A Summary of the PALS 2020 Updates

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Picture of Sam Epstein • Illustrator
Sam Epstein • Illustrator

Aspiring Medical Student and current Critical Care RN. Enjoys everything outdoors but can also be found inside nerding out on her medical education artwork.

The Pre-brief

Late last year, the PALS guidelines were updated. Check out the big highlights in figure 1 and read on below for more details.

Algorithms and visual aids.

  1.       New algorithms and visual aids including new pediatric Chain of Survival with a sixth link, Recovery.
  2.       Cardiac arrest and pediatric bradycardia algorithms updated.
  3.       Single pediatric tachycardia with a pulse algorithm now covers narrow and wide complex tachycardias.
  4.       2 new opioid-associated emergency algorithms were added.
  5.       New post-cardiac arrest care checklist. Check it out: https://cpr.heart.org/-/media/cpr-files/cpr-guidelines-files/algorithms/pcac_checkllst_200814.pdf

Updates on managing cardiac arrest.

The recommended assisted ventilation rate was increased to 1 breath every 2-3 seconds (20-30 breaths per minute) for ALL pediatric resuscitation scenarios.

  • New data show higher ventilation rates 30/min in infants <1yr and 25/min in children are associated with improved rates of ROSC and survival. This was standardized to patients with and without an advanced airway.
  • IMPORTANT NOTE: This is being hotly debated as the study supporting this change was an observational study of only 47 patients with 60% having pre-existing congenital heart disease and all intubated with arterial lines. Of the patients, 74% had bradycardia with poor perfusion leaving very few with asystole. This study does not seem to be representative of the patients typically seen in out of hospital cardiac arrest. Additionally, critics feel this may increase oxygenation – and intrathoracic pressure – at the expense of flow.

Cuffed ETTs are suggested to reduce air leak and the need for tube exchanges for any patient, any age.

  • Amen to this! The safety of cuffed tubes has been demonstrated and when placed initially they decrease the need for tube changes and reintubation – which I can attest, happens almost any time I receive a patient with an uncuffed tube.
  • Careful attention should be paid to ETT size, position, and cuff inflation pressure (<20-25cmH2O). For more on the pediatric airway, check out these tips for the pediatric airway: https://criticalcarenow.com/the-pediatric-airway-tips-and-insights/

Routine use of cricoid pressure during intubation is not recommended.

  • Routine use of cricoid pressure reduces intubation success and does not reduce the rate of regurgitation. However, sometimes it can be helpful and should be employed if it improves speed or ease of intubation.

Emphasis on EARLY epinephrine administration, ideally within 5 minutes of the start of cardiac arrest from a non-shockable rhythm (asystole and PEA). In the event that IV access cannot be routinely obtained, intraosseous access should be obtained promptly.

  • A study from in-hospital cardiac arrest (IHCA) demonstrated that for every minute of delay in epinephrine administration (for asystole or PEA), there was a significant decrease in ROSC, survival at 24 hours, survival to discharge, and survival with favorable neurologic outcome.
  • Studies in out-of-hospital cardiac arrest (OHCA) demonstrated earlier epinephrine administration increases ROSC, survival to ICU admission, survival to discharge, and 30-day survival.

Diastolic blood pressure from an arterial line can be used to improve CPR quality.

  • Rate of survival with favorable outcomes were improved if DBP was at least 25mmHg in infants and 30mmHg in children.
  • Remember in pediatrics, ETCO2 monitoring may be considered to assess chest compression quality but specific values have not been established.

After ROSC, evaluate patients for seizures (convulsive and non-convulsive) and treat accordingly.

  • This emphasizes the need for EEG to detect non-convulsive seizures. Any seizure activity (convulsive or non-convulsive is associated with a poorer outcome.

Formal assessment and support of physical, cognitive, and psychosocial needs post-arrest should be addressed.

  • Obviously, this will improve long-term outcomes.

Updated shock treatment guidelines.

A titrated approach to fluid management, with epinephrine and norepinephrine infusions if needed, is appropriate for septic shock resuscitation.

  • Administer fluid in 10-20ml/kg aliquots with frequent reassessment – because fluid overload can worsen multiple outcomes, including an increased need for mechanical ventilation.
  • Epinephrine and norepinephrine are now specifically named and superior to dopamine as initial vasopressor in this population.
  • Corticosteroids may also help in refractory septic shock.

Balanced blood component resuscitation is reasonable for hemorrhagic shock.

  • Balanced blood component resuscitation means a balance of packed red blood cells, fresh frozen plasma, and platelets.
  • Adult data has shown a benefit to this approach.

Other new updates:

Opioid overdose management includes CPR and timely administration of naloxone.

  • Recommendations are identical for adults and children with the exception of compression-ventilation CPR ratio.

Children with acute myocarditis with arrhythmias, heart block, ST segment changes, or low cardiac output are at risk for cardiac arrest. Early ICU transfer is important as some of these patients require mechanical circulatory support or ECLS.

  • These guidelines did not previously exist.

Infants and children with congenital heart disease and single ventricle physiology during staged reconstruction require special considerations including assessment of systemic vascular resistance, shunt obstruction, and inadequate pulmonary blood flow. ECLS may also be considered.

  • Resuscitation of these children is complex and varies depending on where the child is in their staged surgical correction.

Management of pulmonary hypertension may include: iNO, prostacyclin, analgesia, sedation, NMB, induction of alkalosis, or rescue therapy with ECLS.

  • These guidelines are consistent with guidelines from the AHA and American Thoracic Society in 2015.

The Debrief

  • Assisted ventilation rate of 1 breath every 2-3 seconds for ALL pediatric resuscitations.
  • Cuffed ETTs are always recommended.
  • Routine cricoid pressure during intubation is NOT recommended.
  • EARLY epinephrine administration in the setting of cardiac arrest from a non-shockable rhythm improves outcomes.
  • Diastolic blood pressure on an arterial line can improve CPR quality, target >25mmg in infants and >30mmHg in children.
  • After ROSC, evaluate for seizures.
  • Formal psychosocial assessment is needed post-arrest.
  • For septic shock, administer 10-20ml/kg aliquots of fluid and reassess.
  • Epinephrine and norepinephrine are superior to dopamine in septic shock resuscitation.


  1. Topjian AA, Raymond TT, Atkins D, et al. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16_suppl_2):S469-S523.
  2. Sutton RM, Reeder RW, et al.; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN). Ventilation Rates and Pediatric In-Hospital Cardiac Arrest Survival Outcomes. Crit Care Med. 2019 Nov;47(11):1627-1636. doi: 10.1097/CCM.0000000000003898. PMID: 31369424; PMCID: PMC7898415.
  3. Sankar J, Ismail J, et al. Fluid Bolus Over 15-20 Versus 5-10 Minutes Each in the First Hour of Resuscitation in Children With Septic Shock: A Randomized Controlled Trial. Pediatr Crit Care Med. 2017 Oct;18(10):e435-e445. doi: 10.1097/PCC.0000000000001269. PMID: 28777139.
  4. Laroque Sinott Lopes C, Unchalo Eckert G, et al. Early fluid overload was associated with prolonged mechanical ventilation and more aggressive parameters in critically ill paediatric patients. Acta Paediatr. 2020 Mar;109(3):557-564. doi: 10.1111/apa.15021. Epub 2019 Oct 20. PMID: 31532841.


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