Pediatric Resuscitation: Guideline Algorithm for Children

A pediatric emergency is one of the most emotionally and professionally challenging situations in acute care medicine. Although cardiac arrest in children is rare, this very rarity demands an even more solid understanding of the structured approach to pediatric resuscitation. Unlike in adults, pediatric cardiac arrest is rarely primarily cardiac in origin – in the vast majority of cases, a respiratory cause or shock is at the beginning of the event chain. This understanding of the pathophysiology is the key to the entire PALS algorithm and explains why ventilation and oxygenation hold an even higher priority in pediatric resuscitation than in adults.

Age Definitions and Clinical Relevance

Correct age classification determines technique, dosing, and algorithm details. The AHA guidelines distinguish:

• Neonates: immediately after birth (separate NRP algorithm)
• Infants: from the time of discharge from the delivery room until the completion of the 1st year of life
• Children: from 1 year of age until the onset of puberty (clinical signs: axillary/pubic hair, breast development in girls)
• From puberty onward: adult algorithm (ACLS)

In practice, you won't always know the exact age. Clinical estimation and body weight (estimated using length-based systems such as the Broselow tape) are sufficient to select the correct algorithm.

Causes of Pediatric Cardiac Arrest

Understanding the most common etiologies is central to therapy and the search for reversible causes:

Respiratory Causes (Most Common Group)

• Airway obstruction (foreign body, croup, epiglottitis, anaphylaxis)
• Apnea (seizure, intoxication, central cause)
• Pneumonia, asthma exacerbation, bronchiolitis
• Drowning

Circulatory Causes

• Hypovolemic shock (trauma, gastroenteritis, hemorrhage)
• Septic shock
• Anaphylactic shock

Cardiac Causes (Rare but Relevant)

• Congenital heart defects
• Myocarditis
• Primary arrhythmias (long QT syndrome, Wolff-Parkinson-White)
• Commotio cordis

Reversible Causes – the Hs and Ts

As with adults, the systematic search for Hs and Ts applies to children as well:

Hs: Hypoxia, Hypovolemia, Hypothermia, Hypo-/Hyperkalemia, Hypoglycemia, Hydrogen ions (acidosis)

Ts: Tamponade (cardiac), Thrombosis (coronary/pulmonary), Toxins, Tension pneumothorax

Hypoxia in particular is the number one cause in children – yet another reason why effective ventilation is so critical.

BLS Algorithm for Infants and Children

Recognition and Activation

When you encounter an unresponsive child, check for consciousness and breathing. If normal breathing is absent (gasping does not count), begin resuscitation immediately. If you are a lone rescuer, perform 2 minutes of CPR first before calling for help – unless the collapse was witnessed and a primary cardiac rhythm is likely (in that case, prioritize immediate activation and retrieving a defibrillator). If two or more rescuers are present, one person activates emergency services immediately while the other begins CPR.

Compressions: Technique and Quality

Chest compressions are the cornerstone of any resuscitation. The details differ between infants and children:

Infant (< 1 year):

• Compression point: lower half of the sternum, just below the intermammillary line
• Technique with 2 rescuers (preferred): two-thumb encircling hands technique – both thumbs side by side on the lower third of the sternum, the remaining fingers encircle the thorax from the back
• Technique with 1 rescuer: two-finger technique (index and middle finger on the sternum)
• Compression depth: at least one-third of the anterior-posterior chest diameter, corresponding to approximately 4 cm
• Rate: 100–120/min

Child (1 year to puberty):

• Compression point: lower half of the sternum
• Technique: one-hand or two-hand technique (depending on the size of the child), heel of the hand on the sternum
• Compression depth: at least one-third of the anterior-posterior chest diameter, corresponding to approximately 5 cm
• Rate: 100–120/min

Compression-to-Ventilation Ratio

• Single rescuer: 30:2 (same as for adults)
• Two rescuers: 15:2

This 15:2 ratio with two rescuers underscores the importance of ventilation in pediatric resuscitation. Once an advanced airway (endotracheal tube or supraglottic airway) is in place, compressions are performed continuously and a breath is delivered every 2–3 seconds (corresponding to 20–30 breaths per minute – not every 6 seconds as in adults).

Ventilation

Ventilate with just enough volume to produce visible chest rise. Overinflation must be avoided – it increases intrathoracic pressure, reduces venous return, and worsens hemodynamics. In infants, the mask covers both mouth and nose; in children, a standard mouth-and-nose mask or an appropriately sized bag-valve-mask is used.

PALS Algorithm: Advanced Life Support

Rhythm Analysis – the Central Decision Point

As soon as a defibrillator/monitor is available, rhythm analysis is performed. This leads to two treatment pathways:

Shockable Rhythm (Ventricular Fibrillation / Pulseless Ventricular Tachycardia)

Although a shockable rhythm is less common in children than in adults (approximately 5–15% of pediatric cardiac arrests), the prognosis with early defibrillation is better than with asystole or PEA.

Defibrillation energy:

• 1st shock: 2 J/kg body weight
• 2nd shock: 4 J/kg body weight
• Subsequent shocks: 4 J/kg; in cases of refractory arrest, the energy can be escalated up to 10 J/kg or the maximum adult dose

Algorithm sequence:

1. Shock at 2 J/kg → immediately resume CPR for 2 minutes
2. Rhythm check → still VF/pVT → shock at 4 J/kg → immediately resume CPR for 2 minutes
3. Rhythm check → still VF/pVT → shock at 4 J/kg (or higher) → epinephrine 0.01 mg/kg IV/IO (max. 1 mg) → immediately resume CPR for 2 minutes
4. Rhythm check → still VF/pVT → shock → amiodarone 5 mg/kg IV/IO (max. 300 mg, bolus) → CPR for 2 minutes
5. Further cycles: epinephrine every 3–5 minutes; amiodarone may be repeated after the 5th shock (5 mg/kg, max. 150 mg for the repeat dose)

Remember: Epinephrine is given starting with the third shock and then every 3–5 minutes. Amiodarone follows after the third unsuccessful shock.

Non-Shockable Rhythm (Asystole / Pulseless Electrical Activity)

This pathway applies to the majority of pediatric cardiac arrests and carries an overall worse prognosis.

1. Immediate epinephrine 0.01 mg/kg IV/IO (max. 1 mg) – as early as possible
2. CPR for 2 minutes
3. Rhythm check → still non-shockable → continue CPR
4. Repeat epinephrine every 3–5 minutes
5. During CPR: search for and treat reversible causes

Important: In PEA, always actively search for treatable causes – hypovolemia (volume administration!), tension pneumothorax (needle decompression!), cardiac tamponade.

Weight-Based Medication Dosing

Correct dose calculation is one of the most common sources of error in pediatric emergency medicine. Whenever possible, use the actual body weight or one estimated via the Broselow tape. As a rule of thumb for children over 1 year of age:

Estimated weight (kg) = (age in years + 4) × 2

Key Medications in the PALS Algorithm

Medication	Dosing	Maximum	Notes
Epinephrine	0.01 mg/kg (= 0.1 mL/kg of 1:10,000 solution) IV/IO	1 mg	Repeat every 3–5 min
Amiodarone	5 mg/kg IV/IO bolus	300 mg (1st dose)	For refractory VF/pVT; 2nd dose: max. 150 mg
Lidocaine (alternative)	1 mg/kg IV/IO	100 mg	Alternative to amiodarone
Magnesium	25–50 mg/kg IV/IO	2 g	For torsades de pointes
Adenosine (SVT)	0.1 mg/kg → 0.2 mg/kg	6 mg → 12 mg	Rapid bolus with flush
Normal saline (0.9%)	20 mL/kg bolus IV/IO	Repeat as needed	For hypovolemia
Glucose	0.5–1 g/kg IV	–	Infants: 10% dextrose, Children: 20% dextrose

Note on intraosseous access: If peripheral IV access cannot be established within 60 seconds or after a maximum of two attempts, IO access is the route of choice. All PALS medications can be administered via the intraosseous route.

Airway Management in Detail

Airway management follows a stepwise approach:

1. Basic measures: head in neutral position (infant) or slight sniffing position (child), suctioning as needed, oropharyngeal or nasopharyngeal airway
2. Bag-valve-mask ventilation: remains the foundation and is sufficient in many cases. The mask must have a tight seal, and the tidal volume should be just enough to produce visible chest rise
3. Supraglottic airways: appropriately sized laryngeal mask airway as an alternative to intubation
4. Endotracheal intubation: by experienced personnel. Cuffed tubes are recommended even in infants and toddlers

Tube Size (Internal Diameter)

• Infant < 1 year: 3.0–3.5 mm (cuffed)
• Child 1–2 years: 3.5 mm (cuffed)
• Child > 2 years: (age/4) + 3.5 mm (cuffed)
• Oral insertion depth: internal diameter × 3

During resuscitation, intubation should not interrupt chest compressions for more than 10 seconds. If intubation is not achieved quickly, bag-valve-mask ventilation should be continued.

Post-Resuscitation Care (Post-ROSC Management)

After successful return of spontaneous circulation (ROSC), the critical stabilization phase begins:

• Oxygenation: SpO₂ target 94–99%. Avoid hyperoxia – titrate FiO₂ as soon as reliable pulse oximetry is available
• Ventilation: target normocapnia (etCO₂ 35–45 mmHg). Both hypo- and hyperventilation worsen neurological outcome
• Hemodynamics: maintain blood pressure above the 5th percentile for age and sex. Initiate vasoactive agents (epinephrine or norepinephrine infusion) early
• Temperature management: treat fever aggressively. Consider targeted temperature management (32–34 °C or 36–37.5 °C) in comatose children after cardiac arrest
• Blood glucose: avoid both hypo- and hyperglycemia; monitor frequently
• Transport: organize early transport to a pediatric center with intensive care capacity

Common Errors and Clinical Pearls

• Compressions too shallow: One-third of the chest diameter may sound like very little – in reality, it requires considerable force, even in an infant. Don't hold back.
• Overinflation during ventilation: Too much volume inflates the stomach, restricts diaphragmatic excursion, and compromises compression quality. Ventilate slowly (1-second inspiratory time) and only until visible chest rise.
• Dosing errors: The factor of 10 between epinephrine concentrations (1:1,000 vs. 1:10,000) is a common source of error. Use pre-prepared, weight-based dosing reference sheets or aids.
• Delayed defibrillation: Even though VF/pVT is rare – when present, early defibrillation is the most important prognostic factor. Use pediatric pads; if only adult pads are available, these can be used in children > 1 year in an anterior-posterior configuration.
• Forgetting reversible causes: Especially in children, searching for the "why" is critical. Resuscitation without treating the underlying cause has a significantly worse prognosis.

Teamwork and Structured Communication

Pediatric resuscitations are team efforts. Clear role assignment, closed-loop communication, and a dedicated team leader demonstrably improve performance. Don't forget: time documentation (medication administration, shocks, rhythm checks) is essential and should be explicitly assigned to one person.

Practical Training

Pediatric resuscitation is a scenario that cannot be adequately learned at a desk. Coordinating chest compressions with age-appropriate technique, rapid dose calculation under stress, and structured team leadership must be practiced regularly in hands-on training. In the PALS course (Pediatric Advanced Life Support) by Simulation Tirol – an AHA-certified provider format – you train exactly these algorithms using realistic scenarios with infant and child manikins, including debriefing and hands-on stations. Regular refresher training ensures that you can act confidently and in a structured manner when it matters most.