Written by Joshua Belfer
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The 2025 AHA/AAP Pediatric Advanced Life Support Guidelines refine several core elements of pediatric resuscitation, including shock dosing, airway management, rhythm identification, and post-ROSC care. The updates emphasize physiologic ventilation, minimizing interruption, using ECPR in select cases, and clearer termination guidance, all aimed at improving survival and neurologic outcomes.
Walking through the major updates
The 2025 Pediatric ALS update builds on the BLS changes, but shifts the focus toward high-acuity, high-complexity decision-making during resuscitation. Pediatric cardiac arrest remains primarily respiratory in origin, but once a child progresses to pulselessness, high-quality ALS significantly affects survival.
Major Updates:
- Airway Management and Ventilation
- Stronger emphasis on avoiding hyperventilation
- Reinforcement that advanced airways should not delay other interventions—high-quality bag-valve-mask ventilation is effective.
- Epinephrine Timing
- For nonshockable rhythms, early epinephrine as soon as possible is associated with favorable outcomes.
- Defibrillation Strategy
- For shockable rhythms, rapid defibrillation remains the priority.
- It is recommended to administer epinephrine if defibrillation is not immediately possible.
- For ease of teaching, an initial shock of 2 J/kg is reasonable.
- ECPR
- ECPR can be considered in select patients in clinical settings with established institutional protocols and expertise.
- Post-Cardiac Arrest Care
- Avoid hyperthermia >37.5°C to improve neurologic outcomes for children who remain comatose following cardiac arrest.
- Maintain systolic and mean arterial BP greater than the 10th percentile for age.
- When available, continuous EEG monitoring is recommended post-arrest.
- Prognosis
- Multiple modalities at various timepoints should be used to help with neuroprognostication following cardiac arrest.
- Cardiac arrest survivors often have ongoing physical, cognitive, and behavioral challenges.
How will this change my practice?
PALS scenarios are infrequent but demand immediate coordination and precision. These updates give structure to several areas that may feel ambiguous. The explicit reaffirmation that BVM ventilation remains adequate and appropriate for most pediatric arrests helps to reduce sometimes unnecessary airway escalation during chaotic moments. Use advanced airways when you are in a good spot to do so, but don’t stress if you are maintaining effective BVM ventilation. The guidelines reinforce the first steps in nonshockable (epi) and shockable (defibrillate) rhythms; always good to incorporate these principles in any mock codes you run. We focus (appropriately) so much on cardiac arrest care, but this guideline gives a good refresher on post-ROSC goals, including temperature and blood pressure considerations.
Similar to the recent 2025 BLS Guidelines, use these updates as a learning and teaching tool to support a more disciplined, coordinated, and evidence-based ALS approach. As the saying goes, staying ready means you never have to get ready.
Source
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 Oct 21;152(16_suppl_2):S479-S537. doi: 10.1161/CIR.0000000000001368. Epub 2025 Oct 22. PMID: 41122885.
