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CirculationPediatric Life Support
2024 International Consensus on Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care Science With Treatment
Amelia G. Reis, MD, PhD
Recommendations Stephen M. Schexnayder, MD
Barnaby R. Scholefield,
MBBS, MRCPCH, PhD
ABSTRACT: This 2024 International Consensus on Cardiopulmonary Janice A. Tijssen, MD, MSc
Resuscitation and Emergency Cardiovascular Care Science With Treatment Jerry P. Nolan, MBChB
Recommendations (CoSTR) for pediatric life support is based on the most Peter T. Morley, MBBS
extensive evidence evaluation ever performed by the Pediatric Life Patrick Van de Voorde, MD,
PhD
Support Task Force. Three types of evidence evaluation were used in this
Arno L. Zaritsky, MD
review: systematic reviews, scoping reviews, and evidence updates. Per Allan R. de Caen, MD
agreement with the evidence evaluation recommendations of the On behalf of the Pediatric Life
International Liaison Committee on Resuscitation, only systematic reviews Support Collaborators
could result in a new or revised treatment recommendation.
Systematic reviews performed for this 2020 CoSTR for pediatric life support
included the topics of sequencing of airway-breaths-compressions versus
compressions-airway-breaths in the delivery of pediatric basic life support, the
initial timing and dose intervals for epinephrine administration during Key Words: AHA Scientific Statements ◼
resuscitation, and the targets for oxygen and carbon dioxide levels in pediatric arrhythmia ◼ cardiopulmonary
resuscitation ◼ child ◼ congenital heart
patients after return of spontaneous circulation. The most controversial topics disease ◼ ECMO ◼ pediatrics
included the initial timing and dose intervals of epinephrine administration
© 2020 American Heart Association, Inc.,
(new treatment recommendations were made) and the administration of fluid European Resuscitation Council, and
for infants and children with septic shock (this latter topic was evaluated by International Liaison Committee on
Resuscitation
evidence update). All evidence reviews identified the paucity of pediatric data https://www.ahajournals.org/journal/circ
and the need for more research involving resuscitation of infants and children.
CONTENTS
Abstract
Ian K. Maconochie, MB, BS, ................................................
LMSSA, PhD ...............S140
Richard Aickin, MB, ChB Topics Reviewed in This 2020
Mary Fran Hazinski, RN, MSN PLS CoSTR ..............S143
Dianne L. Atkins, MD PBLS: CPR and CPR Quality
Robert Bingham, MRCS, MB BS, LRCP ..................................S144
Thomaz Bittencourt Couto, MD, PhD
Sequence of
Anne-Marie Guerguerian, MD, PhD
Compression and
Vinay M. Nadkarni, MD
Kee-Chong Ng, MBBS, MMed
Ventilation
(Peds) (BLS 661: Shared SysRev)
Gabrielle A. Nuthall, MBChB ............................S144
Gene Y.K. Ong, MBBS, MRCPCH
, Pulse Check Accuracy (PLS 393: EvUp) ........S145 Versus Epinephrine
Chest Compression–Only Versus Conventional CPR (2017 CoSTR) (PLS 2 New: EvUps)
.................S145 Pediatric Compression Depth (PLS 314: .........S156
ScopRev) ..................................................... S146 Emergency
One-Hand Versus 2-Hand Compressions for Children (PLS 375: EvUp) Transcutaneous Pacing
Combined With Circumferential Compressions for for
Infants (PLS 416: EvUp) .............................S146 Bradycardia (PLS New:
PBLS: Automated External Defibrillation ...............S147 Use of Automated External EvUp)
Defibrillators for Infants With Out-of-Hospital Cardiac ......................S156
Arrest (PLS 425: EvUp) ................................S147 Channelopathies (PLS
PBLS: Prevention of Cardiac Arrest .......................S147 417: EvUp)
Pediatric Early-Warning Scores ...............S157
(PLS 818: ScopRev) .....................................S147 PALS: Manual Defibrillation
Pediatric Medical Emergency/Rapid ..................................S157
Response Teams (PLS 397: EvUp) ................S148 Pad Size, Type, and
PALS: Recognition and Treatment of Septic Shock ....S148 Placement for Pediatric
Fluid Administration for the Child With Defibrillation (PLS 378
Septic Shock (PLS New: EvUp) .....................S148 and PLS 043: EvUp) ....
Vasoactive Drugs for Septic Shock S157
(PLS 1604: ScopRev) ................................S149 Energy Doses for
Corticosteroids for Pediatric Septic Shock Defibrillation
(PLS 413: EvUp) ..........................................S150 (PLS 405: ScopRev)
PALS: Recognition and Prearrest Treatments .....................................
for Shock ...................................................... S151 S158
Graded Volume Resuscitation for Traumatic/ Single or Stacked
Hemorrhagic Shock (PLS 400: ScopRev) ......S151 Shocks for Pediatric
Timing of Intubation for Shock Defibrillation (PLS 389:
(PLS 399: EvUp) ......................................S152 EvUp)
Prearrest Care of the Infant or Child With ......................S158
Dilated Cardiomyopathy or Myocarditis PALS: Airways, Oxygenation,
(PLS 819: EvUp) ..........................................S152 and Ventilation ........S159
Cardiogenic Shock and Inotropes Ventilation Rate When
(PLS 418: EvUp) ..........................................S153 a Perfusing Rhythm
PALS: Management of Deterioration With Is Present (PLS 3103A
Pulmonary Hypertension ......................................S153 Prevention and Management of and PLS 382: EvUp)
Postoperative Pulmonary Hypertensive Crises in Infants and Children (PLS 391: ......S159
EvUp) .....................S153 Opioids, Sedatives, and Neuromuscular Oxygen Concentration
Blocking Drugs for Pulmonary Hypertension During Cardiac
(PLS New: EvUp) .........................................S154 Arrest (PLS 396:
Therapy With Inhaled Nitric Oxide or ScopRev)
Prostaglandin I2 for Pulmonary Hypertensive ...........................S159
Crisis and Right Heart Failure (PLS New: EvUp) ...S154 Ventilation During CPR
PALS: Recognition and Treatment of Nonarrest With Bag and Mask
Arrhythmias ......................................................S155 Compared With an
Drugs for Supraventricular Tachycardia Advanced Airway
(PLS 379: EvUp) ..........................................S155 (2019 CoSTR)
Treatment for Unstable Ventricular .....................................
Tachycardia (PLS 409: EvUp) ....................S155 ........S160
CPR for Heart Rate of Less Than 60/min Use of Cuffed or
(PLS 1535: EvUp) ........................................S155 Drugs for the Treatment of Uncuffed Tracheal
Bradycardia: Tubes
Atropine Versus No Atropine and Atropine
, (PLS 412: EvUp) ..........................................S160 Patients With Return of
Atropine for Emergency Intubation Spontaneous
(PLS 821: EvUp) ..........................................S161 Circulation
Cricoid Pressure During Intubation After Cardiac Arrest
(PLS 376: EvUp) ..........................................S161 (PLS 815: SysRev)
Use of Devices to Verify Advanced Airway ........S174
Placement (PLS 385: EvUp) .........................S162 Post-ROSC Blood
Ventilation Rate With Advanced Airway Pressure Control
During Cardiac Arrest (PLS 3103A and (PLS 820: EvUp)
PLS 382: EvUp) .......................................S162 .....................................
PALS: Circulatory Support During CPR ..................S163 Extracorporeal CPR for In- .....S176
Hospital Cardiac Arrest Post-ROSC
(2019 CoSTR) .............................................S163 Neuroprognostication
PALS: Physiological Monitoring During Arrest to and
Guide Therapy and/or Intra-arrest Prognostication ....S163 Use of
Invasive Blood Pressure Monitoring During Electroencephalogram
CPR (PLS 826: ScopRev) ..............................S163 (PLS 813 and PLS 822:
Use of Near-Infrared Spectroscopy During EvUp) ......................S177
Cardiac Arrest (PLS New: ScopRev) ..............S164 Topics Not Reviewed in 2020
Bedside Ultrasound to Identify Perfusing ...............................S177
Rhythm (PLS 408: ScopRev) ........................S165 End-Tidal CO2 Monitoring During Future Tasks
CPR ................................................
(PLS 827: ScopRev) .....................................S165 .........S177
PALS: Resuscitation Drug Administration and Timing ....S166 Acknowledgments
Methods of Calculating Pediatric Drug ...............................................
Doses (PLS 420: EvUp) ................................S166 S178
Intraosseous Versus Intravenous Route of Drug Disclosures
Administration (PLS, NLS, and ALS: SysRev) ......S167 ................................................
Epinephrine Time of Initial Dose and Dose ...........S178
Interval During CPR (PLS 1541: SysRev) .......S167 References
Amiodarone Versus Lidocaine for Shock- Resistant Ventricular Fibrillation or ................................................
Pulseless ...........S180
Ventricular Tachycardia (2018 CoSTR) .........S171
T
Sodium Bicarbonate Administration for he 2020 International
Children in Cardiac Arrest (PLS 388: EvUp) .....S171 Consensus on
Calcium Administration in Children Cardiopulmonary
(PLS 421: EvUp) ..........................................S172 Resuscitation (CPR) and
PALS: Special Resuscitation Situations—Septic Emergency Cardiovascular
Shock, Congenital Heart Disease, and Trauma ......S172 Care (ECC) Science With
Resuscitation of the Child With Septic Treatment Recommendations
Shock (PLS 1534: EvUp) ..............................S172 (CoSTR) is the fourth in a
Resuscitation of the Patient With a Single series of annual publications
Ventricle (PLS 390: EvUp) ............................S172 from the International Liaison
Resuscitation of the Patient With Hemi- Fontan or Fontan Circulation (PLS 392: Committee on Resuscitation
EvUp) ...S173 (ILCOR). This 2020 CoSTR
Resuscitation After Traumatic Arrest summary for pediatric life
(PLS 498: EvUp) .................................... S173 support (PLS) includes new
PALS: Post–Cardiac Arrest Care, Including topics addressed by
Postarrest Prognostication ....................................S174 Systematic Reviews (SysRevs)
Targeted Temperature Management performed within the past 12
(2019 CoSTR) .............................................S174 months. It also includes
Oxygen and Carbon Dioxide Targets in Pediatric updates of the PLS CoSTR
, statements published from 2010 through 2019 as needed, based on additional topic experts in consultation
evidence evaluations. As a result, this 2020 CoSTR summary for PLS is the most with the PLS Task Force. The
comprehensive update since 2010. The 3 major types of evidence evaluation task force analyzed the
supporting this 2020 publication are the SysRev, the Scoping Review (ScopRev), and the identified evidence and
Evidence Update (EvUp). determined its value and
Topics and types of reviews were prioritized by the PLS Task Force over the past 12 implications for resuscitation
months on the basis of task force consensus that the answers to the review questions practice or research. The
were critical, task force expert awareness of recent studies on the topics that could rationale for the ScopRev,
change treatment recommendations, and input and requests from the ILCOR member the summary of evidence,
councils. SysRevs were performed on topics if deemed critical on the basis of the and task force insights—all
questions involved or if publication of studies suggested the need to consider new or are highlighted in the body
modified treatment recommendations. ScopRevs and EvUps were performed if the task of this publication. Any
force or member councils identified a topic as important or if it had not been reviewed previous treatment
in several years; ScopRevs and EvUps were intended to determine if sufficient published recommendations are
evidence existed to suggest the need for a SysRev. reiterated. The task force
The SysRev is a rigorous process following strict methodology to answer a specific noted whether the ScopRev
question, and each of these ultimately resulted in the generation of a task force CoSTR identified substantive
included in this summary. The SysRevs were performed by a knowledge synthesis unit, evidence that could result in
an expert systematic reviewer, or the PLS Task Force, and many resulted in separate a change in the ILCOR
SysRevs publications. treatment
To begin the SysRev, the question to be answered was phrased in terms of the PICOST recommendations. If
(population, intervention, comparator, outcome, study design, time frame) format. The sufficient evidence was
methodology used to identify the evidence was based on the Preferred Reporting Items identified, the task force
for Systematic Reviews and Meta-Analyses (PRISMA).1 The approach used to evaluate suggested consideration of a
the evidence was based on that proposed by the Grading of Recommendations, (future) SysRev to support
Assessment, Development and Evaluation (GRADE) working group. 2 Using this the development of an
approach, the PLS Task Force rated as high, moderate, low, or very low the updated CoSTR. All ScopRevs
certainty/confidence in the estimates of effect of an intervention or assessment across are included in their entirety
a body of evidence for each of the predefined outcomes. Randomized controlled trials in Appendix B in the
(RCTs) generally began the analysis as high-certainty evidence, and observational Supplemental Materials.
studies generally began the analysis as low-certainty evidence; examination of the The third type of
evidence using the GRADE approach could result in downgrading or upgrading the evidence evaluation
certainty of evidence. For additional information, refer to “Evidence Evaluation Process supporting this 2020 CoSTR
and for PLS is an EvUp. EvUps
Management of Potential Conflicts of Interest.”3,3a were generally performed to
When a pre-2015 CoSTR treatment recommendation was not updated, the language identify new studies
used in the recommendation differed from that used in the GRADE approach because published after the most
GRADE was not used before 2015.4–6 recent ILCOR evidence
Draft 2020 (ie, new) CoSTRs for PLS were posted on the ILCOR website 7 for public evaluation, typically by using
comment between March 26, 2018, and January 10, 2020. The draft CoSTR statements search terms and
were viewed 31 468 times with 16 comments received. All comments were discussed methodologies from
by the PLS Task Force and modifications made as needed to the content or to the previous reviews. These
recommendations for future search strategies. EvUps were performed by
task force members,
This summary contains the final wording of the CoSTR statements as approved by
collaborating experts, or
the ILCOR PLS Task Force and the ILCOR member councils after review and
members of council writing
consideration of comments posted online in response to the draft CoSTRs. In this
groups. The EvUps are cited
publication, each topic includes the PICOST as well as the CoSTR, an expanded
in the body of this
Justification and Evidence to Decision Framework Highlights section, and a list of
publication with a note as to
knowledge gaps requiring future research studies. An evidence-to-decision table is
whether the evidence
included for each CoSTR in Appendix A in the Supplemental Materials.
suggested the need to
The second major type of evidence evaluation performed to support this 2020
consider a SysRev; the most
CoSTR summary for PLS is a ScopRev. ScopRevs are designed to identify the extent,
recent ILCOR treatment
range, and nature of evidence on a topic or question, and they were performed by
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