Authors: Jocelyn Matheson, MD AND Emily Nasser, MD - Medical University of South Carolina, Charleston, SC
A 9-month-old 7-kg infant with Glenn physiology presents to urgent care with stridor and relative hypoxia secondary to viral croup. He experiences loss of consciousness while being evaluated and is found to be in pulseless ventricular tachycardia. A colleague obtains an AED and pads, but only adult pads are available. Which of the following are the MOST appropriate next steps in patient management?
EXPLANATION
According to the updated 2025 AHA Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC), the priorities in pediatric cardiac arrest are high-quality chest compressions, providing sufficient ventilation, and minimizing interruptions in CPR.1
Chest compression methods in infants include the heel of 1-hand technique or the 2 thumb-encircling hand technique. When the rescuer is unable to fully encircle the infant’s chest, compressions should be performed using the heel of 1-hand. The 2025 guidelines eliminate the two-finger technique on the sternum because it does not reliably achieve adequate compression depth.1 Thus, answer choices A and B that involve two-finger technique are incorrect.
The recommended compression-to-ventilation ratio is 15:2 with 2-rescuers and 30:1 with a single rescuer. A respiratory rate of 20 to 30 breaths per minute is recommended for infants and children with an advanced airway in place. Excessive ventilation rates may lead to compromised hemodynamics.2
Cardiac arrest in infants and children most commonly results from progressive respiratory failure or shock rather than a primary cardiac etiology, making shockable rhythms less likely than adults.1 Shockable rhythms are more common in patients with congenital heart disease (CHD).3 In all cases, AED pads should be applied as soon as possible to monitor rhythm and deliver a shock in the case of ventricular fibrillation or pulseless ventricular tachycardia. Because pulseless ventricular tachycardia is a shockable rhythm, answer choice D is the correct answer.
If no pediatric pads or attenuator are available, it is reasonable to use adult pads, ensuring they do not touch. A standard AED energy selection of 120 to 360 J may be used in the absence of appropriate pediatric equipment in children less than 25 kg. When using a manual defibrillator, shocks should be delivered at a dose of 2 to 4 J/kg.3 Rhythm checks should be performed every 2 minutes with minimization of peri-shock pauses to less than 10 seconds.1
The 2025 AHA Guidelines for Pediatric CPR and ECC introduced several updates:
Unified Chain of Survival: Single Chain of Survival applied across all ages and care settings, replacing separate adult, pediatric, in-hospital, and out-of-hospital models1
Technique Updates1
• Severe foreign body airway obstruction
o Adults, children: Cycles of 5 back blows + 5 abdominal thrusts
o Infants, pregnancy, and morbid obesity: Cycles of 5 back blows + 5 chest thrusts
• Infant CPR: Two-finger technique removed
• Mechanical CPR devices and double sequential defibrillation: not routinely recommended
Medication Updates 3
• Early administration of first-dose epinephrine in nonshockable rhythms
• Refractory SVT: Consider IV procainamide, amiodarone, or sotalol after vagal maneuvers, adenosine, and synchronized cardioversion
Post–Cardiac Arrest Care3
• Maintain MAP >10th percentile for age
• Expanded guidance on neurologic prognostication after cardiac arrest
Expanded Scope of CPR/ECC4
• Opioid overdose response: Recognition, rescue breathing, and public-access naloxone
• CPR and AED training supported for children ≥12 years
• Dedicated chapter addressing foundational ethical principles and contemporary challenges across all age groups
REFERENCES
1. Joyner Jr B., Dewan M, et al. Part 6: Pediatric Basic Life Support: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025; 152(16).
2. Sutton RM, Reeder RW, Landis WP, et al. Ventilation rates and pediatric in-hospital cardiac arrest survival outcomes. Crit Care Med. 2019;47:1627–1636.
3. Lasa J, Duff J, et al. 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; 152(16).
4. Del Rios M, Bartos JA, Panchal AR, et al. Part 1: Executive summary: 2025 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2025; 152(16).