Cardiopulmonary resuscitation (CPR) is a coordinated set of interventions designed to restore and support vital organ function after apparent clinical death. The immediate objective is to reestablish oxygen and substrate delivery to meet the metabolic demands of the myocardium, brain, and other critical organs. The ultimate goal is survival with favorable neurologic outcome and without morbidity from either the underlying disease or the resuscitation process.
Because pediatric cardiac arrest carries a poor prognosis, prevention, early recognition of deterioration, and rapid intervention remain essential components of improving childhood survival. This review summarizes the management of the critically ill child and neonate, integrating current AHA Pediatric Basic and Advanced Life Support (PALS) guidelines, contemporary literature, and clinical experience.
Infants under one year of age experience the highest incidence of out‑of‑hospital cardiac arrest (OHCA) and the lowest survival rates among pediatric age groups. Large population‑based studies consistently show that more than half of pediatric OHCAs occur in infants.
Although pediatric CPR training emphasizes the unique anatomic and physiologic features of infants and young children, emergency departments must be prepared to manage the full spectrum of ages and sizes. In some pediatric centers, a small but meaningful proportion of resuscitations involve adult patients.
Pediatric OHCA arises from a broad range of causes. The most common include trauma, sudden unexpected infant death (SUID), respiratory failure leading to secondary cardiac arrest, congenital anomalies, and chronic medical conditions. In contrast to adults—where primary cardiac etiologies predominate—fewer than 10% of pediatric OHCAs present with ventricular tachycardia (VT) or ventricular fibrillation (VF).
Most children follow one of two arrest pathways:
Children with congenital heart disease or myocardial trauma may present with complex arrhythmias requiring subspecialty input.
Demographic data on pediatric cardiac arrest remain limited. Multicity studies suggest a disproportionate number of affected children are Black, though findings vary by region. Most arrests occur in private residences, and fewer than half are witnessed.
National and local surveillance efforts are expanding. The Cardiac Arrest Registry to Enhance Survival (CARES) collects pediatric and adult OHCA data across participating U.S. cities to improve system‑level care. State‑level child death review teams and hospital‑based quality improvement programs also contribute to prevention and early recognition strategies.
Pediatric CPR presents unique challenges for emergency clinicians. Children often arrive with limited prehospital interventions, as paramedics have less exposure to pediatric arrests. Wide variability in age, size, and underlying diagnoses complicates rapid assessment and intervention.
The pediatric chain of survival includes:
In the ED, successful resuscitation requires a skilled team led by an organized, decisive leader. Many centers use a structured primary survey (ABCD) followed by a secondary survey to identify reversible causes and guide definitive management.
Because most pediatric arrests are asphyxial, airway and ventilation management are central to resuscitation. Bag‑valve‑mask (BVM) ventilation is highly effective and remains the preferred initial method. Prehospital studies show that BVM alone may outperform early intubation in pediatric respiratory arrest.
Rapid correction of hypoxemia can restore circulation in many children without the need for advanced airway placement. Failure to respond to airway and breathing interventions often signals the need for pharmacologic support.
Obtaining vascular access in critically ill children can be difficult. Peripheral IV access should be attempted but may be challenging. Intraosseous (IO) access is recommended when IV access is not immediately available. Central venous access is rarely required during initial resuscitation and takes longer to establish.
Arrhythmias are less common in pediatric arrest than in adults. Most children present with sinus bradycardia, pulseless electrical activity (PEA), or asystole. Shockable rhythms (VT/VF) are uncommon but must be recognized promptly. Children with congenital heart disease or myocardial trauma may develop complex arrhythmias requiring cardiology involvement.
Pediatric resuscitation science continues to advance through multicenter research networks, CPR registries, and improved data standardization using Utstein-style reporting. Large, prospective studies remain essential to refine interventions and improve survival with good neurologic outcomes.
Despite advances in pediatric critical care and improvements in EMS systems, survival after pediatric out‑of‑hospital cardiac arrest (OHCA) remains low. Fewer than 15% of children survive an OHCA, and many survivors experience significant neurologic impairment. Contributing factors include the high proportion of unwitnessed arrests (approximately 70%) and the relatively low rate of bystander CPR (about 50%).
In contrast, outcomes for in‑hospital arrest (IHA) are substantially better. When respiratory arrest is recognized early and managed promptly, immediate survival can approach 90%. Overall, 30–40% of children experiencing IHA survive to hospital discharge. Improvements in early recognition of clinical deterioration, rapid response systems, and standardized resuscitation training have contributed to these gains.
Return of spontaneous circulation (ROSC) remains an important early benchmark, but long‑term outcomes depend heavily on the etiology of arrest, duration of hypoxia, and quality of post‑arrest care.
Children requiring immediate life support typically show signs of inadequate oxygen delivery to vital organs, including the brain, skin, kidneys, and cardiovascular system. Early identification of life‑threatening conditions relies on assessing general appearance, airway, breathing, circulation, and disability (mental status). This ABCD framework helps clinicians recognize children at risk for respiratory failure and impending cardiovascular collapse.
The 2010 AHA guidelines introduced the C‑A‑B sequence for basic life support to reduce delays in initiating chest compressions. Although pediatric arrests are most often respiratory in origin, the brief delay in ventilation is outweighed by the benefit of a universal algorithm that improves bystander CPR rates. In professional, team‑based resuscitation, clinicians typically perform simultaneous A‑B‑C interventions tailored to the child’s physiology.
Because asphyxia is the leading cause of pediatric arrest, rapid recognition and management of airway obstruction and respiratory failure are essential. Prehospital intubation has not consistently shown benefit over effective bag‑valve‑mask (BVM) ventilation in systems without prolonged transport times. When a child arrives intubated, immediate verification of endotracheal tube (ETT) placement is mandatory using end‑tidal CO₂ (ETCO₂), chest radiography, and, when needed, direct laryngoscopy.
If cervical spine trauma is suspected, maintain manual in‑line stabilization during all airway maneuvers. Airway obstruction often results from posterior displacement of the tongue. Initial maneuvers include the head tilt–chin lift or jaw thrust (preferred when cervical injury is a concern).
Size the OPA from the corner of the mouth to the angle of the mandible. Insert with a tongue depressor or rotate into position. Use only in unconscious patients. Incorrect sizing can worsen obstruction or trigger gagging or laryngospasm.
Size from the nares to the tragus. NPAs can be used in conscious patients but should be avoided in children with adenoidal hypertrophy or bleeding disorders due to risk of trauma.
Endotracheal tubes are used to relieve upper airway
obstruction, protect the airway from aspiration, facilitate
mechanical ventilation and PEEP, and allow suctioning of lower
airway secretions.
Breathing is assessed by observing chest wall movement, respiratory effort, and symmetry. Auscultation helps evaluate air entry, while pulse oximetry and end‑tidal CO₂ (ETCO₂) monitoring provide information about gas exchange.
Supplemental oxygen is provided to children who are breathing spontaneously. If spontaneous respirations are absent or inadequate, positive pressure ventilation (PPV) is required. During CPR, 100% oxygen is reasonable, but after return of spontaneous circulation, FiO₂ should be titrated to maintain oxygen saturation of at least 94% to avoid hyperoxia‑related injury.
Delivers humidified oxygen at 4–6 L/min, typically achieving 30–40% FiO₂ due to entrainment of room air.
HFNC provides warmed, humidified gas at high flow rates and offers mild CPAP support, improved airway mechanics, and reduced work of breathing. It is commonly used for bronchiolitis and other respiratory distress syndromes and requires close monitoring.
CPAP helps maintain airway patency and improve oxygenation. It can be delivered via nasal prongs, nasal masks, or full face masks.
Rescue breathing rates vary by age and clinical context. For isolated respiratory arrest, provide 12–20 breaths/min (higher for infants). Newborns may require 40–60 breaths/min. During CPR with an advanced airway, ventilate at 8–10 breaths/min asynchronously with compressions. Without an advanced airway, use a 15:2 ratio for two providers or 30:2 for one provider, with compressions at 100–120/min. Ventilation should produce minimal chest rise to avoid over‑ventilation.
Mouth‑to‑mouth ventilation is no longer recommended due to infection risk; use a pocket mask instead.
Mechanical ventilation is preferred for children needing
prolonged or high‑pressure ventilation. Settings must be
tailored to patient size and clinical goals, ideally with
support from respiratory therapy.
High‑quality chest compressions remain the cornerstone of pediatric resuscitation. While adult cardiac arrest survival has improved with immediate compressions and rapid defibrillation, pediatric arrests—most often asphyxial—require rapid recognition of deterioration, early airway management, and immediate compressions once circulatory arrest occurs.
Pulse checks are unreliable and should take no more than 10 seconds. Providers may assess the brachial, femoral, or carotid pulse depending on age. Circulation is also evaluated by observing skin color, mucous membranes, and capillary refill. Continuous ECG monitoring and frequent blood pressure measurements are essential. Modern defibrillators allow rapid rhythm assessment using quick‑look paddles or adhesive pads.
Circulatory management includes external cardiac compressions, establishing intravascular access, administering primary and secondary medications, and defibrillation when indicated.
High‑quality compressions are the most important intervention in pediatric arrest. Compress one‑third of the chest depth (about 1.5 inches in infants and 2 inches in children) at a rate of 100–120/min, allowing full recoil and minimizing interruptions. Avoid hyperventilation and switch compressors every 2 minutes. Before an advanced airway is placed, use a 15:2 ratio for two providers or 30:2 for one provider. After airway placement, compressions are continuous with asynchronous ventilations.
End‑tidal CO₂ (ETCO₂) and accelerometer/force sensors provide real‑time feedback on CPR quality. ETCO₂ values below 10 mm Hg may indicate inadequate compressions, while a sudden rise to 35 mm Hg or higher often signals return of spontaneous circulation (ROSC). Pediatric‑specific feedback electrodes are now available for infants and young children.
High‑quality compressions generate about one‑third of normal cardiac output and produce a coronary perfusion pressure (CPP) of 10–20 mm Hg, the minimum needed for myocardial blood flow. Pauses in compressions reduce CPP, emphasizing the need to minimize interruptions.
Blood flow during CPR is explained by the direct compression and thoracic pump models. In children, the compliant chest wall makes direct compression a more significant contributor to forward flow.
Techniques such as high‑frequency compressions, interposed abdominal compression CPR, active compression–decompression CPR, vest CPR, and open‑chest massage have been explored but lack pediatric evidence. Only optimized compression rates and automated feedback devices show meaningful benefit.
Compression rates above 100/min improve cardiac output and CPP. A 50% duty cycle is believed optimal. Leaning during recoil reduces venous return and cardiac output. Compression‑only CPR is not recommended for children due to their asphyxial arrest physiology.
Studies show that CPR quality often falls below AHA standards, with recommended depth and rate achieved less than half the time. Interruptions, over‑ventilation, and leaning are common. Compression quality deteriorates within 2 minutes, supporting the recommendation to switch compressors frequently. Real‑time feedback systems improve compression rate, depth, ventilation rate, and preshock pauses, and have been associated with improved survival.
The choice of vascular access in critically ill or arrested children depends on the patient’s condition, urgency, and provider experience. Common options include peripheral IV access, intraosseous (IO) access, and central venous access via the femoral vein.
In cardiac arrest or severe shock, IO access is the preferred initial route because it can be established rapidly—typically within 30–60 seconds—and allows administration of all resuscitation medications and fluids. Drug absorption via the IO route is comparable to central venous administration. Adenosine may be less effective via IO due to rapid metabolism, and rapid fluid delivery requires manual pressure, a push–pull technique, or a pressure bag.
IO access may be obtained using manual, rigid, styletted needles or semi‑automated devices such as the Bone Injection Gun (BIG) or the EZ‑IO drill. Research is ongoing to compare the efficacy of automated versus manual devices in children.
Complications are rare (less than 1%) and include extravasation, epiphyseal injury, fracture, compartment syndrome, fat embolism, and thrombosis.
Peripheral IV access is appropriate for pre‑arrest resuscitation. Common sites include veins of the hands, forearm, and ankle. Prolonged attempts at IV placement delay critical interventions; IO placement should not be delayed. Ultrasound‑guided IV placement has improved success rates in children with difficult access, and many EDs use an IV escalation plan.
The femoral vein is the easiest central vein to access in
critically ill children and carries fewer complications. Central
lines provide secure access, allow central venous pressure
monitoring, and permit blood sampling. Although central access
may improve drug delivery in adults, this has not been
demonstrated in pediatric patients. In children with
uncompensated shock or arrest, IO access should be obtained
first, with central venous access considered later if needed.
Accurate weight estimation is essential because pediatric drug doses, fluid therapy, and equipment sizes are weight‑based. When actual weight is unknown, clinicians may use standardized growth curves or length‑based systems such as the Broselow tape. For obese children, current AHA guidance recommends using actual or tape‑based weight. Drug doses should never exceed adult maximum doses.
A short‑acting nucleoside that slows AV nodal conduction. Indicated for stable or unstable SVT. Requires rapid IV/IO push followed by a flush. Side effects include flushing, chest discomfort, dyspnea, and brief asystole.
A Class III antiarrhythmic used for pulseless VT/VF unresponsive to CPR, defibrillation, and epinephrine. May cause hypotension, bradycardia, and QT prolongation.
An anticholinergic agent used for vagally mediated bradycardia or primary heart block. Low doses may worsen bradycardia.
Indicated for hypocalcemia, hypermagnesemia, hyperkalemia, and calcium channel blocker overdose. Routine use in cardiac arrest is not recommended.
An alpha‑ and beta‑adrenergic agonist used for PEA, asystole, severe hypotension, and refractory VT/VF. Repeat every 3–5 minutes. Side effects include hypertension, tachycardia, and arrhythmias.
Used only when IV/IO access is unavailable. Requires 10× the IV dose due to poor pulmonary absorption.
Treat documented hypoglycemia with age‑appropriate concentrations. Avoid hyperglycemia, which may worsen neurologic injury.
A Class I antiarrhythmic used for pulseless VT/VF unresponsive to standard therapy. Side effects include myocardial and CNS depression.
Indicated for torsades de pointes, hypomagnesemia, and severe asthma. May cause hypotension.
Not routinely recommended in cardiac arrest. Indicated for hyperkalemia, hypermagnesemia, tricyclic antidepressant overdose, calcium channel blocker overdose, or severe acidosis during prolonged arrest with adequate ventilation.
IV/IO access is preferred, but certain medications—lidocaine, epinephrine, atropine, and naloxone (LEAN)—may be administered via the endotracheal tube when vascular access is unavailable. ET doses are 2–10 times higher than IV doses and should be diluted in 5 mL saline and delivered with five manual ventilations. Other alternative routes include intramuscular, subcutaneous, and transmucosal administration.
Isotonic crystalloids such as normal saline (NS) or lactated Ringer’s (LR) remain the mainstay of pediatric volume resuscitation. Boluses are given in 20 mL/kg aliquots as rapidly as possible, with reassessment after each bolus to evaluate perfusion and clinical response. Dextrose-containing solutions are not used for initial volume expansion. Children may show signs of shock despite normal blood pressure, so early recognition of compensated shock is essential.
The AHA recommends caution when administering fluid boluses to children with severe febrile illness in resource-limited settings, where aggressive fluid resuscitation may be harmful. This caution does not apply to children treated in well-resourced emergency or critical care environments.
Hypertonic saline shifts water from intracellular and interstitial spaces into the intravascular compartment, potentially providing rapid volume expansion with less edema. It may also reduce intracranial pressure (ICP). However, it may worsen bleeding or increase ICP if the blood–brain barrier is disrupted. Current evidence does not support hypertonic saline over isotonic crystalloids for routine resuscitation of hypovolemic children.
ATLS guidelines recommend a crystalloid-restrictive, balanced blood product resuscitation strategy for hemorrhagic shock. This typically involves a single 20 mL/kg crystalloid bolus followed by weight-based blood product administration. Pediatric-specific evidence is limited, but this approach aims to avoid dilutional coagulopathy and excessive crystalloid use.
Although low serum albumin levels correlate with increased
mortality, studies have not shown benefit from albumin
administration in pediatric resuscitation. Albumin is costly,
may leak across capillaries, and can contribute to edema.
Crystalloids remain the preferred initial resuscitation fluid.
Ventricular tachycardia (VT) and ventricular fibrillation (VF) are less common causes of pediatric cardiac arrest compared with adults, but they remain critically important to recognize. Approximately 10% of children with in-hospital (IHA) or out-of-hospital cardiac arrest (OHCA) present with VT/VF as the initial rhythm, and an additional 10–15% will develop VT/VF during resuscitation.
Although shockable rhythms are relatively uncommon in younger children, defibrillation must always be considered—particularly in older children, those with congenital heart disease or known dysrhythmias, and children who experience a witnessed sudden collapse.
A secondary analysis of the CARES registry demonstrated that younger children (1–8 years old) had an initial shockable rhythm in about 11% of OHCAs, whereas older children and adolescents (9–18 years old) had an incidence of approximately 32%, similar to adult rates. This underscores the importance of rapid rhythm assessment and early defibrillation in older pediatric patients.