Paediatric cardiac arrest is rare, but when it happens, you need to act fast and correctly. The stakes are high. Children differ from adults in physiology, arrest patterns, and response to treatment. Most paediatric arrests stem from respiratory failure rather than primary cardiac events. You cannot simply scale down adult protocols and expect optimal outcomes.
The Australian and New Zealand Committee on Resuscitation (ANZCOR) provides clear, evidence based algorithms specifically for paediatric resuscitation. These 2025 guidelines reflect the latest international consensus on cardiopulmonary resuscitation science. They give you a structured approach from recognition through basic life support, advanced interventions, and post arrest care. Following these protocols improves your chances of achieving return of spontaneous circulation and good neurological outcomes.
This guide walks you through each step of the ANZCOR 2025 paediatric resuscitation pathway. You’ll find practical information on compression ratios, ventilation techniques, drug dosages, and rhythm management. We cover both basic and advanced life support, explain modifications for special circumstances, and show you how to apply these guidelines in real clinical scenarios. Whether you’re refreshing your knowledge or preparing for certification, this article breaks down what you need to know.
What ANZCOR 2025 paediatric guidance covers
The ANZCOR paediatric resuscitation guidelines span Guidelines 12.1 through 12.5, forming a complete resuscitation framework. You’ll find specific protocols for paediatric basic life support (PBLS), paediatric advanced life support (PALS), arrhythmia management, special circumstances, and post-resuscitation care. These guidelines apply to infants (from a few hours after birth up to 12 months) and children (up to 18 years old), but exclude newborns at the time of birth.
The scope of paediatric patients
These paediatric resuscitation guidelines define your patient groups by physiology and practical considerations rather than arbitrary age cutoffs alone. An infant refers to any child from 0 to 12 months of age, whilst a child extends from infancy through to the 18th birthday. You should note that newborns (babies at the time of birth) require different neonatal resuscitation protocols found in ANZCOR Guidelines 13.1 to 13.10. The practical rule remains straightforward: if you believe the patient is a child, follow paediatric guidelines.
If the patient appears to be a child, use paediatric techniques. The patterns of arrest in young adults often mirror paediatric physiology more than typical adult arrest patterns.
Key guideline documents you need
ANZCOR structures its paediatric guidance across five core documents that work together as an integrated system:
| Guideline | Focus Area | Primary Users |
|---|---|---|
| 12.1 | Paediatric basic life support for health professionals | All healthcare providers |
| 12.2 | Paediatric advanced life support (PALS) | Advanced practitioners with equipment access |
| 12.3 | Non-arrest arrhythmia management | Practitioners managing unstable rhythms |
| 12.4 | Special circumstances (trauma, poisoning, hypothermia) | Emergency and intensive care teams |
| 12.5 | Post-resuscitation care and stabilisation | All providers managing return of circulation |
You need familiarity with Guidelines 12.1 and 12.2 at minimum. Guideline 12.1 covers the essential PBLS sequence you’ll start with any arrest. Guideline 12.2 then builds on this foundation with advanced airway management, drug therapy, rhythm analysis, and team coordination. The remaining guidelines address specific clinical scenarios you’ll encounter less frequently but must still recognise and manage appropriately.
Step 1. Recognise and prevent cardiac arrest
You need to catch deterioration before it becomes arrest. Most paediatric cardiac arrests don’t happen suddenly. Children typically show progressive signs of respiratory or circulatory failure over minutes to hours before they arrest. These early warning signs give you a window to intervene. Research shows that many in-hospital paediatric arrests are preventable when you recognise and treat deterioration early.
Signs of deterioration to watch for
Your assessment must focus on respiratory effort, circulation, and neurological status. Children compensate differently than adults. They maintain blood pressure until very late in shock, then decompensate rapidly. Watch for tachypnoea, increased work of breathing, nasal flaring, grunting, or accessory muscle use. These respiratory signs often appear first. For circulation, you’ll notice tachycardia, prolonged capillary refill (>2 seconds), cool peripheries, weak pulses, or reduced urine output. Neurological changes include irritability, reduced responsiveness, or altered consciousness.
Children who deteriorate show patterns. You’ll typically see respiratory distress first, then circulatory compromise, then altered consciousness as perfusion drops.
Recognition tools help standardise your assessment. Paediatric early warning scores (PEWS) provide structured observation frameworks, though evidence for preventing deterioration remains limited. These scoring systems work best as part of a broader clinical response culture rather than as standalone interventions. Your clinical judgment still outweighs any score. Trust your instinct when something feels wrong.
Activating rapid response systems
Medical emergency teams (MET) and rapid response teams (RRT) exist specifically to prevent arrests on general wards. ANZCOR suggests implementing these systems in all hospitals caring for children. You should activate the MET or RRT when you observe concerning vital signs, deteriorating clinical parameters, or simply when you’re worried about a child’s condition.
Different hospitals use different trigger criteria. Single-parameter triggers might include respiratory rate outside normal range, heart rate extremes, oxygen saturation below threshold, or systolic blood pressure concerns. Multi-parameter aggregate scores combine several measurements. Some systems allow activation for clinician concern or family worry, even without objective parameters.
Early activation matters more than perfect criteria. Don’t wait for all signs to align before calling for help. The paediatric resuscitation guidelines emphasise that your concern alone justifies MET activation. You want the expert team present before arrest occurs, not after.
Step 2. Start paediatric basic life support
You must start resuscitation immediately when you find an unresponsive child who isn’t breathing normally. The paediatric resuscitation guidelines differ from adult protocols in critical ways. Children arrest primarily from respiratory causes, so you’ll prioritise airway and breathing interventions before chest compressions. This approach differs from adult BLS where compressions come first. Your sequence matters because effective ventilation often prevents progression to full cardiac arrest in children.
Check for response and normal breathing
Your first action involves a rapid assessment of responsiveness and breathing. Gently stimulate the child and call their name. Check if they respond to voice or touch. Simultaneously, look at their chest for normal breathing movements. You have 10 seconds to assess breathing quality. Agonal gasps don’t count as normal breathing. These irregular, laboured breaths signal cardiac arrest. If you cannot confidently identify a pulse within 10 seconds or if the heart rate sits below 60 beats per minute with poor perfusion signs, you must start CPR immediately.
Shout for help as soon as you recognise the problem. You need additional hands. A single rescuer should call for assistance then begin CPR immediately. When you have witnessed the collapse and suspect a primary cardiac cause (rare in children but possible), prioritise getting a defibrillator. Otherwise, start resuscitation first.
Give five rescue breaths first
You must deliver five initial ventilations before starting chest compressions. This respiratory-first approach reflects the asphyxial nature of most paediatric arrests. Open the airway using head tilt and chin lift (or jaw thrust if you suspect spinal injury). For infants, maintain a neutral neck position. For children, use the sniffing position with slight head extension.
The five initial breaths address the hypoxia that caused most paediatric arrests. This step often restores spontaneous circulation without needing chest compressions.
Each breath should last approximately one second. Watch for visible chest rise with each ventilation. You’ll use mouth-to-mouth and nose for infants or mouth-to-mouth for children if no equipment is available. With bag-valve-mask equipment, select the appropriate mask size and achieve a proper seal before ventilating.
Deliver chest compressions correctly
Your compression technique changes based on the child’s size. For infants, you’ll use the two-thumb encircling technique if you’re a healthcare provider (Figure 8 reference from guidelines). Place both thumbs on the lower sternum whilst your hands encircle the chest. A single rescuer may use the two-finger technique instead to minimise the transition time between compressions and ventilations. For children, use the heel of one or two hands on the lower sternum, depending on the child’s size and your ability to achieve adequate depth.
Compress the chest to at least one-third of its anteroposterior diameter. This translates to approximately 4 cm for infants and 5 cm for children. You must allow complete chest recoil between compressions. Your compression rate should sit between 100 and 120 per minute for all ages. Count aloud to maintain rhythm and coordinate with your team.
| Patient Type | Technique | Depth | Rate |
|---|---|---|---|
| Infant | Two-thumb encircling or two-finger | ~4 cm (1/3 AP diameter) | 100-120/min |
| Child | One or two-hand heel | ~5 cm (1/3 AP diameter) | 100-120/min |
Maintain the compression-ventilation ratio
Healthcare providers use a 15:2 compression to ventilation ratio for paediatric patients. This differs from the 30:2 ratio used for adults or by lay rescuers. You’ll deliver 15 chest compressions followed by 2 ventilations, then immediately resume compressions. The 15:2 ratio provides more frequent ventilation to address the respiratory cause of arrest whilst maintaining adequate circulation through compressions. Each cycle takes approximately 15 seconds.
Continue CPR until help arrives, the child shows signs of life, you become exhausted, or a team leader instructs you to stop. When additional rescuers arrive, you should rotate the compressor role every 2 minutes to prevent fatigue and maintain compression quality.
Step 3. Manage airway, breathing and oxygen
Effective airway management and oxygenation form the cornerstone of paediatric resuscitation. You must establish a patent airway, deliver adequate ventilation, and provide high-concentration oxygen as quickly as possible. Most paediatric arrests result from respiratory failure, so your airway and breathing interventions often matter more than any other intervention. Poor airway management leads to continued hypoxia, failed resuscitation attempts, and worse neurological outcomes.
Position and open the airway properly
Your first task involves positioning the child’s head and neck correctly. For infants, you’ll maintain a neutral position without hyperextension, as excessive neck extension can actually obstruct their airway. For children, use the sniffing position with mild extension of the head on the neck and slight flexion of the neck on the shoulders. This alignment opens the airway by lifting the tongue away from the posterior pharynx.
You can use either head tilt with chin lift or jaw thrust to maintain airway patency. Place your fingers under the bony part of the jaw and lift forward whilst tilting the head back gently. If you suspect cervical spine injury, use jaw thrust alone without head tilt. This technique minimises spinal movement whilst still opening the airway. Watch for chest wall indrawing or abdominal distension during inspiration, both signs of airway obstruction requiring repositioning.
If airway positioning fails to relieve obstruction, inspect the pharynx with a laryngoscope and suction any blood, secretions, or vomit immediately.
Airway adjuncts help maintain patency in unconscious children. An oropharyngeal airway works for deeply unconscious patients without a gag reflex. You’ll size it by measuring from the centre of the mouth to the angle of the mandible. Nasopharyngeal airways suit semi-conscious children better but you must avoid them with suspected skull base fractures or coagulopathy. Size these by measuring from the nose tip to the ear tragus.
Start with 100% oxygen and bag-valve-mask
The paediatric resuscitation guidelines recommend you administer the highest oxygen concentration available during initial resuscitation, regardless of any pre-existing condition. This means 100% oxygen for all arrested children. You’ll connect your oxygen source directly to a bag-valve-mask device with a reservoir attached. Self-inflating bags work for most rescuers, whilst flow-inflating systems require more skill but offer better tactile feedback.
Your mask must extend from the bridge of the nose to between the lower lip and chin. Masks with inflatable rims create better seals. You’ll need two hands to achieve an effective seal when working alone. Press the mask firmly onto the face whilst lifting the jaw into the mask using a C-E grip technique. Each ventilation should last one second and produce visible chest rise without excessive pressure.
Consider advanced airways only when necessary
ANZCOR suggests you use bag-valve-mask ventilation rather than endotracheal intubation for out-of-hospital cardiac arrests. BVM ventilation works well when performed correctly and avoids the risks of failed intubation, prolonged interruptions to chest compressions, and unrecognised oesophageal placement. You should only attempt intubation if BVM proves inadequate or you need prolonged airway control after achieving return of spontaneous circulation.
Supraglottic airways offer a middle option for trained providers. These devices sit above the larynx and don’t require laryngoscopy. You must follow manufacturer sizing guidelines based on the child’s weight. Both cuffed and uncuffed endotracheal tubes are acceptable if you do intubate. Confirm correct placement immediately using exhaled CO2 detection with colorimetric devices or capnography, bilateral breath sounds, and visible chest rise.
Step 4. Assess rhythm and deliver shocks
You must attach monitoring equipment as soon as it arrives to identify the cardiac rhythm. The paediatric resuscitation guidelines show that shockable rhythms occur in only 15% of paediatric arrests, with ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) being far less common than in adults. Most children present with asystole or pulseless electrical activity (PEA) from respiratory or circulatory failure. Your rhythm analysis determines whether you’ll deliver immediate defibrillation or continue CPR with adrenaline administration.
Connect monitoring and identify the rhythm
Attach defibrillator pads or ECG electrodes immediately when the equipment arrives. You can use self-adhesive defibrillation pads directly for both monitoring and shocking if needed. These pads must be the largest size that fits the child’s chest without touching each other. Place one pad on the upper right chest below the clavicle and the other on the left lower chest in the mid-axillary line. For infants, you may position pads in an anterior-posterior configuration if needed.
Check the monitor display to identify the rhythm. You’ll categorise it as either shockable (VF or pulseless VT) or non-shockable (asystole or PEA). Your team must minimise interruptions to chest compressions during rhythm checks. Pause only briefly to assess the rhythm every 2 minutes (after each cycle of CPR). Don’t stop compressions to attach pads or charge the defibrillator.
Rhythm checks must be brief. You’ll lose critical perfusion pressure with each pause in compressions, so keep interruptions under 10 seconds.
Manage shockable rhythms appropriately
When you identify VF or pulseless VT, you must deliver an immediate unsynchronised shock of 4 J/kg. This single energy dose applies to all shocks in paediatric patients, simplifying your protocol compared to escalating adult doses. Ensure everyone stands clear before delivering the shock by announcing loudly “stand clear” and performing a visual sweep. Press the shock button immediately after confirmation.
Resume CPR straight away after the shock without pausing to check the rhythm. You’ll deliver 15 compressions then 2 ventilations for 2 minutes before your next rhythm check. If VF or pulseless VT persists at the next check, deliver another 4 J/kg shock and continue CPR. After the third shock, you’ll give adrenaline 10 micrograms/kg IV/IO and consider amiodarone 5 mg/kg IV/IO for refractory VF or pulseless VT.
| Action | Timing | Dose |
|---|---|---|
| First shock | Immediately when VF/pVT identified | 4 J/kg |
| CPR cycle | After each shock | 2 minutes (15:2 ratio) |
| Subsequent shocks | Every 2 minutes if VF/pVT persists | 4 J/kg |
| Adrenaline | After 3rd shock onwards | 10 mcg/kg IV/IO |
| Amiodarone | After 3rd shock | 5 mg/kg IV/IO |
Handle non-shockable rhythms correctly
Asystole and PEA require a different approach without defibrillation. You must continue high-quality CPR with minimal interruptions whilst your team addresses reversible causes. Give adrenaline 10 micrograms/kg IV/IO as soon as you gain vascular access, then repeat every 3 to 5 minutes (every second CPR cycle). Check the rhythm briefly after each 2-minute cycle.
Search actively for the 4H4T causes during CPR: hypoxia, hypovolaemia, hyper/hypokalaemia, hypothermia, tension pneumothorax, tamponade, toxins, and thrombosis. Your team should assign specific roles for airway management, compressions, vascular access, drug preparation, and cause identification. If the rhythm changes to VF or pulseless VT during a check, immediately switch to the shockable pathway with defibrillation.
Step 5. Use vascular access and drugs safely
You must establish vascular access quickly to deliver medications during cardiac arrest. The paediatric resuscitation guidelines prioritise intraosseous (IO) access when peripheral or central venous access isn’t already in place. Speed matters more than route during arrest. You cannot waste time searching for difficult veins whilst compressions pause and the child remains unperfused. Your drug delivery route directly affects the speed and success of your resuscitation efforts.
Establish intraosseous access quickly
Insert an IO needle immediately if you don’t have existing IV access and peripheral attempts will delay drug delivery. The IO route provides rapid access to the central circulation with equivalent drug absorption times to central venous lines. You’ll typically use the proximal tibia, distal femur, or proximal humerus as insertion sites. The anteromedial surface of the tibia, approximately 2 cm below the tibial tuberosity, offers the most accessible location in infants and children.
IO access during cardiac arrest isn’t a backup option. It’s your primary route when no IV line exists, giving you reliable access in under 60 seconds.
Flush all IO medications with at least 5 mL of normal saline and elevate the limb briefly to aid circulation. You must avoid attempting IO insertion in fractured bones or through infected skin. Manual or powered insertion devices both work effectively, though powered systems may speed insertion in older children with harder cortical bone.
Calculate drug doses accurately
You need the child’s weight in kilograms to calculate accurate medication doses. When you don’t know the weight, use a body length tape with precalculated doses such as the Broselow tape. These colour-coded tapes eliminate calculation errors under stress. For non-obese children, base doses on actual body weight. For obese patients, calculate using ideal body weight estimated from length to avoid toxicity from overdosing.
| Medication | Indication | Dose | Route | Timing |
|---|---|---|---|---|
| Adrenaline | Non-shockable rhythm | 10 mcg/kg (0.1 mL/kg of 1:10,000) | IV/IO | Immediately, then every 3-5 min |
| Adrenaline | Shockable rhythm | 10 mcg/kg | IV/IO | After 3rd shock, then every 3-5 min |
| Amiodarone | Refractory VF/pVT | 5 mg/kg | IV/IO | After 3rd shock |
Prepare medications in advance when possible. You’ll draw up adrenaline as 0.1 mL/kg of 1:10,000 solution (giving 10 micrograms/kg). Check your calculations independently and have another team member verify doses before administration. Never exceed adult maximum doses regardless of the child’s size.
Give adrenaline at correct intervals
Administer your first dose of adrenaline as early as possible for non-shockable rhythms. In shockable rhythms, give adrenaline after the third shock. Continue dosing every 3 to 5 minutes throughout the resuscitation, which equates to every second CPR cycle of 2 minutes. You must maintain this regular interval because adrenaline’s effects fade quickly during arrest.
Subsequent drug titration depends on the observed clinical effects. Watch for return of spontaneous pulses, improved end-tidal CO2 readings, or rhythm changes suggesting response to treatment. Document every dose with timing to prevent under or overdosing.
Avoid harmful interventions
You should not administer sodium bicarbonate routinely during paediatric cardiac arrest. The paediatric resuscitation guidelines reserve bicarbonate only for specific situations like hyperkalaemia or tricyclic antidepressant poisoning. Routine use doesn’t improve outcomes and may worsen intracellular acidosis. Similarly, avoid calcium unless you’re treating documented hypocalcaemia, hypermagnesaemia, or calcium channel blocker toxicity. Focus your efforts on high-quality CPR, adequate ventilation, and adrenaline delivery rather than unproven adjunct medications.
Step 6. Tailor care to special circumstances
You must adapt your resuscitation approach when specific conditions caused the arrest or when standard protocols won’t work. The paediatric resuscitation guidelines recognise that trauma, poisoning, hypothermia, and post-cardiac surgery arrests require modified management strategies. Your team needs to identify these scenarios quickly and adjust treatment whilst maintaining high-quality CPR. These special circumstances often demand you prioritise certain interventions over the standard sequence, search for specific reversible causes, or consider advanced rescue therapies like extracorporeal life support.
Manage traumatic cardiac arrest differently
Paediatric traumatic cardiac arrest carries a poor prognosis but demands immediate correction of reversible causes alongside CPR. You must control external bleeding using direct pressure with haemostatic dressings or tourniquets at appropriate sites. Your team should perform bilateral finger or tube thoracostomy (or needle thoracentesis) early to treat assumed tension pneumothorax without waiting for confirmation. Resuscitate with blood products rather than crystalloid as soon as these become available.
Traumatic arrest requires you to treat reversible causes first, then support with CPR rather than the reverse sequence used in medical arrests.
Consider emergency thoracotomy for penetrating trauma with signs of life on emergency department arrival. Avoid this procedure in blunt trauma where it shows no benefit. Transport traumatic arrest patients directly to major trauma centres equipped for paediatric care when possible.
Address the 4H4T reversible causes systematically
Your team must actively search for and correct the 8 reversible causes during every arrest. The 4H4T mnemonic helps you remember these: hypoxia, hypovolaemia, hyper/hypokalaemia (metabolic), hypothermia, tension pneumothorax, tamponade (cardiac), toxins, and thrombosis. Assign a team member specifically to consider these causes and recommend targeted treatments. You’ll treat hypoxia with 100% oxygen and effective ventilation, hypovolaemia with fluid or blood resuscitation, electrolyte abnormalities with specific corrections, and tension pneumothorax with immediate decompression.
For toxic ingestions, contact the Australian Poisons Information Centre (13 11 26) or New Zealand Poisons Centre (0800 764 766) for specific antidote advice. These experts guide treatment for high-risk medications like beta-blockers, calcium channel blockers, or tricyclic antidepressants that may respond to specific therapies beyond standard CPR.
Consider extracorporeal life support for refractory arrest
ANZCOR suggests you consider extracorporeal life support (ECLS or ECMO) for selected children with in-hospital cardiac arrest unresponsive to conventional CPR when a reversible cause exists. This intervention requires hospitals with appropriate expertise, resources, and established ECLS programmes with active quality improvement systems. You cannot implement ECLS effectively without these elements in place. Your team should initiate ECLS discussions early for refractory arrests in equipped centres rather than waiting until after prolonged unsuccessful resuscitation attempts.
Step 7. Plan post arrest care and debrief
Achieving return of spontaneous circulation (ROSC) marks a critical transition point, not the end of your resuscitation effort. Your management during the first hours after ROSC determines neurological outcomes as much as the quality of your CPR. The paediatric resuscitation guidelines show that children who survive to hospital discharge often deteriorate again in the post-arrest period from inadequate stabilisation. You must shift your focus from basic life support to comprehensive organ support and neuroprotection whilst preparing for safe transport to intensive care.
Stabilise circulation and monitor vital signs
You need to establish continuous monitoring of heart rate, blood pressure, oxygen saturation, and end-tidal CO2 immediately after ROSC. Target a systolic blood pressure at or above the 5th percentile for the child’s age. Your team should maintain vascular access and continue fluid resuscitation if hypovolaemia contributed to the arrest. Consider starting an adrenaline or noradrenaline infusion if the child remains hypotensive despite adequate volume replacement. Obtain a 12-lead ECG to identify any cardiac abnormalities that may have caused or resulted from the arrest. Insert an indwelling urinary catheter to monitor urine output as a marker of end-organ perfusion.
Control temperature and glucose levels
Avoid hyperthermia in the post-arrest period by targeting normothermia (36-37.5°C). Actively treat fever with antipyretics and cooling measures. The paediatric resuscitation guidelines don’t recommend routine therapeutic hypothermia for children after cardiac arrest, though you may consider it in specific circumstances after consultation with intensive care specialists. Check the child’s blood glucose immediately and hourly during stabilisation. Treat hypoglycaemia with intravenous dextrose but avoid hyperglycaemia, as both extremes worsen brain injury. Maintain glucose between 4 and 10 mmol/L.
Post-arrest glucose control matters as much as your CPR quality. Hypoglycaemia kills neurons directly whilst hyperglycaemia worsens reperfusion injury.
Optimise ventilation and oxygenation
Adjust your ventilator settings to achieve normoxia and normocapnia once you have arterial blood gas results. Target an oxygen saturation between 94-98% by titrating inspired oxygen concentration. The paediatric resuscitation guidelines recommend you avoid both hyperventilation and hypoventilation, as these disturb cerebral blood flow. Aim for PaCO2 between 35-45 mmHg (5.0-6.0 kPa). Perform a chest X-ray to confirm endotracheal tube position and assess for complications like pneumothorax or aspiration. Consider therapeutic ventilation strategies based on the child’s lung compliance and gas exchange.
Debrief with team and family
Your team needs a structured debrief within 24 hours of the resuscitation to review performance, identify learning points, and support emotional wellbeing. Discuss what went well, what could improve, and any equipment or system issues that arose. This process strengthens future resuscitation responses. You must also provide honest, compassionate communication with the family about the child’s condition and prognosis. Explain the interventions performed, current status, and planned intensive care management. Document your resuscitation thoroughly, including times of key interventions, doses given, and rhythm changes observed. This record supports continuity of care and quality improvement processes.
Putting these guidelines into practice
You now have a complete framework for managing paediatric cardiac arrest based on ANZCOR 2025 algorithms. These paediatric resuscitation guidelines give you the structure, but real competence comes from hands-on training and regular practice. You cannot learn effective bag-valve-mask ventilation or proper compression technique from reading alone. Your muscle memory for the 15:2 ratio, drug calculations, and rhythm recognition develops through simulation and repetition.
Book regular training sessions to maintain your skills. You’ll find that your confidence and speed improve dramatically with practical courses that simulate real arrest scenarios. The difference between knowing the guidelines and performing them under pressure becomes clear when you work through cases with expert instructors and realistic equipment.
Consider refreshing your paediatric advanced life support certification if it’s been over 12 months since your last course. Browse our accredited PALS training options to keep your resuscitation skills current and evidence-based. Your next paediatric arrest will require immediate, confident action.
