What’s new Resus Council Guidance 2025- Paediatric Life Support

You are working in the Children’s ED. The alert phone rings with an 8-year-old in cardiac arrest. They have been in a shockable rhythm for some time.

It’s been a while since you looked at the most up-to-date Resus guidance and have heard there are some changes.

You wonder, what are the key updates?

Who is behind these new guidelines?

This key resuscitation resource is compiled by the Resuscitation Council UK (RCUK) based on European Resus Council (ERC) 2025 guidelines, tailored to UK practice. RCUK and ERC are esteemed bodies that work with the International Liaison Committee on Resuscitation (ILCOR) to produce cutting-edge, evidence-based guidance on the resuscitation of children. The publication is the culmination of systematic reviews, randomised controlled trials, observational data, and expert consensus on all aspects of paediatric resuscitation, providing an up-to-date framework for managing critically unwell children.

We have reviewed the key changes from the previous iteration (RCUK 2021) to provide you with a summary of the updates.

Paediatric Basic Life Support

There were no changes made in recommendations regarding paediatric BLS- Keep doing what you are doing!

PBLS vs NLS (use NLS during neonatal and maternity unit stays, if OOH can be used up to 24 hours of life- after that it’s PBLS).

The Deteriorating Patient

Airway

– Consider apnoeic oxygenation or high-flow nasal oxygen to avoid hypoxia during intubation.

– Limit each intubation attempt to 30-60 seconds and re-ventilate immediately in the event of desaturation or bradycardia.

– Limit attempts to intubate to FOUR then focus on oxygenation, e.g. face mask or supraglottic airway, and call for additional support, e.g. anaesthetics or intensive care.

Check out A Simplified Approach to Managing the Difficult Airway in Children – Don’t Forget the Bubbles for more info.

Circulation

– In shocked patients, IV access can be tricky, and time can fly quickly! Aim to spend no more than 5 mins attempting IV access before inserting an IO. Provide effective analgesia unless the child is comatose.

– Competent providers should use point-of-care ultrasound (POCUS) to guide IV cannulation.

– Fluid boluses at 10ml/kg can now be given up to 500ml in adolescents (14+) in line with adult practice. This has been increased from the previous 250ml cap. This should ideally be a balanced crystalloid, e.g. PlasmaLyte 148 or Hartmann’s solution.

– Noradrenaline is recommended as the first-line vasopressor; adrenaline is recommended as the first-line inotrope; milrinone is recommended as the first-line inodilator. Decisions regarding the need for vasopressor vs inotropes are left to the clinician’s discretion.

Check out these posts A Beginner’s Guide to Vasoactive Drugs for Children with Septic Shock – Don’t Forget the Bubbles and All you need to know about Adrenaline – Don’t Forget the Bubbles for some more context.

In traumatic brain injury (TBI), use fluids and vasoactive medications to target mean arterial pressure (MAP) at or above the 50th centile for age (to maintain cerebral perfusion pressure). 0.9% sodium chloride may be preferred over balanced crystalloids in this setting (to drive hypernatraemia and provide neuroprotection).

Drugs

– In patients with a high BMI, use the ideal body weight for drug dosing.

Most resuscitation drugs are hydrophilic (and therefore do not distribute into fatty tissue) so should be dosed based on ideal body weight, not actual body weight. Beware of exceeding adult doses- especially in children with a high BMI.

Cardiac Arrest

Non-shockable

Breathe a sigh of relief here, nothing new to see as there have been no significant changes in guidance for patients on the non-shockable side of the algorithm (which is the case for the majority of paediatric arrests).

Shockable

Pad positioning: In the anterolateral position, one pad is placed below the right clavicle and the other in the left axilla. In the anteroposterior position, the anterior pad is placed mid-chest, immediately left of the sternum, and the posterior pad in the middle of the back between the scapulae.

Use the anteroposterior position in infants and children (< 25 kg) who can easily be turned onto their side for pad placement and in whom the anterolateral position is more challenging to achieve without contact between the pads. Use the anterolateral position in larger children, as it results in less interruption of chest compressions than the anteroposterior position. Avoid breast tissue in adolescents.

– Defibrillate at 4J/kg for the initial shock, not exceeding the recommended adult energy (120- 200J, manufacturer dependent).

– In refractory VT/VF (>5 shocks), escalate energy in a step-wise fashion to a maximum of 8J/kg

– If the child gets ROSC but re-arrests in VT/VF, keep the same energy. Defibrillate using the energy that previously worked to get ROSC.

When charging the defibrillator, keep the pads or paddles attached. To minimise “hands-off” time, continue CPR during charging if using pads. This needs to be done with clear communication and in a safe manner… don’t shock the rescuers, you’re busy enough!

If a child arrests in a shockable rhythm whilst being monitored, deliver up to 3 stacked shocks at 4J/kg. Check for a change in rhythm and signs of life between shocks, but if the patient remains in VT/VF and pulseless, rapidly charge and defibrillate again.

Start CPR if the patient remains in cardiac arrest after three shocks. If the rhythm remains shockable, administer adrenaline and amiodarone after five shocks (stacked 3 plus 2 more cycles) with further amiodarone after the 7th shock (stacked 3 plus 4 more cycles).

Note that this differs from adult practice, where amiodarone is given immediately after stacked shocks.

Monitoring

If an arterial line is in situ, monitor diastolic pressure during CPR and drug administration. Aim for a diastolic pressure >25mmHg in infants or >30mmHg in children and adolescents.

This is important because of the heart’s perfusion. Coronary filling occurs in diastole, so the diastolic pressure must be adequate to send vital oxygen to the struggling heart muscle to achieve that all-important ROSC. If we have the luxury of invasive monitoring, we should target a number we know will deliver this coronary perfusion.

Special Circumstances

The latest iteration of the guidelines makes guidance on special circumstances much more explicit and more in line with established adult guidance. Nothing is especially ground-breaking, but the strength of recommendation seems to have increased.

Bradycardia

In children with circulatory failure due to bradycardia, optimise oxygenation, ventilation and circulation.

If HR<60 with poor perfusion despite adequate respiratory support, start CPR.

Consider a small bolus of IV adrenaline (1-2 mcg/kg) or as a continuous infusion. Consider atropine only in specific cases of bradycardia, e.g. increased vagal tone or cardiac conduction diseases.

Pacing may be required in complete heart block or sick sinus syndrome, so it’s important in any case of bradycardia- especially those not improving after optimisation and fluid bolus that you get your friendly cardiologist colleagues on board early.

Pulmonary Embolism (PE)

Suspect in cases of tachycardia, tachypnoea and hypoxia with risk factors. Risk factors include previous venous thrombo-embolism (VTE), central lines, cardiac surgery, cancer (especially with leucocytosis) and recent surgery or immobility, especially if associated with unilateral leg swelling.

Consider echocardiography and refer to local policy and expert advice regarding thrombolysis, which can be systemic or catheter-directed.

In cardiac arrest due to PE, consider thrombolysis using e.g. alteplase 0.3-0.5mg/kg (max 50mg) as a push (2mins). Consider a repeat dose at 15 minutes. Consider extracorporeal life support with or without surgical embolectomy if facilities allow.

This has been in adult practice for a while, but is now explicitly stated for children.

Septic Shock

Obtain blood samples for culture and PCR if possible, and start broad-spectrum antibiotics within an hour.

If the child is not responding to fluid resuscitation and vasoactive therapy (noradrenaline as 1st-line vasopressor, adrenaline as 1st-line inotrope), or in children with adrenal insufficiency, consider hydrocortisone 1-2mg/kg IV (max 100mg).

This is all in keeping with existing Surviving Sepsis guidelines but is now explicitly stated.

Haemorrhagic Shock

Activate local protocols for major haemorrhage and control catastrophic haemorrhage, for example, using pressure dressings, tourniquets, pelvic binders or limb splints.

Treat coagulopathy – the specific wording is pretty vague “use a strategy that focuses on improving coagulation in children with severe blood loss”.

This would suggest following your MHP and ensuring correction of acidosis, hypothermia, and hypocalcaemia; calcium replacement alongside massive transfusions; and using balanced transfusions (1:1 red cells to fresh frozen plasma/Octaplas), with platelet and cryoprecipitate transfusions considered.

Use tranexamic acid ASAP and at least within 3 hours of the injury in those with life-threatening haemorrhage or requiring a transfusion after injury. Give a 15-20mg/kg IV bolus (max 1g) followed by at least 8 hours of infusion at 2mg/kg/hr (max 1g in 8 hours).

Limit crystalloid use to 20ml/kg maximum. Use blood products as soon as they are available.

If shock remains refractory to transfusion, especially in those with traumatic brain injury or under anaesthesia, use vasoactive agents to support BP. In those with TBI, aim MAP >50th centile for age, which may require noradrenaline and adrenaline.

In traumatic cardiac arrest, specialist providers should treat using HOTT principles – Hypovolaemia, Oxygenation, Tension and Tamponade. Treating these should be a priority, running concurrently with chest compressions and consideration of IV adrenaline. HOTT has priority over AED/pad placement unless there is a high likelihood of a shockable rhythm, e.g. electrocution or commotio cordis.

Whilst order of priority may vary with circumstances and providers, obtain access and manage haemorrhagic shock with fluids and blood products; oxygenate with airway manoeuvres, supraglottic airways and early intubation; perform bilateral thoracostomies to decompress

tension pneumothoraces; and when it is indicated (mostly penetrating trauma with a short down-time), connect these thoracostomies with a thoracotomy to allow decompression of cardiac tamponade.

This has been in adult practice for years, but is now featured explicitly in the paediatric guidance.

Electrolyte Disorders

Hyperkalaemia should be suspected in children with massive lysis, including haemolysis in neonates, tumour lysis syndrome and crush injuries; those with acute or chronic kidney diseases and certain intoxications, including malignant hyperpyrexia from e.g. suxamethonium or Penthrox (methoxyfluorane).

If severe hyperkalaemia is confirmed (>6.5mmol/L or >7.0mmol/L in neonates <4 days old), rapidly administer 0.1unit/kg (max 10 units) rapid-acting insulin (i.e. Actrapid) in 5ml/kg 10% glucose (max 250ml) over 30 minutes, followed by a glucose infusion.

Monitor glucose and potassium every 15 minutes for 4 hours.

In cardiac arrest, give the insulin and glucose as a bolus.

Give nebulised or IV salbutamol and consider furosemide or dialysis.

If there are ECG changes, give calcium gluconate 10% 0.5ml/kg up to a maximum of 30ml. Do not use calcium in cardiac arrest. It does not improve survival and, in some studies, has been shown to worsen outcomes. Focus on potassium-lowering agents instead.

Hypokalaemia in arrest now has a specific treatment algorithm. Give 1mmol/kg to max 30mmol

– start at 2mmol/min over 10 minutes with the rest of the dose over the next 5-10 minutes. Repeat until K >, then continue with an infusion afterwards. Consider replacing magnesium.

Hypoglycaemia: there remains disagreement among governing bodies regarding optimal management. EPALS continues to advocate for 2ml/kg 10% glucose, in contrast to APLS, which suggests using 3ml/kg. The evidence isn’t strong in either direction (hence the disagreement), so follow your local institutional policy.

Cardiac tamponade

Suspect tamponade as a cause of cardiac arrest after cardiac surgery, in penetrating chest trauma or pericarditis. POCUS can be used to detect tamponade. To treat: perform pericardiocentesis, mini-thoracotomy, resuscitative thoracotomy or re-do sternotomy depending on setting and expertise.

Obstructed Cardiac Shunt

A novel part of the guideline is that there are now specific guidelines on the management of obstructed cardiac shunts, e.g., ductus arteriosus stents or post-Norwood or Glenn procedures. Consider obstruction by kinking or thrombosis as a cause of cardiac arrest in these patients. Maximise alveolar oxygenation with 100% oxygen and optimise perfusion with fluid boluses for preload and vasoactive drugs to improve contractility and afterload.

Anticoagulate these patients using heparin. Load with a 50-100unit/kg bolus before starting an infusion under specialist advice.

Discuss with specialists as soon as possible and consider cath lab interventions or surgery.

In the direct post-operative period, consider re-sternotomy. They do not make it explicit what the direct postoperative period means (is this in the recovery room, or is this 3 days later on the PICU?) However, the adult Cardiothoracic unit Advanced Life Support (CALS) advocates re-sternotomy up to 10 days post-cardiac surgery – discuss with your cardiac surgical and intensivist team.

Drowning

Give 100% oxygen as soon as able and commence PBLS with modifications. Intubate as soon as expertise is available. Monitor core temperature and handle the child as gently as possible in a horizontal position to reduce the risk of cardiac arrest (especially VF).

Initiate non-extracorporeal life support rewarming if an ECPR centre cannot be reached within a reasonable time (e.g. six hours).

No real change in the management of drowning- it’s important to follow the modified algorithm. Simplified: Start rewarming at <35°C; aim for a rate of 1 °C/hour.

Delay CPR if the temperature is <28°C until continuous CPR is feasible.

Below 30°C, adrenaline will accumulate and may have more detrimental than beneficial effects. Below 30°C, give a single dose of adrenaline unless planning immediate initiation of extracorporeal life support. Do not give amiodarone until the temperature is above 30°C.

Prolong the administration intervals of resuscitation drugs while the core temperature remains between 30-35°C (e.g. adrenaline every 8 min, second dose of amiodarone after 8 min).

Attempt defibrillation a maximum of three times if a shockable rhythm is present under 30°C. If this is ineffective, delay further attempts until the core temperature exceeds 30°C. Then use the standard defibrillation sequence (every 2 minutes).

>35°C use the standard algorithm.

Hyperthermia

Identify patients with hyperthermia or heat stroke with a core temperature>40°C not caused by fever. Remove the child from the heat source, stop exercising, loosen or remove clothing.

>40°C start cooling aggressively, immersion in cool water up to the neck if able.

Stop aggressive cooling when temp < 39°C and stop all active cooling when temp reaches 38°C—no change to the PALS algorithm. If due to malignant hyperthermia, stop all triggering agents, optimise oxygenation and ventilation, correct acidosis, and administer dantrolene. If they were on an anaesthetic circuit with inhalational agents, which may have triggered the reaction, change the entire circuit.

I also work with adults. Did anything change there?

For years, there has been discussion around optimal pad placement, especially in refractory VT/VF, including vector change (antero-posterior) or dual sequential defibrillation (AP and standard anterolateral). Vector change has officially been incorporated into the core algorithm, with antero-posterior pad placement to be used after 3 shocks (alongside adrenaline and amiodarone).

This hasn’t translated to paediatric practice…. Yet!

References

Resuscitation Council UK Guidelines 2025. Skellett S et al. Oct 2025. Available from URL: https://www.resus.org.uk/professional-library/2025-resuscitation-guidelines/paediatric-basic-life- support-guidelines

European Resuscitation Council Guidelines 2025 Paediatric Life Support. Djakow J et al. Resuscitation 2025;215 (Suppl 1):110767. https://doi.org/10.1016/j.resuscitation.2025.110767