Acls

Part 12: Pediatric Advanced Life Support
2015 American Heart Association Guidelines Update for

Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care (Reprint)
AUTHORS: Allan R. de Caen, Chair; Marc D. Berg; Leon
Reprint: The American Heart Association requests that this document be
Chameides; Cheryl K. Gooden; Robert W. Hickey; Halden F.
cited as follows: de Caen AR, Berg MD, Chameides L, Gooden CK, Hickey RW, Scott; Robert M. Sutton; Janice A. Tijssen; Alexis Topjian;
Scott HF, Sutton RM, Tijssen JA, Topjian A, van der Jagt E, Schexnayder SM, lise W. van der Jagt; Stephen M. Schexnayder; Ricardo A.
Samson RA. Part 12: pediatric advanced life support: 2015 American Heart Samson
Association Guidelines Update for Cardiopulmonary Resuscitation and KEY WORDS
Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S526S542. arrhythmia n cardiopulmonary resuscitation n pediatrics
Reprinted with permission of the American Heart Association, Inc. This www.pediatrics.org/cgi/doi/10.1542/peds.2015-3373F
article has been published in Circulation. doi:10.1542/peds.2015-3373F
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
INTRODUCTION (Circulation. 2015;132[suppl 2]:S526S542. DOI: 10.1161/CIR.
0000000000000266.)
Over the past 13 years, survival to discharge from pediatric in-hospital
Copyright 2015 American Heart Association, Inc.
cardiac arrest (IHCA) has markedly improved. From 2001 to 2013, rates of
return of spontaneous circulation (ROSC) from IHCA increased signi-
cantly from 39% to 77%, and survival to hospital discharge improved
from 24% to 36% to 43% (Girotra et al1 and personal communication with
Paul Chan, MD, MSc, April 3, 2015). In a single center, implementation of
an intensive care unit (ICU)based interdisciplinary debrieng pro-
gram improved survival with favorable neurologic outcome from 29%
to 50%.2 Furthermore, new data show that prolonged cardiopulmonary
resuscitation (CPR) is not futile: 12% of patients receiving CPR in IHCA
for more than 35 minutes survived to discharge, and 60% of the sur-
vivors had a favorable neurologic outcome.3 This improvement in sur-
vival rate from IHCA can be attributed to multiple factors, including
emphasis on high-quality CPR and advances in post-resuscitation care.
Over the past decade, the percent of cardiac arrests occurring in an ICU
setting has increased (87% to 91% in 2000 to 2003 to 94% to 96% in 2004
to 2010).4 While rates of survival from pulseless electrical activity and
asystole have increased, there has been no change in survival rates
from in-hospital ventricular brillation (VF) or pulseless ventricular
tachycardia (pVT).
Conversely, survival from out-of-hospital cardiac arrest (OHCA) has
not improved as dramatically over the past 5 years. Data from 11 US
and Canadian hospital emergency medical service systems (the Re-
suscitation Outcomes Consortium) during 2005 to 2007 showed age-
dependent discharge survival rates of 3.3% for infants (less than 1
year), 9.1% for children (1 to 11 years), and 8.9% for adolescents (12 to 19
years).5 More recently published data (through 2012) from this network
demonstrate 8.3% survival to hospital discharge across all age groups,
with 10.5% survival for children aged 1 to 11 years and 15.8% survival
for adolescents aged 12 to 18 years.6
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SUPPLEMENT ARTICLE
EVIDENCE EVALUATION PROCESS supplement and the related article recommendation will be labeled as
INFORMING THIS GUIDELINES Part 2: Evidence Evaluation and Man- New or Updated.
UPDATE agement of Conict of Interest in the As with all AHA Guidelines, each 2015
The American Heart Association (AHA) 2015 CoSTR publication.9,10 recommendation is labeled with a Class
Emergency Cardiovascular Care (ECC) This update to the 2010 AHA Guidelines of Recommendation (COR) and a Level of
Committee uses a rigorous process to for CPR and ECC for pediatric advanced Evidence (LOE). This update uses the
review and analyze the peer-reviewed life support (PALS) targets key questions newest AHA COR and LOE classication
published scientic evidence support- related to pediatric resuscitation. Areas system, which contains modications
ing the AHA Guidelines for CPR and of update were selected by a group of of the Class III recommendation and
ECC, including this update. In 2000, the international pediatric resuscitation introduces LOE B-R (randomized stud-
AHA began collaborating with other re- experts from ILCOR, and the questions ies) and B-NR (nonrandomized studies)
suscitation councils throughout the world, encompass resuscitation topics in pre- as well as LOE C-LD (limited data) and
via the International Liaison Committee arrest care, intra-arrest care, and post- LOE C-EO (consensus of expert opinion).
on Resuscitation (ILCOR), in a formal in- resuscitation care. The ILCOR Pediatric
These PALS recommendations are in-
ternational process to evaluate resusci- Life Support Task Force experts reviewed
formed by the rigorous systematic review
tation science. This process resulted in the the topics addressed in the 2010 Guide-
and consensus recommendations of the
publication of the International Consensus lines for PALS and, based on in-depth
ILCOR Pediatric Task Force, and readers
on CPR and ECC Science With Treatment knowledge of new research develop-
are referred to the complete consensus
Recommendations (CoSTR) in 2005 and ments, formulated 18 questions for
document in the 2015 CoSTR.12,13 In the
2010.7,8 These publications provided the further systematic evaluation.11 Three
online version of this document, live links
scientic support for AHA Guidelines questions that address pediatric basic
are provided so the reader can connect
revisions in those years. life support appear in Part 11: Pedi-
atric Basic Life Support and Cardio- directly to the systematic reviews on the
In 2011, the AHA created an online evi- SEERS website. These links are indicated
dence review process, the Scientic pulmonary Resuscitation Quality.
by a superscript combination of letters
Evidence Evaluation and Review System Beginning with the publication of the
and numbers (eg, Peds 397). We en-
(SEERS), to support ILCOR systematic 2015 CoSTR, the ILCOR evidence evalua-
courage readers to use the links and
reviews for 2015 and beyond. This new tion process will be continuous, rather
review the evidence and appendixes, in-
process includes the use of Grading of than batched into 5-year cycles. The goal
cluding the GRADE tables.
Recommendations Assessment, Devel- of this continuous evidence review is to
opment, and Evaluation (GRADE) soft- improve survival from cardiac arrest by This 2015 Guidelines Update for PALS
ware to create systematic reviews that shortening the time between resusci- includes science review in the following
will be available online and used by tation science discoveries and their ap- subjects:
resuscitation councils to develop their plication in resuscitation practice. As Prearrest Care
guidelines for CPR and ECC. The drafts of additional resuscitation topics are pri- Effectiveness of medical emergency
the online reviews were posted for oritized and reviewed, these Guidelines teams or rapid response teams
public comment, and ongoing reviews may be updated again. When the evi- to improve outcomes
will be accessible to the public (https:// dence supports sufcient changes to the
Effectiveness of a pediatric early
volunteer.heart.org/apps/pico/Pages/ Guidelines or a change in sequence or
warning score (PEWS) to improve
default.aspx). treatments that must be woven through-
outcomes
The AHA process for identication and out the Guidelines, then the Guidelines
will be revised completely. Restrictive volume of isotonic
management of potential conicts of
crystalloid for resuscitation from
interest was used, and potential con- Because the 2015 AHA Guidelines Up-
septic shock
icts for writing group members are date for CPR and ECC represents the
listed at the end of each Part of the 2015 rst update to the previous Guide- Use of atropine as a premedica-
AHA Guidelines Update for CPR and ECC. lines, recommendations from both tion in infants and children requir-
For additional information about this this 2015 Guidelines Update and the ing emergency tracheal intubation
systematic review or management of 2010 Guidelines are contained in the Treatment for infants and children
the potential conicts of interest, see Appendix. If the 2015 ILCOR review with myocarditis or dilated car-
Part 2: Evidence Evaluation and Man- resulted in a new or signicantly re- diomyopathy and impending
agement of Conicts of Interest in this vised Guidelines recommendation, that cardiac arrest
PEDIATRICS Volume 136, Supplement 2, November 2015 S177

Intra-arrest Care changes noted in a patients condition Fluid Resuscitation in Septic
Effectiveness of extracorporeal and may prevent cardiac or respiratory ShockPeds 545
membrane oxygenation (ECMO) arrest. Several variables, including the This update regarding intravenous uid
resuscitation compared to stan- composition of the team, the type of resuscitation in infants and children in
dard resuscitation without ECMO patient, the hospital setting, and the septic shock in all settings addressed 2
confounder of a wider system benet,
Targeting a specic end-tidal CO2 specic therapeutic elements: (1) With-
further complicate objective analyses. holding the use of bolus uids was
(ETCO2) threshold to improve chest
compression technique compared with the use of bolus uids,
2015 Evidence Summary and (2) noncrystalloid was compared
Reliability of intra-arrest prognos- Observational data have been contra- with crystalloid uids.
tic factors to predict outcome
dictory and have not consistently shown Early and rapid administration of in-
Use of invasive hemodynamic a decreased incidence of cardiac and/ travenousuid to reverse decompensated
monitoring during CPR to titrate or respiratory arrest outside of the shock, and to prevent progression from
to a specic systolic/diastolic blood ICU setting.1416 The data addressing compensated to decompensated shock,
pressure to improve outcomes effects on hospital mortality were in- hasbeenwidelyacceptedbasedonlimited
Effectiveness of NO vasopressor conclusive.1621 observational studies.23 Mortality from
compared with ANY vasopressors pediatric sepsis has declined in recent
for resuscitation from cardiac arrest 2015 RecommendationUpdated
years, during which guidelines and pub-
Use of amiodarone compared with Pediatric medical emergency team/rapid lications have emphasized the role of
lidocaine for shock-refractory VF response team systems may be consid- early rapid uid administration (along
or pVT eredinfacilitieswherechildrenwithhigh- with early antibiotic and vasopressor
Optimal energy dose for debril- risk illnesses are cared for on general therapy, and careful cardiovascular
lation in-patient units (Class IIb, LOE C-LD). monitoring) in treating septic shock.24,25
Postarrest Care Since the 2010 Guidelines, a large ran-
Pediatric Early Warning domized controlled trial of uid re-
Use of targeted temperature ScoresPeds 818 suscitation in pediatric severe febrile
management to improve outcomes
In-hospital pediatric cardiac or re- illness in a resource-limited setting
Use of a targeted PaO2 strategy spiratory arrest can potentially be found intravenous uid boluses to be
to improve outcomes averted by early recognition of and in- harmful.26 This new information, con-
Use of a specic PaCO2 target to tervention for the deteriorating patient. tradicting long-held beliefs and prac-
improve outcomes The use of scoring systems might help tices, prompted careful analysis of the
Use of parenteral uids and ino- to identify such patients sufciently effect of uid resuscitation on many
tropes and/or vasopressors to early so as to enable effective inter- outcomes in specic infectious illnesses.
maintain targeted measures of per- vention.
fusion such as blood pressure to 2015 Evidence Summary
improve outcomes 2015 Evidence Summary Specic infection-related shock states
Use of electroencephalograms There is no evidence that the use of appear to behave differently with re-
(EEGs) to accurately predict out- PEWS outside of the pediatric ICU setting spect to uid bolus therapy. Evidence
comes reduces hospital mortality. In 1 obser- was not considered to be specic to
vational study, PEWS use was associ- a particular setting, after determining
Use of any specic postcardiac ated with a reduction in cardiac arrest that resource-limited setting is dif-
arrest factors to accurately pre-
rate when used in a single hospital cult to dene and can vary greatly even
dict outcomes
with an established medical emergency within individual health systems and
team system.22 small geographic regions.
PREARREST CARE UPDATES
The evidence regarding the impact of
Medical Emergency Team/Rapid 2015 RecommendationNew restricting uid boluses during re-
Response TeamPeds 397 The use of PEWS may be considered, but suscitation on outcomes in pediatric
Medical emergency team or rapid re- its effectiveness in the in-hospital set- septic shock is summarized in Figure 1.
sponse team activation by caregivers or ting is not well established (Class IIb, There were no studies for many spe-
parents ideally occurs as a response to LOE C-LD). cic combinations of presenting illness
S178 DE CAEN
SUPPLEMENT ARTICLE
and outcome. In the majority of sce- the preceding paragraph.2632 Evidence This recommendation takes into con-
narios, there was no benet to restrict- is summarized in Figure 2. In most sideration the important work of
ing uid boluses during resuscitation. scenarios, there was no benet to Maitland et al,26 which found that uid
The most important exception is that in noncrystalloids over crystalloids. In boluses as part of resuscitation are
1 large study, restriction of uid boluses patients with Dengue shock, a benet not safe for all patients in all settings.
conveyed a benet for survival to was conferred in using noncrystalloid This study showed that the use of
both 48 hours and 4 weeks after pre- compared with crystalloid uid for uid boluses as part of resuscitation
sentation. This study was conducted in the outcome of time to resolution of increased mortality in a specic pop-
sub-Saharan Africa, and inclusion cri- shock.31 ulation in a resource-limited setting,
teria were severe febrile illness com- without access to some critical care
plicated by impaired consciousness 2015 RecommendationsNew interventions such as mechanical ven-
(prostration or coma), respiratory Administration of an initial uid bolus of tilation and inotrope support.
distress (increased work of breathing), 20 mL/kg to infants and children with The spirit of this recommendation is
or both, and with impaired perfusion, as shock is reasonable, including those a continued emphasis on uid re-
evidenced by 1 or more of the following: with conditions such as severe sepsis suscitation for both compensated (de-
a capillary rell time of 3 or more (Class IIa, LOE C-LD), severe malaria and tected by physical examination) and
seconds, lower limb temperature Dengue (Class IIb, LOE B-R). When caring decompensated (hypotensive) septic
gradient, weak radial-pulse volume, or for children with severe febrile illness shock. Moreover, emphasis is also
severe tachycardia. In this study, ad- (such as those included in the FEAST placed on the use of individualized pa-
ministration of 20 mL/kg or 40 mL/kg in trial26) in settings with limited access tient evaluation before the adminis-
the rst hour was associated with de- to critical care resources (ie, me- tration of intravenous uid boluses,
creased survival compared with the use chanical ventilation and inotropic including physical examination by a
of maintenance uids alone.26 There- support), administration of bolus in- clinician and frequent reassessment
fore, it appears that in this specic travenous uids should be undertaken to determine the appropriate volume of
patient population, where critical care with extreme caution because it may uid resuscitation. The clinician should
resources including inotropic and me- be harmful (Class IIb, LOE B-R). Pro- also integrate clinical signs with patient
chanical ventilator support were lim- viders should reassess the patient and locality-specic information about
ited, bolus uid therapy resulted in after every uid bolus (Class I, LOE prevalent diseases, vulnerabilities (such
higher mortality. C-EO). as severe anemia and malnutrition), and
The use of noncrystalloid uid was Either isotonic crystalloids or colloids available critical care resources.
compared with crystalloid uid for the can be effective as the initial uid choice
same diseases and outcomes listed in for resuscitation (Class IIa, LOE B-R). Atropine for Premedication During
Emergency IntubationPeds 821
Bradycardia commonly occurs during
emergency pediatric intubation, result-
ing from hypoxia/ischemia, as a vagal
response to laryngoscopy, as a reex
response to positive pressure ventila-
tion, or as a pharmacologic effect of
some drugs (eg, succinylcholine or
fentanyl). Practitioners have often tried
to blunt this bradycardia with pro-
phylactic premedication with atropine.
2015 Evidence Summary

Figure 1 The evidence regarding the use of at-
Evidence for the use of restrictive volume of intravenous uid resuscitation, compared with unrestrictive ropine during emergency intubation
volume, by presenting illness and outcome. Benet indicates that studies show a benet to restricting has largely been observational, includ-
uid volume, No Benet indicates that there is no benet to restricting uid volume, and Harm indi-
cates that there is harm associated with restricting uid volume. No Studies Available indicates no ing extrapolation from experience with
studies are available for a particular illness/outcome combination. elective intubation in the operating

and did not include the use of ventric-
ular assist devices.

No literature was identied evaluating
best prearrest management strategies
(including anesthetic technique) for
infants and children with dilated car-
diomyopathy or myocarditis. Limited
observational data support the pre
cardiac arrest use of ECMO in children
with acute fulminant myocarditis.37
2015 RecommendationNew
Venoarterial ECMO use may be con-
sidered in patients with acute fulmi-
Figure 2
Evidence for the use of noncrystalloid intravenous uid resuscitation, compared with crystalloid, by
nant myocarditis who are at high risk
presenting illness and outcome. Benet indicates that studies show a benet to the use of non- of imminent cardiac arrest (Class IIb,
crystalloid intravenous uid resuscitation compared with crystalloid, and No Benet indicates that LOE C-EO). Optimal outcomes from
there is no benet to the use of noncrystalloid intravenous uid resuscitation compared with
crystalloid. No Studies Available indicates no studies are available for a particular illness/outcome ECMO are achieved in settings with
combination. existing ECMO protocols, expertise,
and equipment.
suite. More recent in-hospital literature be reasonable for practitioners to use
INTRA-ARREST CARE UPDATES
involves larger case series of critically atropine as a premedication in specic
ill neonates, infants, and children un- emergency intubations when there is Extracorporeal CPR for In-Hospital
dergoing emergency intubation.3335 higher risk of bradycardia (eg, when Pediatric Cardiac ArrestPeds 407
There is no evidence that preintubation giving succinylcholine as a neuromus- The 2010 AHA PALS Guidelines sug-
use of atropine improves survival or cular blocker to facilitate intubation) gested the use of ECMO when dealing
prevents cardiac arrest in infants and (Class IIb, LOE C-LD). A dose of 0.02 mg/kg with pediatric cardiac arrest refractory
children. Observational data suggest that of atropine with no minimum dose may to conventional interventions and when
it increases the likelihood of survival be considered when atropine is used as managing a reversible underlying dis-
to ICU discharge in children older than a premedication for emergency in- ease process. Pediatric OHCA was not
28 days.33 Evidence is conicting as to tubation (Class IIb, LOE C-LD). This new considered for the 2015 ILCOR system-
whether preintubation atropine admin- recommendation applies only to the atic review.
istration reduces the incidence of use of atropine as a premedication for
arrhythmias or postintubation shock.34,35 infants and children during emergency 2015 Evidence Summary
intubation. Evidence from 4 observational studies
In past Guidelines, a minimum atropine
dose of 0.1 mg IV was recommended of pediatric IHCA has shown no overall
after a report of paradoxical brady- Prearrest Care of Infants and benet to the use of CPR with ECMO
cardia observed in very small infants Children With Dilated (ECPR) compared to CPR without
Cardiomyopathy or ECMO.3841 Observational data from
who received very low atropine doses.36
MyocarditisPeds 819 a registry of pediatric IHCA showed
However, in 2 of the most recent case
series cited above, preintubation doses Optimal care of a critically ill infant or improved survival to hospital dis-
of 0.02 mg/kg, with no minimum dose, child with dilated cardiomyopathy or charge with the use of ECPR in patients
were shown to be effective.33,34 myocarditis should avert cardiac ar- with surgical cardiac diagnoses.42 For
rest. While signicant global experience children with underlying cardiac dis-
2015 RecommendationsNew exists with the care of these patients, ease, when ECPR is initiated in a critical
The available evidence does not support the evidence base is limited. The ILCOR care setting, long-term survival has
the routine use of atropine preintubation systematic review ultimately restricted been reported even after more than 50
of critically ill infants and children. It may its analysis to patients with myocarditis minutes of conventional CPR.43 When
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SUPPLEMENT ARTICLE
ECPR is used during cardiac arrest, the Intra-arrest Prognostic Factors for studies showed increased likelihood
outcome for children with underlying Cardiac ArrestPeds 814 of ROSC and survival to completion of
cardiac disease is better than for those Accurate and reliable prognostication experiment with the use of invasive
with noncardiac disease.44 during pediatric cardiac arrest would hemodynamic monitoring.56,57
allow termination of CPR in patients
2015 RecommendationNew where CPR is futile, while encouraging 2015 RecommendationNew
ECPR may be considered for pediatric continued CPR in patients with a po- For patients with invasive hemodynamic
patients with cardiac diagnoses who tential for good recovery. monitoring in place at the time of cardiac
have IHCA in settings with existing ECMO arrest, it may be reasonable for rescuers
protocols, expertise, and equipment 2015 Evidence Summary to usebloodpressuretoguideCPRquality
(Class IIb, LOE C-LD). For infants and children with OHCA, age (Class IIb, LOE C-EO). Specic target values
less than 1 year,5,47 longer durations of for blood pressure during CPR have not
End-Tidal CO2 Monitoring to Guide cardiac arrest4850 and presentation with been established in children.
CPR QualityPeds 827 a nonshockable as opposed to a shock-
High-quality CPR is associated with able rhythm5,47,49 are all predictors of Vasopressors During Cardiac
improved outcomes after cardiac ar- poor patient outcome. For infants and ArrestPeds 424
rest. Animal data support a direct children with IHCA, negative predictive During cardiac arrest, vasopressors
association between ETCO2 and car- factors include age greater than 1 year3 are used to restore spontaneous cir-
diac output. Capnography is used and longer durations of cardiac ar- culation by optimizing coronary perfu-
during pediatric cardiac arrest to rest.3,5153 The evidence is contradictory sion and to help maintain cerebral
monitor for ROSC as well as CPR as to whether a nonshockable (as op- perfusion. However, they also cause
quality. The 2010 Guidelines recom- posed to shockable) initial cardiac arrest intense vasoconstriction and increase
mended that if the partial pressure of rhythm is a negative predictive factor in myocardial oxygen consumption, which
ETCO2 is consistently less than 15 mm Hg, the in-hospital setting.3,54,55 might be detrimental.
efforts should focus on improving CPR
quality, particularly improving chest 2015 RecommendationNew 2015 Evidence Summary
compressions and ensuring that the Multiple variables should be used when There are no pediatric studies that
victim does not receive excessive attempting to prognosticate outcomes demonstrate the effectiveness of any
ventilation. during cardiac arrest (Class I, LOE C-LD). vasopressors (epinephrine, or com-
Although there are factors associated bination of vasopressors) in cardiac
2015 Evidence Summary with better or worse outcomes, no arrest. Two pediatric observational out-
There is no pediatric evidence that single factor studied predicts outcome of-hospital studies58,59 had too many
ETCO2 monitoring improves outcomes with sufcient accuracy to recommend confounders to determine if vasopressors
from cardiac arrest. One pediatric an- termination or continuation of CPR. were benecial. One adult OHCA ran-
imal study showed that ETCO2-guided domized controlled trial60 showed epi-
chest compressions are as effective Invasive Hemodynamic Monitoring nephrine use was associated with
as standard chest compressions opti- During CPRPeds 826 increased ROSC and survival to hospi-
mized by marker, video, and verbal Children often have cardiac arrests in tal admission but no improvement in
feedback for achieving ROSC.45 A recent settings where invasive hemodynamic survival to hospital discharge.
study in adults found that ETCO2 values monitoring already exists or is rapidly
generated during CPR were signi- obtained. If a patient has an indwelling 2015 RecommendationNew
cantly associated with chest compres- arterial catheter, the waveform can be It is reasonable to administer epi-
sion depth and ventilation rate.46 used as feedback to evaluate chest nephrine in pediatric cardiac arrest
compressions. (Class IIa, LOE C-LD).
ETCO2 monitoring may be considered 2015 Evidence Summary Amiodarone and Lidocaine
to evaluate the quality of chest com- Adjusting chest compression technique for Shock-Refractory VF and
pressions, but specic values to guide to a specic systolic blood pressure pVTPeds 825
therapy have not been established in target has not been studied in humans. The 2005 and 2010 Guidelines recom-
children (Class IIb, LOE C-LD). Two randomized controlled animal mended administering amiodarone in

preference to lidocaine for the man- advantage of any energy dose com- energy levels, a dose of 4 J/kg may be
agement of VF or pVT. This recommen- pared with 2 to 4 J/kg for initial de- reasonable and higher energy levels
dation was based predominantly on brillation. may be considered, though not to ex-
pediatric case series or extrapolation ceed 10 J/kg or the adult maximum
from adult studies that used short-term 2015 RecommendationsUpdated dose (Class IIb, LOE C-LD).
outcomes. It is reasonable to use an initial dose of
2 to 4 J/kg of monophasic or biphasic POSTARREST CARE UPDATES
2015 Evidence Summary energy for debrillation (Class IIa, LOE
C-LD), but for ease of teaching, an initial PostCardiac Arrest Temperature
New pediatric observational data61 ManagementPeds 387
showed improved ROSC with the use of dose of 2 J/kg may be considered (Class
lidocaine as compared with amiodarone. IIb, LOE C-EO). For refractory VF, it is rea- Data suggest that fever after pediatric
Use of lidocaine compared with no sonable to increase the dose to 4 J/kg cardiac arrest is common and is as-
lidocaine was signicantly associated (Class IIa, LOE C-LD). For subsequent sociated with poor outcomes.67 The
with an increased likelihood of ROSC.
The same study did not show an as-
sociation between lidocaine or amio-
darone use and survival to hospital
discharge.
For shock-refractory VF or pVT, either
amiodarone or lidocaine may be used
(Class IIb, LOE C-LD).
The Pediatric Cardiac Arrest Algorithm
(Figure 3) reects this change.
Energy Doses for

DebrillationPeds 405
The 2015 ILCOR systematic review
addressed the dose of energy for pe-
diatric manual debrillation during
cardiac arrest. Neither the energy dose
specically related to automated ex-
ternal debrillators, nor the energy
dose for cardioversion was evaluated in
this evidence review.

Two small case series demonstrated
termination of VF/pVT with either 2
J/kg62 or 2 to 4 J/kg.63 In 1 observational
study of IHCA,64 a higher initial energy
dose of more than 3 to 5 J/kg was less
effective than 1 to 3 J/kg in achieving
ROSC. One small observational study of
IHCA65 showed no benet in achieving
ROSC with a specic energy dose for
initial debrillation. Three small obser-
vational studies of IHCA and OHCA63,65,66 Figure 3
showed no survival to discharge Pediatric Cardiac Arrest Algorithm2015 Update.
S182 DE CAEN
SUPPLEMENT ARTICLE
2010 AHA PALS Guidelines suggested evidence to recommend cooling over PostCardiac Arrest PaCO2Peds 815
a role for targeted temperature man- normothermia. Cerebral vascular autoregulation may
agement after pediatric cardiac arrest Fever (temperature 38C or higher) be abnormal after ROSC. Adult data show
(fever control for all patients, thera- should be aggressively treated after an association between post-ROSC
peutic hypothermia for some patients), ROSC (Class I, LOE B-NR). hypocapnia and worse patient out-
but the recommendations were based comes.78,79 In other types of pediatric
predominantly on extrapolation from PostCardiac Arrest brain injury, hypocapnia is associated
adult and asphyxiated newborn data. OxygenationPeds 544 with worse clinical outcomes.8083
2015 Evidence Summary Animal studies suggest that elevated
levels of tissue PO2 after ROSC (hyper- 2015 Evidence Summary
A large multi-institutional, prospective,
randomized study of pediatric patients oxia) contribute to oxidative stress that There were no studies in children after
(aged 2 days to 18 years) with OHCA may potentiate the postresuscitation cardiac arrest specically comparing
found no difference in survival with syndrome, while some adult studies ventilation with a predetermined PaCO2
good functional outcome at 1 year show associations between hyperoxemia target. One small observational study
and no additional complications in co- and increased mortality.72,73 of both pediatric IHCA and OHCA74 dem-
matose patients who were treated with onstrated no association between hy-
2015 Evidence Summary percapnia (PaCO2 greater than 50 mm Hg)
therapeutic hypothermia (32C to 34C),
compared to those treated with nor- Three small observational studies of or hypocapnia (PaCO2 less than 30 mm Hg)
mothermia (36C to 37.5C).68 Obser- pediatric IHCA and OHCA survivors7476 and outcome. However, in an observa-
vational data of pediatric patients did not show an association between tional study of pediatric IHCA,76 hyper-
resuscitated from IHCA or OHCA69,70 elevated PaO2 and outcome. In a larger capnia (PaCO2 50 mm Hg or greater) was
have also shown that ICU duration of observational study of 1427 pediatric associated with worse survival to hos-
stay, neurologic outcomes, and mor- IHCA and OHCA victims who survived pital discharge.
tality are unchanged with the use of to pediatric ICU admission,77 after ad-
justment of confounders, the presence 2015 RecommendationNew
therapeutic hypothermia. Only 1 small
study of therapeutic hypothermia in of normoxemia (dened as a PaO2 It is reasonable for practitioners to
survivors of pediatric asphyxial car- 60 mm Hg or greater and less than target a PaCO2 after ROSC that is ap-
diac arrest71 showed an improvement 300 mm Hg) when compared with hyper- propriate to the specic patient con-
in mortality at hospital discharge, but oxemia (PaO2 greater than 300 mm Hg) dition, and limit exposure to severe
with no difference in neurologic out- after ROSC was associated with im- hypercapnia or hypocapnia (Class IIb,
comes. Results are pending from a large proved survival to pediatric ICU LOE C-LD).
multicenter randomized controlled trial discharge.
of targeted temperature management PostCardiac Arrest Fluids and
for pediatric patients with IHCA (see 2015 RecommendationsNew InotropesPeds 820
Therapeutic Hypothermia After Cardiac It may be reasonable for rescuers to Myocardial dysfunction and vascular
Arrest website: www.THAPCA.org). target normoxemia after ROSC (Class instability are common after resusci-
IIb, LOE B-NR). Because an arterial tation from cardiac arrest.8490
2015 RecommendationsNew
oxyhemoglobin saturation of 100% may
For infants and children remaining correspond to a PaO2 anywhere be- 2015 Evidence Summary
comatose after OHCA, it is reasonable tween 80 and approximately 500 mm Hg, Three small observational studies in-
either to maintain 5 days of continuous it may be reasonablewhen the neces- volving pediatric IHCA and OHCA9193
normothermia (36C to 37.5C) or to sary equipment is availablefor res- demonstrated worse survival to hos-
maintain 2 days of initial continuous cuers to wean oxygen to target an pital discharge when children were
hypothermia (32C to 34C) followed by oxyhemoglobin saturation of less than exposed to post-ROSC hypotension.
3 days of continuous normothermia 100%, but 94% or greater. The goal of One of these studies91 associated post-
(Class IIa, LOE B-R). Continuous measure- such an approach is to achieve nor- ROSC hypotension (dened as a sys-
ment of temperature during this time pe- moxemia while ensuring that hypox- tolic blood pressure less than fth
riod is recommended (Class I, LOE B-NR). emia is strictly avoided. Ideally, oxygen percentile for age) after IHCA with
For infants and children remaining is titrated to a value appropriate to the lower likelihood of survival to discharge
comatose after IHCA, there is insufcient specic patient condition. with favorable neurologic outcome. There

are no studies evaluating the benet of a signicantly higher likelihood of good hours after cardiac arrest in predicting
specic vasoactive agents after ROSC in neurologic outcome at hospital dis- survival to discharge,49,53,95,96 while 1
infants and children. charge, while an EEG demonstrating observational study found that reactive
a discontinuous or isoelectric tracing pupils 24 hours after cardiac arrest
2015 RecommendationsNew was associated with a poorer neuro- were associated with improved sur-
After ROSC, we recommend that par- logic outcome at hospital discharge. vival at 180 days with favorable neu-
enteral uids and/or inotropes or There are no data correlating EEG rologic outcome.97
vasoactive drugs be used to maintain ndings with neurologic outcome after Several serum biomarkers of neuro-
a systolic blood pressure greater than hospital discharge. logic injury have been considered for
fth percentile for age (Class I, LOE their prognostic value. Two small ob-
C-LD). When appropriate resources 2015 RecommendationNew servational studies found that lower
are available, continuous arterial EEGs performed within the rst 7 days neuron-specic enolase and S100B
pressure monitoring is recommended after pediatric cardiac arrest may be serum levels after arrest were as-
to identify and treat hypotension (Class considered in prognosticating neuro- sociated with improved survival to
I, LOE C-EO). logic outcome at the time of hospital hospital discharge and with improved
discharge (Class IIb, LOE C-LD) but should survival with favorable neurologic
Postresuscitation Use of EEG for not be used as the sole criterion. outcome.97,98
PrognosisPeds 822 One observational study found that
Early and reliable prognostication of Predictive Factors After Cardiac children with lower lactate levels in the
neurologic outcome in pediatric survi- ArrestPeds 813 rst 12 hours after arrest had an im-
vors of cardiac arrest is essential to Several post-ROSC factors have been proved survival to hospital discharge.99
enable effective planning and family studied as possible predictors of sur-
support (whether it be to continue or vival and neurologic outcome after 2015 RecommendationNew
discontinue life-sustaining therapy). pediatric cardiac arrest. These include The reliability of any 1 variable for
pupillary responses, the presence of prognostication in children after car-
2015 Evidence Summary hypotension, serum neurologic bio- diac arrest has not been established.
Observational data from 2 small pedi- markers, and serum lactate. Practitioners should consider multi-
atric studies94,95 showed that a contin- ple factors when predicting outcomes
uous and reactive tracing on an EEG 2015 Evidence Summary in infants and children who achieve
performed in the rst 7 days after Four observational studies supported ROSC after cardiac arrest (Class I, LOE
cardiac arrest was associated with the use of pupillary reactivity at 12 to 24 C-LD).
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S188 DE CAEN
SUPPLEMENT ARTICLE
DISCLOSURES
Part 12: Pediatric Advanced Life Support: 2015 Guidelines Update Writing Group Disclosures
Writing Group Member Employment Research Other Speakers Expert Ownership Consultant/ Other
Grant Research Bureau/ Witness Interest Advisory
Support Honoraria Board
Allan R. de Caen University of Alberta Stollery None None None None None None None
Childrens Hospital
Marc D. Berg University of Arizona None None None None None None None
Leon Chameides Connecticut Childrens None None None None None None None
Medical Center
Cheryl K. Gooden Mount Sinai Medical Center None None None None None None None
Robert W. Hickey Childrens Hospital of None None None None None None None
Pittsburgh
Halden F. Scott Childrens Hospital Colorado None None None None None None None
Robert M. Sutton The Childrens Hospital of NIH None Zoll Medical Sales Webber and None None None
Philadelphia; University Meeting Lecture Gallagher*
of Pennsylvania School (Speaking
of Medicine Honoraria)*
Janice A. Tijssen London Health Services AMOSO Opportunities None None None None None None
Center Fund*
Alexis Topjian The Childrens Hospital of NIH* None None Expert witness None None None
Philadelphia; University of for defense and
Pennsylvania School plantiff*
of Medicine
lise W. van University of Rochester NHLBI* None None None None None None
der Jagt School of Medicine
Consultants
Ricardo A. The University of Arizona None None None None None American None
Samson Heart
Association
Stephen M. University of Arkansas; None None None Arkansas Dept. of None American None
Schexnayder Arkansas Childrens Human Services*; Heart
Hospital Lewis Thomason*; Association
University of
Chicago*
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conicts of interest as reported on the Disclosure
Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be signicant if (a) the person receives $10 000 or more
during any 12-month period, or 5% or more of the persons gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair
market value of the entity. A relationship is considered to be modest if it is less than signicant under the preceding denition.
* Modest.
Signicant.

APPENDIX
2015 Guidelines Update: Part 12 Recommendations

Year Last Reviewed Topic Recommendation Comments
2015 Prearrest Care Updates Pediatric medical emergency team/rapid response team systems updated for 2015
may be considered in facilities where children with high-risk
illnesses are cared for on general in-patient units (Class IIb,
LOE C-LD).
2015 Prearrest Care Updates The use of PEWS may be considered, but its effectiveness in the new for 2015
in-hospital setting is not well established (Class IIb, LOE C-LD).
2015 Prearrest Care Updates Administration of an initial uid bolus of 20 mL/kg to infants and new for 2015
children with shock is reasonable, including those with
conditions such as severe sepsis (Class IIa, LOE C-LD), malaria
and Dengue (Class IIb, LOE B-R).
2015 Prearrest Care Updates When caring for children with severe febrile illness (such as those new for 2015
included in the FEAST trial), in settings with limited access to
critical care resources (ie mechanical ventilation and inotropic
support), administration of bolus intravenous uids should be
undertaken with extreme caution because it may be harmful
(Class IIb, LOE B-R).
2015 Prearrest Care Updates Providers should reassess the patient after every uid bolus new for 2015
(Class I, LOE C-EO).
2015 Prearrest Care Updates Either isotonic crystalloids or colloids can be effective as the new for 2015
initial uid choice for resuscitation (Class IIa, LOE B-R).
2015 Prearrest Care Updates The available evidence does not support the routine use of atropine new for 2015
preintubation of critically ill infants and children. It may be
reasonable for practitioners to use atropine as a premedication
in specic emergent intubations when there is higher risk of
bradycardia (eg, when giving succinylcholine as a
neuromuscular blocker to facilitate intubation) (Class IIb,
LOE C-LD).
2015 Prearrest Care Updates A dose of 0.02 mg/kg of atropine with no minimum dose may be new for 2015
considered when atropine is used as a premedication for
emergency intubation (Class IIb, LOE C-LD).
2015 Prearrest Care Updates Venoarterial ECMO use may be considered in patients with acute new for 2015
fulminant myocarditis who are at high risk of imminent cardiac
arrest (Class IIb, LOE C-EO).
2015 Intra-arrest Care Updates ECPR may be considered for pediatric patients with cardiac new for 2015
diagnoses who have IHCA in settings with existing ECMO
protocols, expertise, and equipment (Class IIb, LOE C-LD).
2015 Intra-arrest Care Updates ETCO2 monitoring may be considered to evaluate the quality of new for 2015
chest compressions, but specic values to guide therapy have
not been established in children (Class IIb, LOE C-LD).
2015 Intra-arrest Care Updates Multiple variables should be used when attempting to prognosticate new for 2015
outcomes during cardiac arrest (Class I, LOE C-LD).
2015 Intra-arrest Care Updates For patients with invasive hemodynamic monitoring in place at the new for 2015
time of cardiac arrest, it may be reasonable for rescuers to use
blood pressure to guide CPR quality (Class IIb, LOE C-EO).
2015 Intra-arrest Care Updates It is reasonable to administer epinephrine in pediatric cardiac new for 2015
arrest (Class IIa, LOE C-LD).
2015 Intra-arrest Care Updates For shock-refractory VF or pVT, either amiodarone or lidocaine may new for 2015
be used (Class IIb, LOE C-LD).
2015 Intra-arrest Care Updates It is reasonable to use an initial dose of 2 to 4 J/kg of monophasic updated for 2015
or biphasic energy for debrillation (Class IIa, LOE C-LD), but for
ease of teaching, an initial dose of 2 J/kg may be considered
(Class IIb, LOE C-EO).
2015 Intra-arrest Care Updates For refractory VF, it is reasonable to increase the dose to 4 J/kg updated for 2015
(Class IIa, LOE C-LD).
2015 Intra-arrest Care Updates For subsequent energy levels, a dose of 4 J/kg may be reasonable updated for 2015
and higher energy levels may be considered, though not to
exceed 10 J/kg or the adult maximum dose (Class IIb, LOE C-LD).
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Appendix Continued
2015 Postarrest Care Updates For infants and children remaining comatose after OHCA, it is new for 2015
reasonable either to maintain 5 days of continuous
normothermia (36C to 37.5C) or to maintain 2 days of initial
continuous hypothermia (32C to 34C) followed by 3 days of
continuous normothermia (Class IIa, LOE B-R).
2015 Postarrest Care Updates Continuous measurement of temperature during this time period is new for 2015
recommended (Class I, LOE B-NR).
2015 Postarrest Care Updates Fever (temperature 38C or higher) should be aggressively treated new for 2015
after ROSC (Class I, LOE B-NR).
2015 Postarrest Care Updates It may be reasonable for rescuers to target normoxemia after ROSC new for 2015
(Class IIb, LOE B-NR).
2015 Postarrest Care Updates It is reasonable for practitioners to target a PaCO2 after ROSC that is new for 2015
appropriate to the specic patient condition, and limit exposure
to severe hypercapnia or hypocapnia (Class IIb, LOE C-LD).
2015 Postarrest Care Updates After ROSC, we recommend that parenteral uids and/or inotropes new for 2015
or vasoactive drugs be used to maintain a systolic blood
pressure greater than fth percentile for age (Class I, LOE C-LD).
2015 Postarrest Care Updates When appropriate resources are available, continuous arterial new for 2015
pressure monitoring is recommended to identify and treat
hypotension (Class I, LOE C-EO).
2015 Postarrest Care Updates EEGs performed within the rst 7 days after pediatric cardiac arrest new for 2015
may be considered in prognosticating neurologic outcome at the
time of hospital discharge (Class IIb, LOE C-LD) but should not be
used as the sole criterion.
2015 Postarrest Care Updates The reliability of any one variable for prognostication in children new for 2015
after cardiac arrest has not been established. Practitioners
should consider multiple factors when predicting outcomes in
infants and children who achieve ROSC after cardiac arrest
(Class I, LOE C-LD).
The following recommendations were not reviewed in 2015. For more information, see the 2010 AHA Guidelines for CPR and ECC, Part 14: Pediatric Advanced Life Support.
2010 Family Presence During Resuscitation Whenever possible, provide family members with the option of being not reviewed in 2015
present during resuscitation of an infant or child (Class I, LOE B).
2010 Laryngeal Mask Airway (LMA) When bag-mask ventilation (see Bag-Mask Ventilation, below) is not reviewed in 2015
unsuccessful and when endotracheal intubation is not possible,
the LMA is acceptable when used by experienced providers to
provide a patent airway and support ventilation (Class IIa, LOE C).
2010 Bag-Mask Ventilation In the prehospital setting it is reasonable to ventilate and oxygenate not reviewed in 2015
infants and children with a bag-mask device, especially if
transport time is short (Class IIa, LOE B).
2010 Precautions Use only the force and tidal volume needed to just make the chest not reviewed in 2015
rise visibly (Class I, LOE C)
2010 Precautions Avoid delivering excessive ventilation during cardiac arrest not reviewed in 2015
(Class III, LOE C).
2010 Precautions If the infant or child is intubated, ventilate at a rate of about 1 breath not reviewed in 2015
every 6 to 8 seconds (8 to 10 times per minute) without
interrupting chest compressions (Class I, LOE C).
2010 Precautions It may be reasonable to do the same if an LMA is in place not reviewed in 2015
(Class IIb, LOE C).
2010 Precautions In the victim with a perfusing rhythm but absent or inadequate not reviewed in 2015
respiratory effort, give 1 breath every 3 to 5 seconds (12 to 20
breaths per minute), using the higher rate for the younger child
(Class I, LOE C).
2010 Two-Person Bag-Mask Ventilation Apply cricoid pressure in an unresponsive victim to reduce air entry not reviewed in 2015
into the stomach (Class IIa, LOE B).
2010 Two-Person Bag-Mask Ventilation Avoid excessive cricoid pressure so as not to obstruct the trachea not reviewed in 2015
(Class III, LOE B)
2010 Cricoid Pressure During Intubation Do not continue cricoid pressure if it interferes with ventilation or not reviewed in 2015
the speed or ease of intubation (Class III, LOE C).
2010 Cuffed Versus Uncuffed Endotracheal Tubes Both cuffed and uncuffed endotracheal tubes are acceptable for not reviewed in 2015
intubating infants and children (Class IIa, LOE C).

Appendix Continued
2010 Cuffed Versus Uncuffed Endotracheal Tubes In certain circumstances (eg, poor lung compliance, high airway not reviewed in 2015
resistance, or a large glottic air leak) a cuffed endotracheal tube
may be preferable to an uncuffed tube, provided that attention is
paid to endotracheal tube size, position, and cuff ination
pressure (Class IIa, LOE B).
2010 Endotracheal Tube Size For children between 1 and 2 years of age, it is reasonable to use not reviewed in 2015
a cuffed endotracheal tube with an internal diameter of 3.5 mm
(Class IIa, LOE B).
2010 Endotracheal Tube Size After age 2 it is reasonable to estimate tube size with the following not reviewed in 2015
formula (Class IIa, LOE B): Cuffed endotracheal tube ID (mm)
3.51 (age/4).
2010 Esophageal Detector Device (EDD) If capnography is not available, an esophageal detector device (EDD) not reviewed in 2015
may be considered to conrm endotracheal tube placement in
children weighing .20 kg with a perfusing rhythm (Class IIb,
LOE B), but the data are insufcient to make a recommendation
for or against its use in children during cardiac arrest.
2010 Transtracheal Catheter Oxygenation and Attempt this procedure only after proper training and with not reviewed in 2015
Ventilation appropriate equipment (Class IIb, LOE C).
2010 CPR Guidelines for Newborns With Cardiac It is reasonable to resuscitate newborns with a primary cardiac not reviewed in 2015
Arrest of Cardiac Origin etiology of arrest, regardless of location, according to infant
guidelines, with emphasis on chest compressions (Class IIa,
LOE C).
2010 Echocardiography When appropriately trained personnel are available, not reviewed in 2015
echocardiography may be considered to identify patients with
potentially treatable causes of the arrest, particularly
pericardial tamponade and inadequate ventricular lling
(Class IIb, LOE C).
2010 Intraosseous (IO) Access IO access is a rapid, safe, effective, and acceptable route for vascular not reviewed in 2015
access in children, and it is useful as the initial vascular access
in cases of cardiac arrest (Class I, LOE C).
2010 Medication Dose Calculation If the childs weight is unknown, it is reasonable to use a body length not reviewed in 2015
tape with precalculated doses (Class IIa, LOE C).
2010 Medication Dose Calculation Regardless of the patients habitus, use the actual body weight for not reviewed in 2015
calculating initial resuscitation drug doses or use a body length
tape with precalculated doses (Class IIb, LOE C).
2010 Calcium Calcium administration is not recommended for pediatric not reviewed in 2015
cardiopulmonary arrest in the absence of documented
hypocalcemia, calcium channel blocker overdose,
hypermagnesemia, or hyperkalemia (Class III, LOE B).
2010 Glucose Check blood glucose concentration during the resuscitation and not reviewed in 2015
treat hypoglycemia promptly (Class I, LOE C).
2010 Sodium Bicarbonate Routine administration of sodium bicarbonate is not recommended not reviewed in 2015
in cardiac arrest (Class III, LOE B).
2010 AEDs If an AED with an attenuator is not available, use an AED with not reviewed in 2015
standard electrodes (Class IIa, LOE C).
2010 AEDs An AED without a dose attenuator may be used if neither a manual not reviewed in 2015
debrillator nor one with a dose attenuator is available
(Class IIb, LOE C).
2010 Bradycardia Continue to support airway, ventilation, oxygenation, and chest not reviewed in 2015
compressions (Class I, LOE B).
2010 Bradycardia Emergency transcutaneous pacing may be lifesaving if the not reviewed in 2015
bradycardia is due to complete heart block or sinus node
dysfunction unresponsive to ventilation, oxygenation, chest
compressions, and medications, especially if it is associated
with congenital or acquired heart disease (Class IIb, LOE C).
2010 Supraventricular Tachycardia Attempt vagal stimulation rst, unless the patient is not reviewed in 2015
hemodynamically unstable or the procedure will unduly delay
chemical or electric cardioversion (Class IIa, LOE C).
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Appendix Continued
2010 Supraventricular Tachycardia An IV/IO dose of verapamil, 0.1 to 0.3 mg/kg is also effective in not reviewed in 2015
terminating SVT in older children, but it should not be used in
infants without expert consultation (Class III, LOE C) because it
may cause potential myocardial depression, hypotension, and
cardiac arrest.
2010 Supraventricular Tachycardia Use sedation, if possible. Start with a dose of 0.5 to 1 J/kg. If not reviewed in 2015
unsuccessful, increase the dose to 2 J/kg (Class IIb, LOE C).
2010 Supraventricular Tachycardia Consider amiodarone 5 mg/kg IO/IV or procainamide 15 mg/kg not reviewed in 2015
IO/IV236 for a patient with SVT unresponsive to vagal maneuvers
and adenosine and/or electric cardioversion; for
hemodynamically stable patients, expert consultation is
strongly recommended prior to administration (Class IIb, LOE C).
2010 Wide-Complex (.0.09 Second) Tachycardia Consider electric cardioversion after sedation using a starting not reviewed in 2015
energy dose of 0.5 to 1 J/kg. If that fails, increase the dose to
2 J/kg (Class IIb, LOE C).
2010 Wide-Complex (.0.09 Second) Tachycardia Electric cardioversion is recommended using a starting energy not reviewed in 2015
dose of 0.5 to 1 J/kg. If that fails, increase the dose to 2 J/kg
(Class I, LOE C).
2010 Septic Shock Early assisted ventilation may be considered as part of a protocol- not reviewed in 2015
driven strategy for septic shock (Class IIb, LOE C).
2010 Septic Shock Etomidate has been shown to facilitate endotracheal intubation in not reviewed in 2015
infants and children with minimal hemodynamic effect, but do
not use it routinely in pediatric patients with evidence of septic
shock (Class III, LOE B).
2010 Trauma Do not routinely hyperventilate even in case of head injury not reviewed in 2015
(Class III, LOE C).
2010 Trauma If the patient has maxillofacial trauma or if you suspect a basilar not reviewed in 2015
skull fracture, insert an orogastric rather than a nasogastric
tube (Class IIa, LOE C).
2010 Trauma In the very select circumstances of children with cardiac arrest from not reviewed in 2015
penetrating trauma with short transport times, consider
performing resuscitative thoracotomy (Class IIb, LOE C).
2010 Single Ventricle Neonates in a prearrest state due to elevated pulmonary-to- not reviewed in 2015
systemic ow ratio prior to Stage I repair might benet from
a PaCO2 of 50 to 60 mm Hg, which can be achieved during
mechanical ventilation by reducing minute ventilation,
increasing the inspired fraction of CO2, or administering opioids
with or without chemical paralysis (Class IIb, LOE B).
2010 Single Ventricle Neonates in a low cardiac output state following stage I repair may not reviewed in 2015
benet from systemic vasodilators such as a-adrenergic
antagonists (eg, phenoxybenzamine) to treat or ameliorate
increased systemic vascular resistance, improve systemic
oxygen delivery, and reduce the likelihood of cardiac arrest
(Class IIa, LOE B).
2010 Single Ventricle Other drugs that reduce systemic vascular resistance (eg, milrinone not reviewed in 2015
or nipride) may also be considered for patients with excessive
Qp:Qs (Class IIa, LOE B).
2010 Single Ventricle During cardiopulmonary arrest, it is reasonable to consider not reviewed in 2015
extracorporeal membrane oxygenation (ECMO) for patients with
single ventricle anatomy who have undergone Stage I procedure
(Class IIa, LOE B).
2010 Single Ventricle Hypoventilation may improve oxygen delivery in patients in not reviewed in 2015
a prearrest state with Fontan or hemi-Fontan/bidirectional
Glenn (BDG) physiology (Class IIa, LOE B).
2010 Single Ventricle Negative-pressure ventilation may improve cardiac output not reviewed in 2015
(Class IIa, LOE C).
2010 Single Ventricle During cardiopulmonary arrest, it is reasonable to consider not reviewed in 2015
extracorporeal membrane oxygenation (ECMO) for patients with
Fontan physiology (Class IIa, LOE C).

Appendix Continued
2010 Pulmonary Hypertension If intravenous or inhaled therapy to decrease pulmonary not reviewed in 2015
hypertension has been interrupted, reinstitute it (Class IIa,
LOE C).
2010 Pulmonary Hypertension Consider administering inhaled nitric oxide (iNO) or aerosolized not reviewed in 2015
prostacyclin or analogue to reduce pulmonary vascular
resistance (Class IIa, LOE C).
2010 Pulmonary Hypertension If iNO is not available, consider giving an intravenous bolus of not reviewed in 2015
prostacyclin (Class IIa, LOE C).
2010 Pulmonary Hypertension ECMO may be benecial if instituted early in the resuscitation (Class not reviewed in 2015
IIa, LOE C).
2010 Cocaine For coronary vasospasm consider nitroglycerin (Class IIa, LOE C), not reviewed in 2015
a benzodiazepine, and phentolamine (an a-adrenergic
antagonist) (Class IIb, LOE C).
2010 Cocaine Do not give b-adrenergic blockers (Class III, LOE C). not reviewed in 2015
2010 Cocaine For ventricular arrhythmia, consider sodium bicarbonate (1 to not reviewed in 2015
2 mEq/kg) administration (Class IIb, LOE C) in addition to
standard treatment.
2010 Cocaine To prevent arrhythmias secondary to myocardial infarction, not reviewed in 2015
consider a lidocaine bolus followed by a lidocaine infusion
(Class IIb, LOE C).
2010 Tricyclic Antidepressants and Other Sodium Do not administer Class IA (quinidine, procainamide), Class IC not reviewed in 2015
Channel Blockers (ecainide, propafenone), or Class III (amiodarone and sotalol)
antiarrhythmics, which may exacerbate cardiac toxicity
(Class III, LOE C).
2010 Calcium Channel Blockers The effectiveness of calcium administration is variable (Class IIb, not reviewed in 2015
LOE C).
2010 Calcium Channel Blockers For bradycardia and hypotension, consider vasopressors and not reviewed in 2015
inotropes such as norepinephrine or epinephrine (Class IIb,
LOE C).
2010 Beta-Adrenergic Blockers High-dose epinephrine infusion may be effective (Class IIb, LOE C). not reviewed in 2015
2010 Beta-Adrenergic Blockers Consider glucagon (Class IIb, LOE C). not reviewed in 2015
2010 Beta-Adrenergic Blockers Consider an infusion of glucose and insulin (Class IIb, LOE C). not reviewed in 2015
2010 Beta-Adrenergic Blockers There are insufcient data to make a recommendation for or against not reviewed in 2015
using calcium (Class IIb, LOE C).
2010 Beta-Adrenergic Blockers Calcium may be considered if glucagon and catecholamines are not reviewed in 2015
ineffective (Class IIb, LOE C).
2010 Opioids Support of oxygenation and ventilation is the initial treatment for not reviewed in 2015
severe respiratory depression from any cause (Class I).
2010 Opioids Naloxone reverses the respiratory depression of narcotic overdose not reviewed in 2015
(Class I, LOE B).
2010 Respiratory System Monitor exhaled CO2 (PETCO2), especially during transport and not reviewed in 2015
diagnostic procedures (Class IIa, LOE B).
2010 Dopamine Titrate dopamine to treat shock that is unresponsive to uids and not reviewed in 2015
when systemic vascular resistance is low (Class IIb, LOE C).
2010 Inodilators It is reasonable to use an inodilator in a highly monitored setting for not reviewed in 2015
treatment of myocardial dysfunction with increased systemic or
pulmonary vascular resistance (Class IIa, LOE B).
2010 Neurologic System It is reasonable for adolescents resuscitated from sudden, not reviewed in 2015
witnessed, out-of-hospital VF cardiac arrest (Class IIa, LOE C).
2010 Neurologic System Monitor temperature continuously, if possible, and treat fever not reviewed in 2015
(.38C) aggressively with antipyretics and cooling devices
because fever adversely inuences recovery from ischemic
brain injury (Class IIa, LOE C).
2010 Interhospital Transport Monitor exhaled CO2 (qualitative colorimetric detector or not reviewed in 2015
capnography) during interhospital or intrahospital transport of
intubated patients (Class IIa, LOE B).
2010 Family Presence During Resuscitation Whenever possible, provide family members with the option of not reviewed in 2015
being present during resuscitation of an infant or child
(Class I, LOE B).
S194 DE CAEN
SUPPLEMENT ARTICLE
Appendix Continued
2010 Family Presence During Resuscitation If the presence of family members creates undue staff stress not reviewed in 2015
or is considered detrimental to the resuscitation, then
family members should be respectfully asked to leave
(Class IIa, LOE C).
2010 Sudden Unexplained Deaths Refer families of patients that do not have a cause of death found not reviewed in 2015
on autopsy to a healthcare provider or center with expertise
in arrhythmias (Class I, LOE C).

Part 12: Pediatric Advanced Life Support: 2015 American Heart Association
Guidelines Update for Cardiopulmonary Resuscitation and Emergency
Allan R. de Caen, Marc D. Berg, Leon Chameides, Cheryl K. Gooden, Robert W.
Hickey, Halden F. Scott, Robert M. Sutton, Janice A. Tijssen, Alexis Topjian, lise
W. van der Jagt, Stephen M. Schexnayder and Ricardo A. Samson
Pediatrics 2015;136;S176; originally published online October 14, 2015;
DOI: 10.1542/peds.2015-3373F
Updated Information & including high resolution figures, can be found at:
Services /content/136/Supplement_2/S176.full.html
References This article cites 93 articles, 20 of which can be accessed free
at:
/content/136/Supplement_2/S176.full.html#ref-list-1
Permissions & Licensing Information about reproducing this article in parts (figures,
tables) or in its entirety can be found online at:
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright 2015 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Part 12: Pediatric Advanced Life Support: 2015 American Heart Association
Guidelines Update for Cardiopulmonary Resuscitation and Emergency
Allan R. de Caen, Marc D. Berg, Leon Chameides, Cheryl K. Gooden, Robert W.
Hickey, Halden F. Scott, Robert M. Sutton, Janice A. Tijssen, Alexis Topjian, lise
W. van der Jagt, Stephen M. Schexnayder and Ricardo A. Samson
Pediatrics 2015;136;S176; originally published online October 14, 2015;
DOI: 10.1542/peds.2015-3373F
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/136/Supplement_2/S176.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2015 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Part 12: Pediatric Advanced Life Support

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