Figure 11. Pediatric Cardiac Arrest Algorithm.

16 American Heart Association

 Pediatric Basic and Advanced Life Support

Figure 12. Pediatric Bradycardia With a Pulse Algorithm.

eccguidelines.heart.org 17
Figure 13. Pediatric Tachycardia With a Pulse Algorithm.

18 American Heart Association

 Pediatric Basic and Advanced Life Support

Figure 14. Pediatric Post–Cardiac Arrest Care Checklist.

eccguidelines.heart.org 19
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Pediatric Basic and Advanced Life Support
Summary of Key Issues and Major Changes
More than 20 000 infants and children have a cardiac arrest
each year in the United States. Despite increases in survival
and comparatively good rates of good neurologic outcome
after pediatric IHCA, survival rates from pediatric OHCA
remain poor, particularly in infants. Recommendations
for pediatric basic life support (PBLS) and CPR in infants,
children, and adolescents have been combined with rec-
ommendations for pediatric advanced life support (PALS)
in a single document in the 2020 Guidelines. The causes
of cardiac arrest in infants and children differ from cardiac
arrest in adults, and a growing body of pediatric-specif-
ic evidence supports these recommendations. Key issues,
major changes, and enhancements in the 2020 Guidelines
include the following:
• Algorithms and visual aids were revised to incorporate
the best science and improve clarity for PBLS and PALS
resuscitation providers.
• Based on newly available data from pediatric resuscitations,
the recommended assisted ventilation rate has been
increased to 1 breath every 2 to 3 seconds (20-30 breaths
per minute) for all pediatric resuscitation scenarios.
• Cuffed ETTs are suggested to reduce air leak and the need
for tube exchanges for patients of any age who require
intubation.
• The routine use of cricoid pressure during intubation is no
longer recommended.
• To maximize the chance of good resuscitation outcomes,
epinephrine should be administered as early as possible,
ideally within 5 minutes of the start of cardiac arrest from
a nonshockable rhythm (asystole and pulseless
electrical activity).
• For patients with arterial lines in place, using feedback from
continuous measurement of arterial blood pressure may
improve CPR quality.
• After ROSC, patients should be evaluated for seizures; status
epilepticus and any convulsive seizures should be treated.
• Because recovery from cardiac arrest continues long
after the initial hospitalization, patients should have formal
assessment and support for their physical, cognitive, and
psychosocial needs.
• A titrated approach to fluid management, with epinephrine
14 American Heart Association
or norepinephrine infusions if vasopressors are needed,
is appropriate in resuscitation from septic shock.
• On the basis largely of extrapolation from adult data,
balanced blood component resuscitation is reasonable
for infants and children with hemorrhagic shock.
• Opioid overdose management includes CPR and the timely
administration of naloxone by either lay rescuers or trained
rescuers.
• Children with acute myocarditis who have arrhythmias, heart
block, ST-segment changes, or low cardiac output are at
high risk of cardiac arrest. Early transfer to an intensive care
unit is important, and some patients may require mechanical
circulatory support or extracorporeal life support (ECLS).
• Infants and children with congenital heart disease and
single ventricle physiology who are in the process of staged
reconstruction require special considerations in PALS
management.
• Management of pulmonary hypertension may include the
use of inhaled nitric oxide, prostacyclin, analgesia, sedation,
neuromuscular blockade, the induction of alkalosis, or
rescue therapy with ECLS.
Algorithms and Visual Aids
The writing group updated all algorithms to reflect the latest
science and made several major changes to improve the
visual training and performance aids:
• A new pediatric Chain of Survival was created for IHCA in
infants, children, and adolescents (Figure 10).
• A sixth link, Recovery, was added to the pediatric OHCA
Chain of Survival and is included in the new pediatric IHCA
Chain of Survival (Figure 10).
• The Pediatric Cardiac Arrest Algorithm and the Pediatric
Bradycardia With a Pulse Algorithm have been updated to
reflect the latest science (Figures 11 and 12).
• The single Pediatric Tachycardia With a Pulse Algorithm
now covers both narrow- and wide-complex tachycardias in
pediatric patients (Figure 13).
• Two new Opioid-Associated Emergency Algorithms have
been added for lay rescuers and trained rescuers (Figures 5
and 6).
• A new checklist is provided for pediatric post–cardiac arrest
care (Figure 14).