Authors: Jeong Eun Lee, Mihui Kim, Eun Kyung Choi, Jiyong Yeom, Jinyoung Oh, Sung-Hye Byun, Dong Gun Lim, Hoon Jung
Categories: Pediatric Anesthesia, Cardiopulmonary resuscitation, Guideline, Pediatrics, Post-cardiac arrest care
Source: Anesthesia and Pain Medicine
Doi: 10.17085/apm.26581
Authors: Jeong Eun Lee, Mihui Kim, Eun Kyung Choi, Jiyong Yeom, Jinyoung Oh, Sung-Hye Byun, Dong Gun Lim, Hoon Jung
Pediatric cardiac arrest differs fundamentally from adult arrest in its etiology, physiology, and clinical course. In children, most events arise from progressive respiratory failure or circulatory compromise rather than primary cardiac causes. The 2025 American Heart Association pediatric cardiopulmonary resuscitation (CPR) guidelines provide an updated, evidence-based framework that reflects these distinctions. This review summarizes key revisions across basic life support, advanced life support, and post-cardiac arrest care (PCAC), and outlines practical considerations for clinical implementation. Major updates include refined chest compression techniques for infants, earlier administration of epinephrine for non-shockable rhythms, revised management of foreign-body airway obstruction, and clearer guidance on the use and limitations of end-tidal carbon dioxide monitoring. The guidelines also emphasize targeted hemodynamic management, including maintaining diastolic pressures ≥ 25 mmHg in infants and ≥ 30 mmHg in children during CPR, and sustaining systolic and mean arterial pressures above the age-specific 10th percentile after return of spontaneous circulation. Temperature management prioritizes the strict avoidance of hyperthermia, with the optional use of structured temperature control protocols. The unified Chain of Survival—comprising (1) recognition and emergency activation, (2) high-quality CPR, (3) defibrillation, (4) advanced resuscitation, (5) PCAC, and (6) recovery and survivorship—serves as an integrated framework linking early recognition of arrest to long-term rehabilitation. Implementation of these recommendations requires coordinated teamwork, system-level preparedness, and age-appropriate clinical decision-making. Applied within this framework, the 2025 pediatric CPR guidelines have the potential to improve survival and neurological outcomes in infants and children experiencing cardiac arrest.
Pediatric cardiac arrest is a distinct clinical entity that differs markedly from adult cardiac arrest in its etiology, pathophysiology, and clinical presentation. Rapid recognition and age-appropriate management are essential, as most arrests in infants and children result not from primary cardiac pathology but from progressive respiratory failure or circulatory compromise [1]. Accordingly, timely support of oxygenation and ventilation is central to improving survival and neurological outcomes [2].
The 2025 American Heart Association (AHA) guidelines incorporate these pediatric-specific features and provide integrated recommendations for basic life support (BLS), advanced life support (ALS), and post-cardiac arrest care (PCAC). Compared with the 2020 guidelines, the updated document reflects new epidemiologic data, refined pharmacologic and defibrillation strategies, strengthened criteria for high-quality chest compressions, and more detailed guidance for special situations, including trauma and foreign-body airway obstruction (FBAO).
This review has three primary (1) to synthesize the major practice-changing elements of the 2025 AHA pediatric cardiopulmonary resuscitation (CPR) guidelines from a clinical perspective; (2) to outline the practical application of the revised BLS, ALS, and PCAC algorithms in real-world settings; and (3) to support anesthesiologists, pain physicians, emergency clinicians, and pediatric critical care teams in translating these recommendations into routine clinical practice for children at risk of or recovering from cardiac arrest.
Cardiac arrest guidelines are regularly updated by major international resuscitation organizations, including the AHA, the European Resuscitation Council (ERC), and the Korean Association of Cardiopulmonary Resuscitation (KACPR).
American Heart Association (AHA): https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines
European Resuscitation Council (ERC): https://www.erc.edu/science-research/guidelines/guidelines-2025/guidelines-2025-english/
Korean Association of Cardiopulmonary Resuscitation (KACPR): https://www.kacpr.org/
The most recent update cycle resulted in the independent publication of the 2025 AHA and ERC guidelines in October 2025, followed by the release of the 2025 Korean CPR guidelines in December of the same year. This near-synchronous international revision has facilitated harmonized, evidence-based recommendations for CPR across all age groups, including pediatric cardiac arrest. At the same time, it allows for regional adaptation based on local healthcare systems and regulatory frameworks.
The pediatric BLS and ALS sections of the 2025 guidelines each provide a set of ten key recommendations presented as the “Top 10 Take-Home Messages.” Tables 1 and 2 provide the detailed content of these recommendations [1,3].
[New] For infants and children in cardiac arrest, interruptions in CPR should be minimized; any pause in chest compressions should be limited to less than 10 s.
[Updated] In infants, chest compressions should be delivered using either the heel of one hand placed on the sternum or the two-thumb encircling hands technique, in which the rescuer supports the infant’s back while compressing the sternum with both thumbs. If the rescuer cannot physically encircle the chest, the heel-of-one-hand technique is recommended.
[Updated] For FBAO in children, cycles of five back blows alternating with five abdominal thrusts should be continued until the obstruction is relieved or the child becomes unresponsive.
[Updated] For FBAO in infants, repeated cycles of five back blows and five chest thrusts should be performed until the obstruction is relieved or the infant becomes unresponsive.
[Updated] In infants and children presenting with an initial non-shockable rhythm, epinephrine should be administered as early as possible.
[Updated] For infants and children undergoing CPR with an advanced airway in place, monitoring end-tidal carbon dioxide (ETCO2) may be used to assess the quality of resuscitation.
[New] A specific ETCO2 threshold should not be used as the sole criterion for terminating resuscitation efforts in infants and children.
[New] When invasive arterial blood pressure monitoring is available during CPR, it may be reasonable to target a diastolic pressure ≥ 25 mmHg in infants and ≥ 30 mmHg in children older than 1 year.
[Updated] Following return of spontaneous circulation (ROSC), systolic and mean arterial pressures in infants and children should be maintained above the age-appropriate 10th percentile.
Because the anatomy and physiology underlying cardiac arrest vary across developmental stages, current guidelines provide distinct algorithms for neonates, infants, children, adolescents, and adults. Neonates are typically defined as birth to 28 days of age; infants as younger than 1 year; children as 1 year to the onset of puberty; and adolescents as puberty to 18 years [3]. In contrast, some Korean guidelines classify children as approximately 1 to 8 years of age, which affects the selection of BLS and ALS protocols (Fig. 1). In clinical practice, infants and children from about 4 weeks of age to puberty (approximately 8 years in many Korean training programs) are generally managed using pediatric CPR algorithms.
From a pathophysiologic perspective, most pediatric cardiac arrests result from progressive respiratory failure or shock, culminating in hypoxic-ischemic injury and subsequent deterioration into bradycardia and non-shockable rhythms, such as asystole [1]. Primary cardiac etiologies, including congenital heart disease and arrhythmias, account for a smaller proportion of cases and are more common in specific subgroups with underlying cardiac pathology. Understanding developmental differences in airway anatomy, circulatory physiology, autonomic regulation, and common etiologies—such as respiratory infections, dehydration, sepsis, and congenital cardiac disorders—is essential for early identification, appropriate drug dosing, and timely determination of the need for defibrillation [1].
The chain of survival is a continuous sequence of interventions spanning prevention of cardiac arrest through long-term recovery, designed to optimize survival and neurological outcomes. In contrast to the 2020 guidelines—which presented four distinct chains for adults and children in both in-hospital and out-of-hospital settings—the 2025 update consolidates these into a single, unified framework applicable across all age groups and care environments (Fig. 2).
The unified chain of survival comprises six interconnected
(1) Recognition and emergency Rapid identification of cardiac arrest and immediate activation of the emergency response system.
(2) High-quality CPR: Delivery of effective chest compressions with appropriate ventilation to maintain perfusion of vital organs.
(3) Defibrillation: Timely delivery of electrical therapy for shockable rhythms to restore organized cardiac activity.
(4) Advanced Specialized management including airway control, pharmacologic therapy, and rhythm-guided interventions.
(5) Post-cardiac arrest Optimization of oxygenation, hemodynamics, temperature management, and neurological monitoring following ROSC.
(6) Recovery and Multidisciplinary rehabilitation and long-term support to enhance functional and psychological outcomes.
Pediatric BLS comprises a structured sequence of actions that should be initiated immediately when cardiac arrest is suspected (Fig. 3). The 2025 AHA guidelines present a clear, pediatric-specific algorithm that begins with ensuring scene safety and proceeds through recognition of cardiac arrest, activation of the emergency response system, delivery of high-quality CPR, and timely
(1) Verify scene safety.
(2) Assess responsiveness; shout for nearby assistance. Activate the emergency response system and instruct someone to retrieve an automated external defibrillator (AED) or defibrillator.
(3) Assess breathing and pulse simultaneously within 10 s.
(4) Initiate CPR. A single rescuer should perform cycles of 30 compressions followed by 2 breaths. When a second rescuer is available, switch to cycles of 15 compressions and 2 breaths.
(5) Provide early defibrillation when indicated.
Pulse and breathing should be assessed within 10 s. If either is absent, uncertain, or difficult to determine, CPR should be initiated without delay.
High-quality CPR is critical for effective resuscitation. This includes delivering chest compressions at an appropriate rate and depth, minimizing interruptions, allowing complete chest recoil after each compression, and avoiding excessive ventilation (Table 3). The recommended compression rate is 100–120 compressions per minute, with a depth of approximately one-third of the anterior–posterior diameter of the chest.
In infants, chest compressions should be delivered using either the heel of one hand on the sternum or the two-thumb encircling hands technique; if the chest cannot be encircled, the heel-of-one-hand technique is preferred. The traditional two-finger technique is no longer recommended because it does not consistently achieve adequate compression depth (Fig. 4).
As soon as an AED or defibrillator becomes available, the cardiac rhythm should be analyzed promptly, and a shock delivered if indicated. Chest compressions should be resumed immediately after.
Even during the ALS phase (Fig. 5), high-quality CPR must be maintained, with rhythm assessment performed approximately every 2 min.
Pediatric cardiac arrest rhythms are classified into four categories (Fig. 6): two shockable rhythms—ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT)—which require defibrillation in addition to CPR, and two non‑shockable rhythms—asystole and pulseless electrical activity (PEA)—which are managed with CPR without defibrillation.
When VF is identified, a pulse check is unnecessary. A shock should be delivered immediately, followed by prompt resumption of chest compressions.
If VT is present without a pulse, it is treated as pulseless VT, requiring immediate defibrillation and CPR.
If a pulse is present, management should follow the tachycardia-with-a-pulse algorithm.
Asystole is a non-shockable rhythm and should be managed with immediate CPR, without defibrillation.
No This indicates PEA, which requires CPR without defibrillation.
Pulse This indicates ROSC, and care should transition to the PCAC pathway.
During pediatric ALS, epinephrine should be administered every 3–5 min (Fig. 7). The recommended pediatric intravenous (IV) or intraosseous dose is 0.01 mg/kg (0.1 ml/kg of a 0.1 mg/ml [1:10,000] solution; maximum dose, 1 mg). In neonates, the recommended IV dose is 0.01–0.03 mg/kg. If vascular access is not yet available, endotracheal epinephrine (0.05–0.1 mg/kg) may be administered while access is being established. Comparison of the 2025 AHA and ERC guidelines shows differences in the recommended timing of epinephrine administration based on the initial arrest rhythm (Fig. 8). For non-shockable rhythms (asystole and PEA), both guidelines recommend administering epinephrine as soon as possible. For shockable rhythms (VF and pulseless VT), the 2025 AHA guidelines recommend epinephrine after the second defibrillation attempt, whereas the 2025 ERC guidelines recommend administration after the third defibrillation attempt. Current evidence does not clearly support the superiority of either strategy. If a shockable rhythm persists, antiarrhythmic therapy with amiodarone or lidocaine may be considered.
Ventilation should initially be provided using bag-mask ventilation with a compression-to-ventilation ratio of 2 when two or more rescuers are present. Once an advanced airway (e.g., endotracheal tube or supraglottic airway) is in place, chest compressions should continue uninterrupted at the recommended rate, while breaths are delivered every 2–3 s, with continuous waveform capnography monitoring. Additionally, according to the KACPR, there is insufficient evidence to recommend a specific ventilation rate during CPR in pediatric patients with an advanced airway. Efforts should be made to avoid both hypoventilation and hyperventilation. Ventilation should generally follow age-appropriate respiratory approximately 30 breaths/min for infants younger than 1 year, 20–30 breaths/min for children aged 1–8 years, and 10–20 breaths/min for patients aged 8–18 years, particularly in in-hospital settings or when managed by healthcare providers (expert consensus).
Throughout ALS, identifying and correcting reversible causes is critical, as successful resuscitation often depends on addressing underlying factors [4-6]. Table 4 summarizes the common reversible causes and includes hypoxia, hypovolemia, acidosis (hydrogen ion excess), hypo- or hyperkalemia, hypoglycemia, hypothermia, tension pneumothorax, cardiac tamponade, toxins, and pulmonary or coronary thrombosis.
Table 5 summarizes the 2025 AHA PCAC checklist.
Temperature In comatose infants and children after cardiac arrest, continuous monitoring of core temperature is recommended, with active prevention of fever and avoidance of temperatures above 37.5°C [7]. A 5-day course of targeted temperature management is reasonable, either with an initial phase at 32–34°C followed by 36–37.5°C, or by maintaining 36–37.5°C throughout, provided hyperthermia is strictly avoided [8,9].
Blood Post-cardiac arrest hypotension is common and strongly associated with poorer survival and neurologic outcomes. Therefore, systolic and mean arterial pressures should be maintained above the 10th percentile for age whenever possible (Table 6) [5,10]. Continuous invasive arterial monitoring is recommended when available, as it enables rapid detection and correction of blood pressure instability during the early post-cardiac arrest period [11,12].
Oxygenation and Following ROSC, oxygenation and ventilation should be carefully titrated to avoid both hypoxemia and hyperoxemia. In children, the target oxyhemoglobin saturation is approximately 94–99%, which is slightly narrower than the 90–98% range commonly used in adults. Normocapnia should also be maintained, with an arterial partial pressure of carbon dioxide (PaCO2) of 35–45 mmHg [7,13]. These targets aim to minimize secondary brain and organ injury associated with extremes of oxygen and carbon dioxide levels while accounting for the child’s underlying condition [7,9].
Pediatric cardiac arrest remains a uniquely challenging clinical condition, distinguished from adult arrest by developmental physiology, a predominantly respiratory etiology, and a distinct response to resuscitation. The 2025 AHA pediatric CPR guidelines synthesize the most current evidence into a unified framework encompassing recognition and emergency activation, high-quality CPR, defibrillation, advanced resuscitation, PCAC, and recovery and survivorship. This framework provides clear guidance from the moment of collapse through long-term rehabilitation.
The updated guidelines offer more precise recommendations on chest compression techniques, timing of epinephrine administration, ETCO2 interpretation, age-specific hemodynamic targets, temperature management, and structured rehabilitation. Effective implementation requires coordinated teamwork, regular training, and institution-specific preparedness, particularly in settings where pediatric cardiac arrest is infrequent but high-stakes. By integrating guideline-based algorithms with vigilant clinical assessment and timely intervention, clinicians can improve survival and long-term neurological outcomes in infants and children experiencing cardiac arrest. Continued research, system-level optimization, and education across all levels of care will be essential to further advance pediatric resuscitation.