PALS Provider: Course

High-Quality CPR for Infants and Children (PALS Guidelines)

High-quality cardiopulmonary resuscitation (CPR) is the single most effective intervention for pediatric cardiac arrest. Unlike adults, where cardiac causes dominate, pediatric arrests are usually respiratory in origin, making early, effective CPR critical for survival.

Key Goals of High-Quality CPR

  • Maximize perfusion to vital organs (brain, heart).
  • Optimize chest compressions and ventilation.
  • Minimize interruptions for continuous circulation.
  • Ensure rapid defibrillation for shockable rhythms (VF/pVT).

1. Basic Principles of High-Quality CPR

  • Start CPR immediately when a child is unresponsive, not breathing, and has no pulse (or HR <60 bpm with poor perfusion).
  • Push hard, push fast, allow full recoil.
  • Minimize interruptions—compressions should be continuous whenever possible.
  • Avoid over-ventilation—hyperventilation can worsen outcomes.

2. Compression Technique & Depth

Age Group Compression Depth Compression Technique Hand Placement
Infants (<1 year) At least 1.5 inches (4 cm) 2-finger (single rescuer) or 2-thumb encircling (preferred) Just below the nipple line
Children (1 year to puberty) At least 2 inches (5 cm) 1-hand (small child) or 2-hand (larger child) Lower half of the sternum
Adolescents (puberty and older) At least 2 inches (5 cm) Same as adult (2-hand technique) Lower half of the sternum

Key Differences:

  • Infants: 2-thumb technique is preferred for better depth and consistency.
  • Children: Use 1 or 2 hands depending on size and rescuer strength.

3. Compression-to-Ventilation Ratios

Scenario Compression-to-Ventilation Ratio
Single Rescuer (All Ages) 30:2
Two Rescuers (Infants & Children) 15:2
With Advanced Airway (ETT/LMA) Continuous compressions + 1 breath every 2–3 sec (20–30 breaths/min)

Note: Higher ventilation rates are critical in pediatrics due to high oxygen demand.

4. Optimizing Compression Quality

  • Compression Rate: 100–120 per minute
  • Full Chest Recoil: Allow full expansion after each compression to maximize cardiac output.
  • Minimize Interruptions:
    • Keep interruptions <10 seconds.
    • Pre-charge defibrillator before pausing compressions.
    • Rotate rescuers every 2 minutes to prevent fatigue.

5. Effective Ventilation Technique

  • If NO Advanced Airway:
    • Deliver 2 breaths every 30 compressions (single rescuer) or every 15 (two rescuers).
    • Each breath over 1 second, enough for chest rise.
    • Avoid excessive volume to prevent gastric inflation.
  • If Advanced Airway in Place (ETT/LMA):
    • 1 breath every 2–3 seconds (20–30 per minute).
    • Continuous compressions, no pause for breaths.

Important: Avoid hyperventilation—excessive ventilation decreases venous return and cardiac output.

6. Minimizing Interruptions: The “C-A-B” Approach

  • C – Circulation: Start compressions immediately.
  • A – Airway: Open airway after compressions.
  • B – Breathing: Deliver breaths after compressions.

Priority: Push hard, push fast—compressions first, then airway and breathing.

7. Defibrillation for Shockable Rhythms (VF/pVT)

  • Attach AED or defibrillator as soon as possible.
  • Shockable rhythms: VF and pulseless VT
  • Energy Doses:
    • First shock: 2 J/kg
    • Second shock: 4 J/kg
    • Subsequent shocks: 4 J/kg (max 10 J/kg or adult dose)
  • Resume CPR immediately after shock.

Defibrillation is most effective within 3 minutes of arrest.

8. Signs of High-Quality CPR & Effective Resuscitation

  • Capnography (ETCO₂):
    • >15 mmHg → Good CPR
    • <10 mmHg → Improve compressions
  • Arterial Diastolic BP (if arterial line present):
    • >25 mmHg = Adequate CPR
    • <20 mmHg = Inadequate compressions
  • ROSC Indicators:
    • Sudden rise in ETCO₂ (>40 mmHg)
    • Spontaneous pulse returns
    • Improved perfusion (warm skin, strong pulses)

9. When to Stop CPR? (Termination of Resuscitation)

Consider stopping CPR if:

  • No ROSC after 20–30 minutes of high-quality CPR
  • Persistent asystole despite epinephrine and defibrillation (if initially shockable)
  • No reversible causes (H’s & T’s) identified
  • Family/provider decision per ethical guidelines

Note: Children have higher survival post-arrest—continue CPR aggressively unless futility is clear.

10. Final Takeaways: Why High-Quality CPR Matters

  • Start CPR immediately when pulseless or HR <60 bpm with poor perfusion.
  • Compression rate: 100–120/min; Depth: 1.5” (infants), 2” (children).
  • Full chest recoil and minimal interruptions improve survival.
  • Ventilation: 20–30 breaths/min in pediatrics; avoid hyperventilation.
  • Use ETCO₂ and diastolic BP to assess CPR effectiveness.
  • Defibrillate VF/pVT ASAP – first dose: 2 J/kg.

Takeaway: High-quality CPR improves survival—push hard, push fast, and don’t stop unless absolutely necessary.