PALS Manual Updates At-A-Glance: 2020 to 2025

Current Recommendations – Guideline Updates
Cardiopulmonary Resuscitation (CPR)

• Bystanders should provide CPR with ventilation for infants and children less than 18 years of age with OHCA
• Bystanders who cannot provide rescue breaths as part of CPR for infants and children less than 18 years of age with OHCA, should at least provide chest compressions
• EMS dispatchers should offer dispatcher-assisted CPR instructions for presumed pediatric cardiac arrest
• EMS dispatchers should offer dispatcher-assisted CPR instructions for pediatric cardiac arrest when no bystander CPR is in progress
• There is insufficient evidence to recommend the routine use of extracorporeal CPR for patients with out-of-hospital cardiac arrest in pediatrics
• Extracorporeal CPR may be considered for select pediatric patients with in-hospital cardiac arrest as a rescue therapy when conventional CPR is failing, if it can be implemented competently and efficiently
• Continuous arterial blood pressure and end-tidal carbon dioxide measurement can be used to improve the quality of CPR during ACLS resuscitation
• After a resuscitation, lay rescuers, EMS providers, and hospital-based healthcare workers may benefit from debriefing to support their mental health and well-being
• Extracorporeal CPR may be considered for pediatric in-hospital cardiac arrest (IHCA) for cardiac diagnoses if it can be implemented; It is unclear whether extracorporeal CPR is beneficial for pediatric out-of-hospital cardiac arrest (OHCA)

Respiratory Arrest

• For pediatric patients in respiratory distress or arrest (pulse is present but inadequate breathing), provide 1 breath every 2 to 3 seconds. Previous recommendations suggested 1 breath every 3 to 5 seconds.
• The same rate—1 breath every 2 to 3 seconds—should be used during CPR with an advanced airway in place. Previous recommendations suggested intubated pediatric patients should receive 1 breath every 6 seconds.
• For patients in respiratory arrest, rescue breathing (or other assisted ventilation) should be maintained until spontaneous breathing returns or care is withdrawn

Cardiac Arrest

• The first dose of epinephrine should be administered within 5 minutes of starting chest compressions in pediatric patients
• Diastolic blood pressure should be used to assess the quality of CPR when arterial blood pressure monitoring is in place. Target diastolic blood pressures are ≥25 mm Hg in infants and ≥30 mm Hg in children

Airways

• Bag-mask ventilation is a reasonable alternative to endotracheal intubation or supraglottic airway in the management of children during OHCA
• Cuffed endotracheal tubes are preferred over uncuffed endotracheal tubes; however, it is important to use the correct size and cuff inflation for the specific pediatric patient
• Routine use of cricoid pressure during endotracheal intubation of pediatric patients is not recommended

Targeted Temperature Management

• For infants and children between 24 hours and 18 years of age who remain comatose after out-of-hospital or in-hospital
  cardiac arrest, it is reasonable to use either targeted temperature management 32°C to 34°C followed by targeted temperature management 36°C to 37.5°C or to use targeted temperature management 36°C to 37.5°C. There is insufficient evidence to support a recommendation about treatment duration.

Ventricular Fibrillation/Pulseless Ventricular Tachycardia

• Amiodarone or lidocaine may be used for ventricular fibrillation/pulseless ventricular tachycardia that does not respond to defibrillation

Shock Management

• In trauma-related hypotensive hemorrhagic shock, blood products may be used instead of crystalloid for volume resuscitation in pediatric patients
• In septic shock, pediatric patients may receive 10 – 20 mL/kg intravenous fluid aliquots. Previously, a 20 mL/kg bolus was recommended, but less fluid initially may be considered.
• For infants and children with septic shock that does not respond favorably to fluid administration, either epinephrine or norepinephrine should be used initially. Dopamine may be considered secondarily.
• For infants and children with septic shock that does not respond favorably to fluid administration and consequently require vasopressors, consider stress-dose corticosteroids

Supplemental Oxygen

• Patients in cardiac arrest should receive 100% supplemental oxygen; pulse oximetry measurements are not used to titrate supplemental oxygen
• Acute coronary syndrome pulse oximetry range: 90% or higher (i.e., supplement below 90%)
• Stroke pulse oximetry range: pulse oximetry 95% to 98% (inclusive)
• ROSC and post-cardiac arrest care pulse oximetry range: pulse oximetry 92% to 98% (inclusive)

Post-Cardiac Arrest Care

• In pediatric patients who have persistent encephalopathy following cardiac arrest, consider continuous electroencephalography to detect nonconvulsive status epilepticus
• Clinical seizures and nonconvulsive status epilepticus should be treated, as appropriate
• Pediatric cardiac arrest survivors should be evaluated for rehabilitation services and be followed by neurology for at least one year

Suspected Opioid Overdose

• For pediatric patients with suspected opioid overdose, naloxone administration is reasonable in addition to BLS/PALS; however, resuscitative measures for cardiac arrest (e.g., high quality CPR) should take priority over naloxone administration

Myocarditis/Cardiomyopathy

• For pediatric patients with myocarditis or cardiomyopathy, it is reasonable to use extracorporeal life support such as mechanical circulation devices to prevent cardiac arrest
• If cardiac arrest does occur in pediatric patients with myocarditis or cardiomyopathy, consider extracorporeal CPR and transfer to an ICU as early as possible

Hypoglycemia

• For pediatric patients with hypoglycemia who are awake but unwilling to swallow oral glucose, it is reasonable to place a slurry of sugar and water under the child’s tongue