The 2025 PALS Guidelines released by the American Heart Association in collaboration with the American Academy of Pediatrics emphasize high-quality CPR, early physiologic-guided interventions, and refined use of airway management and medications to improve pediatric cardiac arrest outcomes.
1. CPR Quality & Physiologic Targets – STRONGER EMPHASIS
High-quality CPR remains the foundation of PALS:
• Adequate compression rate and depth
• Minimal interruptions
• Full chest recoil
• Avoid excessive ventilation
New hemodynamic CPR targets (with invasive monitoring):
👉 Target diastolic BP:
• ≥25 mmHg in infants
• ≥30 mmHg in children
COR 2a | LOE C-LD
Clinical implication:
Physiology-guided CPR may improve coronary and cerebral perfusion.
ETCO₂ monitoring:
• Useful indicator of CPR quality
• NOT recommended as a sole criterion for termination of resuscitation
COR 2a | LOE C-LD
2. Airway & Ventilation Strategy – SIMPLER IS OFTEN BETTER
Out-of-hospital cardiac arrest:
👉 Bag-mask ventilation preferred over advanced airway
COR 2a | LOE C-LD
In-hospital cardiac arrest:
👉 Bag-mask ventilation OR advanced airway may be reasonable
COR 2b | LOE C-LD
With advanced airway in place:
👉 Target ventilation rate: 20–30 breaths/min (1 breath every 2–3 sec)
COR 2b | LOE C-LD
Key message:
Avoid hyperventilation — it compromises hemodynamics and survival.
3. Vascular Access – SPEED MATTERS
👉 Rapid IV or IO access recommended for drug delivery
COR 1 | LOE C-LD
👉 Choice of IV vs IO based on availability, expertise, and timeliness
COR 1 | LOE C-EO
Clinical focus:
Do not delay medications while attempting difficult IV access.
4. Epinephrine – TIMING REFINED
Nonshockable rhythms (asystole/PEA):
👉 Administer epinephrine as early as possible
COR 2a | LOE C-LD
Shockable rhythms (VF/pVT):
👉 Consider epinephrine after 2 defibrillation attempts
(or sooner only if defibrillation delayed)
COR 2b | LOE C-LD
Dosing interval:
👉 Every 3–5 minutes reasonable
COR 2b | LOE C-LD
5. Antiarrhythmics for Shock-Refractory VF/pVT
👉 Either amiodarone OR lidocaine may be used
COR 2b | LOE C-LD
Evidence shows similar outcomes between both agents.
6. Strong “DO NOT ROUTINELY USE” Recommendations
❌ Sodium bicarbonate (routine use)
Not recommended except for special situations:
• Sodium channel blocker toxicity
• Hyperkalemia
COR 3 (No Benefit) | LOE B-NR
❌ Calcium (routine use)
Not recommended except for:
• Hypocalcemia
• Calcium channel blocker overdose
• Hyperkalemia
COR 3 (No Benefit) | LOE B-NR
Clinical insight:
Routine use associated with worse outcomes in observational data.
7. Post–Cardiac Arrest Care – GREATER FOCUS
Temperature management:
👉 Prevent hyperthermia (>37.5°C)
Improves neurologic outcomes in comatose children.
Blood pressure:
👉 Maintain systolic & mean arterial pressure
above the 10th percentile for age/sex
Supported by newer survival data.
Neuroprognostication:
👉 Use MULTIPLE modalities over time
(single tests alone are unreliable)
8. New Antiarrhythmic Highlight
👉 IV sotalol supported for unstable SVT refractory to:
• Vagal maneuvers
• Adenosine
• Synchronized cardioversion (when expert consultation unavailable)
Key Negative Updates (Practice to Avoid)
• Routine bicarbonate during arrest
• Routine calcium during arrest
• Hyperventilation
• Over-reliance on advanced airway placement early in OHCA
• Using ETCO₂ alone to terminate resuscitation
Clinical Takeaways from PALS 2025
• CPR quality and physiology-guided targets matter more than ever
• Bag-mask ventilation is often sufficient early in arrest
• Early epinephrine improves outcomes in nonshockable rhythms
• Defibrillation remains priority in shockable arrest
• Avoid routine adjunct medications that show no benefit
• Post-arrest care is critical for neurologic recovery
Source:
2025 AHA–AAP Pediatric Advanced Life Support Guidelines
https://www.ahajournals.org/doi/10.1161/CIR.0000000000001368