The 2025 European Resuscitation Council Guidelines for Pediatric Resuscitation emphasized clear, simplified procedures. The goal is to improve the quality of care in emergencies. Family physicians and pediatricians should also adapt their equipment and procedures promptly.

Rapid Diagnosis

Cardiac arrest in children is generally not a primarily cardiac event. It is usually preceded by respiratory or circulatory decompensation. The guidelines therefore emphasize the importance of early clinical assessment. The pediatric assessment triangle is helpful in this regard: Behavior (eg, altered consciousness), breathing (eg, flaring nostrils), and skin color (eg, mottling and cyanosis) should be routinely assessed. Calling emergency services early can often still prevent cardiac arrest.

Mandatory Two-Thumb Rule

A key change concerns chest compressions in infants. Previously, a single rescuer could use the two-finger technique in this situation. Now, the two-thumb encircling technique is recommended for all situations. The rescuer encircles the child’s chest with both hands. This allows for greater compression depth. At the same time, rescuers tire more slowly. The protocol for foreign-body aspiration has been refined: Infants: five back blows, alternating with five chest compressions using the two-thumb technique (no upper abdominal compressions or Heimlich maneuver for infants). For children: the standard five back blows alternating with five upper abdominal compressions (Heimlich maneuver).

Compressions and Ventilation

If a cardiac arrest occurs in an infant or child, resuscitation always begins with five initial rescue breaths after respiratory arrest has been confirmed. Rescuers who are formally trained in pediatric basic life support (BLS) perform resuscitation at a ratio of 15 chest compressions to 2 rescue breaths (15:2). Individuals without specific pediatric training but who are knowledgeable in adult BLS should use a 30:2 ratio.

Intubation Without Delay

In advanced life support, there are significant changes regarding airway management. Intubations should be performed with caution. A rescuer is now allowed a maximum of two attempts to place the tube. Each of these attempts should take no more than 30-60 seconds. If an attempt fails, effective bag-valve-mask ventilation or laryngeal mask ventilation must be resumed immediately. Atropine is no longer recommended for preparing for intubation. Another new development is the choice of equipment: cuffed tubes are now the standard for children of all ages, including infants. They ensure a better seal and reduce the risk for leaks.

Use Capnography

Continuous waveform capnography is a newly defined standard for every advanced airway management procedure. It is no longer used merely to confirm correct tube placement but provides valuable real-time information about the quality of chest compressions. A sudden, significant increase in end-expiratory CO₂ is also considered one of the most reliable clinical indicators of an impending return of spontaneous circulation (ROSC).

Emergency Medications

Pharmacologic therapy has also been refined in several key areas. For seizures, benzodiazepines remain the first-line treatment, including buccal midazolam, such as Buccolam. Levetiracetam is now the preferred second-line treatment for status epilepticus. It has replaced older active ingredients such as phenytoin in the treatment hierarchy. The recommended dose for correcting hypoglycemia has been slightly reduced. The recommendation is 0.2 g/kg of glucose as a bolus. This corresponds to 2 mL/kg of body weight of a 10% glucose solution.

Atropine Is Out

Atropine has largely fallen out of favor, except in cases of vagal stimulation and atrioventricular block. Epinephrine remains the mainstay of cardiac arrest treatment and should be given as early as possible in patients with nonshockable rhythms. Subsequent doses are recommended at approximately 4-minute intervals. In hypothermic patients, however, dosing is modified: only a single dose of epinephrine is given when the core temperature is below 30 °C, while in moderate hypothermia (30 °C to 35 °C), epinephrine is administered intravenously or intraosseously at roughly 8-minute intervals.

Caution With Fluid Volume

Regarding fluid management, the 2025 guideline calls for a more nuanced approach. Instead of large volumes, a more cautious bolus of 10 mL/kg body weight of an isotonic crystalloid solution is now recommended for nonhemorrhagic shock. A clinical reevaluation is required after each bolus to detect impending volume overload early and minimize the risk for secondary damage.

Treatment of Hyperkalemia

There has been a clear shift in thinking regarding hyperkalemia during resuscitation. Calcium and sodium bicarbonate are no longer routinely used in this situation. Instead, the focus is on a combination of insulin with glucose and beta-agonists.

Automated External Defibrillators (AEDs) With a ‘Pediatric Button’

Defibrillation for pediatric patients now follows more precise geometric guidelines. Children weighing less than 25 kg should have the pads placed on the front and back. This positioning is referred to as anteroposterior. For larger children, however, the choice of position remains flexible. Defibrillation is weight-adjusted; an initial dose of 4 J/kg is recommended. There are also new recommendations for equipment in public areas. AEDs should use a standardized pad size in the future. The necessary energy adjustment for children is then made via a button on the device.

Upper-Normal Blood Pressure Values

Following successful resuscitation (post-ROSC), the target values have shifted. The focus is now on very aggressive circulatory stabilization. Blood pressure should be above the 10th percentile after resuscitation. This applies to both the systolic and diastolic pressures. (Example: a 7-year-old child, target systolic pressure approx. 88 mm Hg to 92 mm Hg, diastolic pressure approx. 52 mm Hg to 55 mm Hg). In the past, the fifth percentile was often cited as the target value. Oxygen should be administered at 100% FiO₂ during CPR but must be titrated immediately after ROSC to a target SpO₂ of 94%-98%. This helps avoid the harmful effects of excessively high oxygen concentrations. Fever must be prevented.

Pediatric Emergency Equipment

Emergency equipment, including that in medical offices, should be reviewed and updated accordingly. Cuffed tubes in all standard sizes should be readily available in the emergency kit. The same applies to 10% glucose and levetiracetam. Modern AEDs with a pediatric mode significantly simplify use in an emergency. If intravenous access fails, the intraosseous route is the first choice. The necessary equipment must therefore be immediately at hand.

Practicing Emergency Procedures

More important than any new technology, however, is the adaptation of internal procedures. Teams should work in a clearly structured manner. Communication among responders must be structured and precise. Practice teams should regularly practice these new rules in small-scale simulations. In particular, avoiding delays during intubation, alerting emergency services, and establishing venous access requires a great deal of practical practice.

This story was translated from Coliquio, part of the Medscape Professional Network.