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rescue breathing (or other assisted ventilation) should be maintained until spontaneous breathing returns or care is withdrawn |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 |
