Pediatric Cardiac Arrest (PALS 2025)

Algorithm Steps

1. ▶

   Start

   Pediatric Cardiac Arrest

   Unresponsive child, no pulse, not breathing normally

   1. ●

      Action

      Start High-Quality CPR

      Begin CPR immediately while preparing for rhythm analysis

      • Push hard (≥1/3 AP diameter): Infants 4cm, Children 5cm
      • Push fast: 100-120 compressions/min
      • Allow complete chest recoil
      • Minimize interruptions (<10 sec)
      • Compression:ventilation ratio: 15:2 (2 rescuers), 30:2 (1 rescuer)
      • If advanced airway: continuous compressions, 1 breath q2-3 sec
      1. ●

         Action

         Attach Monitor/Defibrillator + IV/IO Access

         Attach pads in anterior-posterior or anterior-lateral position

         • Use pediatric pads/dose attenuator for <25 kg if available
         • Adult pads acceptable if pediatric not available
         • Establish IV or IO access (IO preferred if IV not rapid)
         1. ◆

            Decision

            Rhythm Check: Shockable?

            Is the rhythm VF or pulseless VT?

            1. ●

               Action

               Defibrillation

               Shock for VF/pVT

               • First shock: 2 J/kg
               • Subsequent shocks: 4 J/kg (max 10 J/kg or adult dose)
               • Resume CPR immediately for 2 minutes after shock
               • Minimize peri-shock pause
               1. ●

                  Action

                  Epinephrine (after 2nd shock)

                  Give epinephrine if VF/pVT persists after initial shock

                  • Epinephrine: 0.01 mg/kg IV/IO (max 1 mg)
                  • Repeat every 3-5 minutes
                  • Can give via ETT: 0.1 mg/kg if no IV/IO
                  1. ●

                     Action

                     Antiarrhythmic for Refractory VF/pVT

                     Consider after 2-3 shocks

                     • Amiodarone: 5 mg/kg IV/IO bolus (max 300 mg)
                     • May repeat x2 for refractory VF/pVT
                     • OR Lidocaine: 1 mg/kg IV/IO (if amiodarone unavailable)
                     1. ◆

                        Decision

                        ROSC?

                        Check for return of spontaneous circulation every 2 minutes

                        1. ✓

                           Outcome

                           Post-Cardiac Arrest Care

                           ROSC achieved - initiate post-arrest care

                           • Optimize ventilation and oxygenation (SpO2 94-99%)
                           • Avoid hyperventilation
                           • Maintain BP with fluids/vasopressors
                           • Obtain 12-lead ECG
                           • Consider targeted temperature management
                           • Identify and treat underlying cause
                           • Transfer to PICU
                        2. ●

                           Action

                           Continue Resuscitation

                           Continue CPR cycles, reassess rhythm every 2 minutes

                           • Continue CPR 2-min cycles
                           • Reassess rhythm after each cycle
                           • Consider reversible causes
                           • ETCO2 <10 mmHg after 20 min may indicate poor prognosis
                           • Consult team for duration of resuscitation
            2. ●

               Action

               Asystole/PEA Management

               Non-shockable rhythm: Focus on CPR and epinephrine

               • Continue high-quality CPR
               • Epinephrine: 0.01 mg/kg IV/IO (max 1 mg) ASAP
               • Repeat epinephrine every 3-5 minutes
               • Identify and treat reversible causes (H's and T's)
               1. ⚠

                  Warning

                  Treat Reversible Causes (H's and T's)

                  Search for and treat underlying causes

                  • Hypovolemia - fluid bolus 20 mL/kg
                  • Hypoxia - ensure adequate ventilation/oxygenation
                  • Hydrogen ion (acidosis)
                  • Hypo/Hyperkalemia - check glucose
                  • Hypothermia
                  • Tension pneumothorax - needle decompression
                  • Tamponade (cardiac) - pericardiocentesis
                  • Toxins - consider specific antidotes
                  • Thrombosis (coronary/pulmonary)