2020 AHA Pediatric Advanced Life Support (PALS) Guidelines

Pediatric Chains of Survival

A new pediatric Chain of Survival was created for in-hospital cardiac arrest in infants, children, and adolescents.

A sixth link, recovery, was added to the pediatric out-of-hospital Chain of Survival and is included in the new pediatric in-hospital Chain of Survival.

Pediatric Tachycardia With a Pulse Algorithm

A single algorithm now covers both narrow- and wide-complex tachycardias.

Opioid-Associated Emergency for Healthcare Providers Algorithm

The opioid-associated resuscitation emergency algorithm is used for both adult and pediatric patients.

Pediatric Post–Cardiac Arrest Care Checklist

A checklist is provided for pediatric post–cardiac arrest care. Healthcare providers should use this checklist as a training tool, and to ensure that the most high-impact interventions are being used.

Ventilation Rate During CPR With an Advanced Airway

2020 (Updated): When performing CPR in infants and children with an advanced airway, it may be reasonable to target a respiratory rate range of 1 breath every 2 to 3 seconds (20 to 30 breaths/min), accounting for age and clinical condition. Rates exceeding these recommendations may compromise hemodynamics.

Cuffed Endotracheal Tubes

2020 (Updated): It is reasonable to choose cuffed endotracheal tubes (ETTs) over uncuffed ETTs for intubating infants and children. When a cuffed ETT is used, attention should be paid to ETT size, position, and cuff inflation pressure (usually less than 20-25 cm H₂O).

Why: Several studies and systematic reviews support the safety of cuffed ETTs and demonstrate decreased need for tube changes and reintubation. Cuffed tubes may decrease the risk of aspiration. Subglottic stenosis is rare when cuffed ETTs are used in children and careful technique is followed.

Cricoid Pressure During Intubation

2020 (Updated): Routine use of cricoid pressure is not recommended during endotracheal intubation of pediatric patients.

Why: New studies have shown that routine use of cricoid pressure reduces intubation success rates and does not reduce the rate of regurgitation. Previous recommendations to discontinue cricoid pressure if it interferes with ventilation or the speed or ease of intubation have been reaffirmed.

Emphasis on Early Epinephrine Administration

2020 (Updated): For pediatric patients in any setting, it is reasonable to administer the initial dose of epinephrine within 5 minutes from the start of chest compressions.

Why: A study of children with in-hospital cardiac arrest who received epinephrine for an initial nonshockable rhythm (asystole and pulseless electrical activity) demonstrated that, for every minute delay in administration of epinephrine, there was a significant decrease in ROSC, survival at 24 hours, survival to discharge, and survival with favorable neurologic outcome. Patients who received epinephrine within 5 minutes of CPR initiation compared with those who received epinephrine more than 5 minutes after CPR initiation were more likely to survive to discharge. Studies of pediatric out-of-hospital cardiac arrest demonstrated that earlier epinephrine administration increased rates of ROSC, survival to intensive care unit admission, survival to discharge, and 30-day survival.

In the previous (2018) version of the Pediatric Cardiac Arrest Algorithm, patients with nonshockable rhythms received epinephrine every 3 to 5 minutes, but early administration of epinephrine was not emphasized. Although the sequence of resuscitation has not changed, the algorithm and recommendation language have been updated to emphasize the importance of giving epinephrine as early as possible, particularly when the rhythm is nonshockable.

Invasive Blood Pressure Monitoring to Assess CPR Quality

2020 (Updated): For patients with continuous invasive arterial blood pressure monitoring in place at the time of cardiac arrest, it is reasonable for providers to use diastolic blood pressure to assess CPR quality.

Why: Providing high-quality chest compressions is critical to successful resuscitation. A new study showed that, among pediatric patients receiving CPR with an arterial line in place, rates of survival with favorable neurologic outcome were improved if the diastolic blood pressure was at least 25 mm Hg in infants and at least 30 mm Hg in children.

Detecting and Treating Seizures After ROSC

2020 (Updated): When resources are available, continuous electroencephalographic monitoring is recommended for the detection of seizures after cardiac arrest in patients with persistent encephalopathy.

2020 (Updated): It is recommended to treat clinical seizures after cardiac arrest.

2020 (Updated): It is reasonable to treat nonconvulsive status epilepticus after cardiac arrest in consultation with experts.

Why: For the first time, the 2020 Guidelines provide pediatric-specific recommendations for the management of seizures after cardiac arrest. Nonconvulsive seizures, including nonconvulsive status epilepticus, are common and cannot be detected without electroencephalography. Although outcome data from the post–cardiac arrest population are lacking, both convulsive and nonconvulsive status epilepticus are associated with poor outcome, and treatment of status epilepticus is beneficial in pediatric patients in general.

Evaluation and Support for Cardiac Arrest Survivors

2020 (New): It is recommended that pediatric cardiac arrest survivors be evaluated for rehabilitation services.

2020 (New): It is reasonable to refer pediatric cardiac arrest survivors for ongoing neurologic evaluation for at least the first year after cardiac arrest.

Why: There is a growing recognition that recovery from cardiac arrest extends for a long time after the initial hospitalization. Survivors may require ongoing integrated medical, rehabilitative, caregiver, and community support in the months to years after their cardiac arrest. A recent AHA Scientific Statement highlights the importance of supporting patients and families during this time to achieve the best possible long-term outcome.

Septic Shock: Fluid Boluses

2020 (Updated): In patients with septic shock, it is reasonable to administer fluid in 10-mL/kg or 20-mL/kg aliquots with frequent reassessment.

Why: Although fluids remain the mainstay of initial therapy for infants and children in shock, especially in hypovolemic and septic shock, fluid overload can lead to increased morbidity. In recent trials of patients with septic shock, those who received higher fluid volumes or faster fluid resuscitation were more likely to develop clinically significant fluid overload and require mechanical ventilation. Previous recommendations to reassess patients after each fluid bolus and to use either crystalloid or colloid fluids for septic shock resuscitation are reaffirmed.

Septic Shock: Choice of Vasopressor

2020 (New): In infants and children with fluid-refractory septic shock, it is reasonable to use either epinephrine or norepinephrine as an initial vasoactive infusion.

2020 (New): In infants and children with fluid-refractory septic shock, if epinephrine and norepinephrine are unavailable, dopamine may be considered.

Why: Previous versions of the Guidelines did not provide recommendations about choice of vasopressor or the use of corticosteroids in septic shock. Two RCTs suggest that epinephrine is superior to dopamine as the initial vasopressor in pediatric septic shock, and norepinephrine is also appropriate.

Septic Shock: Corticosteroid Administration

2020 (New): For infants and children with septic shock unresponsive to fluids and requiring vasoactive support, it may be reasonable to consider stress-dose corticosteroids.

Why: Recent clinical trials suggest a benefit from corticosteroid administration in some pediatric patients with refractory septic shock.

Hemorrhagic Shock

2020 (New): Among infants and children with hypotensive hemorrhagic shock after trauma, it is reasonable to administer blood products, when available, instead of crystalloid for ongoing volume resuscitation.

Why: Previous versions of the Guidelines did not differentiate the treatment of hemorrhagic shock from other causes of hypovolemic shock. A growing body of evidence (largely from adults, but with some pediatric data) suggests a benefit to early, balanced resuscitation with packed red blood cells, fresh frozen plasma, and platelets. Balanced resuscitation is supported by recommendations from the several US and international trauma societies.

Opioid Overdose

2020 (Updated): For patients in respiratory arrest, rescue breathing or bag-mask ventilation should be maintained until spontaneous breathing returns, and standard pediatric basic life support or advanced life support measures should continue if return of spontaneous breathing does not occur.

2020 (Updated): For a patient with suspected opioid overdose who has a definite pulse but no normal breathing or only gasping (ie, a respiratory arrest), in addition to providing standard pediatric BLS or PALS care, it is reasonable for responders to administer intramuscular or intranasal naloxone.

2020 (Updated): For patients known or suspected to be in cardiac arrest, in the absence of a proven benefit from the use of naloxone, standard resuscitative measures should take priority over naloxone administration, with a focus on high-quality CPR (compressions plus ventilation).

Why: The opioid epidemic has not spared children. In the United States in 2018, opioid overdose caused 65 deaths in children younger than 15 years old and 3618 deaths in people 15 to 24 years old (Wilson 2020), and many more children required resuscitation. These Guidelines contain new recommendations for the management of children with respiratory arrest or cardiac arrest from opioid overdose. These recommendations are identical for adults and children, except that compression-ventilation CPR is recommended for all pediatric victims of suspected cardiac arrest. Naloxone can be administered by trained providers, lay responders with focused training, and the lay public. Separate treatment algorithms are provided for management of opioid-associated resuscitation emergencies by lay responders (who cannot reliably check for a pulse) and by trained rescuers. Opioid-associated out-of-hospital cardiac arrest is the subject of a 2020 AHA Scientific Statement (Dezfulian 2020 in press).

Myocarditis

2020 (New): Given the high risk of cardiac arrest in children with acute myocarditis who demonstrate arrhythmias, heart block, ST-segment changes, and/or low cardiac output, early consideration of transfer to an intensive care unit for monitoring and therapy is recommended.

2020 (New): For children with myocarditis or cardiomyopathy and refractory low cardiac output, prearrest use of extracorporeal life support (ECLS) or mechanical circulatory support can be beneficial to provide end-organ support and prevent cardiac arrest.

2020 (New): Given the challenges to successful resuscitation of children with myocarditis and cardiomyopathy, once cardiac arrest occurs, early consideration of extracorporeal CPR may be beneficial.

Why: Although myocarditis accounts for about 2% of sudden cardiovascular deaths in infants, 5% of sudden cardiovascular deaths in children, and 6% to 20% of sudden cardiac death in athletes, previous PALS guidelines did not contain specific recommendations for management. These recommendations are consistent with the 2018 AHA Scientific Statement on CPR in infants and children with cardiac disease (Marino 2018).

Single Ventricle: Preoperative and Postoperative Stage I Palliation (Norwood/Blalock-Tausig Shunt)

2020 (New): Direct (superior vena cava catheter) and/or indirect (near-infrared spectroscopy) oxygen saturation monitoring can be beneficial to trend and direct management in critically ill neonates after stage I Norwood palliation or shunt placement.

2020 (Updated): For neonates before stage I repair with pulmonary over circulation and symptomatic low systemic cardiac output and delivery of oxygen (DO₂), it is reasonable to target a PaCO₂ of 50 to 60 mm Hg. This can be achieved during mechanical ventilation by reducing minute ventilation or by administering analgesia/sedation with or without neuromuscular blockade.

2010 (Old): Neonates in a prearrest state due to elevated pulmonary-to-systemic flow ratio before stage I repair might benefit from a PaCO₂ of 50 to 60 mm Hg, which can be achieved during mechanical ventilation by reducing minute ventilation, increasing the inspired fraction of CO₂, or administering opioids with or without chemical paralysis.

2020 (New): In a patient with an appropriately restrictive shunt, manipulation of pulmonary vascular resistance may have little effect, whereas lowering systemic vascular resistance with the use of systemic vasodilators (α-adrenergic antagonists and/or phosphodiesterase type III inhibitors) with or without the use of oxygen can be useful to increase systemic DO₂.

2020 (New): ECLS after stage I Norwood palliation can be useful to treat low systemic DO₂.

2020 (New): In the situation of known or suspected shunt obstruction, it is reasonable to administer oxygen, vasoactive agents to increase shunt perfusion pressure, and heparin (50-100 units/kg bolus) while preparing for catheter-based or surgical intervention.

Single Ventricle: Postoperative Stage II (Bidirectional Glenn/Hemi-Fontan) and Stage III (Fontan) Palliation

2020 (New): For patients in a prearrest state with superior cavopulmonary anastomosis physiology and severe hypoxemia due to inadequate pulmonary blood flow (Qp), ventilatory strategies that target a mild respiratory acidosis and a minimum mean airway pressure without atelectasis can be useful to increase cerebral and systemic arterial oxygenation.

2020 (New): ECLS in patients with superior cavopulmonary anastomosis or Fontan circulation may be considered to treat low DO₂ from reversible causes or as a bridge to a ventricular assist device or surgical revision.

Why: Approximately 1 in 600 infants and children are born with critical congenital heart disease. Staged surgery for children born with single-ventricle physiology, such as hypoplastic left heart syndrome, spans the first several years of life (Oster 2013). Resuscitation of these infants and children is complex and differs in important ways from standard PALS care. Previous PALS guidelines did not contain recommendations for the management of this specialized patient population. These recommendations are consistent with the 2018 AHA Scientific Statement on CPR in infants and children with cardiac disease (Marino 2018).

Pulmonary Hypertension

2020 (Updated): Inhaled nitric oxide or prostacyclin should be used as the initial therapy to treat pulmonary hypertensive crises or acute right-sided heart failure secondary to increased pulmonary vascular resistance.

2020 (New): Provide careful respiratory management and monitoring to avoid hypoxia and acidosis in the postoperative care of children with pulmonary hypertension.

2020 (New): For pediatric patients who are at high risk for pulmonary hypertensive crises, provide adequate analgesics, sedatives, and neuromuscular blocking agents.

2020 (New): For the initial treatment of pulmonary hypertensive crises, oxygen administration and induction of alkalosis through hyperventilation or alkali administration can be useful while pulmonary-specific vasodilators are administered.

2020 (New): For children who develop refractory pulmonary hypertension, including signs of low cardiac output or profound respiratory failure despite optimal medical therapy, ECLS may be considered.

2010 (Old): Consider administering inhaled nitric oxide (iNO) or aerosolized prostacyclin or analogue to reduce pulmonary vascular resistance.

Why: Pulmonary hypertension is a rare disease in infants and children that is associated with significant morbidity and mortality and requires specialized management. Previous PALS guidelines did not provide recommendations for the management of infants and children with pulmonary hypertension. These recommendations are consistent with guidelines on pediatric pulmonary hypertension published by the AHA and the American Thoracic Society in 2015 (Abman 2015) and with recommendations in a 2018 AHA Scientific Statement on CPR in infants and children with cardiac disease (Marino 2018).