Pediatric CPR: Techniques and Process

Pulse Check Accuracy During Pediatric Resuscitation

Last Full Review: ILCOR 2025

Assessment of a child or infant begins with checking for responsiveness and obvious life-threatening bleeding. If the child or infant is unresponsive and not breathing normally, they are considered to be in cardiac arrest and cardiopulmonary resuscitation (CPR) is initiated. Past recommendations for healthcare professionals have included a check for circulation with a carotid pulse in children or with a brachial pulse in infants for no more than 10 seconds. However, pulses can be difficult to palpate, even for experienced healthcare professionals, and new methods of assessing circulation have developed, including ultrasound, end-tidal carbon dioxide (ETCO₂) levels and pulse oximetry. This topic was prioritized for review by the International Liaison Committee on Resuscitation (ILCOR) in 2024.

 

Evidence Summary

In 2024 ILCOR conducted a systematic review and developed a Consensus on Science with Treatment Recommendations (CoSTR) (Katzenschlager et al. 2024; Scholefield et al.2025, S116) to evaluate the effectiveness of various pulse assessment sites and methods in infants and children suspected of cardiac arrest. The review by Katzenschlager et al. (Katzenschlager et al. 2024) aimed to determine whether alternative pulse check locations (such as the femoral artery) or techniques (including cardiac auscultation, pulse oximetry, ultrasonography, monitoring ETCO₂ levels and invasive monitoring) offer advantages over the traditional guideline-recommended sites (brachial pulse for infants and carotid pulse for children and adolescents) in deciding when to initiate or continue CPR. Outcomes of interest for this review were accuracy (sensitivity and specificity of detecting a perfusing rhythm), duration of cardiac compression pauses and any clinical outcomes.

Three studies (Tibballs et al. 2009, 61; Tibballs et al. 2010, 671; Tsung et al. 2008, 264) with 39 total patients and 376 pulse checks provided data on accuracy, with sensitivity ranging from 76% to 100% and specificity ranging from 64% to 79%. One study (Tibballs et al. 2010, 671) performed with children with left ventricular assist devices (LVADs) or receiving extracorporeal membrane oxygenation (ECMO) reported that 60/153 (39%) of the participants decided on the presence of a pulse within 10 seconds, with a median duration until any decision of 18 seconds, and accuracy of 85%. Although indirect, this evidence was concerning for prolonged chest compression delays or pauses with attempts to palpate a pulse. No other studies were identified that assessed clinical outcomes in infants and children (Katzenschlager et al. 2024; Scholefield et al.2025, S116).

A weak recommendation by ILCOR suggests that the palpation of a pulse (or its absence) is unreliable as the sole determinant of cardiac arrest and the need for chest compressions.

In unresponsive children (not breathing normally and without signs of life), lay rescuers and healthcare professionals should begin CPR (good practice statement). The following treatment recommendation has been withdrawn: In infants and children with no signs of life, healthcare providers should begin CPR unless they can definitely palpate a pulse within 10 seconds (Katzenschlager et al. 2024; Scholefield et al.2025 S116).

Insights and Implications

For lay providers, the Red Cross guidelines to begin CPR after confirming unresponsiveness and absent normal breathing remain unchanged. For healthcare providers, the withdrawal of the ILCOR recommendation for healthcare providers to check for a pulse is based largely on a single study in children with LVADs or receiving ECMO. The ILCOR recommendation that palpation of a pulse (or its absence) is unreliable as the sole determinant of cardiac arrest and the need for chest compressions suggests the need for additional studies comparing arterial blood pressure, alternative pulse check sites, ultrasound or ETCO₂ changes combined with pulse checks versus pulse checks alone in children with cardiac arrest. The Red Cross guidelines no longer recommend that healthcare providers check a pulse in an unresponsive, apneic child, but allows for consideration of a pulse check in select cases, such as monitored inpatients who become unresponsive.

Measuring Invasive Blood Pressure During Pediatric In-Hospital Cardiac Arrest

Last Full Review: ILCOR 2025

During cardiopulmonary resuscitation (CPR), it is important to maintain an adequate systolic, diastolic and mean arterial blood pressure to support coronary and cerebral perfusion. For children who are hospitalized and have an intra-arterial blood pressure monitor in place, physiologic feedback can potentially guide CPR. A minimum threshold blood pressure that would be associated with improved clinical outcomes was not identified in a previous 2015 International Liaison Committee on Resuscitation (ILCOR) systematic review (de Caen et al. 2015, S177). However, a 2020 scoping review (Maconochie 2020, S140) identified one observational study (Berg et al. 2018, 1784) in critical pediatric patients with invasive arterial blood pressure monitoring at the time of cardiac arrest, showing an association between the mean diastolic blood pressure of 25 millimeters of mercury (mmHg) or greater in infants and 30 mmHg or greater in children within the first 10 minutes post arrest and survival outcomes. The evidence from the 2020 scoping review was not considered sufficient to make a treatment recommendation or good practice statement. Since then, publication of new studies has triggered an updated systematic review by ILCOR.

 

Evidence Summary

A 2025 ILCOR systematic review and Consensus on Science with Treatment Recommendations (CoSTR) (Gray et al. 2025; Scholefield et al. 2025, S116) sought evidence in infants and children receiving resuscitation after in-hospital cardiac arrest with intra-arterial blood pressure monitoring in place for a specific blood pressure target during cardiac arrest that would improve clinical outcomes. Five observational cohort studies were ultimately included, including three analyses of different subpopulations or outcomes from the same cohort.

For the outcomes of return of spontaneous circulation (ROSC), survival to hospital discharge, and survival with favorable neurological outcome, two observational studies were identified with a total of 577 patients with in-hospital cardiac arrest who had invasive arterial blood pressure monitoring at the time of arrest. Maintaining a diastolic blood pressure of 25 mmHg or greater in infants less than 1 year old and 30 mmHg in children 1 or more years old during the first 10 minutes of CPR was associated with improved outcomes compared with lower diastolic blood pressure, including higher rates of ROSC (RR, 1.22; 95% CI, 1.12–1.59), survival to hospital discharge (RR, 1.55; 95% CI, 1.18–1.91), and favorable neurological outcomes (RR, 1.37; 95% CI, 1.04–1.69) (Gray et al. 2025; Scholefield et al. 2025, S116).

For the analysis of systolic blood pressure and outcomes of survival to hospital discharge and survival with favorable neurological outcome, data from the same two studies (Berg et al. 2023, 91; Berg et al. 2018, 1784) showed no difference from exposure to a systolic blood pressure of 60 mmHg or greater for infants under 1 year old and 80 mmHg or greater for children 1 or more years old for the first 10 minutes of CPR compared with lower blood pressure (Gray et al. 2025; Scholefield et al.2025,S116).

A weak treatment recommendation by ILCOR (Gray et al. 2025; Scholefield et al.2025, S116) suggests targeting an intra-arrest diastolic blood pressure of 25 mmHg or greater for infants less than 1 year and 30 mmHg or greater for children 1 to 18 years with invasive arterial blood pressure monitoring in place at the time of cardiac arrest.

Insights and Implications

This review was limited by the lack of any randomized controlled trials and the very low certainty of evidence across all outcomes. The population of interest is very narrow: pediatric patients who already had an indwelling arterial blood pressure monitor when they developed cardiac arrest. However, the authors point out that this very population may be at higher risk of cardiac arrest, making a recommendation valuable. The 2018 study by Berg et al. (Berg et al. 2018, 1784) used the same population to generate and validate the cutoffs of 25 mmHg and 30 mmHg for infants and children, respectively. In the 2023 study by Berg et al. (Berg et al. 2023, 91) other cutoffs were examined, but 25 mmHg and 30 mmHg were found to be the most predictive. There are several knowledge gaps identified with this review, including use of noninvasive blood pressure measurements during cardiac arrest, blood pressure targets for older children or adolescents, and the importance of diastolic and systolic blood pressure in arrests with a duration beyond the first 10 minutes of CPR.

Extracorporeal CPR in Pediatric Patients with Single Ventricle Physiology

Last Full Review: ILCOR 2025

Pediatric patients born with a single ventricle have a unique physiology, with the one functional ventricle supporting both systemic and pulmonary circulations, leading to parallel blood flow. Many of these children undergo staged palliative surgery for the defect (Rao 2021, 441). There is a higher risk of cardiac arrest in this population (Alten et al. 2022, 1027), but with conventional cardiopulmonary resuscitation (CPR), systemic blood flow is often reduced and the oxygen content of the blood is low, increasing the risk of coronary and cerebral ischemia (Wolf et al. 2012, 874). The International Liaison Committee on Resuscitation (ILCOR) has previously recommended that extracorporeal cardiopulmonary resuscitation (ECPR) may be considered as an intervention for select infants and children, such as pediatric cardiac populations with in-hospital cardiac arrest refractory to conventional CPR in settings where resuscitation systems allow ECPR to be well performed and implemented (Maconochie et al. 202, S140). However, there is no recommendation for ECPR specific to children with single ventricle physiology with in-hospital cardiac arrest refractory to conventional CPR.

 

Evidence Summary

A 2025 ILCOR systematic review (Raymond et al. 2025, 100997) and Consensus on Science with Treatment Recommendations (CoSTR) (Raymond et al. 2025; Scholefield et al.2025, S116) sought evidence for the use of ECPR, including extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass during resuscitation of infants, children and adolescents with cardiac arrest in the hospital setting following Stage I (Norwood/Hybrid), Stage II (Hemi-Fontan/Bidirectional Glenn) or Stage III (Fontan) palliation for congenital heart disease with single ventricle physiology. The interventions were to be compared with conventional (manual) CPR without ECPR. Extracorporeal cardiopulmonary resuscitation was defined as being placed on cardiopulmonary bypass or extracorporeal membrane oxygenation (ECMO) during active chest compressions for cardiac arrest, while ECMO was defined as elective cardiopulmonary bypass or ECMO without active chest compressions for cardiac arrest. No studies were identified from the literature search that included pediatric cardiac patients with single ventricle physiology who received ECPR compared with manual or conventional CPR (no ECPR). Other studies identified were observational, providing very low-certainty evidence for critical outcomes (Raymond et al. 2025; Scholefield et al.2025, S116).

These studies compared children with single ventricle physiology who received ECPR with children receiving ECMO without ECPR, or they described ECPR in single ventricle patients without a comparator group. Two cohort studies (Rood et al. 2011, 504; Sherwin et al. 2012, 1337) used registry data from overlapping years of patient inclusion from the Extracorporeal Life Support Organization and reported a survival to hospital discharge rate between 32% to 34% in 805 single ventricle ECPR patients. The collective evidence from the registry studies and meta-analysis of data from three observational studies (Chrysostomou et al. 2013, 317; Hoskote et al. 2006, 1114; Stephens et al. 2020, 183) indicates no statistically significant difference in survival to hospital discharge with ECPR compared with ECMO non-ECPR in pediatric single ventricle patients (Raymond et al. 2025; Scholefield et al.2025, S116. Subgroup analyses for pediatric single ventricle patients status post Stage I Norwood palliation and Stage III Fontan palliation also found no difference in survival to hospital discharge with ECPR compared with ECMO non-ECPR (Raymond et al. 2025; Scholefield et al.2025, S116).

The ILCOR review concludes that for patients with single ventricle physiology, there is insufficient evidence to make a treatment recommendation for or against the use of ECPR during cardiac arrest, and there is insufficient evidence to make a treatment recommendation for or against the use of ECPR compared to ECMO non-ECPR (Raymond et al. 2025; Scholefield et al.2025, S116).

Insights and Implications

Many knowledge gaps were identified with this review. Although the choice between ECPR and conventional ECMO does not significantly affect survival to hospital discharge in pediatric patients with single ventricle physiology, individual patient factors and clinical circumstances should be considered when choosing the most appropriate resuscitation strategy.

Assessment

Last Full Review: American Red Cross Scientific Advisory Council 2011
Last: Update: 2023

Rapid assessment begins with performing a visual survey, checking for responsiveness and life-threatening bleeding, opening the airway and simultaneously checking for breathing and a pulse. The use of a mnemonic can be helpful for learning and recalling the sequence for assessment and initial actions.

 

Evidence Summary

The American Red Cross Scientific Advisory Council reviewed this topic in 2020 (American Red Cross Scientific Advisory Council. Resuscitation: 2020) and a joint American Heart Association and Red Cross statement on this topic was issued in 2012. These reviews showed no changes to this guidance.

Insights and Implications

Early assessment for life-threatening bleeding is performed with the check for responsiveness. The A-B-C mnemonic is a universal means to recall and perform assessment and initial actions, including opening of the airway (A), checking for the presence or absence of normal breathing (B), and, for healthcare professionals, the simultaneous assessment for circulation (C) by a pulse check, or for lay responders, beginning compressions (C).

Pediatric CPR Techniques

Last Full Review: American Red Cross Scientific Advisory Council 2020; ILCOR Scoping Review 2020

Past guidelines advised using two fingers for compressions during single-rescuer infant cardiopulmonary resuscitation (CPR) and using two thumbs and hands encircling the chest for compressions for two-rescuer infant CPR. The single-rescuer two-finger technique has been historically taught based on concerns that the two-thumb/encircling hands technique may interfere with ventilation performance, while the two-thumb technique has been recommended for two healthcare professionals due to higher quality compressions. A 2020 systematic review has led to a change in the Red Cross recommendations (Millin et al. 2020, 161).

 

Evidence Summary

A 2020 systematic review with meta-analysis by the American Red Cross Scientific Advisory Council Resuscitation Subcouncil members compared the quality of chest compressions and ventilation parameters between the two-thumb and two-finger techniques (Millin et al. 2020, 161). All studies identified were performed on a manikin. Pooled data from 16 observational studies using a random-effects model showed that use of the two-thumb technique resulted in greater compression depth compared with the two-finger technique (MD, 5.61 mm; 95% CI, 2.79–8.43) and 36.91% more compressions of adequate depth (95% CI, 10.07–63.74) (Millin et al. 2020, 161). No difference was found between the two compression techniques for ventilation parameters, although only five studies were able to be included in the ventilation volume meta-analysis. There was not enough data to abstract the total number of ventilations performed during a compression-to-ventilation sequence. The reviewers concluded that for CPR performed on a simulated infant manikin by a single rescuer, the two-thumb technique improves chest compression quality without compromising ventilation (Millin et al. 2020, 161). An American Red Cross Scientific Advisory Council scientific review on infant CPR techniques and sequences1 noted that the precise location for the rescuer to place their fingers or thumbs is not clear.

A scoping review by the International Liaison Committee on Resuscitation in 2020 did not find new published evidence related to the effectiveness of specific compression depths during CPR in children and infants (Maconochie et al. 2020, S140). The International Liaison Committee on Resuscitation recommendations remain unchanged, with a suggestion that rescuers compress an infant’s chest by at least one-third the anteroposterior dimension, or approximately 1½ inches (Maconochie et al. 2020, S140).

Insights and Implications

This systematic review with meta-analysis suggests that CPR quality is significantly greater when performed using a two-thumb/encircling hands technique compared with the two-finger technique, without compromising ventilation volume, and when performed by a single rescuer (Millin et al. 2020, 161). Limitations include the heterogeneity in measures between studies, the inability to determine total number of ventilations in a given sequence, lack of certainty assessment for individual studies or across outcomes, and lack of studies in infants with clinical outcomes. Risk of bias was high for all studies. Despite the limitations, the unknown but potential survival benefit from increased quality of CPR supports the change in recommendations to the use of two thumbs with encircling hands for single-rescuer CPR, while retaining the option of the two-finger technique. Lay responders with thumb, finger, hand or wrist arthritis now have the option to use the technique that can be performed best, including the one-hand technique, within their physical limitations in order to deliver compressions of recommended depth.

Pediatric Advanced Airway Interventions in Cardiac Arrest

Last Full Review: ILCOR 2019
Last Update: 2024

Pediatric cardiac arrest is frequently preceded by a respiratory condition, such as severe asthma, bronchiolitis or pneumonia with respiratory failure, foreign body airway obstruction or drowning. The ability to maintain an open airway and to provide effective ventilations is a critical component of child and infant resuscitation. Bag-mask ventilation (BMV) is commonly used in the initial resuscitation, followed by the placement of a supraglottic airway or tracheal tube. 

A 2019 systematic review by the International Committee on Resuscitation (ILCOR) (Lavonas et al. 2019, 114) found limited evidence suggesting that tracheal intubation or use of a supraglottal airway are not superior to BMV for resuscitation of children in cardiac arrest for critical outcomes, but the overall certainty of evidence is low to very low. For 2024, an updated review incorporates new evidence to support the Red Cross guidelines.  

 

Evidence Summary

A 2024 ILCOR updated systematic review and Consensus on Science with Treatment Recommendations (CoSTR) (Acworth et al. 2024; Greif et al. 2024) evaluated evidence for the placement of an advanced airway device in infants (excluding newborns) and children who receive cardiopulmonary resuscitation (CPR) after out-of-hospital cardiac arrest (OHCA) or in-hospital cardiac arrest (IHCA), compared with the use of BMV alone or another advanced airway device. Specific comparisons included tracheal intubation compared with BMV, supraglottic airway compared with BMV, and tracheal intubation compared with supraglottic airway during pediatric cardiac arrest. 

Results of meta-analysis of 15 studies suggest that resuscitation with tracheal intubation is not superior to BMV for resuscitation of children in cardiac arrest for survival with favorable neurological outcome and survival-to-hospital discharge. There was very low-certainty evidence suggesting that tracheal intubation may be associated with harm. Similar results were found when studies of IHCA were analyzed separately from studies of OHCA, although the evidence for IHCA is limited and the reported findings are inconsistent (Acworth et al. 2024; Greif et al. 2024).

The authors note that most of the available data for this review came from registries, and it is unclear how many events labeled as BMV resuscitation may have been failed intubation and/or supraglottic airway attempts. Alternatively, in some studies, longer resuscitation times may have introduced resuscitation-time bias, in which the child is more likely to receive advanced airway interventions and less likely to survive, creating bias against tracheal intubation and supraglottic airway placement. The evidence included with this review is considered very low certainty regarding whether attempting advanced airway placement before return of spontaneous circulation improves outcomes in resuscitation (Acworth et al. 2024; Greif et al. 2024).

Treatment recommendations from ILCOR are unchanged from 2019 and include a weak recommendation suggesting the use of BMV rather than tracheal intubation or supraglottic airway placement in the management of children during cardiac arrest in the out-of-hospital setting. There remains insufficient evidence to support any recommendation for or against the use of BMV compared with tracheal intubation or supraglottic airways for in-hospital arrest.

A new good practice statement suggests that clinicians consider transitioning to an advanced airway intervention (supraglottic airway or tracheal intubation) when the team has sufficient expertise, resources and equipment to enable placement to occur with minimal interruptions to chest compressions, or when a BMV device is not providing adequate oxygenation and ventilation (Acworth et al. 2024; Greif et al. 2024).

Insights and Implications

High-quality CPR requires effective chest compressions, ventilation and oxygenation. Choosing an approach for airway management of an infant or child in cardiac arrest is not straightforward. The choice depends on the setting, the age of the child, the circumstances leading to the cardiac arrest, emergency medical services transport time, the skill of the healthcare professional, and the availability and experience of the care team. The new good practice statement suggests that healthcare professionals take these considerations into account when transitioning to an advanced airway device. High-quality, randomized controlled trials are needed in all settings to compare airway management with tracheal intubation, supraglottic airway placement and BMV for different age groups and etiologies of cardiac arrest.

Management of Pulmonary
Hypertension with In-Hospital Cardiac Arrest

Last Full Review: ILCOR 2024

Pulmonary hypertension (i.e., elevated pulmonary arterial pressure) is a relatively rare condition in children and infants. Morbidity and mortality are related to progressive right ventricular dysfunction and arrhythmias with sudden cardiac arrest. The condition may be due to congenital heart disease, persistent pulmonary hypertension of the newborn syndrome, left heart disease, lung disease and/or hypoxia, pulmonary artery obstruction, or it can be multifactorial. Persistent pulmonary hypertension syndrome is the most frequent cause of transient pulmonary hypertension. It occurs when pulmonary vascular resistance remains abnormally high after birth, leading to right-to-left shunting of blood through fetal circulatory pathways and causing severe hypoxemia that may not respond to conventional respiratory support. For pediatric in-hospital cardiac arrests (IHCA), pre-existing pulmonary hypertension is present in up to 16% of children (Morgan et al. 2023, 109897).

 

Evidence Summary

A new scoping review (Ng et al. 2024; Greif et al. 2024) by the International Liaison Committee on Resuscitation (ILCOR) sought evidence for specific management strategies compared with standard care for infants and children with pulmonary hypertension at high risk of pulmonary hypertensive crises with a cardiac arrest in the in-hospital setting, including post-operatively. Specific management strategies of interest included:

• Respiratory management and monitoring to avoid hypoxia and acidosis
• Use of opioids, sedatives and neuromuscular blocking agents
• Pulmonary arterial hypertension-specific targeted medical therapy 

 

The studies included in this scoping review were limited to randomized controlled trials, nonrandomized studies and case series with greater than five cases between January 1, 2012 and December 22, 2023. Of the 19 studies included in the review, only three presented data on the management of cardiac arrest in children with pulmonary hypertension, while the others provided background literature on the acute management of children with pulmonary hypertension. The review identified information on updated definitions and classifications of pulmonary hypertension, risk of death and intensive care hospitalizations, and use of extracorporeal membrane oxygenation (ECMO).

The current international hemodynamic definition for pulmonary hypertension in children has been aligned with the adult definition as a mean pulmonary artery pressure of greater than 20 mmHg (Galiè et al. 2019; Rosenzweig et al. 2019; Simonneau, 2019). Clinical groups defined include:

• Pulmonary arterial hypertension, which includes both pulmonary arterial hypertension associated with congenital heart disease, and persistent pulmonary hypertension of the newborn (PPHN) syndrome 
• Pulmonary hypertension due to left heart disease
• Pulmonary hypertension due to lung disease and/or hypoxia
• Pulmonary hypertension due to pulmonary artery obstruction
• Pulmonary hypertension with unclear multifactorial mechanism

 

This classification system is important to follow, as related outcomes are being reported in registries. In addition, the term “clinical worsening” is being used as a composite endpoint for interventional trials.

In the U.S., the incidence of sustained pulmonary hypertension is reported at 26 to 33 cases per million children per year (Li et al. 2017, 126), with most presenting as infants with either PPHN or repairable cardiac shunt defects (van Loon 2011. 1755). A prospective multicenter study with data from pediatric intensive care units and cardiac intensive care units in the U.S. reported that of 1276 IHCAs, 16% of children had pre-existing pulmonary hypertension (Morgan et al. 2023, 109897).

The risk for mortality in hospitalized pediatric patients with pulmonary hypertension is greater than the risk for patients without pulmonary hypertension (Frank et al 2015, 339). Furthermore, the mortality risk is higher in these patients compared to all other medical cardiac admissions (10% versus 3.9%) (Morell et al. 2021 454). A multicenter study from 2014 to 2019 reported that 6.1% of the patients admitted with pulmonary hypertension experienced a cardiopulmonary resuscitation event. A significant increase in odds of mortality was noted among patients with pulmonary hypertension who received mechanical ventilation and vasoactive therapies within the first two days in the intensive care unit (Morell et al. 2021 454). 

There is limited comparative evidence for the use of ECMO during refractory cardiac arrest in pediatric patients with pulmonary hypertension, and mortality may be higher with ECMO than without ECMO. Studies of additional specific therapies and interventions for the treatment of cardiac arrest in pediatric patients with pulmonary hypertension are limited. Please refer to the online Consensus on Science with Treatment Recommendations  for full narrative descriptions (Ng et al. 2024; Greif et al. 2024).

The use of ECMO has been reported for stabilizing infants with PPHN or congenital diaphragmatic hernia in the post-operative period of congenital heart disease when inhaled nitric oxide and mechanical ventilation with general measures are insufficient (Abman et al. 2015, 2037).

The review concluded that there are insufficient studies to support a systematic review on specific interventions or management strategies for the resuscitation of children with pulmonary hypertension in cardiac arrest. However, several new good practice statements were issued by ILCOR to help healthcare professionals caring for children with pulmonary hypertension who are hospitalized with a clinical worsening event (Ng et al. 2024; Greif et al. 2024):

• In children (including neonates with pulmonary hypertension) hospitalized for a clinical worsening event, a suggestion was made to avoid factors that may increase pulmonary vascular resistance while treating the aggravating condition to decrease the risk of cardiac arrest.
• There is insufficient evidence to suggest using specific interventions over others. Management strategies include avoidance of hypoxia, hypercapnia, acidosis, and stressors such as pain, agitation, dehydration or fluid overload, anemia, infection or arrhythmias. Pulmonary hypertension specific treatments (e.g., inhaled nitrous oxide, L-Arginine, phosphodiesterase inhibitors [e.g., milrinone, sildenafil] or endothelin-1 inhibitors [e.g., bosentan]) may be considered.
• In children who develop signs of pulmonary hypertensive crisis, low cardiac output or right ventricular failure despite optimal medical therapy ECMO may be considered before cardiac arrest or for refractory cardiac arrest as a bridge to recovery. In very select cases, ECMO can be used as a bridge to evaluate for organ replacement and transplantation.

 

Insights and Implications

The Red Cross guidelines are informed by this ILCOR review and the good practice statements. Further research is needed, but due to the relative rarity of pulmonary hypertension in pediatric patients, it will likely require multi-center studies or retrospective database analyses from registries—with a focus on specific categories of pulmonary hypertension.

 

CPR Compression-to-Ventilation Ratio for Children and Infants: Healthcare Professionals

Last Full Review: ILCOR 2017

Last Update: 2019

Since 2015, it has been recommended by the Red Cross that lay responders and healthcare professionals provide rescue breaths and chest compressions for children and infants with in-hospital cardiac arrest and out-of-hospital cardiac arrest. It has also been a Red Cross guideline recommendation that if someone is unwilling or unable to provide ventilations (i.e., mouth-to-mouth, mouth-to-mask) for children and infants in cardiac arrest, they should at least perform chest compressions. Is there new evidence to support these recommendations?

 

Evidence Summary

An evidence update (Wyckoff et al. 2022, 1095) of a 2017 International Liaison Committee on Resuscitation (ILCOR) and Consensus on Science with Treatment Recommendations (CoSTR) (Olasveengen et al. 2017, e424) on compression-only CPR (CO-CPR) in pediatric patients identified one relevant study. A retrospective review of data from the Cardiac Arrest Registry to Enhance Survival (CARES) database evaluated 13,060 pediatric (18 years of age or younger) nontraumatic out-of-hospital cardiac arrests (Naim et al. 2021, 1042). In multivariable analysis of the overall cohort, neurologically favorable survival was associated with rescue breathing-cardiopulmonary resuscitation (CPR) (aOR, 2.16; 95% CI, 1.78–2.62) and with CO-CPR (aOR, 1.61; 95% CI, 1.34–1.94) compared with no cardiopulmonary resuscitation (CPR). Rescue breathing CPR was associated with higher odds of neurologically favorable survival compared with CO-CPR (aOR, 1.36; 95% CI, 1.10–1.68). Risk stratification by age group was also reported. For the comparison of RB-CPR with no CPR, adjusted OR for neurologically favorable survival was greater for infants less than 1 year of age (aOR, 1.65; 95% CI, 1.19–2.3; P<0.003), children (1 to 11 years of age) (aOR, 2.73; 95% CI, 2.00–3.72; P<0.001) and adolescents (12 years of age or older) (aOR 2.12; 95% CI, 1.44–3.11; P<0.001). When comparing data for patients who received CO-CPR with data for patients with no CPR, CO-CPR was associated with better neurologically favorable survival in children (aOR 1.94; 95% CI, 1.41–2.68; P<0.001) and adolescents (aOR, 1.71; 95% CI, 1.23–2.37; P<0.001), but not for infants (aOR, 1.16; 95% CI, 0.083–1.62; P=0.294) (Naim et al. 2021, 1042).

The identified study was considered supportive of current ILCOR recommendations for providing rescue breathing with chest compressions in pediatric in-hospital cardiac arrest and out-of-hospital cardiac arrest, and to provide CO-CPR when rescuers are unwilling or unable to provide rescue breathing (Wyckoff et al. 2022, 1095). The evidence update authors noted that a previously identified study from 2010 (Kitamura et al. 2010) found that CO-CPR for infants was not associated with a more favorable neurologic outcome compared with no CPR. Although the new study (Naim et al. 2021, 1042) also found that CO-CPR was not associated with better neurologically favorable survival for infants compared with no CPR, the ILCOR Pediatric Task Force continues to recommend CO-CPR for infants in cardiac arrest when rescuers are unwilling or unable to provide rescue breathing (Wyckoff et al. 2022, 1095).

Insights and Implications

The Red Cross guidelines for the use of conventional compression-ventilation CPR in children and infants and for the use of CO-CPR when someone is unwilling or unable to provide ventilations are reaffirmed with this ILCOR evidence update. Further studies are needed to determine the benefit of CO-CPR for infants.

Ventilation Rates with an Advanced Airway During Pediatric CPR

Last Full Review: ILCOR 2024
Last Update: 2020 

The optimal ventilation rate for children and infants in cardiac arrest, and with an advanced airway in place, has been the subject of research and debate. Previous 2010 International Liaison Committee on Resuscitation (ILCOR) (Kleinman et al. 2010, S466) recommendations for minute ventilation were based on expert consensus. In 2019, a prospective multicenter observational study (Sutton et al. 2019, 1627) evaluated ventilation rates during cardiopulmonary (CPR) among intubated children (37 or greater weeks’ gestation and less than 19 years old) who received at least 1 minute of CPR in the setting of pediatric and pediatric cardiac intensive care units. The guideline rate was defined as 10 +/- 2 breaths per minute. The high ventilation rate was defined as 30 or more breaths per minute in children less than 1 year old, and greater than or equal to 25 breaths per minute in older children. The study reported that ventilation rates exceeding guidelines were common, and that higher ventilation rates (30 or more breaths per minute in infants less than 1 year old, and 25 or more breaths per minute in children 1 year or older) were associated with a higher odds ratio for survival-to-hospital discharge with good neurological outcome. This study was considered supportive of past Red Cross guidelines for providing 1 ventilation every 2 to 3 seconds (20 to 30 breaths per minute) for children and infants in cardiac arrest with an advanced airway in place and with continuous chest compressions. An updated ILCOR systematic review was completed on this topic for 2024.

 

Evidence Summary

A 2024 ILCOR systematic review and Consensus on Science with Treatment Recommendations (CoSTR) (del Castillo et al. 2024; Greif et al. 2024) sought evidence for the use of any specific respiratory rate, compared with a ventilation rate of 8 to 10 breaths per minute in children and infants (excluding newborn infants) with out-of-hospital cardiac arrest or in-hospital cardiac arrest (IHCA) and an advanced airway. The review did not identify any studies that compared a ventilatory rate of 8 to 10 breaths per minute with any other specific ventilatory rate.

A revised ILCOR treatment recommendation states that there is currently no supporting evidence to make a treatment recommendation on a specific ventilatory rate in pediatric CPR with an advanced airway. A good practice statement was made that for cardiac arrest occurring with an advanced airway in place, the use of ventilatory rates greater than 10 breaths per minute may be reasonable. It is suggested to use ventilatory rates close to age-appropriate respiratory rates with avoidance of hypoventilation and hyperventilation.

The Justifications section of the online CoSTR (del Castillo et al. 2024) discusses evidence that did not meet inclusion criteria for the systematic review. The 2019 observational study by Sutton et al. (Sutton et al. 2019, 1627) of pediatric IHCA observed a higher odds ratio for survival-to-hospital discharge and survival with good neurological outcome rates in patients with higher ventilation rates. The ILCOR task force considered the ventilation rates referred to in this study as adequate based on a mathematical model of ventilation in the pediatric intensive care unit for IHCA that cannot be applied to other populations. In addition, the potential harm of higher ventilation rates was considered, including reduced systolic blood pressures (-17.8 mmHg per 10 breaths per minute increase; 95% CI, -2.7 to -8.1; P<0.01) reported in the study by Sutton et al. (Sutton et al. 2019, 1627)

Insights and Implications

Previous treatment recommendations by ILCOR for ventilation rates of 10 breaths per minute during cardiac arrest were derived from adult data. A ventilation rate of 10 breaths per minute could cause hypoventilation in children and infants, and there is no pediatric data to support this ventilation rate.

The revised guidelines, based on ILCOR recommendations, have implications for training and implementation. Tables with age-appropriate ranges of respiratory rates may be difficult to memorize, and cognitive aids may be necessary for use in code scenarios. The previous Red Cross guidelines for the delivery of 20 to 30 breaths per minute may not be appropriate for all age groups, but provide a range that can be used as a starting point in resuscitation—with the higher end (30 breaths per minute) for infants through preschoolers, and the lower end (20 breaths per minute) for school-age children.

Studies have shown that the actual delivery rate of ventilation tends to be higher than the guideline rate. Because high ventilation rates in children greater than 1 year old are associated with lower systolic blood pressures, using a range between 20 to 30 breaths per minute as a general guideline for the initial ventilation rate in pediatric CPR with an advanced airway present may be appropriate. Further adjustment of ventilation parameters should be guided by capnography, oximetry and blood gas analysis.

Studies are needed to determine the effect of other variables in ventilation, such as tidal volume, minute volume and positive end-expiratory pressure on oxygenation and ventilation during CPR.

 

CPR and Defibrillation in the Prone Patient

Last Full Review: ILCOR 2021

The coronavirus disease 2019 (COVID-19) pandemic has led to the further use of the prone position to improve oxygenation, with and without advanced airway management. This has led to questions regarding the feasibility of performing cardiopulmonary resuscitation (CPR) and defibrillation with the patient in the prone position and its effectiveness compared with resuscitation in the supine position.

 

Evidence Summary

A 2021 systematic review and Consensus on Science with Treatment Recommendations (Wyckoff et al. 2021a; Wyckoff et al. 2021b; Berg et al. 2021) by the International Liaison Committee on Resuscitation (ILCOR) focused on CPR and defibrillation for cardiac arrest in adults and children in any setting when in the prone position, compared with turning the patient to the supine position prior to the initiation of CPR and/or defibrillation. Outcomes of interest included survival with/without favorable neurologic outcome, return of spontaneous circulation, end-tidal carbon dioxide (ETCO₂) and arterial blood pressure readings during CPR, and time to defibrillation.

The search included all years. Two prospective nonrandomized studies and two simulation studies were identified. An additional 20 adult case reports were included, of which 12 had CPR initiated while in a prone position, and the remaining cases were supinated before starting CPR. The operating room was the predominant setting for case reports (Berg et al. 2021). The majority of evidence included for this review was assessed to be of very low certainty and difficult to interpret. The authors of the review commented that each case may be unique and require weighing the potential risk of delayed CPR and defibrillation against the possible risk of less effective CPR and defibrillation while prone. It was noted that it may be difficult to supinate a patient who is prone and mechanically ventilated and with capnography and additional arterial lines in place. In addition, the etiology of the cardiac arrest may define the urgency of supination (Wyckoff et al. 2021b; Wyckoff et al. 2021a; Berg et al. 2021).

The treatment recommendations stemming from this review include several good practice statements, reflecting the lack of higher certainty evidence. A strong recommendation was made, for patients with cardiac arrest occurring while in the prone position without an advanced airway already in place, to turn that patient to the supine position as quickly as possible and begin CPR (Berg et al. 2021). For patients with cardiac arrest while in the prone position with an advanced airway already in place, and where immediate supination is not feasible or poses a significant risk to the patient, initiating CPR while the patient is still prone may be a reasonable approach (good practice statement). Invasive blood pressure monitoring and continuous (ETCO₂) monitoring may be useful to ascertain whether or not prone compressions are meeting benchmarks for adequate perfusion, and this information could inform decision making on when to prioritize supination (good practice statement). For patients with cardiac arrest with a shockable rhythm who are in the prone position and cannot be supinated immediately, attempting defibrillation in the prone position is a reasonable approach (good practice statement) (Wyckoff et al. 2021b; Wyckoff et al. 2021a; Berg et al. 2021).

Insights and Implications

Use of the prone position in the critical care of COVID-19 patients became commonplace over a short period of time, and the lack of comparative outcomes data makes it difficult to form treatment recommendations. The ILCOR recommendations stem from a review of the best available evidence combined with task force discussion and expert consensus to create good practice statements that are reflected in the Red Cross guidelines. Further research will be needed to address knowledge gaps, such as the time needed to supinate a patient with advanced airway in place, optimal hand and defibrillator pad placement while prone, and clinical outcomes following CPR or defibrillation while in the prone position.

Extracorporeal CPR for Pediatric Cardiac Arrest

Last Full Review: ILCOR 2023

Extracorporeal CPR (ECPR) is an advanced resuscitative technique that involves the withdrawal of blood, the use of extracorporeal membrane oxygenation (ECMO) followed by reperfusion of oxygenated blood back into the patient’s body, with support of perfusion through the addition of an external pump. In practice, ECPR is used to support circulation in selected patients with refractory cardiac arrest, potentially extending the time for treatment of reversible causes. By definition, ECPR occurs when ECMO flow is instituted during resuscitation or within 20 minutes of the return of spontaneous circulation without ongoing compressions (Guerguerian et al. 2021, 229). The goals of ECPR with ECMO during cardiopulmonary arrest are to deliver oxygen, support perfusion, remove carbon dioxide and decrease ischemic reperfusion injury. What evidence supports the use of ECPR for cardiac arrest?

 

Evidence Summary

A 2023 updated systematic review (Holmberg et al. 2023a, 109665; Berg et al. 2023) of a 2018 International Liaison Committee on Resuscitation (ILCOR) systematic review (Holmberg et al. 2018, 91) and Consensus on Science with Treatment Recommendations (CoSTR) (Soar et al. 2018, e714; Holmberg et al. 2023) sought evidence for children (under 18 years of age or younger) and for adults in cardiac arrest in any setting comparing the use of ECPR, including ECMO or cardiopulmonary bypass, during cardiac arrest with manual or mechanical CPR. Studies of children were evaluated and summarized separately for the ILCOR CoSTR (Holmberg et al. 2023b). The updated review included four observational studies of children with in-hospital cardiac arrest. No studies compared ECPR with no ECPR in children. Of the four observational studies, two were secondary analyses of an in-hospital cardiac arrest trial of pediatric patients comatose after in-hospital cardiac arrest and randomized to one of two different targeted temperature protocols (Moler et al. 2017, 318). Odds of survival were lower at 12 months in the ECMO group compared with the no ECMO group (OR, 0.52; 95% CI, 0.29–0.94) or for survival at 12 months with a Vineland Adaptive Behavior Scales Second Edition score of 70 (OR, 0.34; 95% CI, 0.17–0.67) (Meert et al. 2018, 96). Other included studies (Meert et al. 2019, 1441; Taeb et al. 2018, 831; Hamzah et al. 2021, 2513) with outcomes of mid-term survival and mid-term favorable neurological outcome generally favored no use of ECPR, although confidence intervals were wide. All studies were at critical risk of bias due to confounding and selection bias.

The weak treatment recommendation by ILCOR remains unchanged, with a suggestion that ECPR may be considered as an intervention for select infants and children (e.g., pediatric cardiac populations) with in-hospital cardiac arrests refractory to conventional CPR in settings where resuscitation systems allow ECPR to be well performed and implemented. There is insufficient evidence in pediatric out-of-hospital cardiac arrests to formulate a treatment recommendation for the use of ECPR (Holmberg et al. 2023b; Berg et al. 2023).

Insights and Implications

Extracorporeal cardiopulmonary resuscitation is a resource-demanding intervention not available in many hospitals. However, the use of ECPR has become more common in some locations for pediatric patients with cardiac arrest after cardiac surgery.

 

Termination of Resuscitation Rules 

Last Full Review: ILCOR 2020

Termination of resuscitation for adults by prehospital professionals is often guided by a set of rules adopted by emergency medical service systems. 

 

Evidence Summary 

A systematic review by the International Liaison Committee on Resuscitation in 2020 evaluated the use of termination of resuscitation rules for their ability to reliably predict in-hospital outcomes of death and unfavorable neurologic outcome following adult out-of-hospital cardiac arrest (Greif et al. 2020, S222). Studies included were reported to describe the derivation and internal validation of individual termination of resuscitation rules, or the external validation of previously published termination of resuscitation rules. Only a single study addressed clinical validation of a termination of resuscitation rule. A retrospective cohort review evaluated the extent to which existing termination of resuscitation criteria can be transferred to pediatric out-of-hospital cardiac arrest patients, with only 48% sensitivity for Basic Life Support (BLS) termination of resuscitation criteria predicting death, and 10% sensitivity for Advanced Life Support (ALS) termination of resuscitation criteria for death (Rotering et al. 2016, 144).

Insights and Implications 

Both BLS and ALS termination of resuscitation rules in this retrospective review appear not to be transferable to the pediatric population. Decisions to terminate resuscitation should be made individually and based on clinical decision rather than current BLS and ALS termination of resuscitation rules.