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homecirculationvol 142 16suppl2part 4 pediatric basic advanced life support 2020 american heart association guidelines cardiopulmonary resuscitation emergency cardiovascular care free accessreview articlepdfepubaboutview pdfview epubsections toolsadd favoritesdownload citationstrack citationspermissions shareshare onfacebooktwitterlinked inmendeleyredditdiggemail jump tofree accessreview articlepdfepubpart 4 pediatric basic advanced life support 2020 american heart association guidelines cardiopulmonary resuscitation emergency cardiovascular care alexis topjian md msce chair tia raymond md vicechair dianne atkins md melissa chan md jonathan p duff md med benny l joyner jr md mph javier j lasa md eric j lavonas md ms arielle levy md med melissa mahgoub phd garth meckler md mshs kathryn e roberts msn rn robert sutton md msce stephen schexnayder md alexis topjianalexis topjian search papers author tia raymondtia raymond search papers author dianne atkinsdianne atkins search papers author melissa chanmelissa chan search papers author jonathan p duffjonathan p duff search papers author benny l joyner jrbenny l joyner jr search papers author javier j lasajavier j lasa search papers author eric j lavonaseric j lavonas search papers author arielle levyarielle levy search papers author melissa mahgoubmelissa mahgoub search papers author garth mecklergarth meckler search papers author kathryn e robertskathryn e roberts search papers author robert suttonrobert sutton search papers author stephen schexnayderstephen schexnayder search papers author behalf pediatric basic advanced life support collaborators originally published21 oct 2020httpsdoiorg101161cir0000000000000901circulation 2020142s469s523top 10 takehome messageshighquality cardiopulmonary resuscitation cpr foundation resuscitation new data reaffirm key components highquality cpr providing adequate chest compression rate depth minimizing interruptions cpr allowing full chest recoil compressions avoiding excessive ventilationa respiratory rate 20 30 breaths per minute new infants children receiving cpr advanced airway place b receiving rescue breathing pulsefor patients nonshockable rhythms earlier epinephrine administered cpr initiation likely patient surviveusing cuffed endotracheal tube decreases need endotracheal tube changesthe routine use cricoid pressure reduce risk regurgitation bagmask ventilation may impede intubation successfor outofhospital cardiac arrest bagmask ventilation results resuscitation outcomes advanced airway interventions endotracheal intubationresuscitation end return spontaneous circulation rosc excellent postcardiac arrest care critically important achieving best patient outcomes children regain consciousness rosc care includes targeted temperature management continuous electroencephalography monitoring prevention andor treatment hypotension hyperoxia hypoxia hypercapnia hypocapnia importantafter discharge hospital cardiac arrest survivors physical cognitive emotional challenges may need ongoing therapies interventionsnaloxone reverse respiratory arrest due opioid overdose evidence benefits patients cardiac arrestfluid resuscitation sepsis based patient response requires frequent reassessment balanced crystalloid unbalanced crystalloid colloid fluids acceptable sepsis resuscitation epinephrine norepinephrine infusions used fluidrefractory septic shockpreamblemore 20 000 infants children cardiac arrest per year united states14 2015 emergency medical servicedocumented outofhospital cardiac arrest ohca occurred 7000 infants children4 approximately 114 pediatric ohca patients survived hospital discharge outcomes varied age survival rates 171 adolescents 132 children 49 infants year pediatric inhospital cardiac arrest ihca incidence 1266 events per 1000 infant child hospital admissions overall survival hospital discharge rate 4114 neurological outcomes remain difficult assess across pediatric age spectrum variability reporting metrics time followup across studies ohca ihca favorable neurological outcome reported 47 survivors discharge5 despite increases survival ihca done improve survival neurological outcomes6the international liaison committee resuscitation ilcor formula survival emphasizes 3 essential components good resuscitation outcomes guidelines based sound resuscitation science effective education lay public resuscitation providers implementation wellfunctioning chain survival7these guidelines contain recommendations pediatric basic advanced life support excluding newborn period based best available resuscitation science chain survival section 2 expanded include recovery cardiac arrest requires coordinated efforts medical professionals variety disciplines case ohca bystanders emergency dispatchers first responders addition specific recommendations training resuscitation providers provided part 6 resuscitation education science recommendations systems care provided part 7introductionscope guidelinesthese guidelines intended resource lay rescuers healthcare providers identify treat infants children prearrest intraarrest postarrest states apply infants children multiple settings community prehospital hospital environment prearrest intraarrest postarrest topics reviewed including cardiac arrest special circumstances patients congenital heart diseasefor purposes pediatric advanced life support guidelines pediatric patients infants children adolescents 18 years age excluding newborns pediatric basic life support bls guidelines apply followsinfant guidelines apply infants younger approximately 1 year agechild guidelines apply children approximately 1 year age puberty teaching purposes puberty defined breast development females presence axillary hair malesfor signs puberty beyond adult basic life support guidelines followedresuscitation neonate addressed part 5 neonatal resuscitation applies newborn typically first hospitalization following birth pediatric basic advanced life support guidelines apply neonates less 30 days old hospital dischargecoronavirus disease 2019 guidancetogether professional societies american heart association aha provided interim guidance basic advanced life support adults children neonates suspected confirmed coronavirus disease 2019 covid19 evidence guidance evolving covid19 situation interim guidance maintained separately emergency cardiovascular care ecc guidelines readers directed aha website recent guidance8organization pediatric writing committeethe pediatric writing group consisted pediatric clinicians including intensivists cardiac intensivists cardiologists emergency medicine physicians medical toxicologists nurses volunteers recognized expertise resuscitation nominated writing group chair selected aha ecc committee aha rigorous conflict interest policies procedures minimize risk bias improper influence development guidelines9 prior appointment writing group members peer reviewers disclosed commercial relationships potential including intellectual conflicts writing group members whose research led changes guidelines required declare conflicts discussions abstain voting specific recommendations process described fully part 2 evidence evaluation guidelines development disclosure information writing group members listed appendix 1methodology evidence reviewthese pediatric guidelines based extensive evidence evaluation performed conjunction ilcor affiliated ilcor member councils three different types evidence reviews systematic reviews scoping reviews evidence updates used 2020 process1011 review ilcor science advisory committee chair evidence update worksheets included appendix c 2020 ilcor consensus cpr ecc science treatment recommendations11a resulted description literature facilitated guideline development process described fully part 2 evidence evaluation guidelines development12class recommendation level evidencethe writing group reviewed relevant current aha guidelines cardiopulmonary resuscitation cpr ecc relevant 2020 ilcor consensus cpr ecc science treatment recommendations evidence recommendations determine current guidelines reaffirmed revised retired new recommendations needed writing group drafted reviewed approved recommendations assigning class recommendation cor ie strength level evidence loe ie quality certainty criteria cor loe described table 1table 1 applying class recommendation level evidence clinical strategies interventions treatments diagnostic testing patient care updated may 2019this table defines classes recommendation cor levels evidence loe cor indicates strength writing group assigns recommendation loe assigned based quality scientific evidence outcome result intervention specified improved clinical outcome increased diagnostic accuracy incremental prognostic informationclasses recommendationcor designations include class 1 strong recommendation potential benefit greatly outweighs risk class 2a moderate recommendation benefit likely outweighs risk class 2b weak recommendation unknown whether benefit outweigh risk class 3 benefit moderate recommendation signifying equal likelihood benefit risk class 3 harm strong recommendation risk outweighs potential benefitsuggested phrases writing class 1 recommendations includeis recommendedis indicatedusefuleffectivebeneficialshould performedadministeredothercomparativeeffectiveness phrases include treatmentstrategy recommendedindicated preference treatment b treatment chosen treatment bsuggested phrases writing class 2a recommendations includeis reasonablecan usefuleffectivebeneficialcomparativeeffectiveness phrases include treatmentstrategy probably recommendedindicated preference treatment b reasonable choose treatment treatment bfor comparativeeffectiveness recommendations cor 1 2a loe b studies support use comparator verbs involve direct comparisons treatments strategies evaluatedsuggested phrases writing class 2b recommendations includemaymight reasonablemaymight consideredusefulnesseffectiveness unknownunclearuncertain wellestablishedsuggested phrases writing class 3 benefit recommendations generally loe b use includeis recommendedis indicatedusefuleffectivebeneficialshould performedadministeredothersuggested phrases writing class 3 harm recommendations includepotentially harmfulcauses harmassociated excess morbiditymortalityshould performedadministeredotherlevels evidencefor loes method assessing quality evolving including application standardized widelyused preferably validated evidence grading tools systematic reviews incorporation evidence review committee loe designations include level level br level bnr level cld level ceothose categorized level derived fromhighquality evidence 1 randomized clinical trial rctmetaanalyses highquality rctsone rcts corroborated highquality registry studiesthose categorized level br randomized derived frommoderatequality evidence 1 rctsmetaanalyses moderatequality rctsthose categorized level bnr nonrandomized derived frommoderatequality evidence 1 welldesigned wellexecuted nonrandomized studies observational studies registry studiesmetaanalyses studiesthose categorized level cld limited data derived fromrandomized nonrandomized observational registry studies limitations design executionmetaanalyses studiesphysiological mechanistic studies human subjectsthose categorized level ceo expert opinion derived fromconsensus expert opinion based clinical experiencecor loe determined independently cor may paired loea recommendation loe c imply recommendation weak many important clinical questions addressed guidelines lend clinical trials although rcts unavailable may clear clinical consensus particular test therapy useful effectivetable 1 applying class recommendation level evidence clinical strategies interventions treatments diagnostic testing patient care updated may 2019guideline structurethe 2020 guidelines organized discrete modules information specific topics management issues13 modular knowledge chunk includes table recommendations using standard aha nomenclature cor loe recommendations presented order cor potential benefit class 1 followed lesser certainty benefit class 2 finally potential harm benefit class 3 following cor recommendations ordered certainty supporting loe level highquality randomized controlled trials level ceo expert opinion order reflect order care provideda brief introduction short synopsis provided contextualize recommendations important background information overarching management treatment concepts recommendationspecific supportive text clarifies rationale key study data supporting recommendations appropriate flow diagrams additional tables included hyperlinked references provided facilitate quick access reviewdocument review approvalthe guideline submitted blinded peer review 5 subject matter experts nominated aha peer reviewer feedback provided guidelines draft format final format guideline also reviewed approved publication aha science advisory coordinating committee aha executive committee disclosure information peer reviewers listed appendix 2abbreviationsabbreviationmeaningphraseaclsadvanced cardiovascular life supportaedautomated external defibrillatoralsadvanced life supportahaamerican heart associationblsbasic life supportcoiconflict interestcorclass recommendationcprcardiopulmonary resuscitationeccemergency cardiovascular careeclsextracorporeal life supportecmoextracorporeal membrane oxygenationecprextracorporeal cardiopulmonary resuscitationeoexpert opinionetiendotracheal intubationfbaoforeign body airway obstructionihcainhospital cardiac arrestilcorinternational liaison committee resuscitationldlimited dataloelevel evidencemcsmechanical circulatory supportnrnonrandomizedohcaoutofhospital cardiac arrestpalspediatric advanced life supportpicopopulation intervention comparator outcomepvtpulseless ventricular tachycardiarctrandomized clinical trialroscreturn spontaneous circulationsgasupraglottic airwayttmtargeted temperature managementvfventricular fibrillationreferences1 holmberg mj ross ce fitzmaurice gm chan ps duvalarnould j grossestreuer av yankama donnino mw andersen lw american heart associations get guidelinesresuscitation investigators annual incidence adult pediatric inhospital cardiac arrest united statescirc cardiovasc qual outcomes 2019 12e005580linkgoogle scholar2 atkins dl eversonstewart sears gk daya osmond mh warden cr berg ra resuscitation outcomes consortium investigators epidemiology outcomes outofhospital cardiac arrest children resuscitation outcomes consortium epistrycardiac arrestcirculation 2009 11914841491 doi 101161circulationaha108802678linkgoogle scholar3 knudson jd neish sr cabrera ag lowry aw shamszad p morales dl graves de williams ea rossano jw prevalence outcomes pediatric inhospital cardiopulmonary resuscitation united states analysis kids inpatient databasecrit care med 2012 4029402944 doi 101097ccm0b013e31825feb3fcrossrefmedlinegoogle scholar4 virani ss alonso benjamin 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resuscitation registry large multicenter hospitalbased cardiac arrest registry pediatric cardiac arrest survival hospital discharge 19 2000 38 20182 survival increased average 067 per year though increase plateaued since 20102 new directions research therapy may required improve cardiac arrest survival cardiac arrest events occur intensive care unit icu setting suggesting patients risk cardiac arrest identified sooner transferred higher level care3survival rates ohca remain less encouraging recent analysis resuscitation outcomes consortium epidemiological registry multicenter ohca registry annual survival hospital discharge pediatric ohca 2007 2012 ranged 67 102 depending region patient age4 significant change rates time consistent national registries japan australia new zealand56 resuscitation outcomes consortium epidemiological registry survival ohca higher regions arrests witnessed emergency medical services higher bystander cpr rates stressing importance early recognition treatment patients4as survival rates pediatric cardiac arrest increase shift focus neurodevelopmental physical emotional outcomes survivors recent studies demonstrate quarter patients favorable outcomes global cognitive impairment 85 older children reported favorable outcomes selective neuropsychological deficits7the pediatric chain survivalhistorically cardiac arrest care largely focused management cardiac arrest highlighting highquality cpr early defibrillation effective teamwork however aspects prearrest postarrest care critical improve outcomes pediatric cardiac arrest survival rates plateaued prevention cardiac arrest becomes even important outofhospital environment includes safety initiatives eg bike helmet laws sudden infant death syndrome prevention lay rescuer cpr training early access emergency care ohca occurs early bystander cpr critical improving outcomes inhospital environment cardiac arrest prevention includes early recognition treatment patients risk cardiac arrest neonates undergoing cardiac surgical procedures patients presenting acute fulminant myocarditis acute decompensated heart failure pulmonary hypertensionfollowing resuscitation cardiac arrest management postcardiac arrest syndrome may include brain dysfunction myocardial dysfunction low cardiac output ischemia reperfusion injury important avoid known contributors secondary injury hypotension89 accurate neuroprognostication important guide caregiver discussions decisionmaking finally given high risk neurodevelopmental impairment cardiac arrest survivors early referral rehabilitation assessment intervention keyto highlight different aspects cardiac arrest management pediatric chain survival updated figure 1 separate ohca chain survival created distinguish differences ohca ihca ohca ihca chains sixth link added stress importance recovery focuses short longterm treatment evaluation support survivors families chains survival activating emergency response followed immediately initiation highquality cpr help nearby cell phone available activating emergency response starting cpr nearly simultaneous however outofhospital setting single rescuer access cell phone begin cpr compressionsairwaybreathing infants children calling help respiratory arrest common cause cardiac arrest help may nearby event sudden witnessed collapse rescuers use available automatic external defibrillator aed early defibrillation lifesavingdownload figuredownload powerpointfigure 1 pediatric chains survival inhospital top outofhospital bottom cardiac arrest cpr indicates cardiopulmonary resuscitationreferences1 girotra spertus ja li berg ra nadkarni vm chan ps american heart association get guidelinesresuscitation investigators survival trends pediatric inhospital cardiac arrests analysis get guidelinesresuscitationcirc cardiovasc qual outcomes 2013 64249 doi 101161circoutcomes112967968linkgoogle scholar2 holmberg mj wiberg ross ce kleinman hoeyernielsen ak donnino mw andersen lw trends survival pediatric 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