Pediatric Advanced Life Support (PALS) 2025 Updates – Evidence-Based Changes for Advanced Resuscitation Care
Structured, clinically focused summary of the major positive and negative updates, including Class of Recommendation (COR) and Level of Evidence (LOE).
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