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OverviewAetiologyPathophysiologyClinical features and red flagsInvestigationsDifferential diagnosisManagementComplicationsMonitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
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Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.

Paediatric basic and advanced life support principles

Paediatrics and child health · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Unresponsive child with abnormal breathing

Unresponsiveness with absent or abnormal breathing, or bradycardia below 60/min with poor perfusion despite effective respiratory support, requires immediate paediatric cardiopulmonary resuscitation.

Action: Call the ambulance or resuscitation team, open the airway, give five initial rescue breaths and start high-quality chest compressions. Use 15:2 if specifically trained in paediatric BLS or 30:2 otherwise, attach self-adhesive defibrillator pads as soon as possible, and move into the 2025 paediatric advanced life-support algorithm while treating reversible causes.

Overview

Recognise paediatric cardiorespiratory arrest, deliver effective ventilation and compressions without delay, distinguish shockable from non-shockable rhythms, use weight-based drugs and defibrillation safely, and organise post-resuscitation care around the cause, child and family.

Paediatric cardiac arrest is usually the end of progressive respiratory or circulatory failure rather than a sudden primary cardiac event. Prevention begins with recognising abnormal behaviour, breathing and colour, performing ABCDE and treating hypoxia and shock before bradycardia develops. When arrest occurs, the sequence deliberately prioritises ventilation: open the airway, assess breathing briefly and deliver five effective rescue breaths before compressions.

A trained rescuer uses a 15:2 compression-to-ventilation ratio. Someone trained only in adult BLS can use 30:2, and compression-only CPR is preferable to doing nothing when rescue breaths cannot be delivered. Infant compressions use the two-thumb encircling technique when two rescuers are present; older children use one or two hands according to size. Each compression reaches at least one-third of chest depth while allowing complete recoil.

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Paediatrics and child healthOriginal SBA

Initial trained-rescuer sequence

A 4-year-old is unresponsive and is not breathing normally. A clinician trained in paediatric BLS has called for help. What should happen next?

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Sources and review status3 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • Resuscitation Council UK 2025 Paediatric Life SupportCurrent UK basic and advanced sequence, compression and ventilation ratios, defibrillation, drugs, reversible causes and post-arrest care.
  • Resuscitation Council UK 2025 Guidelines hubCurrent UK guideline framework, development method and links to algorithms and education.
  • Resuscitation Council UK 2025 Ethics guidancePerson-centred emergency planning, family involvement and ethical decision principles during resuscitation.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom
The advanced team continues uninterrupted high-quality CPR, gives 100% oxygen during arrest, establishes IV access without repeated delay or moves promptly to intraosseous access, and applies defibrillator pads. Rhythm checks last less than five seconds every two minutes. Clinical signs and monitoring determine whether an organised rhythm has restored output; an electrical tracing alone does not prove circulation.

Non-shockable rhythms need adrenaline early and relentless treatment of the cause. Shockable rhythms need a 4 J/kg shock followed immediately by two minutes of CPR. Adrenaline and amiodarone follow the third shock, with a second amiodarone dose after the fifth. Drug preparation, concentration, weight basis, maximum dose and flush are spoken aloud and independently checked whenever staffing allows.

Airway escalation follows competence and physiology. Bag-mask ventilation is the first-line method and a two-person seal often improves it. A supraglottic airway can secure oxygenation when mask ventilation is unreliable. Tracheal intubation should be undertaken only by an equipped, competent clinician without prolonged pauses; waveform capnography confirms and continuously monitors an advanced airway.

Return of spontaneous circulation starts a new emergency rather than ending care. Titrate oxygen once saturation is reliable, aim for normocapnia, maintain age-appropriate blood pressure and organ perfusion, prevent fever, treat seizures and hypoglycaemia and investigate the precipitating illness. Do not make early neurological predictions from a single examination, biomarker or scan; RCUK advises multimodal assessment and delayed prognostication in the comatose child.

Communication runs in parallel. The leader allocates compressions, airway, rhythm, access, drugs, timekeeping and family support, uses closed-loop commands and states priorities at each rhythm check. Parents should be offered presence when safe with a named supporter. Afterward, record the timeline precisely, debrief the team, explain uncertainty honestly and screen the recovering child and family for physical, cognitive and psychological consequences.

Key points

  • Check safety and responsiveness, call for emergency help early and assess breathing for no more than 10 seconds.
  • Give five initial rescue breaths, then start compressions if there are no signs of life or if severe bradycardia with poor perfusion persists despite respiratory support.
  • Use 15 compressions to 2 ventilations when trained in paediatric BLS; otherwise use 30:2 and follow the ambulance call handler.
  • Compress at 100 to 120/min to at least one-third of the anteroposterior chest depth, about 4 cm in an infant and 5 cm in a child, with full recoil and minimal interruption.
  • Attach an AED or manual defibrillator promptly; paediatric attenuation is preferred for smaller children when available, but absence of an attenuator must not prevent AED use.
  • First-line rhythm decision is shockable ventricular fibrillation or pulseless VT versus non-shockable bradycardia with poor perfusion, PEA or asystole.
  • For a shockable rhythm give 4 J/kg and resume CPR immediately for 2 minutes; minimise the pre-shock and post-shock pause.
  • For a non-shockable rhythm give IV or IO adrenaline 10 micrograms/kg, maximum 1 mg, as soon as access is available and repeat every 3 to 5 minutes.
  • After the third shock give adrenaline and amiodarone; continue two-minute cycles, rhythm checks and treatment of reversible causes.
  • Use hypoxia, hypovolaemia, electrolyte and metabolic disorders, hypo- or hyperthermia, tension pneumothorax, tamponade, thrombosis and toxins as an active cause checklist.
  • After return of spontaneous circulation, immediately stabilise oxygenation, ventilation, perfusion, glucose, temperature and seizures and identify the cause.
  • Document times, cumulative energy and drugs, enable supported parental presence when safe, and arrange multidisciplinary neurological and family follow-up.

Aetiology

01

Progressive respiratory failure

Airway obstruction, severe lung disease, apnoea, drowning, aspiration and neuromuscular weakness commonly cause hypoxia, bradycardia and then arrest in children.

02

Circulatory failure

Sepsis, dehydration, haemorrhage, anaphylaxis, cardiogenic shock and obstructive physiology can exhaust compensation and produce pulseless electrical activity or asystole.

03

Primary cardiac event

Inherited channelopathy, cardiomyopathy, congenital heart disease, myocarditis and a sudden ventricular arrhythmia are less common but particularly important after an abrupt witnessed collapse.

04

Special circumstance

Trauma, intoxication, hypothermia, electrolyte disturbance and thrombosis require the standard life-support framework plus immediate cause-specific modification.

Pathophysiology

  1. 1
    Hypoxic bradycardia

    Inadequate oxygen delivery depresses myocardial function and conduction; effective airway opening and ventilation can reverse the process before complete circulatory arrest.

  2. 2
    Low coronary perfusion

    During arrest, compressions generate only a fraction of normal flow. Adequate depth, complete recoil, correct rate and minimal pauses are needed to perfuse myocardium and brain.

  3. 3
    Shockable electrical disorder

    Ventricular fibrillation and pulseless ventricular tachycardia have disorganised or ineffective ventricular activity; prompt defibrillation can restore coordinated depolarisation.

  4. 4
    Post-arrest reperfusion injury

    After circulation returns, inflammation, myocardial dysfunction, cerebral injury and disordered temperature, glucose and perfusion can cause secondary harm despite an initially successful resuscitation.

Clinical features and red flags

Cardiac arrest

The child is unresponsive with absent or abnormal breathing and no signs of life; begin the algorithm without a prolonged pulse search.

Peri-arrest bradycardia

Heart rate below 60/min with poor perfusion after adequate oxygenation and ventilation requires compressions.

Shockable rhythm

Ventricular fibrillation is chaotic and pulseless ventricular tachycardia is a rapid broad-complex rhythm without output; both need immediate defibrillation.

Non-shockable rhythm

Asystole, pulseless electrical activity and severe bradycardia with poor perfusion need adrenaline and cause correction rather than a shock.

Return of circulation

Movement, normal breathing, rising end-tidal carbon dioxide, a pulsatile pressure trace and a palpable central pulse support ROSC and prompt post-arrest care.

Red flags requiring action

  • Gasping, irregular or absent breathing is not normal breathing and should not delay CPR while a prolonged pulse check is attempted.
  • A heart rate below 60/min with poor perfusion despite adequate oxygenation and ventilation is a compression trigger even when a pulse remains detectable.
  • Bradycardia, weak central pulses, hypotension, falling consciousness and loss of the capnography or arterial waveform are peri-arrest signs.
  • A witnessed sudden collapse during exercise, a shockable rhythm or a family history of premature sudden death raises concern for a primary electrical or structural cardiac cause.
  • Recurrent deterioration after return of spontaneous circulation suggests an untreated reversible cause, displaced airway, inadequate ventilation, shock or evolving post-cardiac-arrest syndrome.
  • An infant under 24 hours old is generally managed with the newborn algorithm; teams should use the algorithm they know while summoning appropriate expertise rather than withholding effective resuscitation.

Investigations

  1. 01
    First-line clinical arrest assessmentFirst stepFirst line
    Why
    Recognise unresponsiveness, abnormal breathing and absent signs of life without delaying CPR.
    Interpretation and limitations
    Assessment is deliberately brief; gasping counts as abnormal and uncertainty favours starting resuscitation.
  2. 02
    First-line rhythm analysisFirst line
    Why
    Separate shockable ventricular fibrillation or pulseless VT from non-shockable rhythms.
    Interpretation and limitations
    Use pads and a defibrillator as soon as possible, but do not interrupt compressions for prolonged rhythm interpretation.
  3. 03
    Waveform capnography
    Why
    Confirm an advanced airway, monitor ventilation and provide a trend during CPR and after ROSC.
    Interpretation and limitations
    A sudden sustained rise can signal ROSC; a low value prompts review of compression quality, ventilation, pulmonary flow and reversible causes rather than an isolated prognosis.
  4. 04
    Bedside glucose, gas and electrolytes
    Why
    Find reversible hypoglycaemia, acidosis, potassium disturbance and ventilatory failure.
    Interpretation and limitations
    Treat a life-threatening abnormality while CPR continues; sampling must not interrupt ventilation, compressions or defibrillation.
  5. 05
    Cause-directed ultrasound and imaging
    Why
    Identify tamponade, pneumothorax, cardiac dysfunction, trauma or another precipitant after immediate actions.
    Interpretation and limitations
    POCUS is used only by a skilled operator during an existing pause and must never prolong the interruption in compressions.
  6. 06
    Reference-standard cause investigation after sudden arrest
    Why
    Integrate clinical history, ECG, echocardiography, laboratory, toxicology, imaging and genetic assessment when the cause remains unexplained.
    Interpretation and limitations
    No single test excludes inherited cardiac disease; family screening follows specialist interpretation when an inherited cause is possible.

Differential diagnosis

01

Profoundly reduced consciousness with a pulse

Seizure, hypoglycaemia, intoxication or intracranial disease can mimic arrest; support the airway and ventilation while checking for signs of life for no longer than the algorithm permits.

02

Agonal gasping

Occasional noisy gasps are compatible with cardiac arrest and must not be mistaken for effective breathing.

03

Severe bradycardia before arrest

A pulse may remain, but poor perfusion below 60/min after respiratory support is functionally peri-arrest and needs compressions.

04

Monitor artefact

Movement, loose electrodes or pacing spikes can resemble an organised rhythm; rhythm interpretation is reconciled with clinical signs and a very brief pulse assessment.

Management

01Basic life supportBreathe, compress and callFirst stepThe child is unresponsive and not breathing normally.+
  1. 1Call emergency help using speakerphone and open the airway.
  2. 2Give five rescue breaths and confirm visible chest rise.
  3. 3Start high-quality compressions with 15:2 if paediatric-trained or 30:2 otherwise.
  4. 4Attach an AED as soon as available while minimising interruptions.
02Non-shockable arrestAdrenaline and causesThe rhythm is asystole, PEA or bradycardia with poor perfusion.+
  1. 1Continue CPR and obtain IV or immediate IO access.
  2. 2Give adrenaline 10 micrograms/kg, maximum 1 mg, as soon as possible and flush.
  3. 3Repeat adrenaline every 3 to 5 minutes while checking rhythm every 2 minutes.
  4. 4Find and correct the reversible cause throughout each cycle.
03Shockable arrestDefibrillate with minimal pauseVentricular fibrillation or pulseless ventricular tachycardia is present.+
  1. 1Deliver 4 J/kg and resume CPR immediately for 2 minutes.
  2. 2Repeat rhythm analysis and shock at 4 J/kg when the rhythm persists.
  3. 3After the third shock give adrenaline and amiodarone under the algorithm.
  4. 4Continue cycles, drug timing and cause correction until ROSC or a senior decision changes the goal.
04Post-resuscitationPrevent secondary injuryA perfusing rhythm and signs of circulation return.+
  1. 1Reassess ABCDE and secure reliable oxygenation and ventilation.
  2. 2Titrate oxygen, aim for normocapnia and maintain age-appropriate perfusion.
  3. 3Control temperature, glucose and seizures and investigate the precipitant.
  4. 4Transfer to paediatric critical care and plan family communication and later rehabilitation.
Key medicines and prescribing safety2 treatments · regimens, roles and cautions+
First-line vasopressor in paediatric cardiac arrest after ventilation and compressions are established.

Adrenaline 1:10,000, 0.1 mg/mL

Give 10 micrograms/kg IV or IO, equivalent to 0.1 mL/kg, maximum 1 mg, as soon as possible in a non-shockable arrest and immediately after the third shock in a shockable arrest; repeat every 3 to 5 minutes while arrest persists.

Confirm the 1:10,000 concentration, weight basis, route and maximum aloud; flush after administration. This arrest dose is different from small peri-arrest boluses and from 1 mg/mL intramuscular adrenaline used for anaphylaxis.

Antiarrhythmic treatment for refractory shockable paediatric arrest alongside defibrillation and CPR.

Amiodarone

Give 5 mg/kg IV or IO, maximum 300 mg, immediately after the third shock for persistent VF or pulseless VT; give a further 5 mg/kg, maximum 150 mg, after the fifth shock.

Use the resuscitation formulation and local emergency chart, flush the line, and monitor for hypotension, bradycardia and QT prolongation after ROSC. Lidocaine 1 mg/kg is the named alternative when amiodarone is unavailable or locally selected.

Complications

01

Hypoxic-ischaemic brain injury

Duration of no-flow and low-flow states, recurrent hypoxia, hypotension, fever and seizure contribute to later cognitive, motor and behavioural disability.

02

Myocardial and multiorgan dysfunction

Transient ventricular impairment, acute kidney injury, liver injury, coagulopathy and lung injury may evolve during the first days after return of circulation.

03

Resuscitation injury

Rib injury, gastric inflation, aspiration, airway trauma, burns from misplaced pads and medication or defibrillation error can complicate emergency care.

04

Psychological impact

The child, parents, siblings and staff may develop trauma symptoms; explanation, family presence when safe, debrief and planned follow-up are part of care.

Monitoring and follow-up

  • Use a visible two-minute cycle timer and record rhythm, shock energy, drug, dose, route and response contemporaneously.
  • Continuously assess compression rate, depth, recoil and pauses; change the compressor at least every two minutes or earlier with fatigue.
  • Monitor waveform capnography with any advanced airway and repeat clinical tube checks after transfer or sudden deterioration.
  • After ROSC, titrate oxygen to saturation 94–98% in a previously healthy child and confirm ventilation with blood gas and capnography.
  • Maintain systolic and mean arterial pressure above the age-adjusted tenth percentile unless an individual condition needs another target.
  • Track temperature, glucose, urine output, lactate, seizures and neurological examination while avoiding premature prognostic conclusions.
  • Before discharge from follow-up, assess physical, neurocognitive, educational and family psychological needs and coordinate rehabilitation.

Special situations

Ventilation often changes the trajectory

Because paediatric arrest is commonly hypoxic, effective initial breaths and visible chest rise are more than a ritual.

A pulse is not always reassuring

Severe bradycardia with poor perfusion after respiratory support is treated with compressions before the pulse disappears.

Pads shorten the path to a shock

Self-adhesive pads allow rhythm recognition and defibrillation without changing devices or hand-held paddles.

Capnography is a trend

It helps confirm the airway and detect change but cannot determine futility on one low measurement.

The family has a role

Supported presence, honest updates and later follow-up are integral to safe family-centred resuscitation care.

Common pitfalls

  1. 01

    Mistaking gasping for normal breathing.

  2. 02

    Spending longer than 10 seconds checking breathing or a pulse before acting.

  3. 03

    Starting compressions without first attempting effective rescue breaths in a hypoxic child.

  4. 04

    Pausing CPR while access, intubation, imaging or prolonged rhythm interpretation is attempted.

  5. 05

    Confusing adrenaline concentrations or using a fixed adult dose in a small child.

  6. 06

    Failing to resume compressions immediately after a shock.

  7. 07

    Declaring ROSC from an organised ECG rhythm without clinical evidence of output.

  8. 08

    Making early neurological predictions from arrest duration or one test.

  9. 09

    Ending the event without cause investigation, precise documentation, family explanation and team debrief.