This article aims to provide guidance to health care workers for the provision of basic and advanced life support to children and neonates with suspected or confirmed coronavirus disease 2019 (COVID-19). It aligns with the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular care while providing strategies for reducing risk of transmission of severe acute respiratory syndrome coronavirus 2 to health care providers. Patients with suspected or confirmed COVID-19 and cardiac arrest should receive chest compressions and defibrillation, when indicated, as soon as possible. Because of the importance of ventilation during pediatric and neonatal resuscitation, oxygenation and ventilation should be prioritized. All CPR events should therefore be considered aerosol-generating procedures. Thus, personal protective equipment (PPE) appropriate for aerosol-generating procedures (including N95 respirators or an equivalent) should be donned before resuscitation, and high-efficiency particulate air filters should be used. Any personnel without appropriate PPE should be immediately excused by providers wearing appropriate PPE. Neonatal resuscitation guidance is unchanged from standard algorithms, except for specific attention to infection prevention and control. In summary, health care personnel should continue to reduce the risk of severe acute respiratory syndrome coronavirus 2 transmission through vaccination and use of appropriate PPE during pediatric resuscitations. Health care organizations should ensure the availability and appropriate use of PPE. Because delays or withheld CPR increases the risk to patients for poor clinical outcomes, children and neonates with suspected or confirmed COVID-19 should receive prompt, high-quality CPR in accordance with evidence-based guidelines.

Full article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2021-056043

In 2020, the American Heart Association (AHA) Emergency Cardiovascular Care Committee and Get with the Guidelines-Resuscitation adult and pediatric task forces published Interim Guidance for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19).1,2 Created early in the COVID-19 pandemic, this guidance provided strategies for reducing risk to health care providers during resuscitation of patients with suspected or confirmed COVID-19. As the COVID-19 pandemic continues in 2022, there is a more comprehensive understanding of the transmissibility of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), including emerging variants of concern, in both community and health care settings. There is also a more reliable supply of personal protective equipment (PPE). Finally, effective vaccines are widely available and recommendations regarding the optimal vaccination schedule, including booster doses, are continuously updated to reflect knowledge related to long-term protection and effectiveness against variants of concern.3 These developments, along with the need to incorporate the 2020 AHA Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care, necessitated updates to the guidance for adults, children, neonates, and pregnant women.4 Because of the evolving epidemiology of pediatric COVID-19 and differences in resuscitation priorities for children and neonates as compared with adults, the purpose of this statement is to provide updated, focused, pediatric-specific guidance for the resuscitation of patients with suspected or confirmed COVID-19.

The goals of this guidance are to achieve the best possible resuscitation outcomes and to simultaneously ensure optimal protection for health care providers. This guidance provides a focused description of the pediatric-specific components of the 2022 AHA Interim Guidance for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates with Suspected or Confirmed COVID-19,4 but the recommendations, rationale, and algorithms do not differ from the pediatric components of that statement. This guidance is based on available scientific evidence at the time of its development, recommendations from public health organizations, and expert opinion. It is not a guidelines statement, which is based on a formal evidence review. COVID-19 prevalence, vaccination rates, and mitigation strategies and practices are regionally and temporally variable, and individual systems and settings should take local factors into account in implementing this guidance. The standard 2020 CPR algorithms and recommendations for resuscitation apply to those patients who are known to be SARS-CoV-2–negative, or in whom suspicion for infection is low.5 

In children with COVID-19, data regarding cardiac arrest outcomes are limited.6 In adults, numerous reports have described worse cardiac arrest outcomes during the pandemic as compared with historical data and dismal cardiac arrest outcomes in COVID-19 patients in particular.717  However, some institutions have observed similar outcomes between patients with and without COVID-19 during the pandemic.1820  Though the causes of these findings are likely multifactorial,14,15,17,2123  these data collectively suggest the possibility that systemic effects of the COVID-19 pandemic, rather than patient characteristics alone, may be driving outcomes. Importantly, this also demonstrates that these pandemic-associated unfavorable resuscitation outcomes are potentially avoidable with appropriate guidance and planning.

Children are at risk for critical illness because of both acute SARS-CoV-2 infection and its sequelae (eg, multisystem inflammatory syndrome in children).2427  Among children hospitalized for COVID-19, up to 30% are admitted to ICUs and as many as 5% to 15% require mechanical ventilation.2730  Additionally, cardiac arrests because of non–COVID-19–related reasons may occur in children with incidental positive SARS-CoV-2 tests. Although these considerations have been relevant throughout the pandemic, pediatric case numbers and hospitalizations increased dramatically in late 2021, likely spurred by a combination of high transmissibility of the omicron variant and relaxation of mitigation measures, leading to high community prevalence of SARS-CoV-2.27 Further, vaccines were not available to children aged 5 to 11 years until early November 2021, only became available for younger children in June 2022, and vaccination coverage in eligible populations has been incomplete, leaving unvaccinated children particularly vulnerable to SARS-CoV-2 infection. Thus, pediatric health care providers must remain informed and prepared to provide resuscitation care to children who test positive for SARS-CoV-2.

Frontline health care providers are at risk for contracting SARS-CoV-2 when in contact with infected patients (Fig 1). Vaccination is a key strategy to protect health care workers from occupationally acquired SARS-CoV-2, but infections do occur in vaccinated individuals, and health care worker vaccination rates remain <100%.31 Providers should therefore always use appropriate PPE, regardless of vaccination status, during resuscitation of patients with suspected or confirmed COVID-19.32 

SARS-CoV-2 transmission occurs primarily when an individual either inhales respiratory particles from an infectious person or these particles are deposited on a mucosal surface. Transmission therefore generally occurs when individuals are within 6 ft, though transmission through aerosolized particles can happen at greater distances, particularly in poorly ventilated spaces and when larger quantities of aerosols are generated during certain aerosol-generating procedures (AGPs).33 There are conflicting and incomplete data regarding which components of CPR constitute AGPs.3338  Regardless, the overall process of CPR has the potential to generate aerosols and place providers at risk, and should thus be treated as an AGP.39,40 Furthermore, pediatric and neonatal resuscitation algorithms include the provision of ventilations via bag–mask ventilation, regardless of COVID-19 status. As bag–mask ventilation is considered an AGP,36 AGP-appropriate PPE (N95 respirator or positive pressure respirators, eye protection, gowns, and gloves)4143  should be used by providers in all pediatric resuscitation events involving a patient with suspected or confirmed SARS-CoV-2. High-efficiency particulate air (HEPA) filters should be used with both invasive and noninvasive ventilatory interfaces and during both manual and mechanical ventilation.

Consistent and effective use of PPE is important for the safety of resuscitation personnel. Health care organizations should continue to secure and stock appropriate PPE, ensure training regarding its appropriate application and use, monitor and reinforce its effective use, and create and maintain systems that minimize the possibility that health care professionals would have to decide whether to provide emergency care without appropriate PPE.

The combination of appropriate PPE utilization and compliance with the recommended vaccine schedule is the best way of reducing risk of SARS-CoV-2 transmission and severe COVID-19.4345  The AHA strongly encourages all health care providers to receive the vaccines and comply with updated recommendations for boosters.

Patients with cardiac arrest are at considerable risk for death or poor neurologic outcomes when CPR is withheld, delayed, or otherwise compromised. Resuscitation providers and systems should aim to ensure that critical elements of resuscitation care continue to be prioritized in patients with suspected or confirmed SARS-CoV-2.

Because appropriate PPE is widely available in most practice settings, health care provider exposure to SARS-CoV-2 can generally be mitigated without compromising resuscitation quality. Proactive preparation can help to both prevent health care provider exposures and avoid delays in initiating CPR. Providers should be wearing PPE appropriate for AGPs when caring for pediatric patients with suspected or confirmed SARS-CoV-2 who are at risk for requiring resuscitation or other AGPs.42 Initial responders who are not already wearing appropriate PPE at the time of cardiac arrest should immediately don it and begin CPR. Pediatric resuscitation should occur according to evidence-based algorithms (Figs 24), regardless of SARS-CoV-2 status. Chest compressions and ventilations should be initiated as soon as possible, and defibrillation, when indicated, should occur in accordance with CPR algorithms.

FIGURE 1

Summary of key points and adjustments to pediatric CPR algorithms for patients with suspected or confirmed COVID-19.

FIGURE 1

Summary of key points and adjustments to pediatric CPR algorithms for patients with suspected or confirmed COVID-19.

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FIGURE 2

Pediatric basic life support algorithm for health care provider; single rescuer for suspected or confirmed COVID-19. AED, automated external defibrillator; ALS, advanced life support; HR, heart rate.

FIGURE 2

Pediatric basic life support algorithm for health care provider; single rescuer for suspected or confirmed COVID-19. AED, automated external defibrillator; ALS, advanced life support; HR, heart rate.

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FIGURE 3

Pediatric basic life support algorithm for health care providers; 2 or more rescuers for suspected or confirmed COVID-19. AED, automated external defibrillator; ALS, advanced life support; HR, heart rate.

FIGURE 3

Pediatric basic life support algorithm for health care providers; 2 or more rescuers for suspected or confirmed COVID-19. AED, automated external defibrillator; ALS, advanced life support; HR, heart rate.

Close modal
FIGURE 4

Pediatric cardiac arrest algorithm for patients with suspected or confirmed COVID-19. ET, endotracheal; IO, intraosseous; IV, intravenous; PEA, pulseless electrical activity; ROSC, return of spontaneous circulation; VF, ventricular fibrillation; pVT, pulseless ventricular tachycardia.

FIGURE 4

Pediatric cardiac arrest algorithm for patients with suspected or confirmed COVID-19. ET, endotracheal; IO, intraosseous; IV, intravenous; PEA, pulseless electrical activity; ROSC, return of spontaneous circulation; VF, ventricular fibrillation; pVT, pulseless ventricular tachycardia.

Close modal
FIGURE 5

Summary of guidance for specific resuscitation settings and scenarios.

FIGURE 5

Summary of guidance for specific resuscitation settings and scenarios.

Close modal

Because most pediatric cardiac arrests occur in the setting of respiratory failure or respiratory insufficiency, ventilation remains a critical component of pediatric and neonatal CPR in all settings.5,46,47 Observational studies of pediatric cardiac arrest consistently demonstrate that children who receive chest compressions with ventilations have superior survival outcomes to those who receive chest compressions only.48,49 In neonates, delays in providing positive pressure ventilation are associated with increased risk of death and prolonged hospitalization.50 Therefore, ventilations with rates and ratios consistent with 2020 AHA guidelines5,51 should be provided to children and neonates with suspected or confirmed COVID-19 and cardiac arrest. Similarly, children with a pulse but abnormal or absent breathing should receive prompt rescue breathing in accordance with standard guidelines. HEPA filters should be used during ventilation. Of note, although guidance for adult resuscitation endorses the use of passive oxygenation during CPR or in the presence of agonal breathing,4,52 there is no role for this in children and neonates because these patients should all receive assisted ventilations.

Earlier COVID-19 guidance recommended prioritization of early intubation during CPR to minimize provider risk because ventilation via a cuffed endotracheal tube may disperse less aerosols than bag–mask ventilation.2 However, endotracheal intubation itself is considered an AGP that is likely to confer a relatively high risk to unprotected providers.36,38,53 In the absence of evidence to suggest that early intubation reduces provider risk or benefits patients, the 2020 AHA guidelines5,54 should be followed, with decisions regarding the timing of intubation based on the overall clinical picture and per usual care standards. Considerations include both the effectiveness of bag–mask ventilation and the availability of skilled personnel for intubation. Secure placement of a supraglottic airway with a HEPA filter may help maximize chest compression fraction, but it is unclear if it limits aerosol generation before endotracheal intubation.55,56 When actively ventilating via mask, supraglottic airway, endotracheal tube, or any other device, a HEPA filter between the airway or mask and the ventilation device or on the exhaust port of the ventilation device should be employed as soon as available to capture aerosolized particles.

  • The continued use of an N95 respirator and eye protection is advised when the patient’s COVID-19 status is unknown and clinical suspicion is high or community transmission is high.

  • Reduce unnecessary exposure by limiting the number of resuscitation providers to those required for providing high-quality care.

  • Ensure that resuscitation providers are trained and prepared to efficiently don PPE and that PPE is appropriately stocked and optimally located to best reduce provider risk and prevent unnecessary delays.

  • Additional personnel for chest compressions may be required because of increased fatigue or the potential for N95 respirator slippage while providing chest compressions.57,58 The application of mechanical compression devices can reduce the number of health care providers required for compressions in adult CPR events. However, these devices are not available for most pediatric patients and should only be used for patients meeting manufacturer age and size specifications and in centers with appropriate experience.59,60 

  • A HEPA filter should be securely attached to the ventilation device in 1 of the following ways:

    • ∘ Manual ventilation device: on the exhaust port of the device or between the mask or airway and the ventilation device, with a low-dead space viral filter or a heat- and moisture-exchanging filter.

    • ∘ Mechanical ventilator: on the exhaust limb of the ventilator circuit or between the mask or airway and the ventilator with a low-dead space viral filter or heat- and moisture-exchanging filter.

  • Before intubation, mask ventilate with a tight seal and an in-line HEPA filter, ideally using a 2-person technique. The second team member can provide support for additional procedures, such as compressions, once an advanced airway is established.

  • Securing placement of a supraglottic airway with a HEPA filter can help maximize chest compression fraction and may limit aerosol generation before endotracheal intubation, though supporting data are limited.55,56 

  • Assign the airway provider and use the technique with the highest chance of first-pass intubation success while wearing appropriate PPE for AGPs. Intubate adolescents, children, and infants with a cuffed endotracheal tube to minimize aerosolization of respiratory particles after the airway is secure and to optimize delivery of ventilator pressures. For neonates, consider local practices and the patient-specific risk– benefit relationship between aerosol mitigation and cuffed endotracheal tube use.

  • As in any pediatric resuscitation, maximize the chest compression fraction, pausing only to facilitate intubation if needed. Minimizing noncompression time can require team coordination surrounding pulse checks, advanced airway placement, focused ultrasound evaluation, and other potential reasons for interruptions.

  • Consider the use of video laryngoscopy if equipment and experienced personnel are available because this may reduce direct exposure of the airway provider to respiratory aerosols.61,62 There is no known evidence of a difference in transmission risk using video versus direct laryngoscopy in the setting of providers wearing appropriate PPE for AGPs.

  • Minimize endotracheal administration of medications; disconnections may be a source of aerosolization because of unfiltered exhalation.

  • There is inadequate evidence to recommend the use of passive barrier devices such as “intubation boxes.” The United States Food and Drug Administration has advised that health care providers should not use passive protective barrier enclosures without negative pressure and that any protective barrier enclosure (with or without negative pressure) should not substitute for appropriate PPE. Further, any protective barrier that impedes the ability to perform essential medical procedures, such as bag–mask ventilation, intubation, or CPR, should be avoided.63 

Updated algorithms for CPR for patients with suspected or confirmed COVID-19 are depicted in Figs 2, 3, and 4. As noted above, these algorithms are largely consistent with standard pediatric basic life support and pediatric advanced life support algorithms,5 with additional guidance on reducing provider risk. As with the standard algorithms, the pediatric advanced life support algorithm applies to infants, children, and adolescents up to 18 years of age and pediatric basic life support algorithm should be applied as follows:

  • Infant guidelines apply to infants younger than ∼1 year of age.

  • Child guidelines apply from ∼1 year of age until puberty.

  • Adult basic life support should be followed for those with signs of puberty and beyond (not shown in this article).4,64 

Neonatal resuscitation should be performed in accordance with 2020 AHA Neonatal Resuscitation Guidelines,51 with additional considerations as detailed below.

In patients who are known to be SARS-CoV-2–negative or in whom it is not suspected on the basis of symptoms or community prevalence, resuscitation should proceed according to standard algorithms contained in the 2020 AHA Guidelines for CPR and Emergency Cardiovascular Care.5,51 

Guidance regarding emergency medical services and lay rescuer CPR for adults and children with out-of-hospital cardiac arrest (OHCA) is described in detail in other literature.65,66 

  • Before or upon arrival, emergency medical services providers should rapidly don PPE suited for AGPs and excuse unprotected persons from the immediate vicinity of the resuscitation as soon as possible.

  • Chest compressions with ventilations should be immediately initiated for pediatric OHCA. The need for HEPA-filtered ventilation and AGP-appropriate PPE should be anticipated for all pediatric OHCAs.

  • When indoors, opening windows or doors may help disperse aerosolized particles and reduce provider risk. Clear nonresponders from the vicinity.

  • Closely monitor for signs and symptoms of clinical deterioration to minimize the need for emergent intubation or CPR, which places patients and providers at higher risk.

  • Per routine best practice for all critically ill children, address advanced care directives and goals of care with all patients or their decision-makers on hospital arrival and with any significant change in clinical status.

  • If a patient with suspected or confirmed COVID-19 is at risk for cardiac arrest, consider proactive use of N95 respirators and other AGP-appropriate PPE. Consider moving the patient to a negative-pressure room/unit, if available, to minimize risk of exposure to rescuers during a resuscitation. Regardless of the type of hospital room, close the door whenever possible to prevent contamination of adjacent spaces and ensure staff are aware of the patient’s COVID-19 status.

  • Plan for PPE, HEPA filters, and other equipment for reducing risk to providers to be strategically positioned throughout the hospital to avoid unnecessary exposures or delays in CPR initiation.

  • Ensure that resuscitation providers are trained and prepared to efficiently don PPE. Consider instructing resuscitation team responders to always carry N95 respirators and eye protection and don them en route or immediately upon arrival to the patient’s room or bedside.

  • In addition to proactive placement in negative-pressure rooms, closing the door to the resuscitation area, when possible, may minimize contamination of adjacent indoor space.

  • To avoid unnecessary provider exposure to patients with COVID-19, crowd control efforts should minimize the number of persons in the patient room or at the bedside.

  • Consider assigning a PPE monitor to ensure resuscitation team members use appropriate PPE. In the event that initial responders are performing CPR without having fully donned appropriate PPE, they should be immediately relieved by responders wearing appropriate PPE.

To reduce aerosol dispersion, consider leaving patients on invasive mechanical ventilation connected to the closed ventilator circuit with a HEPA filter. As per standard resuscitation guidelines, confirm endotracheal tube position and patency.5 Adjust the ventilator settings to allow asynchronous ventilation with the following suggestions:

  • Increase the fraction of inspired oxygen to 1.0 for children. For neonates, follow usual guidelines for oxygen titration during resuscitation.

  • Use either pressure or volume control ventilation, with peak inspiratory pressure or tidal volume set to generate adequate chest rise. Initial ventilator settings should reflect patient age and size, underlying respiratory disease, prearrest ventilator settings, and local practices.

  • Adjust the trigger settings to prevent the ventilator from auto triggering with chest compressions, which could result in hyperventilation and air trapping.

  • Adjust the mandatory ventilation rate to 20 to 30 breaths per minute for infants and children and 30 breaths per minute for neonates.

  • Assess the need to adjust the positive end-expiratory pressure level to balance lung volumes and venous return.

  • Adjust ventilator settings to deliver full breaths during chest compressions.

  • Ensure endotracheal tube/ tracheostomy and ventilator circuit continuity to prevent unplanned airway dislodgement or tubing disconnections.

  • As with any intubated patient, end-tidal carbon dioxide monitoring should be considered to help assess endotracheal tube placement, quality of CPR, and evidence of return of spontaneous circulation.

  • If return of spontaneous circulation is achieved, set ventilator settings appropriate for the patient’s clinical condition and for achievement of postarrest goals.

Anticipation and preparation are important before rotating patients to a supine position. The limited adult evidence for providing CPR in the prone position suggests that it may be a feasible alternative when a patient cannot be immediately transitioned to a supine position.67 There are minimal data regarding prone CPR in children, but its successful use has been described.6870  Of note, supination of small children and infants may require less personnel and thereby be more readily achievable.

For patients in the prone position with an advanced airway, it may be reasonable to provide manual compressions in the prone position until the patient can be safely transitioned to a supine position with a trained team. The following steps for providing prone CPR and transitioning a patient to a supine position are suggested:

  • Provide compressions with hands centered over the T7 to T10 vertebral bodies.

  • If an advanced airway is in place, ensure that the airway is not dislodged, disconnected, or obstructed.

  • Arrange for sufficient, trained, PPE-protected personnel to achieve safe supination on the first attempt, with minimal risk of ventilator disconnections or endotracheal tube dislodgment.

  • Immediately resume CPR in the supine position once the patient has been rotated.

  • Confirm that the airway, vascular access lines, and other devices have not been dislodged and are in working order.

This guidance primarily applies to infants during the “newly born” period from birth to the end of resuscitation and stabilization in the delivery area. However, the concepts discussed below, as with Neonatal Life Support Guidelines,51 may be applied throughout the neonatal period (birth–28 days).

Every newborn baby should have a skilled attendant prepared to resuscitate, regardless of COVID-19 status. Newborns are unlikely to be a source of SARS-CoV-2 transmission even when mothers have confirmed COVID-19, but maternal respiratory secretions and fluids may be a potential source of SARS-CoV-2 transmission for the neonatal resuscitation team and newborn. Particular attention should be paid to preparation for birth because neonatal resuscitation teams may be called to resuscitate newborns in locations where the team is less accustomed to working (eg, adult ICUs). When appropriate, mothers can be encouraged to wear a surgical mask during the delivery. For mothers with suspected or confirmed COVID-19, health care providers should don appropriate PPE for AGPs to decrease the risk of transmission to themselves and the newborn.

  • Initial steps: Routine neonatal care and the initial steps of neonatal resuscitation are unlikely to be aerosol-generating and should not be delayed or altered because of COVID-19 status; they include drying, tactile stimulation, use of plastic bags or wraps to prevent hypothermia, assessment of heart rate, and placement of pulse oximetry and electrocardiographic leads.51 

  • Suction: Decision-making regarding suctioning in the newborn period should follow standard neonatal resuscitation guidelines51 and should not be based on COVID-19 status. Suction of the airway after delivery should not be performed routinely for clear or meconium-stained amniotic fluid and is not indicated for uncomplicated deliveries, regardless of COVID-19 status. Suctioning should be performed for neonates with suspected airway obstruction, noting that it is an AGP.

  • Opening the airway and delivering positive-pressure ventilation via mask remains the main resuscitation strategy for newborns with apnea, ineffective breathing (gasping), and bradycardia. This should be provided without delay by providers in appropriate PPE. Chest compressions occur later in the resuscitation algorithm,51 and are indicated when the heart rate remains <60 beats per minute despite 30 seconds of adequate positive-pressure ventilation.

  • Endotracheal medications: Endotracheal instillation of medications is suspected to be an AGP, especially via an uncuffed endotracheal tube. Intravascular delivery of epinephrine via a low-lying umbilical venous catheter is the preferred route of administration during neonatal resuscitation, regardless of COVID-19 status.

  • Delayed cord clamping and skin-to-skin contact may be practiced with a clinically stable neonate and a mother with suspected or confirmed COVID-19, provided the mother is appropriately masked.

  • Mothers with suspected or confirmed COVID-19 should practice hand and breast hygiene and wear a mask during care and feeding.

  • Closed incubators: Closed incubator transfer and care (with appropriate distancing) should be used when possible, but incubators do not protect against aerosolized particles.

Maternal respiratory secretions and fluids may be sources of SARS-CoV-2 transmission for newborns and neonatal resuscitation teams. Moreover, pregnant women with symptomatic COVID-19 are at increased risk of more severe illness compared with nonpregnant peers of similar age. Although the absolute risk for severe COVID-19 is low, data indicate an increased risk of ICU admission, need for mechanical ventilation, and death in pregnant women with COVID-19.71 Given their role in newborn resuscitation, neonatal/pediatric providers should be aware of maternal cardiac arrest principles, including: prioritization of oxygenation and early intubation; provision of chest compressions with concurrent left lateral uterine displacement if the uterine fundus is at or above the level of the umbilicus; and preparation for perimortem cesarean delivery.

Health care providers wearing appropriate PPE should continue to provide postcardiac arrest care per the 2020 AHA Guidelines for CPR and Emergency Cardiovascular Care.5 

CPR for patients with suspected or confirmed COVID-19 is not inherently futile, and decisions regarding the degree and duration of resuscitation care provided should be made in a manner consistent with those made for other patients. Because most children with SARS-CoV-2 do not have severe COVID-19 disease, cardiac arrest in patients who are SARS-CoV-2–positive may occur because of non-COVID-19–related disease processes. Address and follow the patient’s goals of care and commit to ethical and evidence-based organizational policies regarding the initiation and continuation of resuscitative efforts. Follow the 2020 AHA Guidelines for CPR and Emergency Cardiovascular Care for termination of resuscitation.5,64 

The American Heart Association Emergency Cardiovascular Committee and Get with the Guidelines-Resuscitation Pediatric Task Force writing group members include Lance B. Becker, MD, Steven M. Bradley, MD, MPH, Steven C. Brooks, MD, MHSc, Paul S. Chan, MD, MS, Brian M. Clemency, DO, MBA, Dana P. Edelson, MD, MS, Gustavo E. Flores, MD, NRP, Saket Girotra, MD, SM, Carl Hinkson, MS, RRT-ACCS, Peter J. Kudenchuk, MD, Eric J. Lavonas, MD, MS, Mary E. Mancini, RN, PhD, NE-BC, Raina M. Merchant, MD, MSHP, Vivek K. Moitra, MD, MHA, Ashish R. Panchal, MD, PhD, Mary Ann Peberdy, MD, Michael R. Sayre, MD, and David S. Wang, MD.

Drs Morgan, Atkins, Hsu, Kamath-Rayne, Sasson, and Topjian conceived and designed this article, reviewed and analyzed the relevant data, and drafted the original manuscript; Mr Aziz, Drs Berg, Bhanji, Chan, Cheng, Chiotos, de Caen, Duff, Fuchs, Joyner, Kleinman, Lasa, Lee, Lehotzky, Levy, McBride, Meckler, Nadkarni, Raymond, Schexnayder, Sutton, Walsh, Zelop, Ms Roberts, and Mr Terry reviewed and analyzed the relevant data; and all authors interpreted the data, led or participated in discussions regarding appropriate guidance, critically revised the manuscript for important intellectual content, approved of the final manuscript, and agree to be accountable for all aspects of the work.

    Abbreviations
     
  • AGP

    aerosol-generating procedure

  •  
  • AHA

    American Heart Association

  •  
  • COVID-19

    coronavirus disease 2019

  •  
  • CPR

    cardiopulmonary resuscitation

  •  
  • HEPA

    high-efficiency particulate air

  •  
  • OHCA

    out-of-hospital cardiac arrest

  •  
  • PPE

    personal protective equipment

  •  
  • SARS-CoV-2

    severe acute respiratory syndrome coronavirus 2

1
Edelson
DP
,
Sasson
C
,
Chan
PS
, et al
American Heart Association ECC Interim COVID Guidance Authors
.
Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: from the Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association
.
Circulation.
2020
;
141
(
25
):
e933
e943
2
Topjian
A
,
Aziz
K
,
Kamath-Rayne
BD
, et al
Interim Guidance for Basic and Advanced Life Support in Children and Neonates With Suspected or Confirmed COVID-19
. [Published online ahead of print May 4, 2020]
Pediatrics.
2020
;
e20201405
3
Aydogdu
MO
,
Rohn
JL
,
Jafari
NV
,
Brako
F
,
Homer-Vanniasinkam
S
,
Edirisinghe
M
.
Severe acute respiratory syndrome type 2-causing coronavirus: variants and preventive strategies
.
Adv Sci (Weinh).
2022
;
9
(
11
):
e2104495
4
Atkins
DL
,
Sasson
C
,
Hsu
A
, et al
Emergency Cardiovascular Care Committee and Get With the Guidelines-Resuscitation
,
Adult and Pediatric Task Forces of the American Heart Association in Collaboration With the American Academy of Pediatrics
,
American Association for Respiratory Care, American Society of Anesthesiologists
, and the
Society of Critical Care Anesthesiologists
.
2022 Interim Guidance to Health Care Providers for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: from the Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, the Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists
.
Circ Cardiovasc Qual Outcomes.
2022
;
15
(
4
):
e008900
5
Topjian
AA
,
Raymond
TT
,
Atkins
D
, et al
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
.
Pediatrics.
2021
;
147
(
Suppl 1
):
e2020038505D
6
Lauridsen
KG
,
Morgan
RW
,
Dewan
M
,
Gawronski
O
,
Sen
AI
.
PediRES-Q Investigators
.
In-hospital cardiac arrest characteristics, CPR quality, and outcomes in children with COVID-19
.
Resuscitation.
2021
;
169
:
39
40
7
Baert
V
,
Jaeger
D
,
Hubert
H
, et al
;
GR-RéAC
.
Assessment of changes in cardiopulmonary resuscitation practices and outcomes on 1005 victims of out-of- hospital cardiac arrest during the COVID-19 outbreak: registry-based study
.
Scand J Trauma Resusc Emerg Med.
2020
;
28
(
1
):
119
8
Baldi
E
,
Sechi
GM
,
Mare
C
, et al
all the Lombardia CARe researchers
.
Treatment of out-of-hospital cardiac arrest in the COVID-19 era: a 100-days experience from the Lombardy region
.
PLoS One.
2020
;
15
(
10
):
e0241028
9
Ball
J
,
Nehme
Z
,
Bernard
S
,
Stub
D
,
Stephenson
M
,
Smith
K
.
Collateral damage: Hidden impact of the COVID-19 pandemic on the out-of-hospital cardiac arrest system-of-care
.
Resuscitation.
2020
;
156
:
157
163
10
Tong
SK
,
Ling
L
,
Zhang
JZ
,
Yap
FHY
,
Law
KL
,
Joynt
GM
.
Effect of the COVID-19 pandemic on cardiac arrest resuscitation practices and outcomes in non-COVID-19 patients
.
J Intensive Care.
2021
;
9
(
1
):
55
11
Borkowska
MJ
,
Jaguszewski
MJ
,
Koda
M
, et al
Impact of coronavirus disease 2019 on out-of-hospital cardiac arrest survival rate: a systematic review with meta-analysis
.
J Clin Med.
2021
;
10
(
6
):
1209
12
Sultanian
P
,
Lundgren
P
,
Strömsöe
A
, et al
Cardiac arrest in COVID-19: characteristics and outcomes of in- and out-of-hospital cardiac arrest. A report from the Swedish Registry for Cardiopulmonary Resuscitation
.
Eur Heart J.
2021
;
42
(
11
):
1094
1106
13
Fothergill
RT
,
Smith
AL
,
Wrigley
F
,
Perkins
GD
.
Out-of-hospital cardiac arrest in London during the COVID-19 pandemic
.
Resusc Plus.
2021
;
5
:
100066
14
Miles
JA
,
Mejia
M
,
Rios
S
, et al
Characteristics and outcomes of in-hospital cardiac arrest events during the COVID-19 Pandemic: a single-center experience from a New York City public hospital
.
Circ Cardiovasc Qual Outcomes.
2020
;
13
(
11
):
e007303
15
Lai
PH
,
Lancet
EA
,
Weiden
MD
, et al
Characteristics associated with out-of-hospital cardiac arrests and resuscitations during the novel coronavirus disease 2019 pandemic in New York City
.
JAMA Cardiol.
2020
;
5
(
10
):
1154
1163
16
Shah
P
,
Smith
H
,
Olarewaju
A
, et al
Is cardiopulmonary resuscitation futile in coronavirus disease 2019 patients experiencing in-hospital cardiac arrest?
Crit Care Med.
2021
;
49
(
2
):
201
208
17
Hayek
SS
,
Brenner
SK
,
Azam
TU
, et al
STOP-COVID Investigators
.
In-hospital cardiac arrest in critically ill patients with COVID-19: multicenter cohort study
.
BMJ.
2020
;
371
:
m3513
18
Yuriditsky
E
,
Mitchell
OJL
,
Brosnahan
SB
, et al
Clinical characteristics and outcomes of in-hospital cardiac arrest among patients with and without COVID-19
.
Resusc Plus.
2020
;
4
:
100054
19
Szarpak
L
,
Borkowska
M
,
Peacock
FW
, et al
Characteristics and outcomes of in-hospital cardiac arrest in COVID-19. A systematic review and meta-analysis
.
Cardiol J.
2021
;
28
(
4
):
503
508
20
Roedl
K
,
Söffker
G
,
Fischer
D
, et al
Effects of COVID-19 on in-hospital cardiac arrest: incidence, causes, and outcome - a retrospective cohort study
.
Scand J Trauma Resusc Emerg Med.
2021
;
29
(
1
):
30
21
Sun
C
,
Dyer
S
,
Salvia
J
,
Segal
L
,
Levi
R
.
Worse cardiac arrest outcomes during the COVID-19 pandemic in Boston can be attributed to patient reluctance to seek care
.
Health Aff (Millwood).
2021
;
40
(
6
):
886
895
22
Chen
J
,
Lu
KZ
,
Yi
B
,
Chen
Y
.
Chest compression with personal protective equipment during cardiopulmonary resuscitation: a randomized crossover simulation study
.
Medicine (Baltimore).
2016
;
95
(
14
):
e3262
23
Mitchell
OJL
,
Yuriditsky
E
,
Johnson
NJ
, et al
Coronavirus 2019 In-Hospital Cardiac Arrest (COVID IHCA) Study Group
.
In-hospital cardiac arrest in patients with coronavirus 2019
.
Resuscitation.
2021
;
160
:
72
78
24
Shekerdemian
LS
,
Mahmood
NR
,
Wolfe
KK
, et al
International COVID-19 PICU Collaborative
.
Characteristics and outcomes of children with coronavirus disease 2019 (COVID-19) infection admitted to US and Canadian pediatric intensive care units
.
JAMA Pediatr.
2020
;
174
(
9
):
868
873
25
Bhalala
US
,
Gist
KM
,
Tripathi
S
, et al
Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS): COVID-19 Registry Investigator Group
.
Characterization and outcomes of hospitalized children with coronavirus disease 2019: a report from a multicenter, viral infection and respiratory illness universal study (coronavirus disease 2019) registry
.
Crit Care Med.
2022
;
50
(
1
):
e40
e51
26
Tripathi
S
,
Gist
KM
,
Bjornstad
EC
, et al
Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS): COVID-19 Registry Investigator Group
.
Coronavirus disease 2019-associated PICU admissions: a report from the society of critical care medicine discovery network viral infection and respiratory illness universal study registry
.
Pediatr Crit Care Med.
2021
;
22
(
7
):
603
615
27
Marks
KJ
,
Whitaker
M
,
Anglin
O
, et al
COVID-NET Surveillance Team
.
Hospitalizations of children and adolescents with laboratory-confirmed COVID-19–COVID-NET, 14 States, July 2021–January 2022
.
MMWR Morb Mortal Wkly Rep.
2022
;
71
(
7
):
271
278
28
Wanga
V
,
Gerdes
ME
,
Shi
DS
, et al
BMBS1
.
Characteristics and clinical outcomes of children and adolescents aged <18 years hospitalized with COVID-19–six hospitals, United States, July–August 2021
.
MMWR Morb Mortal Wkly Rep.
2021
;
70
(
5152
):
1766
1772
29
Delahoy
MJ
,
Ujamaa
D
,
Whitaker
M
, et al
COVID-NET Surveillance Team
;
COVID-NET Surveillance Team
.
Hospitalizations associated with COVID-19 among children and adolescents–COVID-NET, 14 States, March 1, 2020–August 14, 2021
.
MMWR Morb Mortal Wkly Rep.
2021
;
70
(
36
):
1255
1260
30
Havers
FP
,
Whitaker
M
,
Self
JL
, et al
COVID-NET Surveillance Team
.
Hospitalization of adolescents aged 12–17 years with laboratory-confirmed COVID-19–COVID-NET, 14 States, March 1, 2020–April 24, 2021
.
MMWR Morb Mortal Wkly Rep.
2021
;
70
(
23
):
851
857
31
Hacisuleyman
E
,
Hale
C
,
Saito
Y
, et al
Vaccine breakthrough infections with sars-cov-2 variants
.
N Engl J Med.
2021
;
384
(
23
):
2212
2218
32
Lynch
JB
,
Davitkov
P
,
Anderson
DJ
, et al
Infectious Diseases Society of America Guidelines on Infection Prevention for Healthcare Personnel Caring for Patients with Suspected or Known COVID-19
. [Published online ahead of print November 15, 2021]
Clin Infect Dis.
2021
;
ciab953
33
Klompas
M
,
Milton
DK
,
Rhee
C
,
Baker
MA
,
Leekha
S
.
Current insights into respiratory virus transmission and potential implications for infection control programs : a narrative review
.
Ann Intern Med.
2021
;
174
(
12
):
1710
1718
34
Brown
A
,
Schwarcz
L
,
Counts
CR
, et al
Risk for acquiring coronavirus disease illness among emergency medical service personnel exposed to aerosol-generating procedures
.
Emerg Infect Dis.
2021
;
27
(
9
):
2340
2348
35
Couper
K
,
Taylor-Phillips
S
,
Grove
A
, et al
COVID-19 in cardiac arrest and infection risk to rescuers: a systematic review
.
Resuscitation.
2020
;
151
:
59
66
36
Centers for Disease Control and Prevention
.
COVID-19 Risk–Which procedures are considered aerosol generating procedures in healthcare settings?
Available at:
https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-faq.html.
Accessed January 6, 2022
37
Tran
K
,
Cimon
K
,
Severn
M
,
Pessoa-Silva
CL
,
Conly
J
.
Aerosol generating procedures and risk of transmission of acute respiratory infections to health care workers: a systematic review
.
PLoS One.
2012
;
7
(
4
):
e35797
38
Dhillon
RS
,
Rowin
WA
,
Humphries
RS
, et al
Clinical Aerosolisation Study Group
.
Aerosolisation during tracheal intubation and extubation in an operating theatre setting
.
Anaesthesia.
2021
;
76
(
2
):
182
188
39
Centers for Disease Control and Prevention
.
Clinical questions about COVID-19: questions and answers
. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html#Infection-Control. Accessed February 2, 2022
40
Wyckoff
MH
,
Singletary
EM
,
Soar
J
, et al
Collaborators
.
2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with treatment recommendations: summary from the basic life support; advanced life support; neonatal life support; education, implementation, and teams; first aid task forces; and the COVID-19 Working Group
.
Circulation.
2022
;
145
(
9
):
e645
e721
41
Raboud
J
,
Shigayeva
A
,
McGeer
A
, et al
Risk factors for SARS transmission from patients requiring intubation: a multicentre investigation in Toronto, Canada
.
PLoS One.
2010
;
5
(
5
):
e10717
42
World Health Organization
.
WHO recommendations on mask use by health workers, in light of the Omicron variant of concern: WHO interim guidelines, December 22, 2021
. Available at: https://www. who.int/publications/i/item/WHO-2019- nCoV-IPC_Masks-Health_Workers- Omicron_variant-2021.1. Accessed January 6, 2022.
43
Centers for Disease Control and Prevention
.
Interim infection prevention and control recommendations for health care personnel during the coronavirus disease
. Available at: https://www.cdc.gov/coronavirus/2019-nCoV/hcp/infection-control-recommendations.html. Accessed March 23, 2022
44
Keehner
J
,
Horton
LE
,
Pfeffer
MA
, et al
SARS-CoV-2 infection after vaccination in health care workers in California
.
N Engl J Med.
2021
;
384
(
18
):
1774
1775
45
Thompson
MG
,
Burgess
JL
,
Naleway
AL
, et al
Interim estimates of vaccine effectiveness of BNT162b2 and mRNA-1273 COVID-19 vaccines in preventing SARS-CoV-2 infection among health care personnel, first responders, and other essential and frontline workers –Eight US locations, December 2020–March 2021
.
MMWR Morb Mortal Wkly Rep.
2021
;
70
(
13
):
495
500
46
Holmberg
MJ
,
Wiberg
S
,
Ross
CE
, et al
Trends in survival after pediatric in-hospital cardiac arrest in the United States
.
Circulation.
2019
;
140
(
17
):
1398
1408
47
Morgan
RW
,
Kirschen
MP
,
Kilbaugh
TJ
,
Sutton
RM
,
Topjian
AA
.
Pediatric in-hospital cardiac arrest and cardiopulmonary resuscitation in the United States: a review
.
JAMA Pediatr.
2021
;
175
(
3
):
293
302
48
Naim
MY
,
Griffis
HM
,
Berg
RA
, et al
Compression-only versus rescue-breathing cardiopulmonary resuscitation after pediatric out-of-hospital cardiac arrest
.
J Am Coll Cardiol.
2021
;
78
(
10
):
1042
1052
49
Naim
MY
,
Burke
RV
,
McNally
BF
, et al
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
(
2
):
133
141
50
Ersdal
HL
,
Mduma
E
,
Svensen
E
,
Perlman
JM
.
Early initiation of basic resuscitation interventions including face mask ventilation may reduce birth asphyxia related mortality in low-income countries: a prospective descriptive observational study
.
Resuscitation.
2012
;
83
(
7
):
869
873
51
Aziz
K
,
Lee
CHC
,
Escobedo
MB
, et al
Part 5: Neonatal Resuscitation 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
.
Pediatrics.
2021
;
147
(
Suppl 1
):
e2020038505E
52
Hsu
A
,
Sasson
C
,
Kudenchuk
PJ
, et al
2021 Interim Guidance to Health Care Providers for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19
.
Circ Cardiovasc Qual Outcomes.
2021
;
14
(
10
):
e008396
53
Weissman
DN
,
de Perio
MA
,
Radonovich
LJ
Jr
.
COVID-19 and risks posed to personnel during endotracheal intubation
.
JAMA.
2020
;
323
(
20
):
2027
2028
54
Duff
JP
,
Topjian
AA
,
Berg
MD
, et al
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
(
24
):
e904
e914
55
Ott
M
,
Milazzo
A
,
Liebau
S
, et al
Exploration of strategies to reduce aerosol-spread during chest compressions: a simulation and cadaver model
.
Resuscitation.
2020
;
152
:
192
198
56
Shrimpton
AJ
,
Brown
JM
,
Cook
TM
,
Pickering
AE
.
A quantitative evaluation of aerosol generation during supraglottic airway insertion and removal
.
Anaesthesia.
2022
;
77
(
2
):
230
231
57
Tian
Y
,
Tu
X
,
Zhou
X
, et al
Wearing an N95 mask increases rescuer’s fatigue and decreases chest compression quality in simulated cardiopulmonary resuscitation
.
Am J Emerg Med.
2021
;
44
:
434
438
58
Malysz
M
,
Dabrowski
M
,
Böttiger
BW
, et al
Resuscitation of the patient with suspected/confirmed COVID-19 when wearing personal protective equipment: A randomized multicenter crossover simulation trial
.
Cardiol J.
2020
;
27
(
5
):
497
506
59
Kim
HT
,
Kim
JG
,
Jang
YS
, et al
Comparison of in-hospital use of mechanical chest compression devices for out-of-hospital cardiac arrest patients: AUTOPULSE vs LUCAS
.
Medicine (Baltimore).
2019
;
98
(
45
):
e17881
60
Bhatnagar
A
,
Khraishah
H
,
Lee
J
, et al
Rapid implementation of a mechanical chest compression device for in-hospital cardiac arrest during the COVID-19 pandemic
.
Resuscitation.
2020
;
156
:
4
5
61
Yang
SS
,
Zhang
M
,
Chong
JJR
.
Comparison of three tracheal intubation methods for reducing droplet spread for use in COVID-19 patients
.
Br J Anaesth.
2020
;
125
(
1
):
e190
e191
62
Puthenveettil
N
,
Rahman
S
,
Vijayaraghavan
S
,
Suresh
S
,
Kadapamannil
D
,
Paul
J
.
Comparison of aerosol box intubation with C-MAC video laryngoscope and direct laryngoscopy-A randomised controlled trial
.
Indian J Anaesth.
2021
;
65
(
2
):
133
138
63
US Food and Drug Administration
.
Protective barrier enclosures without negative pressure used during the COVID-19 pandemic may increase risk to patients and health care providers–letter to health care providers
. Available at: https://www.fda.gov/medical-devices/letters- health-care-providers/protective- barrier-enclosures-without-negative- pressure-used-during-covid-19-pandemic- may-increase. Accessed October 3, 2021
64
Panchal
AR
,
Bartos
JA
,
Cabañas
JG
, et al
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
(
16_suppl_2
):
S366
S468
65
Sayre
MR
,
Barnard
LM
,
Counts
CR
, et al
Prevalence of COVID-19 in out-of-hospital cardiac arrest: implications for bystander cardiopulmonary resuscitation
.
Circulation.
2020
;
142
(
5
):
507
509
66
Goodloe
JM
,
Topjian
A
,
Hsu
A
, et al
Interim guidance for emergency medical services management of out-of-hospital cardiac arrest during the COVID-19 pandemic
.
Circ Cardiovasc Qual Outcomes.
2021
;
14
(
7
):
e007666
67
Anez
C
,
Becerra-Bolaños
Á
,
Vives-Lopez
A
,
Rodríguez-Pérez
A
.
Cardiopulmonary resuscitation in the prone position in the operating room or in the intensive care unit: a systematic review
.
Anesth Analg.
2021
;
132
(
2
):
285
292
68
Tobias
JD
,
Mencio
GA
,
Atwood
R
,
Gurwitz
GS
.
Intraoperative cardiopulmonary resuscitation in the prone position
.
J Pediatr Surg.
1994
;
29
(
12
):
1537
1538
69
Kelleher
A
,
Mackersie
A
.
Cardiac arrest and resuscitation of a 6-month old achondroplastic baby undergoing neurosurgery in the prone position
.
Anaesthesia.
1995
;
50
(
4
):
348
350
70
Mayorga-Buiza
MJ
,
Rivero-Garvia
M
,
Gomez-Gonzalez
E
,
Marquez-Rivas
J
.
Cardiac pulmonary resuscitation in prone position. The best option for posterior fossa neurosurgical patients
.
Paediatr Anaesth.
2018
;
28
(
8
):
746
747
71
Zambrano
LD
,
Ellington
S
,
Strid
P
, et al
CDC COVID-19 Response Pregnancy and Infant Linked Outcomes Team
.
Update: characteristics of symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status–United States, January 22–October 3, 2020
.
MMWR Morb Mortal Wkly Rep.
2020
;
69
(
44
):
1641
1647

Competing Interests

CONFLICT OF INTEREST DISCLAIMER: Dr Morgan reports grants from National Institutes of Health. Dr Atkins reports compensation from National Institutes of Health for data and safety monitoring services. Dr Kamath-Rayne reports employment by American Academy of Pediatrics. Dr Cheng reports grants from Canadian Institutes of Health Research and employment by Alberta Health Services. Dr Fuchs reports royalty from UpToDate. Dr Kleinman reports compensation from Beth Israel Deaconess Medical Center for data and safety monitoring services, employment by Boston Children's Hospital, and compensation from American Heart Association for consultant services. Dr Lehotzky reports employment by American Heart Association. Dr McBride reports compensation from American Heart Association for consultant services. Ms Roberts reports compensation from American Association of Critical-Care Nurses for consultant services. Dr Zelop reports compensation from Uptodate for consultant services. The other authors have indicated they have no conflicts of interest relevant to this article to disclose.