* Approved by CPG Committee; PIC endorsement pending

See also

ANZCOR Guidelines: Paediatric Advanced Life Support 

APLS: Advanced Paediatric Life Support Algorithm 

Resuscitation: care of the seriously unwell child 

Recognition of the seriously unwell neonate and young infant

These guidelines are point of care guidelines that aligns with ANZCOR and APLS guidelines.

APLS Paediatric Advanced Life Support Algorithm

Key points

1. Cardiopulmonary resuscitation (CPR) should be commenced in an infant or child who is unresponsive and not breathing normally, pulse check should not delay commencement of CPR
2. Optimal resuscitation relies on good team coordination, communication, and early allocation of roles
3. Ongoing management should be directed by the cardiac rhythm identified
4. Early consideration of ECPR/ECMO: contact appropriate services as per local procedures

Background

• Most arrests in children are due to hypoxia or hypotension
• Most common initial arrest rhythms in children are non-shockable: severe bradycardia, asystole, and pulseless electrical activity (PEA)
• Shockable rhythms: ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT), are approximately 15% of initial arrest rhythms
• Cardiac arrest following major trauma (traumatic cardiac arrest) is a unique situation which is outside the scope of this guideline ANZCOR Traumatic Cardiac Arrest

Assessment and management

• Assess environment for danger, ensuring staff and observer safety
• Assess for signs of life or response
• Send for help early: activate hospital emergency response team and consider early contact with local paediatric retrieval service
• Resuscitation includes assessment and prompt management in parallel

Early allocation of roles can optimise resuscitation (if personnel available):

• team leader
• airway nurse and doctor
• circulation nurse and doctor
• cardiac compression personnel
• defibrillator operator
• scribe + timekeeper with stopwatch
• staff member dedicated to family support

Assess for signs of life or response; if absent commence CPR

A - Airway

Optimise head position - infant: neutral position, child: sniffing position

Open the airway - head-tilt, chin-lift or jaw thrust

Suction secretions/blood/vomit under direct vision

Consider oro/nasopharyngeal airway for upper airway obstruction

B - Breathing

Look, listen and feel

If the child is not breathing, provide two initial breaths via bag valve mask (BVM) using 100% oxygen, and continue BVM ventilation as needed

Use 2-person technique as standard (if enough personnel)

Intubate if necessary (should be performed by proficient personnel and should not delay other resuscitation efforts, see Emergency airway management)

If intubated, continuous wave-form end-tidal CO₂ monitoring should be used to:

• ensure adequacy of ventilation
• identify non-tracheal intubation
• warn of accidental extubation during CPR
• monitor for return of spontaneous circulation

C - Circulation

Check for signs of circulation - normal breathing, movement, coughing

If absent, start chest compressions

• Checking for a central pulse (brachial, femoral, carotid) is difficult and unreliable as a sole marker for commencing compressions
• Do not delay compressions if a central pulse cannot be palpated in less than 10 seconds
• If no pulse, slow pulse (<60 in an infant) or unsure, continue CPR and start chest compressions

Apply defibrillation pads and determine the cardiac rhythm as soon as possible: shockable or non-shockable (see Advanced Life Support flow chart below)

Gain IV access: intraosseous access is recommended if peripheral or central IV access is not already in place

Algorithm

Advanced Paediatric Life Support: The Practical Approach 7th Edition, published 2024

Techniques

All images below courtesy of Children's Health Queensland, licensed under CC BY-NC

Airway opening manoeuvres

Chest compressions

• Rate for all ages 100-120 bpm
• CPR ratio 15 compressions:2 breaths
• If the child is intubated, compressions continue at rate 100-120 and breaths at rate of 10
• Place child on a firm surface. If on a bed, place cardiac compression board under child
• Perform chest compressions to lower half of sternum, compress by 1/3 of the AP diameter of the chest
• Infants:
  • The recommended technique is a two-handed hold in which both thumbs compress the sternum
  • The two-finger technique may be preferred by a single rescuer to minimise transition time between breaths and compressions.
• Children:
  • Chest compressions can be performed using the heel of one hand
  • Two-handed technique can also be used

DO NOT interrupt CPR except for rhythm check or defibrillation

Frequent changes of cardiac compression personnel (every 2 minutes) is desirable to avoid inadequate compressions due to fatigue

Defibrillator operator instructions

Minimise interruptions to CPR by charging whist chest compressions continue

DC shocks for VF and pulseless VT should be delivered asynchronously at a dose of 4 J/kg (round up)

Manual defibrillators are preferred in infants and children. Standard AEDs can be used for children >8 years. For children <8 years, the order of preference is:

• Manual defibrillator
• AED with paediatric attenuation
• Standard AED 

Take care to ensure no one is touching the child at the time of delivering shock

For rhythm checks, consider the "COACHED" mnemonic:

• Compressions continue
• Oxygen away
• All else clear
• Charging
• Hands off (compressor stands clear and responds "I'm safe")
• Evaluating rhythm
• Defibrillate or Disarm

If DC shock delivered, recommence CPR immediately for 2 minutes prior to rhythm check

During resuscitation

Address reversible causes: 4 Hs and 4 Ts

• Hypoxaemia
• Hypovolaemia
• Hypo/hyperthermia
• Hypo/hyperkalaemia
• Tension pneumothorax
• Tamponade
• Toxins
• Thrombosis

Medications and fluids

Emergency drug dose calculator 

Monash Children's Hospital Paediatric Emergency Medication Book 

NETS Clinical Calculator

Primary resuscitation drugs are:

• Adrenaline (1:10,000) 10 microg/kg = 0.1 mL/kg IV/IM/intraosseous (max 1 mg)
• Amiodarone 5 mg/kg IV/intraosseous (max 300 mg) -- deliver as a rapid bolus with 5% glucose

Correct hypovolaemia:  

• IV/IO crystalloid bolus of 10-20 mL/kg
• Additional bolus should be titrated to response

Correct hypoglycaemia:

• Aim for normoglycaemia
• IV/IO 10% glucose 2 mL/kg

Atropine, lidocaine, sodium bicarbonate and calcium are not routinely used and should only be considered in specific situations

Special circumstances

Specific conditions require a specific approach to cardiopulmonary resuscitation, such as

• Trauma (ANZCOR Traumatic cardiac arrest)
• Cardiac surgery
• Drowning
• Sepsis
• Pulmonary hypertension
• Toxins (National Poisons Centre 13 11 26)

Extracorporeal cardiopulmonary resuscitation (ECPR)

ECPR is a procedure offered by specialised paediatric intensive care centres in Australia

This should be considered early, within a short period of cardiopulmonary arrest and urgently discussed with appropriate local retrieval or onsite services, see Retrieval services

Cessation of CPR

The decision to cease CPR in children is difficult and must involve experienced senior clinicians, consider the clinical context, and occur in discussion with the child's family

Post resuscitation care - following return of spontaneous circulation

Children resuscitated from a cardiorespiratory arrest should be admitted to PICU

Ongoing reevaluation of ABCD

Perform 12 lead ECG and monitor for arrhythmias

Clinical targets of post-resuscitation care:

Family Support

Family members of children undergoing CPR should be offered to be present, ideally with an assigned support person. Most hospitals have a family presence policy and staff education strategy in place

Staff Support

Regardless of the outcome, resuscitation is stressful and can be psychologically traumatic for team members providing care. Debriefing and support should be offered to all involved staff who wish to attend both immediately post resuscitation and ongoing as required.

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval services

Last updated December 2025