.1177/2150135113507292

  10. Zhu L, Xu Z, Gong X, Zheng J, Sun Y, Liu L, Han L, Zhang H, Xu Z, Liu J, et al. Mechanical ventilation after bidirectional superior cavopulmonary anastomosis for single-ventricle physiology: a comparison of pressure support ventilation and neurally adjusted ventilatory assist. Pediatr Cardiol. 2016;37:1064–1071. doi: 10.1007/s00246-016-1392-9

  11. Jolley M, Thiagarajan RR, Barrett CS, Salvin JW, Cooper DS, Rycus PT, Teele SA. Extracorporeal membrane oxygenation in patients undergoing superior cavopulmonary anastomosis. J Thorac Cardiovasc Surg. 2014;148:1512–1518. doi: 10.1016/j.jtcvs.2014.04.028

  12. Marino BS, Tabbutt S, MacLaren G, Hazinski MF, Adatia I, Atkins DL, Checchia PA, DeCaen A, Fink EL, Hoffman GM, Jefferies JL, Kleinman M, Krawczeski CD, Licht DJ, Macrae D, Ravishankar C, Samson RA, Thiagarajan RR, Toms R, Tweddell J, Laussen PC; American Heart Association Congenital Cardiac Defects Committee of the Council on Cardiovascular Disease in the Young; Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Surgery and Anesthesia; and Emergency Cardiovascular Care Committee. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association. Circulation. 2018;137:e691–e782. doi: 10.1161/CIR.0000000000000524

Pulmonary hypertension is a rare disease in infants and children that is associated with significant morbidity and mortality. In the majority of pediatric patients, pulmonary hypertension is idiopathic or associated with chronic lung disease; congenital heart disease; and, rarely, other conditions, such as connective tissue or thromboembolic disease.1 Pulmonary hypertension occurs in 2% to 20% of patients following congenital heart disease surgery, with substantial morbidity and mortality.2 Pulmonary hypertension occurs in 2% to 5% of pediatric patients after cardiac surgery,3 and 0.7% to 5% of all cardiovascular surgical patients experience postoperative pulmonary hypertensive crises.4 Pulmonary hypertensive crises are acute rapid increases in pulmonary artery pressure accompanied by right-sided (or single-ventricle) heart failure. During pulmonary hypertensive crises, the right ventricle fails, and the increased afterload on the right ventricle produces increased myocardial oxygen demand at the same time that the coronary perfusion pressure and coronary blood flow decrease. The elevated left ventricle and right ventricle pressures lead to a fall in pulmonary blood flow and left-sided heart filling, with a resultant fall in cardiac output. Inotropic agents can be administered to improve right ventricle function, and vasopressors can be administered to treat systemic hypotension and improve coronary artery perfusion pressure. Once cardiac arrest has occurred, outcomes can be improved in the presence of an anatomic right-to-left shunt that permits left ventricle preload to be maintained without pulmonary blood flow.2 These crises are life threatening and may lead to systemic hypotension, myocardial ischemia, cardiac arrest, and death. Because acidosis and hypoxemia are both potent pulmonary vasoconstrictors, careful monitoring and management of these conditions are critical in the management of pulmonary hypertension. Treatment should also include the provision of adequate analgesics, sedatives, and muscle relaxants. Pulmonary vasodilators, including inhaled nitric oxide, inhaled prostacyclin, inhaled and intravenous prostacyclin analogs, and intravenous and oral phosphodiesterase type V inhibitors (eg, sildenafil) are used to prevent and treat pulmonary hypertensive crises.5–8

  • 1. Treatment with inhaled nitric oxide reduces the frequency of pulmonary hypertensive crises and shortens time to extubation.9 In patients with atrioventricular septal defect repair and severe postoperative pulmonary hypertension, inhaled nitric oxide administration is associated with reduced mortality.7,10 Inhaled prostacyclin transiently produces pulmonary vasodilation and improves oxygenation, but the alkalinity of the drug can irritate airways, and precise dosing can be complicated by drug loss in the nebulization circuit.11,12

  • 2. Two physiological reviews and 1 randomized clinical trial have demonstrated that hypercarbia, hypoxemia, acidosis, atelectasis, and ventilation-perfusion mismatch can all lead to increases in pulmonary vascular resistance and, hence, elevation of pulmonary artery pressures in the immediate postoperative period.13–15

  • 3. Two observational studies looking at select high-risk postoperative cardiac patients found an attenuation in the stress response in those patients receiving fentanyl in the postoperative period.2,11,16,17

  • 4. Two physiological reviews and 1 randomized clinical trial have demonstrated that hypercarbia, hypoxemia, acidosis, atelectasis, and ventilation-perfusion mismatch can all lead to increases in pulmonary vascular resistance and, hence, elevation of pulmonary artery pressures in the immediate postoperative period.13–15

  • 5. ECLS has been used in children with pulmonary vascular disease after cardiopulmonary collapse or low cardiac output.18,19 Although outcomes remain poor in certain populations,20 advances in technology of extracorporeal devices may allow for bridging to MCS or to transplantation.21 Although patients with pulmonary hypertension who require ECLS have a high mortality rate, provision of ECLS can be lifesaving.11,22,23

These topics were reviewed previously in “Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association”2 and “Pediatric Pulmonary Hypertension: Guidelines From the American Heart Association and American Thoracic Society.”11

  1. Ivy DD, Abman SH, Barst RJ, Berger RM, Bonnet D, Fleming TR, Haworth SG, Raj JU, Rosenzweig EB, Schulze Neick I, et al. Pediatric pulmonary hypertension. J Am Coll Cardiol. 2013;62(suppl):D117–D126. doi: 10.1016/j.jacc.2013.10.028

  2. Marino BS, Tabbutt S, MacLaren G, Hazinski MF, Adatia I, Atkins DL, Checchia PA, DeCaen A, Fink EL, Hoffman GM, Jefferies JL, Kleinman M, Krawczeski CD, Licht DJ, Macrae D, Ravishankar C, Samson RA, Thiagarajan RR, Toms R, Tweddell J, Laussen PC; American Heart Association Congenital Cardiac Defects Committee of the Council on Cardiovascular Disease in the Young; Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Surgery and Anesthesia; and Emergency Cardiovascular Care Committee. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association. Circulation. 2018;137:e691–e782. doi: 10.1161/CIR.0000000000000524

  3. Bando K, Turrentine MW, Sharp TG, Sekine Y, Aufiero TX, Sun K, Sekine E, Brown JW. Pulmonary hypertension after operations for congenital heart disease: analysis of risk factors and management. J Thorac Cardiovasc Surg. 1996;112:1600–7; discussion 1607. doi: 10.1016/S0022-5223(9670019-3)

  4. Lindberg L, Olsson AK, Jögi P, Jonmarker C. How common is severe pulmonary hypertension after pediatric cardiac surgery? J Thorac Cardiovasc Surg. 2002;123:1155–1163. doi: 10.1067/mtc.2002.121497

  5. Avila-Alvarez A, Del Cerro Marin MJ, Bautista-Hernandez V. Pulmonary Vasodilators in the Management of Low Cardiac Output Syndrome After Pediatric Cardiac Surgery. Curr Vasc Pharmacol. 2016;14:37–47. doi: 10.2174/1570161113666151014124912

  6. Sabri MR, Bigdelian H, Hosseinzadeh M, Ahmadi A, Ghaderian M, Shoja M. Comparison of the therapeutic effects and side effects of tadalafil and sildenafil after surgery in young infants with pulmonary arterial hypertension due to systemic-to-pulmonary shunts. Cardiol Young. 2017;27:1686–1693. doi: 10.1017/S1047951117000981

  7. Bizzarro M, Gross I, Barbosa FT. Inhaled nitric oxide for the postoperative management of pulmonary hypertension in infants and children with congenital heart disease. Cochrane Database Syst Rev. 2014:CD005055. doi: 10.1002/14651858.CD005055.pub3

  8. Unegbu C, Noje C, Coulson JD, Segal JB, Romer L. Pulmonary hypertension therapy and a systematic review of efficacy and safety of PDE-5 inhibitors. Pediatrics. 2017;139:e20161450. doi: 10.1542/peds.2016-1450

  9. Miller OI, Tang SF, Keech A, Pigott NB, Beller E, Celermajer DS. Inhaled nitric oxide and prevention of pulmonary hypertension after congenital heart surgery: a randomised double-blind study. Lancet. 2000;356:1464–1469. doi: 10.1016/S0140-6736(0002869-5)

  10. Journois D, Baufreton C, Mauriat P, Pouard P, Vouhé P, Safran D. Effects of inhaled nitric oxide administration on early postoperative mortality in patients operated for correction of atrioventricular canal defects. Chest. 2005;128:3537–3544. doi: 10.1378/chest.128.5.3537

  11. Abman SH, Hansmann G, Archer SL, Ivy DD, Adatia I, Chung WK, Hanna BD, Rosenzweig EB, Raj JU, Cornfield D, Stenmark KR, Steinhorn R, Thébaud B, Fineman JR, Kuehne T, Feinstein JA, Friedberg MK, Earing M, Barst RJ, Keller RL, Kinsella JP, Mullen M, Deterding R, Kulik T, Mallory G, Humpl T, Wessel DL; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Clinical Cardiology; Council on Cardiovascular Disease in the Young; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Surgery and Anesthesia; and the American Thoracic Society. Pediatric Pulmonary Hypertension: Guidelines From the American Heart Association and American Thoracic Society. Circulation. 2015;132:2037–2099. doi: 10.1161/CIR.0000000000000329

  12. Kelly LK, Porta NF, Goodman DM, Carroll CL, Steinhorn RH. Inhaled prostacyclin for term infants with persistent pulmonary hypertension refractory to inhaled nitric oxide. J Pediatr. 2002;141:830–832. doi: 10.1067/mpd.2002.129849

  13. Morris K, Beghetti M, Petros A, Adatia I, Bohn D. Comparison of hyperventilation and inhaled nitric oxide for pulmonary hypertension after repair of congenital heart disease. Crit Care Med. 2000;28:2974–2978. doi: 10.1097/00003246-200008000-00048

  14. Nair J, Lakshminrusimha S. Update on PPHN: mechanisms and treatment. Semin Perinatol. 2014;38:78–91. doi: 10.1053/j.semperi.2013.11.004

  15. Moudgil R, Michelakis ED, Archer SL. Hypoxic pulmonary vasoconstriction. J Appl Physiol (1985). 2005;98:390–403. doi: 10.1152/ japplphysiol.00733.2004

  16. Hopkins RA, Bull C, Haworth SG, de Leval MR, Stark J. Pulmonary hypertensive crises following surgery for congenital heart defects in young children. Eur J Cardiothorac Surg. 1991;5:628–634. doi: 10.1016/1010-7940(9190118-4)

  17. Anand KJ, Hansen DD, Hickey PR. Hormonal-metabolic stress responses in neonates undergoing cardiac surgery. Anesthesiology. 1990;73:661–670. doi: 10.1097/00000542-199010000-00012

  18. Kolovos NS, Bratton SL, Moler FW, Bove EL, Ohye RG, Bartlett RH, Kulik TJ. Outcome of pediatric patients treated with extracorporeal life support after cardiac surgery. Ann Thorac Surg. 2003;76:1435–41; discussion 1441. doi: 10.1016/s0003-4975(0300898-1)

  19. Dhillon R, Pearson GA, Firmin RK, Chan KC, Leanage R. Extracorporeal membrane oxygenation and the treatment of critical pulmonary hypertension in congenital heart disease. Eur J Cardiothorac Surg. 1995;9:553–556. doi: 10.1016/s1010-7940(0580004-1)

  20. Puri V, Epstein D, Raithel SC, Gandhi SK, Sweet SC, Faro A, Huddleston CB. Extracorporeal membrane oxygenation in pediatric lung transplantation. J Thorac Cardiovasc Surg. 2010;140:427–432. doi: 10.1016/j. jtcvs.2010.04.012

  21. Ricci M, Gaughan CB, Rossi M, Andreopoulos FM, Novello C, Salerno TA, Rosenkranz ER, Panos AL. Initial experience with the TandemHeart circulatory support system in children. ASAIO J. 2008;54:542–545. doi: 10.1097/ MAT.0b013e31818312f1

  22. Morrell NW, Aldred MA, Chung WK, Elliott CG, Nichols WC, Soubrier F, Trembath RC, Loyd JE. Genetics and genomics of pulmonary arterial hypertension. Eur Respir J. 2019;53:Epub ahead of print. doi: 10.1183/13993003.01899-2018

  23. Frank DB, Crystal MA, Morales DL, Gerald K, Hanna BD, Mallory GB Jr, Rossano JW. Trends in pediatric pulmonary hypertension-related hospitalizations in the United States from 2000–2009. Pulm Circ. 2015;5:339–348. doi: 10.1086/681226

Unintentional injuries are the most common cause of death among children and adolescents.1 Although many organizations have established trauma care guidelines,2–4 the management of traumatic cardiac arrest is often inconsistent. Cardiac arrest due to major blunt or penetrating injury in children has a very high mortality rate.5–8 Thoracic injury should be suspected in all thoracoabdominal trauma because tension pneumothorax, hemothorax, pulmonary contusion, or pericardial tamponade may impair hemodynamics, oxygenation, and ventilation.

  • 1. Early correction of reversible causes by reducing delays in the delivery of trauma-specific interventions may increase survival following penetrating traumatic cardiac arrest.9,10 Guidelines for cardiac arrest due to trauma recommend hemorrhage control, restoration of circulating blood volume, opening the airway, and relieving tension pneumothorax. These measures should be performed simultaneously with conventional resuscitation.

  • 2. Recent systematic reviews,11–14 multicenter retrospective studies,15,16 and single-center retrospective studies17 recommend emergent thoracotomy for pediatric patients who present pulseless after penetrating thoracic injury. There is no evidence to support emergent thoracotomy for infants and children with blunt injury who are without signs of life.12,18

  1. Heron M. Deaths: leading causes for 2010. Natl Vital Stat Rep. 2013;62:1–96.

  2. Western Trauma Association. Western Trauma Association algorithms. 2011. https://www.westerntrauma.org/algorithms/algorithms.html. Accessed March 6, 2020.

  3. Eastern Association for the Surgery of Trauma. EAST practice management guidelines. https://www.east.org/education/practice-management- guidelines. Accessed February 3, 2020.

  4. Pediatric Trauma Society. Pediatric trauma society clinical practice guidelines. https://pediatrictraumasociety.org/resources/clinical-resources.cgi. Accessed February 3, 2020.

  5. Calkins CM, Bensard DD, Partrick DA, Karrer FM. A critical analysis of outcome for children sustaining cardiac arrest after blunt trauma. J Pediatr Surg. 2002;37:180–184. doi: 10.1053/jpsu.2002.30251

  6. Crewdson K, Lockey D, Davies G. Outcome from paediatric cardiac arrest associated with trauma. Resuscitation. 2007;75:29–34. doi: 10.1016/j.resuscitation.2007.02.018

  7. Perron AD, Sing RF, Branas CC, Huynh T. Predicting survival in pediatric trauma patients receiving cardiopulmonary resuscitation in the prehospital setting. Prehosp Emerg Care. 2001;5:6–9. doi: 10.1080/10903120190940245

  8. Lopez-Herce Cid J, Dominguez Sampedro P, Rodriguez Nunez A, Garcia Sanz C, Carrillo Alvarez A, Calvo Macias C, Bellon Cano JM. [Cardiorespiratory arrest in children with trauma]. An Pediatr (Barc). 2006;65:439–447. doi: 10.1157/13094250

  9. Shibahashi K, Sugiyama K, Hamabe Y. Pediatric Out-of-Hospital Traumatic Cardiopulmonary Arrest After Traffic Accidents and Termination of Resuscitation. Ann Emerg Med. 2020;75:57–65. doi: 10.1016/j.annemergmed.2019.05.036

  10. Alqudah Z, Nehme Z, Williams B, Oteir A, Bernard S, Smith K. A descriptive analysis of the epidemiology and management of paediatric traumatic out-of-hospital cardiac arrest. Resuscitation. 2019;140:127–134. doi: 10.1016/j.resuscitation.2019.05.020

  11. Nevins EJ, Bird NTE, Malik HZ, Mercer SJ, Shahzad K, Lunevicius R, Taylor JV, Misra N. A systematic review of 3251 emergency department thoracotomies: is it time for a national database? Eur J Trauma Emerg Surg. 2019;45:231–243. doi: 10.1007/s00068-018-0982-z

  12. Moskowitz EE, Burlew CC, Kulungowski AM, Bensard DD. Survival after emergency department thoracotomy in the pediatric trauma population: a review of published data. Pediatr Surg Int. 2018;34:857–860. doi: 10.1007/s00383-018-4290-9

  13. Seamon MJ, Haut ER, Van Arendonk K, Barbosa RR, Chiu WC, Dente CJ, Fox N, Jawa RS, Khwaja K, Lee JK, Magnotti LJ, Mayglothling JA, McDonald AA, Rowell S, To KB, Falck-Ytter Y, Rhee P. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015;79:159–173. doi: 10.1097/TA. 0000000000000648

  14. Moore HB, Moore EE, Bensard DD. Pediatric emergency department thoracotomy: A 40-year review. J Pediatr Surg. 2016;51:315–318. doi: 10.1016/j. jpedsurg.2015.10.040

  15. Flynn-O’Brien KT, Stewart BT, Fallat ME, Maier RV, Arbabi S, Rivara FP, McIntyre LK. Mortality after emergency department thoracotomy for pediatric blunt trauma: analysis of the National Trauma Data Bank 2007–2012. J Pediatr Surg. 2016;51:163–167. doi: 10.1016/j.jpedsurg.2015.10.034

  16. Nicolson NG, Schwulst S, Esposito TA, Crandall ML. Resuscitative thoracotomy for pediatric trauma in Illinois, 1999 to 2009. Am J Surg. 2015;210:720–723. doi: 10.1016/j.amjsurg.2015.05.007

  17. Easter JS, Vinton DT, Haukoos JS. Emergent pediatric thoracotomy following traumatic arrest. Resuscitation. 2012;83:1521–1524. doi: 10.1016/j. resuscitation.2012.05.024

  18. Duron V, Burke RV, Bliss D, Ford HR, Upperman JS. Survival of pediatric blunt trauma patients presenting with no signs of life in the field. J Trauma Acute Care Surg. 2014;77:422–426. doi: 10.1097/TA.0000000000000394

During the literature review process, we identified several critical knowledge gaps related to pediatric basic and advanced life support. These topics are either current areas of ongoing research or lack significant pediatric evidence to support evidence-based recommendations. In addition, we identified topics for which systematic or scoping reviews are in process by the ILCOR Basic Life Support or Pediatric Life Support Task Forces and elected not to make premature recommendations until these reviews are available.

As is so often the case in pediatric medicine, many recommendations are extrapolated from adult data. This is particularly true for the BLS components of pediatric resuscitation. The causes of pediatric cardiac arrest are very different from cardiac arrest in adults, and pediatric studies are critically needed. Furthermore, infants, children, and adolescents are distinct patient populations. Dedicated pediatric resuscitation research is a priority given the more than 20 000 infants, children, and adolescents who suffer cardiac arrest in the United States each year.

Critical knowledge gaps are summarized in Table 2.

Table 2

Critical Knowledge Gaps Due to Insufficient Pediatric Data

What is the optimal method of medication delivery during CPR: IO or IV? 
What is the optimal method to determine body weight for medication administration? 
In what time frame should the first dose of epinephrine be administered during pulseless cardiac arrest? 
With what frequency should subsequent doses of epinephrine be administered? 
With what frequency should epinephrine be administered in infants and children during CPR who are awaiting ECMO cannulation? 
Are alternative compression techniques (cough CPR, fist pacing, interposed abdominal compression CPR) more effective alternatives to CPR? 
With what frequency should the rhythm be checked during CPR? 
What is the optimal method of airway management during OHCA—bag- mask ventilation, supraglottic airway, or endotracheal tube? 
What is the optimal Fio2 to administer during CPR? 
What is the optimal ventilation rate during CPR in patients with or without an advanced airway? Is it age dependent? 
What is the optimal chest compression rate during CPR? Is it age dependent? 
What are the optimal blood pressure targets during CPR? Are they age dependent? 
Can echocardiography improve CPR quality or outcomes from cardiac arrest? 
Are there specific situations in which advanced airway placement is beneficial or harmful in OHCA? 
What is the appropriate timing of advanced airway placement in IHCA? 
What is the role of ECPR for patients with OHCA and IHCA due to noncardiac causes? 
What is the optimal timing and dosing of defibrillation for VF/pVT? 
What clinical tools can be used to help in the decision to terminate pediatric IHCA and OHCA resuscitation? 
What is the optimal blood pressure target during the post–cardiac arrest period? 
Should seizure prophylaxis be administered post cardiac arrest? 
Does the treatment of postarrest convulsive and nonconvulsive seizure improve outcomes? 
What are the reliable methods for postarrest prognostication? 
What rehabilitation therapies and follow-up should be provided to improve outcomes post arrest? 
What are the most effective and safe medications for adenosine-refractory SVT? 
What is the appropriate age and setting to transition from (1) neonatal resuscitation protocols to pediatric resuscitation protocols and (2) from pediatric resuscitation protocols to adult resuscitation protocols? 
What is the optimal method of medication delivery during CPR: IO or IV? 
What is the optimal method to determine body weight for medication administration? 
In what time frame should the first dose of epinephrine be administered during pulseless cardiac arrest? 
With what frequency should subsequent doses of epinephrine be administered? 
With what frequency should epinephrine be administered in infants and children during CPR who are awaiting ECMO cannulation? 
Are alternative compression techniques (cough CPR, fist pacing, interposed abdominal compression CPR) more effective alternatives to CPR? 
With what frequency should the rhythm be checked during CPR? 
What is the optimal method of airway management during OHCA—bag- mask ventilation, supraglottic airway, or endotracheal tube? 
What is the optimal Fio2 to administer during CPR? 
What is the optimal ventilation rate during CPR in patients with or without an advanced airway? Is it age dependent? 
What is the optimal chest compression rate during CPR? Is it age dependent? 
What are the optimal blood pressure targets during CPR? Are they age dependent? 
Can echocardiography improve CPR quality or outcomes from cardiac arrest? 
Are there specific situations in which advanced airway placement is beneficial or harmful in OHCA? 
What is the appropriate timing of advanced airway placement in IHCA? 
What is the role of ECPR for patients with OHCA and IHCA due to noncardiac causes? 
What is the optimal timing and dosing of defibrillation for VF/pVT? 
What clinical tools can be used to help in the decision to terminate pediatric IHCA and OHCA resuscitation? 
What is the optimal blood pressure target during the post–cardiac arrest period? 
Should seizure prophylaxis be administered post cardiac arrest? 
Does the treatment of postarrest convulsive and nonconvulsive seizure improve outcomes? 
What are the reliable methods for postarrest prognostication? 
What rehabilitation therapies and follow-up should be provided to improve outcomes post arrest? 
What are the most effective and safe medications for adenosine-refractory SVT? 
What is the appropriate age and setting to transition from (1) neonatal resuscitation protocols to pediatric resuscitation protocols and (2) from pediatric resuscitation protocols to adult resuscitation protocols? 

CPR indicates cardiopulmonary resuscitation; ECMO, extracorporeal membrane oxygenation; ECPR, extracorporeal cardiopulmonary resuscitation; Fio2, fraction of inspired oxygen; IHCA, in-hospital cardiac arrest; IO, intraosseous; IV, intravenous; OHCA, out-of-hospital cardiac arrest; pVT, pulseless ventricular tachycardia; SVT, supraventricular tachycardia; and VF, ventricular fibrillation.

The American Heart Association requests that this document be cited as follows: Topjian AA, Raymond TT, Atkins D, Chan M, Duff JP, Joyner BL Jr, Lasa JJ, Lavonas EJ, Levy A, Mahgoub M, Meckler GD, Roberts KE, Sutton RM, Schexnayder SM; on behalf of the Pediatric Basic and Advanced Life Support Collaborators. Part 4: pediatric basic and advanced life support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(suppl 2):S469–S523. doi: 10.1161/CIR.0000000000000901

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.

Appendix 1

Writing Group Disclosures

Writing Group MemberEmploymentResearch GrantOther Research SupportSpeakers’ Bureau/ HonorariaExpert WitnessOwnership InterestConsultant/ Advisory BoardOther
Alexis A. Topjian The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine Anesthesia and Critical Care NIH* None None Plaintiff* None None None 
Dianne Atkins University of Iowa Pediatrics None None None None None None None 
Melissa Chan University of British Columbia Pediatrics BC Children’s Hospital None None None None None None None 
Jonathan P. Duff 
  • University of Alberta and Stollery Children’s Hospital

  • Pediatrics

 
None None None None None None None 
Benny L. Joyner Jr University of North Carolina Pediatrics None None None None None None None 
Javier J. Lasa Texas Children’s Hospital, Baylor College of Medicine Pediatrics/Critical Care Medicine and Cardiology None None None None None None None 
Eric J. Lavonas Denver Health Emergency Medicine BTG Pharmaceuticals (Denver Health (Dr Lavonas’ employer) has research, call center, consulting, and teaching agreements with BTG Pharmaceuticals. BTG manufactures the digoxin antidote, DigiFab. Dr Lavonas does not receive bonus or incentive compensation, and these agreements involve an unrelated product. When these guidelines were developed, Dr Lavonas recused from discussions related to digoxin poisoning.) None None None None None American Heart Association (Senior Science Editor) 
Arielle Levy University of Montreal Pediatric None None None None None None None 
Melissa Mahgoub American Heart Association None None None None None None None 
Garth D. Meckler University of British Columbia Pediatrics and Emergency Medicine Ambulatory Care Building, BC Children’s None None None None None None None 
Tia T. Raymond Medical City Children’s Hospital Pediatric Cardiac Intensive Care Unit None None None None None None None 
Kathryn E. Roberts Joe DiMaggio Children’s Hospital None None None None None None None 
Stephen M. Schexnayder Univ. of Arkansas/ Arkansas Children’s Hospital Pediatric Critical Care None None None None None None None 
Robert M. Sutton The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine Anesthesia and Critical Care Medicine NIH None None Roberts & Durkee, Plantiff, 2019 None None None 
Writing Group MemberEmploymentResearch GrantOther Research SupportSpeakers’ Bureau/ HonorariaExpert WitnessOwnership InterestConsultant/ Advisory BoardOther
Alexis A. Topjian The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine Anesthesia and Critical Care NIH* None None Plaintiff* None None None 
Dianne Atkins University of Iowa Pediatrics None None None None None None None 
Melissa Chan University of British Columbia Pediatrics BC Children’s Hospital None None None None None None None 
Jonathan P. Duff 
  • University of Alberta and Stollery Children’s Hospital

  • Pediatrics

 
None None None None None None None 
Benny L. Joyner Jr University of North Carolina Pediatrics None None None None None None None 
Javier J. Lasa Texas Children’s Hospital, Baylor College of Medicine Pediatrics/Critical Care Medicine and Cardiology None None None None None None None 
Eric J. Lavonas Denver Health Emergency Medicine BTG Pharmaceuticals (Denver Health (Dr Lavonas’ employer) has research, call center, consulting, and teaching agreements with BTG Pharmaceuticals. BTG manufactures the digoxin antidote, DigiFab. Dr Lavonas does not receive bonus or incentive compensation, and these agreements involve an unrelated product. When these guidelines were developed, Dr Lavonas recused from discussions related to digoxin poisoning.) None None None None None American Heart Association (Senior Science Editor) 
Arielle Levy University of Montreal Pediatric None None None None None None None 
Melissa Mahgoub American Heart Association None None None None None None None 
Garth D. Meckler University of British Columbia Pediatrics and Emergency Medicine Ambulatory Care Building, BC Children’s None None None None None None None 
Tia T. Raymond Medical City Children’s Hospital Pediatric Cardiac Intensive Care Unit None None None None None None None 
Kathryn E. Roberts Joe DiMaggio Children’s Hospital None None None None None None None 
Stephen M. Schexnayder Univ. of Arkansas/ Arkansas Children’s Hospital Pediatric Critical Care None None None None None None None 
Robert M. Sutton The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine Anesthesia and Critical Care Medicine NIH None None Roberts & Durkee, Plantiff, 2019 None None None 

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.

*

Modest.

Significant.

Appendix 2

Reviewer Disclosures

ReviewerEmploymentResearch GrantOther Research SupportSpeakers’ Bureau/ HonorariaExpert WitnessOwnership InterestConsultant/ Advisory BoardOther
Nandini Calamur Saint Louis University None None None None None None None 
Leon Chameides Connecticut Children’s Medical Center None None None None None None None 
Todd P. Chang Children’s Hospital Los Angeles & Keck School Of Medicine None None None None None None Oculus from FaceBook 
Ericka L. Fink Primary Work Children’s Hospital of Pittsburgh NIH None None None None None None 
Monica E. Kleinman Children’s Hospital Boston None None None None None International Liaison Committee on Resuscitation* None 
Michael-Alice Moga The Hospital for Sick Children, Labatt Family Heart Center and University of Toronto (Canada) CIHR*; CIHR/ NSERC None None None None None None 
Tara Neubrand Children’s Hospital Colorado, University of Colorado None None None None None None None 
Ola Didrik Saugstad University of Oslo (Norway) None None None None None None None 
ReviewerEmploymentResearch GrantOther Research SupportSpeakers’ Bureau/ HonorariaExpert WitnessOwnership InterestConsultant/ Advisory BoardOther
Nandini Calamur Saint Louis University None None None None None None None 
Leon Chameides Connecticut Children’s Medical Center None None None None None None None 
Todd P. Chang Children’s Hospital Los Angeles & Keck School Of Medicine None None None None None None Oculus from FaceBook 
Ericka L. Fink Primary Work Children’s Hospital of Pittsburgh NIH None None None None None None 
Monica E. Kleinman Children’s Hospital Boston None None None None None International Liaison Committee on Resuscitation* None 
Michael-Alice Moga The Hospital for Sick Children, Labatt Family Heart Center and University of Toronto (Canada) CIHR*; CIHR/ NSERC None None None None None None 
Tara Neubrand Children’s Hospital Colorado, University of Colorado None None None None None None None 
Ola Didrik Saugstad University of Oslo (Norway) None None None None None None None 

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.

*

Modest.

Significant.