Pediatric Advanced Life Support: A Review of the 2020 Update

A Review of the 2020 Update of the Pediatric Advanced Life Support Guidelines (Pharmacology CME)

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Table of Contents

About This Issue

While high-quality cardiopulmonary resuscitation (CPR) remains the backbone of any successful resuscitation, recent updates to the Pediatric Advanced Life Support (PALS) guidelines focus on airway management, ventilation, and post-resuscitation management. This issue offers a systematic approach for resuscitation of children in cardiac arrest and highlights practice changes in the 2020 PALS guidelines. In this issue, you will learn:

Physiologic considerations for resuscitation of pediatric patients

Key aspects of the prebrief, history, and physical examination that can help identify reversible causes of cardiac arrest

Diagnostic studies that can be used to evaluate CPR, determine the possible etiology of arrest, and detect return of spontaneous circulation (ROSC)

Measures that can be taken to ensure high-quality CPR and optimize resuscitation outcomes in children

Recommendations for intubation and ventilation in out-of-hospital cardiac arrest and in-hospital cardiac arrest

Medication and defibrillation/cardioversion dosages

Components of post–cardiac arrest syndrome and recommendations for management and disposition of patients after ROSC

Table of Contents
  1. About This Issue
  2. Abstract
  3. Case Presentations
  4. Introduction
  5. Critical Appraisal of the Literature
  6. Etiology and Pathophysiology
    1. Anatomy and Pathophysiology
  7. Physiologic Considerations for Resuscitations in Pediatric Patients
    1. Airway
    2. Vascular Access
    3. Weight
    4. Temperature
    5. Pulse
  8. Differential Diagnosis
    1. Rhythm Abnormalities in Children
  9. Prehospital Care
  10. Emergency Department Evaluation
    1. Prebrief and History
    2. Examination
  11. Diagnostic Studies
    1. Evaluating CPR Quality
    2. Determining Possible Etiology of Arrest
    3. Detecting Return of Spontaneous Circulation
  12. Treatment
    1. High-Quality CPR and the Role of a CPR Coach
      1. Compression Rate
      2. Compression Depth
      3. CPR Quality
    2. Intubation and Ventilation
      1. Out-of-Hospital Cardiac Arrest
      2. In-Hospital Cardiac Arrest
      3. Cuffed Versus Uncuffed Endotracheal Tubes
      4. Cricoid Pressure and Laryngeal Manipulation
      5. Supraglottic Airway Devices
      6. Surgical Airways
      7. Rescue Breath Rate
      8. Transport
    3. Defibrillation
    4. Medication Administration
      1. Epinephrine
      2. Lidocaine and Amiodarone
      3. Calcium and Sodium Bicarbonate
    5. Management of Arrhythmias With Pulses
      1. Bradycardia With Poor Perfusion
      2. Tachycardia With Pulse
  13. Special Circumstances
    1. Extremes of Age
      1. Choosing Between NRP and PALS for Neonates
      2. Choosing Between PALS and ACLS for Adolescents
    2. Cardiac Abnormalities
    3. Concern for Opioid-Associated Cardiac Arrest
    4. COVID-19
    5. Family Presence During Resuscitation
  14. Controversies and Cutting Edge
    1. Extracorporeal Membrane Oxygenation
    2. Physiology-Directed CPR
    3. Termination of Resuscitation
  15. Disposition
  16. Summary
  17. Time- and Cost-Effective Strategies
  18. 5 Things That Will Change Your Practice
  19. Risk Management Pitfalls for Pediatric Patients in Cardiac Arrest
  20. Case Conclusions
  21. Algorithms
    1. American Heart Association Pediatric Cardiac Arrest Algorithm
    2. American Heart Association Pediatric Bradycardia With a Pulse Algorithm
    3. American Heart Association Pediatric Tachycardia With a Pulse Algorithm
  22. Tables and Figures
  23. References


Pediatric cardiac arrest presents an infrequent but high-stakes event for emergency clinicians, who need to maintain expertise in this area. Evidence regarding pediatric resuscitations has been accumulating substantially over the past decade and highlights the unique considerations and challenges when resuscitating children. This issue reviews resuscitation principles of children in cardiac arrest while addressing the newest evidence-based and best-practice recommendations by the American Heart Association.

Case Presentations

A 12-year-old boy presents after collapsing during a football game…
  • Bystanders were unable to palpate a pulse. They immediately called for help and initiated CPR. An automated external defibrillator was brought to the scene, and a shockable rhythm was detected. The shock was applied, and CPR was resumed.
  • You arrive with EMS at the scene shortly after the initial shock is delivered. No pulse is detectable. You begin bag-mask ventilation and confirm adequate chest rise.
  • In anticipation for transport, you begin to consider whether you should intubate the patient now or continue to ventilate the patient using a bag-mask?
An ill-appearing 9-month-old boy is brought into the ED resuscitation bay…
  • You encounter an infant who appears blue, with shallow respirations. Oxygen saturation is not detectable despite high-quality bag-mask ventilation, so you decide to intubate the patient. On Broselow tape, the patient falls into the PURPLE category. A cuffed 3.5 endotracheal tube or an uncuffed 4.0 endotracheal tube is recommended.
  • As you prepare the airway equipment, you consider whether you should use a cuffed or uncuffed tube.
A 3-year-old girl is brought into the ED with severe diarrhea...
  • The triage nurse sees that the child is unresponsive and immediately calls for help. No pulse is identified, and CPR is started as the patient is taken to a resuscitation room. CPR continues as pads are placed. You look up at the monitor and note pulseless electrical activity.
  • You need to obtain venous access but are worried about successfully placing an IV line. What other options should you consider? When should epinephrine be administered and how frequently should it be given? Should you use end-tidal CO2 to monitor the quality of CPR?

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Tables and Figures

Table 3. Medications and Defibrillation/Cardioversion Dosages
Table 1. Reversible Causes of Cardiac Arrest: “Hs and Ts”
Table 2. PALS 2020 Updates Regarding Airway Management
Table 4. Emergency Department Management of Common Patient Scenarios After Return of Spontaneous Circulation

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

6. * Topjian AA, Raymond TT, Atkins D, et al. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020;142(16_suppl_2):S469-S523. (Guidelines) DOI: 10.1161/cir.0000000000000901

34. * Berg RA, Sutton RM, Reeder RW, et al. Association between diastolic blood pressure during pediatric in-hospital cardiopulmonary resuscitation and survival. Circulation. 2018;137(17):1784-1795. (Retrospective; 164 children) DOI: 10.1161/circulationaha.117.032270

55. * Chen L, Zhang J, Pan G, et al. Cuffed versus uncuffed endotracheal tubes in pediatrics: a meta-analysis. Open Med (Wars). 2018;13:366-373. (Meta-analysis; 6 studies) DOI: 10.1515/med-2018-0055

59. * Sutton RM, Reeder RW, Landis WP, et al. Ventilation rates and pediatric in-hospital cardiac arrest survival outcomes. Crit Care Med. 2019;47(11):1627-1636. (Prospective; 52 events) DOI: 10.1097/ccm.0000000000003898

70. * Hansen M, Schmicker RH, Newgard CD, et al. Time to epinephrine administration and survival from nonshockable out-of-hospital cardiac arrest among children and adults. Circulation. 2018;137(19):2032-2040. (Subanalysis; 595 patients) DOI: 10.1161/circulationaha.117.033067

101. *Matos RI, Watson RS, Nadkarni VM, et al. Duration of cardiopulmonary resuscitation and illness category impact survival and neurologic outcomes for in-hospital pediatric cardiac arrests. Circulation. 2013;127(4):442-451. (Retrospective; 3419 patients) DOI: 10.1161/circulationaha.112.125625

106. *Moler FW, Silverstein FS, Holubkov R, et al. Therapeutic hypothermia after in-hospital cardiac arrest in children. N Engl J Med. 2017;376(4):318-329. (Randomized trial; 329 patients) DOI: 10.1056/NEJMoa1610493

Subscribe to get the full list of 109 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: Pediatric Advanced Life Support, PALS, cardiac arrest, resuscitation, cardiopulmonary resuscitation, CPR, out-of-hospital cardiac arrest, OHCA, in-hospital cardiac arrest, IHCA, bag-mask ventilation, cuffed endotracheal tube, intraosseous access, weight estimation, Broselow tape, PAWPER tape, Mercy method, pulse check, rhythm abnormalities, automated external defibrillator, AED, reversible causes of cardiac arrest, CPR quality, return of spontaneous circulation, ROSC, high-quality CPR, CPR coach, compression rate, compression depth, airway management, supraglottic airway device, surgical airway, defibrillation, epinephrine, bradycardia with poor perfusion, tachycardia with pulse, extracorporeal membrane oxygenation, ECMO, physiology-directed CPR, termination of resuscitation, post–cardiac arrest syndrome, post-arrest care

Publication Information

Robert M. Hoffmann, MD; Andrew F. Miller, MD

Peer Reviewed By

Kathleen Berg, MD, FAAEM; Sylvia E. Garcia, MD

Publication Date

June 1, 2023

CME Expiration Date

June 1, 2026    CME Information

CME Credits

4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits.
Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 1 Pharmacology CME credit, subject to your state and institutional approval.

Pub Med ID: 37207313

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