This guide incorporates the American Heart Association (AHA) and American Academy of Pediatrics (AAP) guidelines for CPR and emergency cardiovascular care (ECC), based on an extensive review of published resuscitation studies.
This review highlights many of the key changes for PALS made in 2020.1
Key Takeaway
Early recognition of cardiac arrest and initiation of CPR intervention increase the chances of survival. The ultimate goal of early intervention is to improve patient outcomes and save lives.
2020 PALS Changes in Visuals and Algorithms
Addition of a Recovery link in the Chain of Survival for an outside-hospital cardiac arrest patient.
New Pediatric Chain of Survival for the in-hospital cardiac arrest patient.
Modification of the Pediatric Cardiac Arrest algorithm.
Modification of the Pediatric Bradycardia with a Pulse algorithm.
Modification of the Pediatric Tachycardia with a Pulse algorithm to include narrow and wide QRS complex tachycardias.
New lay-rescuer Opioid-Associated Arrest algorithm.
New trained rescuer Opioid-Associated Arrest algorithm.
New Pediatric Post-Cardiac Arrest Care checklist.
Modification of the Pediatric Septic Shock algorithm.
Modification of the Management of Shock after ROSC algorithm.
In addition to the new algorithms and modifications to the existing algorithms, changes to the pediatric guidelines include:
Rescue breathing rate during assisted ventilation: For the pediatric patient with a pulse but inadequate respirations, AHA and ILCOR now recommend one breath every 2–3 seconds instead of one breath every 3–5 seconds.
Ventilation during CPR with an advanced airway: During CPR with an advanced airway in place, the new recommendation is to give one breath every 2–3 seconds (20–30 per minute) instead of one breath every 6 seconds.
Cuffed ET tubes: Cuffed ET tubes should be used when intubating children and infants. The old recommendation included the use of either cuffed or uncuffed tubes.
Cricoid pressure: Routine cricoid pressure during intubation of children and infants is NOT recommended.
Early epinephrine administration: AHA and ILCOR now recommend the early (within 5 minutes) use of epinephrine for nonshockable rhythms in cardiac arrest.
Invasive blood pressure monitoring: When invasive blood pressure monitoring is in place during cardiac arrest, the provider can use the diastolic blood pressure to monitor CPR quality. The diastolic target is 25 mm Hg for infants and at least 30 mm Hg for children.
Seizures after the return of spontaneous circulation (ROSC): In the presence of persistent encephalopathy, continuous EEG monitoring should be in place when available to detect seizures after a pediatric cardiac arrest. Seizures and nonconvulsive status epilepticus should be treated in consultation with pediatric neurology experts.
Support for cardiac arrest survivors: All pediatric cardiac arrest survivors should be assessed for the need for rehabilitation, including neurologic evaluation, for at least 1 year after cardiac arrest.
Fluid bolus in septic shock: Fluid overload during treatment for septic shock increases morbidity rates. Providers should use their best clinical judgment to determine if fluid boluses should be 10 mL/kg or 20 mL/kg.
Vasopressors in septic shock: If fluid boluses are not successful in controlling pediatric blood pressure in septic shock, the clinician can consider epinephrine or norepinephrine.
Corticosteroids in septic shock: If the child in septic shock requires vasopressors, the provider should consider the administration of stress-dose corticosteroids.
Hemorrhagic shock: For hemorrhagic shock following blood loss from trauma, the provider should consider administering blood products instead of crystalloid IV fluids.
Opioid overdose: For pediatric patients with a suspected opioid overdose and resultant respiratory arrest, rescue breathing should be administered until spontaneous breathing begins. The child in respiratory arrest should receive intranasal or intramuscular naloxone. However, standard PALS measures (CPR) should be the priority for the child in suspected cardiac arrest.
Myocarditis and cardiomyopathy: The acutely ill child with myocarditis should be transferred to the ICU for treatment and monitoring. In the presence of low cardiac output, the provider should consider extracorporeal life support (ECLS). When cardiac arrest occurs in this population, consider extracorporeal CPR.
Pulmonary hypertension: For the pediatric patient with pulmonary hypertension due to increased pulmonary vascular resistance (PVR), inhaled nitric oxide or prostacyclin should be provided. Avoid hypoxia and acidosis. Analgesics, sedation, or neuromuscular blocking agents should be considered for children at high risk for pulmonary hypertension. Initial emergency treatment should include increased oxygen and hyperventilation to induce alkalosis while preparing for vasodilator administration. ECLS should be considered for refractory pulmonary hypertension or low cardiac output despite treatment.
Single ventricle Stage 1 Norwood shunt patients: For children with this congenital heart disease, AHA and ILCOR have added recommendations, including:
Monitoring of oxygen saturation by superior vena cava catheter.
Use of vasodilators to lower systemic vascular resistance and increase oxygen delivery.
ECLS consideration in the presence of low oxygen delivery following a Stage 1 palliation.
Oxygen, vasoactive agents, and heparin in preparation for surgical intervention if shunt obstruction is suspected.
Targeting a PaCO2 of 50–60 mm Hg in neonates before surgical repair by reducing minute ventilation or providing sedation.
Single ventricle Stages 2 and 3 Norwood shunt patients: For single ventricle patients in later stages of management, recommendations include:
Targeting a mild respiratory acidosis and a low mean airway pressure to increase oxygenation to the brain and other organs in children in prearrest with severe hypoxemia.
ECLS as a temporizing measure until a ventricular assist device or surgical revision is available.
1Topjian 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.