Run a pediatric code by weight.
Pediatric cardiac arrest (2025 AHA/AAP): CPR quality by age, shockable and nonshockable sequences, weight-based energies and doses with caps, bradycardia and tachycardia with a pulse, post-ROSC targets.
Reviewed October 2026 · verify against current guidelines
Pediatric resuscitation · 1 of 6
Breaths and compressions come first.
Scope
This page follows the 2025 American Heart Association and American Academy of Pediatrics guidelines (published October 22, 2025, in Circulation): Part 6, Pediatric Basic Life Support, and Part 8, Pediatric Advanced Life Support. They cover infants and children up to 18 years, excluding newborns at birth (Part 5 covers those). Respiratory problems remain the main cause of pediatric arrest, and the guidelines say breaths given with compressions improve survival. Do not run a pediatric code compressions-only.
Not a course — this is an independent summary in our own words. It is not an AHA or AAP product, is not endorsed by either, and does not replace certified AHA/AAP resuscitation training or your hospital's code cards.
Compressions by age
| Infant (under 1 year) | At least one-third of the chest's front-to-back depth, about 1.5 in (4 cm). Use the heel of one hand or two thumbs with hands encircling the chest. If you can't encircle the chest, use the heel of one hand (Class 1). The two-finger technique is gone in 2025. |
|---|---|
| Child (1 year to puberty) | At least one-third of the chest's depth, about 2 in (5 cm) (Class 2a). One or two hands. |
| Signs of puberty | Use adult BLS: at least 2 in (5 cm), and avoid more than 2.4 in (6 cm). For teaching, puberty means breast development in females or axillary hair in males. |
| Every age | Rate 100–120/min. Let the chest recoil fully. Keep pauses under 10 s (Class 1). Rhythm checks last no more than 10 s, about every 2 min. Rotate compressors every 2 min, or sooner if fatigued. Compress on a firm surface, with a backboard in hospital. |
Breaths
| No advanced airway | One rescuer, any age: 30:2. Two rescuers, before puberty: 15:2. Two rescuers, after puberty begins: 30:2. |
|---|---|
| Advanced airway in place | Continuous compressions. One breath every 2–3 s (20–30/min), adjusted for age and clinical condition (Class 2b); don't bag faster. The guideline warns that hyperventilation can compromise hemodynamics. |
| Pulse present, breathing inadequate | One breath every 2–3 s (20–30/min) (Class 2a). Start CPR if the heart rate is under 60/min with signs of poor perfusion despite oxygenation and ventilation. |
| Which airway | Out of hospital: bag-mask ventilation rather than intubation or a supraglottic airway is reasonable (Class 2a). In hospital: either is reasonable (Class 2b). Confirm and monitor any tube with ETCO2. |
BLS basic life supportALS advanced life supportETCO2 end-tidal carbon dioxideAAP American Academy of Pediatrics
Pediatric resuscitation · 2 of 6
Shock fast. Give epinephrine early.
Every arrest: the first minute
- Start CPR, give bag-mask breaths with oxygen, and attach the monitor or defibrillator.
- Get IV or IO access fast. Choose the route by availability, expertise and speed (Class 1).
- Name the rhythm: shockable (VF or pulseless VT) or nonshockable (asystole or PEA).
Shockable: VF or pulseless VT
| Shock 1 | 2 J/kg, as soon as possible. Resume compressions immediately for 2 min. Get IV or IO access. |
|---|---|
| Shock 2 | 4 J/kg. Then 2 min of CPR. Give epinephrine now, every 3–5 min after. Consider an advanced airway and capnography. |
| Shock 3 and later | 4 J/kg, rising if needed up to 10 J/kg or the adult dose, whichever is lower. Then 2 min of CPR. Give amiodarone or lidocaine. Treat reversible causes. |
| Epinephrine timing | Give it after 2 defibrillation attempts. Give it sooner only when rapid defibrillation isn't possible (Class 2b). |
| If the rhythm changes | If it becomes nonshockable, switch to the nonshockable sequence. If an organized rhythm appears, check for a pulse. |
Nonshockable: asystole or PEA
| Now | Epinephrine as soon as possible (Class 2a). The AHA links giving it early to better outcomes. |
|---|---|
| Each 2-min cycle | CPR, then a rhythm check of 10 s or less. Repeat epinephrine every 3–5 min (Class 2b). Consider an advanced airway and capnography. Work through the reversible causes. |
| If it becomes shockable | Shock and follow the shockable sequence. |
Energy and drugs in arrest (IV or IO)
| Defibrillation | First 2 J/kg (2–4 J/kg is acceptable, Class 2a). Second 4 J/kg. Later shocks 4 J/kg up to 10 J/kg or the adult dose, whichever is lower (Class 2b). The 2025 adult algorithm defines the adult dose: biphasic per the manufacturer (for example, 120–200 J for the first shock), or the maximum available if unknown. Give single shocks, not stacked ones (Class 2b). |
|---|---|
| Epinephrine | 0.01 mg/kg = 0.1 mL/kg of the 0.1 mg/mL concentration. Maximum 1 mg (10 mL). Every 3–5 min. |
| Amiodarone | 5 mg/kg bolus, maximum 300 mg. May repeat, up to 3 doses; maximum 150 mg for each later dose. For shock-refractory VF or pVT. |
| Lidocaine | 1 mg/kg. An alternative to amiodarone; the guideline backs either (Class 2b). |
| Bicarbonate, calcium | Not routine in pediatric arrest (Class 3: No Benefit). Give them only for a specific indication. |
Worked example, 15 kg — shocks at 30 J, then 60 J, rising if needed up to 150 J (10 J/kg). Epinephrine 0.15 mg (1.5 mL of 0.1 mg/mL). Amiodarone 75 mg. Lidocaine 15 mg. At 70 kg, epinephrine is still weight-based at 0.7 mg (7 mL), under the 1 mg cap. Amiodarone hits its caps: 300 mg, then 150 mg. The first shock is 140 J (2 J/kg). From the second shock on, 4 J/kg would pass the adult range, so use the adult dose: your defibrillator's recommended energy, or the maximum available if unknown. Use the pediatric code companion to calculate doses, run cycle and epinephrine timers, and keep a log you can copy.
Watching CPR work
| Arterial line | Diastolic pressure is reasonable as a guide (Class 2a). The 2025 targets are at least 25 mm Hg in infants and at least 30 mm Hg in children aged 1 year or older (Class 2b). |
|---|---|
| ETCO2 | May be used to monitor CPR quality with an advanced airway (Class 2b). Never use an ETCO2 cutoff alone to stop resuscitation (Class 3: Harm). |
| Echo | May help find treatable causes such as tamponade, if trained staff are present (Class 2b). |
| ECPR | May be considered for in-hospital arrest refractory to conventional CPR, in selected patients, where protocols and expertise exist (Class 2b). |
VF ventricular fibrillationpVT pulseless ventricular tachycardiaPEA pulseless electrical activityIO intraosseousECPR extracorporeal CPR
Pediatric resuscitation · 3 of 6
Slow heart, pulse present.
Bradycardia with a pulse
| Is there compromise? | A rate under 60/min should always prompt the check (§18). Look for an acute change in mental status, hypotension, or other signs of shock. |
|---|---|
| No compromise | Support the ABCs, consider oxygen, get a 12-lead ECG if you can, treat the cause and observe. |
| Compromise | Open the airway, give oxygen, and use positive-pressure ventilation if needed. Attach the monitor. Correct contributing factors: hypoxia, hypotension, hypoglycemia, hypothermia, acidosis and toxic ingestions (§18). |
| CPR | Start CPR if the heart rate is under 60/min with compromise despite effective ventilation with oxygen (Class 1, C-EO; §18). |
| Epinephrine | Give it IV or IO when compromise persists after other factors, such as hypoxia, are corrected (Class 1, C-EO; §18). The evidence is mixed: one retrospective propensity-matched study found worse outcomes, another found no difference with early dosing. |
| Atropine | Only when compromise comes from increased vagal tone or AV conduction block, not from hypoxia or similar factors (Class 1, C-LD; §18). |
| Pacing | For complete heart block or sinus node dysfunction that does not respond to CPR, emergency transcutaneous pacing may be considered (Class 2b, C-EO; §18). The 2025 algorithm also mentions transvenous pacing. |
| Every 2 min | Recheck the pulse. If there is no pulse, switch to the cardiac arrest sequence. |
Bradycardia doses (IV or IO)
| Epinephrine | 0.01 mg/kg (0.1 mg/mL concentration). Maximum 1 mg. |
|---|---|
| Atropine | 0.02 mg/kg. May repeat once. Minimum dose 0.1 mg; maximum single dose 0.5 mg. |
| Other causes | Increased vagal tone, heart block, raised intracranial pressure and medications. A slow rate can also be physiologic. |
Atropine floor — on April 30, 2026, the 2025 writing group co-chairs confirmed the 0.1 mg minimum for bradycardia with cardiopulmonary compromise, because no evidence shows lower doses work. When atropine is a premedication for intubation, there is no minimum.
Pediatric resuscitation · 4 of 6
Fast heart: sinus or SVT?
Telling them apart
| Probable sinus tachycardia | P waves present and normal, a variable RR interval. Rate usually under 220/min in infants or under 180/min in children. Search for the cause and treat it. Don't cardiovert it. |
|---|---|
| Probable SVT | P waves absent or abnormal, a fixed RR interval, and a history of abrupt rate change. Rate usually 220/min or more in infants, 180/min or more in children. |
| Narrow or wide | Narrow QRS is 0.09 s or less; wide QRS is more than 0.09 s. |
What to do
| Compromised, narrow | Probable SVT. If IV or IO access is already in, give adenosine (Class 1, C-LD; §19.1). Otherwise, synchronized cardioversion at 0.5–1 J/kg, then 2 J/kg if it fails (Class 2a, C-LD). |
|---|---|
| Compromised, wide | Cardiovert urgently, whether the origin looks atrial or ventricular: 0.5–1 J/kg, then 2 J/kg (Class 2a, C-EO; §19.2). Get expert input before any antiarrhythmic. |
| Stable, narrow | Vagal maneuvers first (Class 1, C-LD; §19.1). Then adenosine if IV or IO access is readily available (Class 1, C-LD). If neither works, get expert consultation (Class 1, C-EO). |
| Stable, wide | Expert consultation before any antiarrhythmic (Class 1, C-LD; §19.2). SVT with aberrancy is the most common cause of wide-complex tachycardia in children. Adenosine only if the rhythm is regular and the QRS monomorphic, together with expert input and a rhythm strip running (Class 2a, C-EO). An irregular wide rhythm may be pre-excited atrial fibrillation, and adenosine can trigger VF. |
| Adenosine | 0.1 mg/kg, maximum 6 mg, given as a rapid push with a flush. Consider a second dose of 0.2 mg/kg, maximum 12 mg. |
| Synchronized cardioversion | 0.5–1 J/kg. If it fails, increase to 2 J/kg. Sedation spares pain, but in a compromised child choose the drug and dose with great care (§19.1), and never let it hold up the shock. In an adult-sized patient, check against your device's recommended adult setting; the 2025 adult algorithm defers to device-specific energy (maximum setting if unknown). |
Refractory SVT with compromise — if vagal maneuvers, adenosine and synchronized cardioversion have all failed and no expert is available, IV procainamide, amiodarone or sotalol may be considered (Class 2b, C-LD; §19.1). The guideline gives no doses, so use your institution's dosing with pharmacy. The AHA highlights new data supporting IV sotalol.
Pediatric resuscitation · 5 of 6
After ROSC, prevent the second hit.
Post-arrest targets
| Blood pressure | Keep systolic and mean arterial pressure above the 10th percentile for age (Class 1). Use continuous arterial monitoring when you have the resources (Class 1). The guideline defines hypotension as below the 5th percentile for age and sex. It is common after ROSC. |
|---|---|
| Oxygen | Target normoxemia for the patient's condition. Wean oxygen to an SpO2 of 94–99% (Class 2b). Pulse oximeters may overestimate saturation in patients with darker skin. |
| Carbon dioxide | Target a PaCO2 right for the underlying condition and avoid both high and low values (Class 2b). The supportive text cites normocapnia, 35–45 mm Hg, or the patient's baseline if chronically hypercapnic. |
| Temperature | If comatose, monitor central temperature continuously (Class 1). Avoid central temperatures above 37.5 °C (Class 1). For comatose patients aged 24 hours to 18 years, after in- or out-of-hospital arrest, a 5-day course of TTM is reasonable (Class 2a). Use either 32–34 °C followed by 36–37.5 °C, or 36–37.5 °C throughout. |
| Brain | When resources allow, use continuous EEG to detect seizures in patients with persistent encephalopathy (Class 1). Treat clinical seizures (Class 1). Treating nonconvulsive status epilepticus is reasonable (Class 2a). |
| Prognosis | Combine several tests; a single test on its own risks predicting the neurologic outcome wrongly. Survivors often have ongoing physical, cognitive and behavioral problems, so plan follow-up before discharge. |
ROSC return of spontaneous circulationTTM targeted temperature managementEEG electroencephalographySVT supraventricular tachycardiaAV atrioventricular
Pediatric resuscitation · 6 of 6
Hunt the cause. Avoid the classic errors.
Reversible causes
| Hs | Hypovolemia · Hypoxia · Hydrogen ion (acidosis) · Hypoglycemia · Hypokalemia or hyperkalemia · Hypothermia |
|---|---|
| Ts | Tension pneumothorax · Tamponade (cardiac) · Toxins · Thrombosis (pulmonary) · Thrombosis (coronary) |
Errors that hurt children
- The tenfold epinephrine error. The IV or IO dose is 0.1 mL/kg of the 0.1 mg/mL solution. Say the concentration out loud with every dose.
- Forgetting the caps on teenagers: epinephrine 1 mg, amiodarone 300 mg then 150 mg, adenosine 6 mg then 12 mg, atropine 0.5 mg, and defibrillation no higher than 10 J/kg or the adult dose (your defibrillator's recommended energy), whichever is lower.
- Waiting to give epinephrine in asystole or PEA. Give it as soon as you have access.
- Giving epinephrine before the second shock when a defibrillator is right there. Shock first.
- Hyperventilating through the tube. One breath every 2–3 s (20–30/min); don't bag faster.
- Compressing an infant with two fingers. Use two thumbs with your hands around the chest, or the heel of one hand.
- Long pulse checks. Keep them to 10 s or less.
- Cardioverting sinus tachycardia. Find out why the child is tachycardic.
- Fever after ROSC. Keep the central temperature at or below 37.5 °C.
What changed from 2020
- Infant compressions: the two-finger technique is eliminated. Use the heel of one hand, or two thumbs with your hands encircling the chest.
- Apply an AED with a pediatric attenuator and pediatric pads as soon as possible. An attenuator is recommended under age 8 (Class 1), and a manual defibrillator is reasonable when trained staff are present (Class 2a).
- The cardiac arrest algorithm now gives 30:2 for a single rescuer of any age and for two rescuers once puberty begins (the 2020 version listed 15:2 only).
- Amiodarone caps are now printed: 300 mg for the first dose, 150 mg for later doses. The 2020 algorithm gave 5 mg/kg, up to 3 total doses, with no cap.
- The 2025 arrest and bradycardia algorithms list IV and IO dosing only; the 2020 versions also gave an endotracheal epinephrine dose.
- Diastolic blood pressure targets during CPR are new: at least 25 mm Hg in infants and at least 30 mm Hg from age 1 year.
- Post-ROSC care: avoid central temperatures above 37.5 °C (Class 1), and keep systolic and mean pressure above the 10th percentile for age, a target the AHA says new data support.
- New data support IV sotalol for refractory SVT with compromise when no expert is available.
- Choking, child: management now starts with back blows, alternating 5 back blows with 5 abdominal thrusts. Choking, infant: alternate 5 back blows with 5 chest thrusts, never abdominal thrusts.
- The 2025 bradycardia algorithm no longer prints a repeat interval for epinephrine; the 2020 version said to repeat every 3–5 min.
- Weight-based dosing was not re-reviewed in 2025, so the 2020 approach carries over.
Not covered here — equipment sizes (tube and blade sizes) and weight estimates from age or length. We couldn't confirm them in the 2025 guideline text. Use a measured weight or your hospital's approved estimation method and equipment chart.
Educational reference only — not medical advice. Verify against current AHA guidelines and local protocol.
Sources
Verify against current guidelines and local protocol before acting.
- Lasa JJ, Dhillon GS, Duff JP, et al. Part 8: Pediatric Advanced Life Support: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2025;152(16 Suppl 2):S479-S537. Published October 22, 2025. doi:10.1161/CIR.0000000000001368. PMID 41122885. Recommendation tables cited by section: §6–11 (arrest, post-ROSC), §18 (bradycardia), §19.1 (SVT), §19.2 (wide-complex tachycardia). Online: cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/pediatric-advanced-life-support.
- Joyner BL, Dewan M, Bavare A, et al. Part 6: Pediatric Basic Life Support: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2025;152(16 Suppl 2):S424-S447. doi:10.1161/CIR.0000000000001370. PMID 41122891. Online: cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/pediatric-basic-life-support.
- Part 7: Adult Basic Life Support: 2025 AHA Guidelines for CPR and ECC. Circulation 2025;152(16 Suppl 2):S448-S478. doi:10.1161/CIR.0000000000001369 (compression depth for patients with signs of puberty).
- American Heart Association. 2025 Pediatric Cardiac Arrest Algorithm, text description (Algorithm-PALS-CA-LngDscrp-250729). cpr.heart.org/-/media/CPR-Files/CPR-Guidelines-Files/2025-Accessible/Algorithm-PALS-CA-LngDscrp-250729-Ed.pdf.
- American Heart Association. 2025 Pediatric Bradycardia With a Pulse Algorithm, text description (Algorithm-PALS-Bradycardia-LngDscrp-250729). cpr.heart.org/-/media/CPR-Files/CPR-Guidelines-Files/2025-Accessible/Algorithm-PALS-Bradycardia-LngDscrp-250729-Ed.pdf.
- American Heart Association. 2025 Pediatric Tachyarrhythmia With a Pulse Algorithm, text description (Algorithm-PALS-Tachyarrhythmia-LngDscrp-250729). cpr.heart.org/-/media/CPR-Files/CPR-Guidelines-Files/2025-Accessible/Algorithm-PALS-Tachyarrhythmia-LngDscrp-250729-Ed.pdf.
- American Heart Association. 2025 Adult Cardiac Arrest Algorithm and Adult Tachyarrhythmia With a Pulse Algorithm, text descriptions (Algorithm-ACLS-CA-LngDscrp-250725; Algorithm-ACLS-Tachyarrhythmia-LngDscrp-250726). cpr.heart.org (adult defibrillation and cardioversion energy).
- American Heart Association. 2025 Pediatric BLS Algorithm for 2 or More Rescuers, text description (Algorithm-BLS-Ped-2-Rescuers-LngDscrp-250618). cpr.heart.org.
- Lasa JJ, Topjian A, on behalf of the PALS Writing Group. Writing Group response to a letter on atropine dosing in the 2025 PALS guidelines. Posted April 30, 2026. professional.heart.org.
- American Heart Association. 2020 Pediatric Cardiac Arrest, Bradycardia and Tachycardia Algorithms, text descriptions (200702, 200708). cpr.heart.org (used only to identify 2020-to-2025 changes).