Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

HomeCirculationVol. 142, No. 16_suppl_2Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessReview ArticlePDF/EPUBPart 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Alexis A. Topjian, MD, MSCE, Chair, Tia T. Raymond, MD, Vice-Chair, 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 D. Meckler, MD, MSHS, Kathryn E. Roberts, MSN, RN, Robert M. Sutton, MD, MSCE and Stephen M. Schexnayder, MD Alexis A. TopjianAlexis A. Topjian Search for more papers by this author , Tia T. RaymondTia T. Raymond Search for more papers by this author , Dianne AtkinsDianne Atkins Search for more papers by this author , Melissa ChanMelissa Chan Search for more papers by this author , Jonathan P. DuffJonathan P. Duff Search for more papers by this author , Benny L. Joyner JrBenny L. Joyner Jr Search for more papers by this author , Javier J. LasaJavier J. Lasa Search for more papers by this author , Eric J. LavonasEric J. Lavonas Search for more papers by this author , Arielle LevyArielle Levy Search for more papers by this author , Melissa MahgoubMelissa Mahgoub Search for more papers by this author , Garth D. MecklerGarth D. Meckler Search for more papers by this author , Kathryn E. RobertsKathryn E. Roberts Search for more papers by this author , Robert M. SuttonRobert M. Sutton Search for more papers by this author and Stephen M. SchexnayderStephen M. Schexnayder Search for more papers by this author and On behalf of the Pediatric Basic and Advanced Life Support Collaborators Originally published21 Oct 2020https://doi.org/10.1161/CIR.0000000000000901Circulation. 2020;142:S469–S523Top 10 Take-Home MessagesHigh-quality cardiopulmonary resuscitation (CPR) is the foundation of resuscitation. New data reaffirm the key components of high-quality CPR: providing adequate chest compression rate and depth, minimizing interruptions in CPR, allowing full chest recoil between compressions, and avoiding excessive ventilation.A respiratory rate of 20 to 30 breaths per minute is new for infants and children who are (a) receiving CPR with an advanced airway in place or (b) receiving rescue breathing and have a pulse.For patients with nonshockable rhythms, the earlier epinephrine is administered after CPR initiation, the more likely the patient is to survive.Using a cuffed endotracheal tube decreases the need for endotracheal tube changes.The routine use of cricoid pressure does not reduce the risk of regurgitation during bag-mask ventilation and may impede intubation success.For out-of-hospital cardiac arrest, bag-mask ventilation results in the same resuscitation outcomes as advanced airway interventions such as endotracheal intubation.Resuscitation does not end with return of spontaneous circulation (ROSC). Excellent post–cardiac arrest care is critically important to achieving the best patient outcomes. For children who do not regain consciousness after ROSC, this care includes targeted temperature management and continuous electroencephalography monitoring. The prevention and/or treatment of hypotension, hyperoxia or hypoxia, and hypercapnia or hypocapnia is important.After discharge from the hospital, cardiac arrest survivors can have physical, cognitive, and emotional challenges and may need ongoing therapies and interventions.Naloxone can reverse respiratory arrest due to opioid overdose, but there is no evidence that it benefits patients in cardiac arrest.Fluid resuscitation in sepsis is based on patient response and requires frequent reassessment. Balanced crystalloid, unbalanced crystalloid, and colloid fluids are all acceptable for sepsis resuscitation. Epinephrine or norepinephrine infusions are used for fluid-refractory septic shock.PreambleMore than 20 000 infants and children have a cardiac arrest per year in the United States.1–4 In 2015, emergency medical service–documented out-of-hospital cardiac arrest (OHCA) occurred in more than 7000 infants and children.4 Approximately 11.4% of pediatric OHCA patients survived to hospital discharge, but outcomes varied by age, with survival rates of 17.1% in adolescents, 13.2% in children, and 4.9% in infants. In the same year, pediatric in-hospital cardiac arrest (IHCA) incidence was 12.66 events per 1000 infant and child hospital admissions, with an overall survival to hospital discharge rate of 41.1%.4 Neurological outcomes remain difficult to assess across the pediatric age spectrum, with variability in reporting metrics and time to follow-up across studies of both OHCA and IHCA. Favorable neurological outcome has been reported in up to 47% of survivors to discharge.5 Despite increases in survival from IHCA, there is more to be done to improve both survival and neurological outcomes.6The International Liaison Committee on Resuscitation (ILCOR) Formula for Survival emphasizes 3 essential components for good resuscitation outcomes: guidelines based on sound resuscitation science, effective education of the lay public and resuscitation providers, and implementation of a well-functioning Chain of Survival.7These guidelines contain recommendations for pediatric basic and advanced life support, excluding the newborn period, and are based on the best available resuscitation science. The Chain of Survival (Section 2), which is now expanded to include recovery from cardiac arrest, requires coordinated efforts from medical professionals in a variety of disciplines and, in the case of OHCA, from bystanders, emergency dispatchers, and first responders. In addition, specific recommendations about the training of resuscitation providers are provided in Part 6: Resuscitation Education Science, and recommendations about systems of care are provided in Part 7.IntroductionScope of GuidelinesThese guidelines are intended to be a resource for lay rescuers and healthcare providers to identify and treat infants and children in the prearrest, intra-arrest, and postarrest states. These apply to infants and children in multiple settings; the community, prehospital, and the hospital environment. Prearrest, intra-arrest, and postarrest topics are reviewed, including cardiac arrest in special circumstances, such as in patients with congenital heart disease.For the purposes of the pediatric advanced life support guidelines, pediatric patients are infants, children, and adolescents up to 18 years of age, excluding newborns. For pediatric basic life support (BLS), guidelines apply as follows:Infant guidelines apply to infants younger than approximately 1 year of age.Child guidelines apply to children approximately 1 year of age until puberty. For teaching purposes, puberty is defined as breast development in females and the presence of axillary hair in males.For those with signs of puberty and beyond, adult basic life support guidelines should be followed.Resuscitation of the neonate is addressed in “Part 5: Neonatal Resuscitation” and applies to the newborn typically only during the first hospitalization following birth. Pediatric basic and advanced life support guidelines apply to neonates (less than 30 days old) after hospital discharge.Coronavirus Disease 2019 GuidanceTogether with other professional societies, the American Heart Association (AHA) has provided interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed coronavirus disease 2019 (COVID-19). Because evidence and guidance are evolving with the COVID-19 situation, this interim guidance is maintained separately from the emergency cardiovascular care (ECC) guidelines. Readers are directed to the AHA website for the most recent guidance.8Organization of the Pediatric Writing CommitteeThe Pediatric Writing Group consisted of pediatric clinicians including intensivists, cardiac intensivists, cardiologists, emergency medicine physicians, medical toxicologists, and nurses. Volunteers with recognized expertise in resuscitation are nominated by the writing group chair and selected by the AHA ECC Committee. The AHA has rigorous conflict of interest policies and procedures to minimize the risk of bias or improper influence during development of the guidelines.9 Prior to appointment, writing group members and peer reviewers disclosed all commercial relationships and other potential (including intellectual) conflicts. Writing group members whose research led to changes in guidelines were required to declare those conflicts during discussions and abstain from voting on those specific recommendations. This process is described more fully in “Part 2: Evidence Evaluation and Guidelines Development.” Disclosure information for writing group members is listed in Appendix 1.Methodology and Evidence ReviewThese pediatric guidelines are based on the extensive evidence evaluation performed in conjunction with the ILCOR and affiliated ILCOR member councils. Three different types of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2020 process.10,11 After review by the ILCOR Science Advisory Committee Chair, the evidence update worksheets were included in Appendix C of the 2020 ILCOR Consensus on CPR and ECC Science With Treatment Recommendations.11a Each of these resulted in a description of the literature that facilitated guideline development. This process is described more fully in “Part 2: Evidence Evaluation and Guidelines Development.”12Class of Recommendation and Level of EvidenceThe writing group reviewed all relevant and current AHA Guidelines for Cardiopulmonary Resuscitation (CPR) and ECC and all relevant 2020 ILCOR Consensus on CPR and ECC Science With Treatment Recommendations evidence and recommendations to determine if current guidelines should be reaffirmed, revised, or retired or if new recommendations were needed. The writing group then drafted, reviewed, and approved recommendations, assigning to each a Class of Recommendation (COR; ie, strength) and Level of Evidence (LOE; ie, quality, certainty). Criteria for each COR and LOE are described in Table 1.Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*This table defines the Classes of Recommendation (COR) and Levels of Evidence (LOE). COR indicates the strength the writing group assigns the recommendation, and the LOE is assigned based on the quality of the scientific evidence. The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information).Classes of RecommendationCOR designations include Class 1, a strong recommendation for which the potential benefit greatly outweighs the risk; Class 2a, a moderate recommendation for which benefit most likely outweighs the risk; Class 2b, a weak recommendation for which it’s unknown whether benefit will outweigh the risk; Class 3: No Benefit, a moderate recommendation signifying that there is equal likelihood of benefit and risk; and Class 3: Harm, a strong recommendation for which the risk outweighs the potential benefit.Suggested phrases for writing Class 1 recommendations includeIs recommendedIs indicated/useful/effective/beneficialShould be performed/administered/otherComparative-effectiveness phrases include treatment/strategy A is recommended/indicated in preference to treatment B, and treatment A should be chosen over treatment B.Suggested phrases for writing Class 2a recommendations includeIs reasonableCan be useful/effective/beneficialComparative-effectiveness phrases include treatment/strategy A is probably recommended/indicated in preference to treatment B, and it is reasonable to choose treatment A over treatment B.For comparative-effectiveness recommendations (COR 1 and 2a; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.Suggested phrases for writing Class 2b recommendations includeMay/might be reasonableMay/might be consideredUsefulness/effectiveness is unknown/unclear/uncertain or not well-establishedSuggested phrases for writing Class 3: No Benefit recommendations (generally, LOE A or B use only) includeIs not recommendedIs not indicated/useful/effective/beneficialShould not be performed/administered/otherSuggested phrases for writing Class 3: Harm recommendations includePotentially harmfulCauses harmAssociated with excess morbidity/mortalityShould not be performed/administered/otherLevels of EvidenceFor LOEs, the method of assessing quality is evolving, including the application of standardized, widely-used, and preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee. LOE designations include Level A, Level B-R, Level B-NR, Level C-LD, and Level C-EO.Those categorized as Level A are derived fromHigh-quality evidence from more than 1 randomized clinical trial, or RCTMeta-analyses of high-quality RCTsOne or more RCTs corroborated by high-quality registry studiesThose categorized as Level B-R (randomized) are derived fromModerate-quality evidence from 1 or more RCTsMeta-analyses of moderate-quality RCTsThose categorized as Level B-NR (nonrandomized) are derived fromModerate-quality evidence from 1 or more well-designed, well-executed nonrandomized studies, observational studies, or registry studiesMeta-analyses of such studiesThose categorized as Level C-LD (limited data) are derived fromRandomized or nonrandomized observational or registry studies with limitations of design or executionMeta-analyses of such studiesPhysiological or mechanistic studies in human subjectsThose categorized as Level C-EO (expert opinion) are derived fromConsensus of expert opinion based on clinical experienceCOR and LOE are determined independently (any COR may be paired with any LOE).A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*Guideline StructureThe 2020 Guidelines are organized in discrete modules of information on specific topics or management issues.13 Each modular “knowledge chunk” includes a table of recommendations using standard AHA nomenclature of COR and LOE. Recommendations are presented in order of COR: most potential benefit (Class 1), followed by lesser certainty of benefit (Class 2), and finally potential for harm or no benefit (Class 3). Following the COR, recommendations are ordered by the certainty of supporting LOE: Level A (high-quality randomized controlled trials) to Level C-EO (expert opinion). This order does not reflect the order in which care should be provided.A brief introduction or short synopsis is provided to contextualize the recommendations with important background information and overarching management or treatment concepts. Recommendation-specific supportive text clarifies the rationale and key study data supporting the recommendations. When appropriate, flow diagrams or additional tables are included. Hyperlinked references are provided to facilitate quick access and review.Document Review and ApprovalThe guideline was submitted for blinded peer review to 5 subject matter experts nominated by the AHA. Peer reviewer feedback was provided for guidelines in draft format and again in final format. The guideline was also reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and AHA Executive Committee. Disclosure information for peer reviewers is listed in Appendix 2.AbbreviationsAbbreviationMeaning/PhraseACLSadvanced cardiovascular life supportAEDautomated external defibrillatorALSadvanced life supportAHAAmerican Heart AssociationBLSbasic life supportCOIconflict of interestCORClass of RecommendationCPRcardiopulmonary resuscitationECCemergency cardiovascular careECLSextracorporeal life supportECMOextracorporeal membrane oxygenationECPRextracorporeal cardiopulmonary resuscitationEOExpert OpinionETIendotracheal intubationFBAOforeign body airway obstructionIHCAin-hospital cardiac arrestILCORInternational Liaison Committee on ResuscitationLDlimited dataLOELevel of EvidenceMCSmechanical circulatory supportNRnonrandomizedOHCAout-of-hospital cardiac arrestPALSpediatric advanced life supportPICOpopulation, intervention, comparator, outcomepVTpulseless ventricular tachycardiaRCTrandomized clinical trialROSCreturn of spontaneous circulationSGAsupraglottic airwayTTMtargeted temperature managementVFventricular fibrillationReferences1. Holmberg MJ, Ross CE, Fitzmaurice GM, Chan PS, Duval-Arnould J, Grossestreuer AV, Yankama T, Donnino MW, Andersen LW; American Heart Association’s Get With The Guidelines–Resuscitation Investigators. Annual Incidence of Adult and Pediatric In-Hospital Cardiac Arrest in the United States.Circ Cardiovasc Qual Outcomes. 2019; 12:e005580.LinkGoogle Scholar2. Atkins DL, Everson-Stewart S, Sears GK, Daya M, Osmond MH, Warden CR, Berg RA; Resuscitation Outcomes Consortium Investigators. Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest.Circulation. 2009; 119:1484–1491. doi: 10.1161/CIRCULATIONAHA.108.802678LinkGoogle Scholar3. Knudson JD, Neish SR, Cabrera AG, Lowry AW, Shamszad P, Morales DL, Graves DE, Williams EA, Rossano JW. Prevalence and outcomes of pediatric in-hospital cardiopulmonary resuscitation in the United States: an analysis of the Kids’ Inpatient Database*.Crit Care Med. 2012; 40:2940–2944. doi: 10.1097/CCM.0b013e31825feb3fCrossrefMedlineGoogle Scholar4. Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Delling FN, et al.; on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2020 update: a report from the American Heart Association.Circulation. 2020; 141:e139–e596. doi: 10.1161/CIR.0000000000000757LinkGoogle Scholar5. Matos RI, Watson RS, Nadkarni VM, Huang HH, Berg RA, Meaney PA, Carroll CL, Berens RJ, Praestgaard A, Weissfeld L, Spinella PC; American Heart Association’s Get With The Guidelines–Resuscitation (Formerly the National Registry of Cardiopulmonary Resuscitation) Investigators. Duration of cardiopulmonary resuscitation and illness category impact survival and neurologic outcomes for in-hospital pediatric cardiac arrests.Circulation. 2013; 127:442–451. doi: 10.1161/CIRCULATIONAHA.112.125625LinkGoogle Scholar6. Girotra S, Spertus JA, Li Y, Berg RA, Nadkarni VM, Chan PS; American Heart Association Get With the Guidelines–Resuscitation Investigators. Survival trends in pediatric in-hospital cardiac arrests: an analysis from Get With the Guidelines-Resuscitation.Circ Cardiovasc Qual Outcomes. 2013; 6:42–49. doi: 10.1161/CIRCOUTCOMES.112.967968LinkGoogle Scholar7. Søreide E, Morrison L, Hillman K, Monsieurs K, Sunde K, Zideman D, Eisenberg M, Sterz F, Nadkarni VM, Soar J, Nolan JP; Utstein Formula for Survival Collaborators. The formula for survival in resuscitation.Resuscitation. 2013; 84:1487–1493. doi: 10.1016/j.resuscitation.2013.07.020CrossrefMedlineGoogle Scholar8. American Heart Association. CPR & ECC.https://cpr.heart.org/. Accessed June 19, 2020.Google Scholar9. American Heart Association. Conflict of interest policy.https://www.heart.org/en/about-us/statements-and-policies/conflict-of-interest-policy. Accessed December 31, 2019.Google Scholar10. International Liaison Committee on Resuscitation (ILCOR). Continuous evidence evaluation guidance and templates: 2020 evidence update process final.https://www.ilcor.org/documents/continuous-evidence-evaluation-guidance-and-templates. Accessed December 31, 2019.Google Scholar11. Institute of Medicine (US) Committee of Standards for Systematic Reviews of Comparative Effectiveness Research. Finding What Works in Health Care: Standards for Systematic Reviews. Eden J, Levit L, Berg A, Morton S, eds. Washington, DC: The National Academies Press; 2011.Google Scholar11a. Maconochie IK, Aickin R, Hazinski MF, Atkins DL, Bingham R, Couto TB, Guerguerian A-M, Nadkarni VM, Ng K-C, Nuthall GA, et al.; on behalf of the Pediatric Life Support Collaborators. Pediatric life support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.Circulation. 2020; 142(suppl 1):S140–S184. doi: 10.1161/CIR.0000000000000894LinkGoogle Scholar12. Magid DJ, Aziz K, Cheng A, Hazinski MF, Hoover AV, Mahgoub M, Panchal AR, Sasson C, Topjian AA, Rodriguez AJ, et al.. Part 2: evidence evaluation and guidelines development: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.Circulation. 2020; 142(suppl 2):S358–S365. doi: 10.1161/CIR.0000000000000898LinkGoogle Scholar13. Levine GN, O’Gara PT, Beckman JA, Al-Khatib SM, Birtcher KK, Cigarroa JE, de Las Fuentes L, Deswal A, Fleisher LA, Gentile F, Goldberger ZD, Hlatky MA, Joglar JA, Piano MR, Wijeysundera DN. Recent Innovations, Modifications, and Evolution of ACC/AHA Clinical Practice Guidelines: An Update for Our Constituencies: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Circulation. 2019; 139:e879–e886. doi: 10.1161/CIR.0000000000000651LinkGoogle ScholarMajor ConceptsThe epidemiology, pathophysiology, and common etiologies of pediatric cardiac arrest are distinct from adult and neonatal cardiac arrest. Cardiac arrest in infants and children does not usually result from a primary cardiac cause; rather, it is the end result of progressive respiratory failure or shock. In these patients, cardiac arrest is preceded by a variable period of deterioration, which eventually results in cardiopulmonary failure, bradycardia, and cardiac arrest. In children with congenital heart disease, cardiac arrest is often due to a primary cardiac cause, although the etiology is distinct from adults.Outcomes for pediatric IHCA have improved over the past 20 years, in part because of early recognition, high-quality CPR, postarrest care, and extracorporeal cardiopulmonary resuscitation (ECPR).1,2 In a recent analysis of the Get With The Guidelines Resuscitation Registry, a large multicenter, hospital-based cardiac arrest registry, pediatric cardiac arrest survival to hospital discharge was 19% in 2000 and 38% in 2018.2 Survival has increased on average by 0.67% per year, though that increase has plateaued since 2010.2 New directions of research and therapy may be required to improve cardiac arrest survival. More cardiac arrest events now occur in an intensive care unit (ICU) setting, suggesting that patients at risk for cardiac arrest are being identified sooner and transferred to a higher level of care.3Survival rates from OHCA remain less encouraging. In a recent analysis of the Resuscitation Outcomes Consortium Epidemiological Registry, a multicenter OHCA registry, annual survival to hospital discharge of pediatric OHCA between 2007 and 2012 ranged from 6.7% to 10.2% depending on region and patient age.4 There was no significant change in these rates over time, consistent with other national registries from Japan and from Australia and New Zealand.5,6 In the Resuscitation Outcomes Consortium Epidemiological Registry, survival of OHCA was higher in regions with more arrests that were witnessed by emergency medical services and with higher bystander CPR rates, stressing the importance of early recognition and treatment of these patients.4As survival rates from pediatric cardiac arrest increase, there has been a shift with more focus on neurodevelopmental, physical, and emotional outcomes of survivors. Recent studies demonstrate that a quarter of patients with favorable outcomes have global cognitive impairment and that 85% of older children who were reported to have favorable outcomes have selective neuropsychological deficits.7The Pediatric Chain of SurvivalHistorically, cardiac arrest care has largely focused on the management of the cardiac arrest itself, highlighting high-quality CPR, early defibrillation, and effective teamwork. However, there are aspects of prearrest and postarrest care that are critical to improve outcomes. As pediatric cardiac arrest survival rates have plateaued, the prevention of cardiac arrest becomes even more important. In the out-of-hospital environment, this includes safety initiatives (eg, bike helmet laws), sudden infant death syndrome prevention, lay rescuer CPR training, and early access to emergency care. When OHCA occurs, early bystander CPR is critical in improving outcomes. In the in-hospital environment, cardiac arrest prevention includes early recognition and treatment of patients at risk for cardiac arrest such as neonates undergoing cardiac surgical procedures, patients presenting with acute fulminant myocarditis, acute decompensated heart failure, or pulmonary hypertension.Following resuscitation from cardiac arrest, management of the post–cardiac arrest syndrome (which may include brain dysfunction, myocardial dysfunction with low cardiac output, and ischemia or reperfusion injury) is important to avoid known contributors to secondary injury, such as hypotension.8,9 Accurate neuroprognostication is important to guide caregiver discussions and decision-making. Finally, given the high risk of neurodevelopmental impairment in cardiac arrest survivors, early referral for rehabilitation assessment and intervention is key.To highlight these different aspects of cardiac arrest management, the Pediatric Chain of Survival has been updated (Figure 1). A separate OHCA Chain of Survival has been created to distinguish the differences between OHCA and IHCA. In both the OHCA and IHCA chains, a sixth link has been added to stress the importance of recovery, which focuses on short- and long-term treatment evaluation, and support for survivors and their families. For both chains of survival, activating the emergency response is followed immediately by the initiation of high-quality CPR. If help is nearby or a cell phone is available, activating the emergency response and starting CPR can be nearly simultaneous. However, in the out-of-hospital setting, a single rescuer who does not have access to a cell phone should begin CPR (compressions-airway-breathing) for infants and children before calling for help because respiratory arrest is the most common cause of cardiac arrest and help may not be nearby. In the event of sudden witnessed collapse, rescuers should use an available automatic external defibrillator (AED), because early defibrillation can be lifesaving.Download figureDownload PowerPointFigure 1. Pediatric Chains of Survival for in-hospital (top) and out-of-hospital (bottom) cardiac arrest. CPR indicates cardiopulmonary resuscitation.References1. Girotra S, Spertus JA, Li Y, Berg RA, Nadkarni VM, Chan PS; American Heart Association Get With the Guidelines–Resuscitation Investigators. Survival trends in pediatric in-hospital cardiac arrests: an analysis from Get With the Guidelines-Resuscitation.Circ Cardiovasc Qual Outcomes. 2013; 6:42–49. doi: 10.1161/CIRCOUTCOMES.112.967968LinkGoogle Scholar2. Holmberg MJ, Wiberg S, Ross CE, Kleinman M, Hoeyer-Nielsen AK, Donnino MW, Andersen LW. Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States.Circulation. 2019; 140:1398–1408. doi: 10.1161/CIRCULATIONAHA.119.041667LinkGoogle Scholar3. Berg RA, Sutton RM, Holubkov R, Nicholson CE, Dean JM, Harrison R, Heidemann S, Meert K, Newth C, Moler F, Pollack M, Dalton H, Doctor A, Wessel D, Berger J, Shanley T, Carcillo J, Nadkarni VM; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network and for the American Heart Association’s Get With the Guidelines-Resuscitation (formerly the National Registry of Cardiopulmonary Resuscitation) Investigators. Ratio of PICU versus ward cardiopulmonary resuscitation events is increasing.Crit Care Med. 2013; 41:2292–2297. doi: 10.1097/CCM.0b013e31828cf0c0CrossrefMedlineGoogle Scholar4. Fink EL, Prince DK, Kaltman JR, Atkins DL, Austin M, Warden C, Hutchison J, Daya M, Goldberg S, Herren H, Tijssen JA, Christenson J, Vaillancourt C, Miller R, Schmicker RH, Callaway CW; Resuscitation Outcomes Consortium. Unchanged pediatric out-of-hospital cardiac arrest incidence and survival rates with regional variation in North America.Resuscitation. 2016; 107:121–128. doi: 10.1016/j.resuscitation.2016.07.244CrossrefMedlineGoogle Scholar5. Kitamura T, Iwami T, Kawamura T, Nitta M, Nagao K, Nonogi H, Yonemoto N, Kimura T; Japanese Circulation Society Resuscitation Science Study Group. Nationwide improvements in survival from out-of-hospital cardiac arrest in Japan.Circulation. 2012; 126:2834–2843. doi: 10.1161/CIRCULATIONAHA.112.109496LinkGoogle Scholar6. Straney LD, Sch