Cardiac arrest in children: emerging trends in resuscitation and outcomes in low-resource pediatric emergency departments

Abstract

Pediatric cardiac arrest is a rare but life-threatening condition that often arises from respiratory failure. While survival rates in pediatric emergency settings are generally low, outcomes are significantly worse in low-resource environments. Most resuscitation guidelines are designed for high-resource settings, limiting their applicability in low- and middle-income countries, where infrastructure, staffing, and equipment shortages pose critical challenges. This narrative review explores emerging trends in pediatric cardiac arrest resuscitation in low-resource settings, focusing on the application of basic and advanced life support protocols, telemedicine, and low-cost technologies. Furthermore, we address post-resuscitation care gaps and propose practical solutions for improving survival and neurological outcomes. Key barriers to guideline implementation include ethical challenges, infrastructural limitations, and educational constraints. Tailored interventions, including community-based Cardiopulmonary Resuscitation training and low-cost resuscitation tools, are critical to improving outcomes in these regions. Future research should focus on developing context-specific guidelines and sustainable healthcare infrastructure to bridge the gap in pediatric cardiac arrest care between high- and low-resource settings.

Introduction

Pediatric cardiac arrest, while uncommon, represents a critical condition where outcomes vary dramatically by setting. In the US (a high-resource country), survival to hospital discharge for out-of-hospital cardiac arrest (OHCA) transported to the emergency department (ED) is approximately 19%. Only 8.5% of survivors achieved favorable neurologic outcomes, with better outcomes in pediatric-specialized EDs (24%) [1]. In contrast, in-hospital cardiac arrest (IHCA) in pediatric wards shows a higher survival rate of around 40.4%, with 25–30% of survivors experiencing moderate-to-severe disability [1, 2].

In Tanzania PEDs, atraumatic OHCAs show a 32.8% survival and traumatic OHCAs 30.7%, but neurologic outcomes are rarely reported, reflecting gaps in post-resuscitation care. However, these categories do not encompass all arrest types, as other causes (e.g., drowning) may have distinct outcomes [1, 3]. These variations indicate the profound impact of setting and available resources on pediatric cardiac arrest outcomes.

Pediatric cardiac arrest frequently results from an initial respiratory incident progressing into cardiac failure [4, 5]. Because respiratory conditions often precede cardiac arrest in children, ensuring proper oxygenation and ventilation is crucial. These elements are central to the 2020 American Heart Association Guidelines (AHA) for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care [5–7]. AHA guidelines also emphasize that chest compressions are indicated in both pulseless cardiac arrest (absence of palpable pulse) or Profound circulatory failure (e.g., heart rate < 60 bpm with poor perfusion despite oxygenation), reflecting children’s unique physiology, where interventions during pre-arrest states can prevent deterioration [2, 4–7]. However, most predictors of arrest (e.g., respiratory failure, sepsis) derive from high-income studies. They may not apply to low-resource settings, where delays in care and limited diagnostics alter risk profiles [3, 8, 9].

The World Bank defined Low- and Middle-Income Countries (LMICs) as countries with a gross national income per capita of $1025 or less [ 8 ]. Most low-income countries are also considered low-resource countries or potential settings where resources can be limited in quantity, quality, or both, both in time and space [ 9 ]. The World Health Assembly’s 2019 resolution highlights the importance of emergency care in LMICs, stressing that enhanced emergency services could potentially address over half of the global deaths occurring in low-income regions [ 10 ]. Predictors of arrest are critical for determining the risk of experiencing a cardiac arrest [ 3 ]. They have been the focus of many studies in high-income nations; however, these studies may not be applicable to low- and middle-income countries, where resources and healthcare systems are limited and treatment times are longer [ 3, 9 ]. There is also little research addressing the applicability of existing resuscitation guidelines to these settings, further complicating efforts to reduce pediatric mortality from cardiac arrest [ 8 ].

The survival of critically ill pediatric patients in low-resource settings remains at risk due to inadequacies in healthcare infrastructure, logistics, and the shortage of qualified personnel [11]. These nations bear the brunt of the world’s pediatric population, mortality, and serious illnesses [11].

This review aims to evaluate the challenges and advancements in managing pediatric cardiac arrest in low-resource settings with an emphasis on resuscitation protocols, post-resuscitation care, and innovative solutions such as telemedicine and low-cost technologies. A comprehensive understanding of current practices and knowledge gaps can contribute to the development of context-specific guidelines and sustainable healthcare initiatives that address disparities in pediatric emergency care globally.

Methodology

We conducted searches in PubMed and Google Scholar databases using the following MeSH terms and keywords:

• MeSH Terms: “Pediatric Cardiac Arrest,” “Resuscitation,” “Developing Countries,” “Emergency Medical Services,” “Child,” “Infant,” “Adolescent.”

• Keywords: “Pediatric cardiac arrest,” “low-resource settings,” “resuscitation outcomes,” “emergency care in developing countries,” “child resuscitation,” “infant cardiac arrest,” “adolescent resuscitation.”

The search covered literature published from 1993 to 2024. We included studies that focused on pediatric patients (ages 0–18) experiencing cardiac arrest in low-resource or developing settings. High-resource studies were included when they provided contextually relevant comparisons or adaptable strategies. Due to the difficulties in conducting research in resource-limited settings, both peer-reviewed articles and relevant gray literature were considered, ensuring a comprehensive understanding of the topic. We also reviewed reference sections of highly relevant articles.

Epidemiology

IHCA and OHCA occur [12] with two incidence peaks: the first in infancy, with 2.1 cases per 100,000 person-years, and the second in adolescence, with 1.44 cases per 100,000 person-years [5]. The global incidence of pediatric OHCA and IHCA arrest varies widely throughout the world, with a range of 2.0–20.0/100,000 person-years for OHCA: (2.0/100,000) typically seen in high-income countries with robust prevention systems and (20.0/100,000) reported in some low-resource settings with limited access to preventive care [4, 12]. In addition, the US incidence of pediatric IHCA is 1-2cases/1,000 hospital admissions [6, 7], increasing to (8–10 cases/1,000 admissions) in pediatric intensive care units PICUs for IHCA [2, 7].

OHCA outcomes demonstrate disparities due to cardiac arrest causes, initial ECG rhythm, eyewitness cardiac arrest, and use of an external automatic defibrillator [1, 4, 5, 12] with OHCA mortality rates reaching 90–92% in most studies. Only 8.5–10% of survivors were discharged with favorable neurologic outcomes [1, 2, 4, 5, 12]. The IHCA outcomes show even greater disparities as survival rates in the US (a high resource country) versus LMICs are 45% vs. 15–22%, respectively, highlighting the significant gap [2, 7, 9, 13]. The gap is primarily due to the critical differences in monitoring, team availability, and post-resuscitation care [6, 7, 9, 13].

Critically ill children arriving at the EDs requiring oxygen therapy and intubation [14, 15] are at a significantly higher risk of cardiac arrest [3, 14, 15] particularly in resource-limited settings where interventions are delayed due to equipment shortages and triage prioritization of the most severe cases, resulting in higher disease burden and poorer outcomes [2, 3, 13]. The strong association between impaired circulation, delayed intubation, and increased risk of cardiac arrest underscores the critical need to address these resource gaps [3]. Nishisaki et al. [14] emphasized that delayed intubation due to resource limitations or challenges in the emergency department setting increases intubation-associated cardiac arrest odds in pediatric patients due to worsening oxygen saturation, prolonged hypoxia, and acidosis [14]. Emerson et al. [15] results of significant oxygen desaturation (SpO₂ <80%) in 14% of intubation attempts highlight the need for immediate intervention to avoid these critical outcomes [15].

Unfortunately, scarce epidemiological data on CPR in low-resourced settings reveal varying rates of restoration of a heartbeat and adequate blood circulation after a cardiac arrest, marking the return of spontaneous circulation (ROSC) ranging from 0 to 62%, with low survival rates of 1 to 17% and poor neurological outcomes of 1 to 9% [8].

While clinical research has long been supported in high-income countries (HICs), research in low- and middle-income countries (LMICs) has faced challenges such as limited infrastructure, funding, and ethical concerns, highlighting the need for locally conducted studies that address the specific needs of these regions [9, 13, 16].

Challenges in early recognition and diagnosis

Most Cardiopulmonary Resuscitation (CPR) studies and approaches originate from high-income, well-resourced healthcare settings, making it difficult or even impossible to apply standard resuscitation guidelines in low-resourced settings [17, 18]. Pediatric cardiac arrest incidence is rising in low-income countries with a documented increase in both OHCA and IHCA [17]. Pediatric OHCA incidence grew by 22% from 2014 to 2018 in Cape Town, South Africa [17]. Results from an African scoping review documented that pediatric arrests increase at 1.5 times the rate of adult cases in LMICs caused primarily by preventable respiratory conditions (58% of pediatric arrests), perinatal complication (31% of neonatal arrests), and delayed resuscitation access (median EMS response 8–15 min longer for pediatric cases) [17, 18].

The WHO defines a functionally limited emergency system as one that lacks a functional prehospital ambulance system, experiences a delayed recognition of cardiac arrest, and struggles to implement resuscitation guidelines or provide post-resuscitation intensive care [8, 19]. In 2019, the World Health Assembly emphasized that more than half of deaths in low and middle-income countries could be prevented by improving emergency healthcare services [10] through Pediatric-specific CPR protocols (e.g., simplified respiratory-focused algorithms), Community-based neonatal resuscitation training, and Context-appropriate resource allocation [10, 17, 18].

In high-resource settings, the availability of diagnostic modalities such as electrocardiogram (ECG) and blood pressure cuffs allows rapid assessment and recognition of cardiac arrest [9, 20]. In contrast, in low-resource settings, recognition of cardiac arrest is often delayed due to the shortage or even complete absence of basic monitoring equipment. In Mally et al. [21] ECG limitation is an obstacle, with only 12% of Tanzanian emergency departments having functioning ECG machines suitable for pediatric patients, and 38% of pediatric arrests were initially missed due to reliance on respiratory signs rather than circulatory assessment [21]. Also, the Scarcity of pediatric blood pressure cuffs in low-resource regions necessitates circulation assessment through alternative methods such as skin examination, mucous membranes, and capillary refill time [9].

63% of LMIC hospitals lack pediatric-sized cuffs [21] and pulse checks are often performed by general nurses without pediatric advanced life support training [20]. These diagnostic limitations hinder the ability to recognize a cardiac arrest and its underlying cause in many emergency departments [20].

Resource scarcity has led to high mortality rates for otherwise treatable conditions. A descriptive study on pediatric sepsis patients in a Tanzanian hospital showed a high in-hospital mortality rate of 14.2%, attributed to limited resources, treatment failure, or poor follow-up [22]. Moreover, other challenges such as power outages and malfunctioning equipment may affect hospitals’ ability to provide adequate care for pediatric critical care and emergency patients, with equipment failure attributed to 18% of delays in initiating CPR in a healthcare center in South Africa [23, 24].

Environmental and logistical challenges further complicate the situation in low-resource pediatric emergency departments. For instance, overcrowded facilities, limited access to essential medications, and inadequate staffing levels contribute to delays in making an accurate diagnosis and proper management [25]. These challenges are particularly evident during high-volume situations when high demand for emergency care is required [21].

BLS in low-resource settings

Basic life support (BLS) is initial management until definitive management can be initiated, usually done by bystanders [26]. The success of BLS depends on the etiology of arrest, initial arrest rhythm, bystander CPR, and emergency medical services (EMS) access. In shockable rhythm cases such as ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT), defibrillation is used to restore normal sinus rhythm and achieve return of spontaneous circulation (ROSC). Both Basic Life Support (BLS) and defibrillation are time-sensitive interventions; the earlier they are performed, the better the outcomes, with significant reductions in morbidity and mortality rates [27–29]. A study by Awad et al. [29]. found that the probability of achieving ROSC decreased by 19% for every one-minute increase in the duration of intra-arrest ventricular fibrillation (VF) [29].

Automated external defibrillators (AEDs) are a key component of BLS. Untrained members of the public can utilize them to treat shockable ventricular arrhythmias in the event of an OHCA. Accessibility and availability of AEDs have a sizable impact on the effectiveness of BLS measures and ROSC rates, and easier access has been linked with better outcomes. However, disparities remain in AED accessibility, and resource-poor environments face significant challenges in that regard. Studies conducted in the United Kingdom show that the nearest AED is further in more deprived areas [29]. Affluent residential areas, with inhabitants from a predominantly white background and with higher socioeconomically classed occupations, were associated with higher AED availability [30]. Further studies conducted in Germany and Denmark drew similar conclusions, with lower AED availability in districts with lower incomes, higher rates of unemployment, and higher percentages of immigrant residents [31, 32]. Despite most of the world’s population residing in lower and middle-income countries, limited data on the availability of AEDs in resource-poor environments remains a formidable challenge, with most data originating from studies conducted in higher-income and middle-income countries. Comparing the percentage of ROSC achievement and the number of patients surviving hospital discharge in different countries can potentially give insights into AED accessibility. In Japan, classified as a high-income country, the percentage of OHCAs surviving to discharge was 5.2% [33]. On the other hand, the percentage of OHCAs surviving to discharge in Pakistan, classified as a lower-middle-income country, was quoted at 1.6% [8].

Promoting BLS training among healthcare workers and the public and improving access to AEDs are key to increasing rates of bystander CPR and, therefore, the rates of ROSC in OHCAs. In resource-limited settings, BLS training has been adapted to reflect local resource availability. As Fig. 1 shows, one adaptation is the removal of components of the training curriculum that utilize certain devices not available at the healthcare facility, such as the AED [34]. Numerous community-driven global initiatives have been founded to promote resuscitation awareness among the public. One prime example is the World Restart a Heart (WRAH) initiative, founded by the International Liaison Committee on Resuscitation (ILCOR). The initiative aims to increase public awareness of CPR and, therefore, increase the rates of bystander CPR for OHCA victims [35].

Fig. 1.

Pediatric basic life support in low-resource settings

ILCOR has also designated the day, October 16, as World Restart a Heart Day and has shared numerous resources targeted at the public and regional and national resuscitation councils, with the encouragement that awareness activities be held on or around that date [36]. Moreover, BLS courses have been successfully conducted for marginalized groups. Schnaubelt et al. [36]. have described the successful facilitation of a BLS course for refugees, with translations to the refugees’ native languages made available and teaching chest-compression-only CPR. As a result, the willingness to perform CPR increased by 74% among the course’s participants [36].

ALS protocols and adaptations

The Pediatric Advanced Life Support (PALS) guidelines were developed to address the unique physiology and requirements of children. The guidelines are stratified by age group, with infant guidelines applying to individuals younger than 1 year of age, child guidelines applying to individuals aged 1 year to puberty, and adult guidelines applying to individuals showing signs of puberty [6]. Despite targeting a different age group, the PALS guidelines are very similar to the ALS guidelines [6]. Like the ALS guidelines, the PALS guidelines heavily emphasize the importance of prompt and effective chest compressions while putting equal importance on ventilation. PALS also highlights the importance of an open airway, access to drugs like epinephrine, and early defibrillation for shockable rhythms [6].

Efforts to address differences in resuscitation efforts in high and low-resource countries have gained momentum in recent years. For example, the European Resuscitation Council and the American Heart Association (AHA) have called for resource mindfulness in low-resource countries, with an emphasis on improving CPR education and acknowledging geographical differences. Moreover, some countries have implemented local guidelines [6, 8, 9]. For example, The Indian Resuscitation Council developed an algorithm based on local resource availability in India. Pakistan and South Africa have also issued recommendations that are similarly adapted to local needs [9]. However, many countries still use American or European guidelines [3].

The AHA and ILCOR also stress prioritizing oxygenation and adequate ventilation during resuscitation [37] as hypoxia is the most common cause of cardiac arrest in children of all age groups [38, 39]. Despite numerous advancements in pediatric critical and emergency care, low-middle-income countries still face numerous challenges. Numerous hospitals lack rapid access to medications and supplies such as defibrillators, as shown in Fig. 2 [16].

Fig. 2.

Pediatric advanced life support (ALS) in low resources settings

Recalibrating global BLS and ALS guidelines to accommodate the limitations of low-resource countries can potentially improve outcomes in these settings. While limited evidence exists on the effect of adapted guidelines on outcomes, adapted BLS courses have shown significant promise in improving resuscitation outcomes [40]. Research shows that adapting BLS training courses to local needs can improve baseline knowledge and skills in healthcare personnel. In a BLS course in Rwanda modified to suit local needs, they changed three main aspects: they replaced advanced airway scenarios with hands-only CPR training, used pictorial mannequin stickers demonstrating hand placement for pediatric vs. adult CPR, and implemented monthly 10-minute refresher drills using repurposed mattress mannequins for sustainability. These modifications led to an increase in providers’ competency from 16.2% pre-course up to 63.2% post-course, deemed capable of providing high-quality one-rescuer CPR after the course, with particular improvement in correct compression depth and appropriate rate [34].

Changing legislation on bystander CPR has also been shown to improve cardiac arrest outcomes. The Emergency Medical Aid Act, implemented in the Chinese city of Shenzen in October 2018, provided legal guidance for OHCA resuscitation and endorsed AED usage and CPR training. As a result, bystander CPR rates increased from 4.1% pre-legislation to 18.73% after legislation, and prehospital ROSC rates increased to 7.21% from 0.92% [41].

Use of low-cost technology in cardiac arrest management

In LMICs, automated CPR devices for cardiac arrest management show promise for adults. As detailed by Khan et al. [ 42 ] a new automated cardio-pulmonary resuscitation (CPR) device significantly reduces costs to around USD 500, compared to traditional devices priced at USD 15,000–20,000 [ 42, 43 ]. However, their application to pediatric populations remains limited due to lack of size-appropriate designs, insufficient training for pediatric CPR [ 20 ] and resource allocation priorities [ 43 ]. Instead, low-cost pediatric-specific innovations may offer more feasible solutions until pediatric mechanical CPR evidence emerges. One example is cardboard color-coded disposable compression depth feedback devices ($2/unit) that were implemented in Rwandan course training, where they make an audible click sound when optimal depth is reached [ 34 ]. Smartphone apps are another example of real-time CPR guidance because these applications utilize built-in accelerometers and audiovisual alerts to provide real-time feedback on compression rate (100–120 bpm) and depth (1.5–2 inches for children), giving immediate feedback, improving training and results with low cost [ 44 ].

In remote areas, telemedicine serves as a vital link between local healthcare providers and specialist intensivists, particularly where access to pediatric care is limited, to address critical gaps in medical experience and resources [42, 44]. Telemedicine offers prevention and education through high-quality audiovisual communication, enabling healthcare teams to receive direct guidance on critical procedures for monitoring, medication adjustment, and managing critically ill and high-risk patients, particularly in settings where delays in accessing specialized care can result in poor outcomes [13, 20, 44]. Real-time consultations during emergencies allow frontline providers to receive prompt advice on life-saving measures, including acute management and complex decisions regarding patient transfers and critical care [42, 44].

Moreover, telemedicine enables ongoing education and training for regional professionals, reducing reliance on distant centers and building confidence in managing pediatric emergencies [44]. Studies show that teleconsultations improve the identification of life-threatening conditions and patient management, ultimately decreasing mortality rates [13]. Although the cost of establishing basic telemedicine systems is initially high [44] sustainable models have been developed using existing smartphones and messaging platforms like WhatsApp [16].

When it comes to low-cost interventions for cardiac arrest, establishing emergency medical services (EMS) systems is crucial. These systems enhance early recognition, are highly economical, and significantly improve survival rates [45, 46]. Examples include EMS development for cardiac arrest and reproductive health services in Uganda, as well as studies from Thailand projecting savings through faster EMS response times [46]. In underdeveloped healthcare systems, these interventions can significantly enhance health outcomes and efficiency [47].

So, despite the challenges, there are promising trends and approaches that could improve outcomes for pediatric cardiac arrest in low-resource settings. Telemedicine can help bridge the diagnostic gap by enabling remote consultations with specialists [20]. In addition, mobile diagnostic units equipped with portable ECG and echocardiography can increase advanced diagnostic tools in low-resource areas. These solutions, along with establishing emergency medical services, improving training, and education for healthcare providers, lead to better outcomes in pediatric cardiac arrest cases [34, 45, 46].

Scalability, sustainability, and Cost-Effectiveness considerations

The scalability of telemedicine is promising as it can be integrated into existing healthcare systems, providing continuous support and education to local providers [48].

Cost-effectiveness is incompletely understood despite the financial constraints being a significant challenge in pediatric emergency medical services development [49]. In LMICs, not only do they suffer under the financial burden, but they also face resource barriers, lack of relevant and reproducible measures, ethical constraints, and discrepancies in recognized emergency care [48]. Standardizing measured metrics, such as mortality rate and fostering partnerships between academic institutions and healthcare centers, are all key to addressing this issue [48].

Costs in LMICs were lower when measured in US dollars but correlated to high costs when measured in the local currency; costs also varied significantly depending on the resource utilized. For example, in Guinea, the cost of treatment interventions for pediatric injuries was $483 per child’s life saved. Improvement of infrastructure also poses an economic burden. In Sierra Leone, the cost of treatment training and triage implementation was $165 per pediatric death averted [ 48 ].

The potential economic benefits incurred from the reduction of mortality rates are significant when compared to the costs of improving the standard of care. A model utilized by Kotagal et al. [ 50 ] estimated an economic benefit of US$ 758 billion–786 billion per year globally if the mortality rates in LMICs were reduced to the rates in high-income countries [ 50 ]. However, limited evidence is available on the social impacts and economic burden of lost workforce. Further research is required to accurately assess the positive effects of emergency care interventions on economic growth and productivity [ 48 ].

Post-resuscitation care: gaps and innovations

Post-cardiac arrest care (PCAC) plays a vital role in improving survival rates and neurological outcomes, particularly in pediatric patients [51, 52]. Despite advances in resuscitation techniques, significant challenges remain in managing post-cardiac arrest syndrome (PCAS), which includes brain damage, heart dysfunction, and other systemic issues [51, 52]. According to Topjian et al. [52] effective PCAC should address these complex problems to improve both survival and neurological recovery.

Regular neurological assessments, including electroencephalography (EEG), help detect issues like seizures or reduced brain activity early, which are common after cardiac arrest. Hemodynamic instability, abnormal blood pressure, and circulation are other significant challenges in post-resuscitation care. Early detection of hypotension (low blood pressure) is crucial, as it is linked to poorer outcomes. Aggressive fluid Resuscitation and vasopressor support are often necessary during the post-arrest phase to maintain stable blood circulation [53].

Echocardiography, a technique used to assess the heart’s function in real-time, provides valuable information for managing fluid levels and optimizing cardiac output. However, this technology is often unavailable in resource-limited settings [52] which complicates care in these environments.

Currently, most recommendations for post-cardiac arrest care are based on adult studies, which may not account for the unique physiological differences in pediatric patients [53]. There is a need for more research specifically focused on children and the development of standardized protocols for assessing and treating myocardial dysfunction in pediatric patients. This includes using echocardiography for real-time evaluation and enhancing data collection to support better care decisions [51]. A multidisciplinary approach tailored to the individual needs of each child is crucial for improving long-term outcomes in post-cardiac arrest care [52].

Resource limitations significantly hinder post-resuscitation care, particularly in rural emergency departments. The study highlighted a critical issue: the limited availability of beds at receiving hospitals creates dangerous delays in transferring post-cardiac arrest patients to intensive care units. These delays are concerning, as the timely transfer is vital for effective management following cardiac arrest. A study by Town et al. [54] examined the relationship between intensive care unit bed availability and adult patient outcomes, finding that decreased availability correlates with increased odds of intensive care unit readmission [54, 55]. Evidence shows median delays of 4.5 h to ICU admission in low-resource settings [21]. For IHCA, delays > 1 h to PICU admission are associated with reduced survival [51].

In rural EDs, inadequate staffing and limited resources, such as cooling therapies and advanced monitoring equipment, further complicate the care of post-cardiac arrest patients, especially during pandemics like COVID-19 [56]. These limitations can significantly hinder the implementation of best practices and negatively affect patient outcomes.

Regional referral systems have been implemented to address the challenges faced by rural EDs. These systems facilitate the transfer of patients from rural hospitals to tertiary care centers, ensuring they receive the specialized care needed after a cardiac arrest. Effective communication and coordination are essential for prompt transfers, which can significantly improve patient outcomes [56]. There is a clear need to streamline transfer protocols to reduce the burden on rural providers, who often manage multiple responsibilities while caring for critically ill patients. By optimizing these referral systems, healthcare providers can ensure timely and appropriate care, ultimately improving outcomes for patients in rural areas. Without a robust referral network, rural EDs may struggle with patient management and face long-term challenges related to healthcare quality and equity. This can worsen disparities between urban and rural healthcare settings [56].

Barriers to implementing standard resuscitation guidelines

Implementing standard resuscitation guidelines in low-resource settings involves overcoming a multitude of barriers to various aspects, including awareness, educational, systems, personal, and ethical issues. For instance, there is often a lack of knowledge about resuscitation in both national and local communities, as well as an absence of organizations for resuscitation training. Negative misinterpretations, misconceptions regarding CPR, limited hospital access, and restricted movement of ambulances further exacerbate the problem. Additionally, heterogeneously educated staff, poor cooperation and referral system, poor communication between systems, limited post-cardiac arrest care, cultural values and stressing inequities, and local social, religious, and cultural beliefs about life and death pose additional challenges [10, 57–59].

Awareness and educational barriers

A lack of awareness about resuscitation protocols, underfunded training programs, and limited access to research-based medicine among healthcare providers and the public [60].

Cultural and social barriers

Cultural and religious beliefs about life, death, and the role of medical intervention complicate communication barriers between healthcare providers and families [61].

Infrastructural barriers

The lack of a transportation system, restricted ambulance mobility, and poor coordination between prehospital and hospital services hinder timely intervention [9]. Hospital infrastructures are also inadequate, with limited access to ICU beds, ventilators, and essential medical supplies [53].

Training gaps and personnel barriers

In resource-limited areas, limited resources and a lack of instructors result in an inability to support continuous education for nurses and physicians. Staffing shortages, the absence of senior, well-trained staff to mentor new personnel, particularly in ICUs, and low nurse-to-patient ratios further exacerbate the issue [62]. Insufficient technology infrastructure and financial constraints further exacerbate the issue [16, 62

Ethical considerations

Ethical issues in pediatric and neonatal resuscitation can be complex and require careful consideration from healthcare providers to ensure that the care provided aligns with both ethical principles and the needs of patients and their families [63]. In limited healthcare resource settings, decisions about DNR orders must be made with consideration of quality of life. There should be a balance between aggressive interventions wanting to prolong life and the quality of life, taking into account the likelihood of meaningful recovery and the needs of individual patients against the allocation of scarce medical resources. In such settings, decisions about resuscitation efforts can have implications for the whole health system. For instance, focused allocation of resources providing aggressive resuscitation efforts for children with poor prognosis and low chance of survival may detract from essential resources and the ability to provide care for other patients who have a higher likelihood of survival [63, 64].

Further details and innovative solutions are discussed in Table 1.

Table 1.

Barriers to implementing standard resuscitation guidelines

Primary Category	Specific Barrier	Impact	Potential Solution
Awareness and educational barriers [60]	Underfunded training programs for CPR and ALS led to Delays in initiating CPR.	Lack of trained personnel to manage pediatric cardiac arrest, leading to ineffective interventions and increased mortality and morbidity due to prolonged lack of oxygenation	• Secure funding for CPR training programs. • Implement community-based CPR training programs to empower bystanders to act promptly • integrate resuscitation protocols into national healthcare policy.
	Limited access to evidence-based research on pediatric resuscitation	Development of outdated or ineffective training programs	• Increase access to global research on pediatric resuscitation and include it in the local training curriculum • Open access digital libraries
Cultural and social barriers [61]	Cultural and religious beliefs against resuscitation.	Difficulty in accepting and implementing resuscitation, leading to a family refusal to consent to CPR.	Engage with communities to understand and respect cultural values while providing educational programs on CPR.
	Communication barriers between healthcare providers and families due to language differences	Delayed treatment, increased risk of miscommunication, and difficulties in decision-making	Promote cultural competence training and improve translation services in healthcare settings.
Infrastructural barriers [9, 34, 47, 61]	Lack of transportation and restricted ambulance mobility	Delays in emergency response and prolonged time to initiate resuscitation	Invest in ambulance services, emergency transport systems, and nationwide emergency dispatch infrastructure
	Poor coordination between prehospital and hospital services	Disruptions in continuity of care, leading to worsened outcomes	Develop integrated healthcare systems with improved coordination between emergency services and hospitals
	• Inadequate hospital infrastructure (ICU beds, ventilators, medical supplies) • power outage	Limited capacity for post-cardiac arrest care, resulting in higher mortality rates	• Improve hospital infrastructure by increasing funding for critical care equipment and ICU capacity. • Solar-powered monitors and dedicated pediatric crash carts • Low-cost technology, such as low-cost feedback devices and smartphone apps for CPR guidance • Telemedicine innovations like SMS-based ECG triage and video consults
Personnel barriers [44, 62]	• Staffing shortages • lack of trained healthcare professionals • absence of senior staff for mentoring new healthcare providers.	Reduced capacity for providing high-quality resuscitation leads to poor outcomes and critical care and inadequate training of new staff.	• Address staffing issues through recruitment and Establish mentorship programs and professional development opportunities for junior healthcare providers. • Telemedicine addresses critical gaps such as pre-arrest prevention by monitoring and medication adjustment for high-risk patients, real-time emergency support, updated training programs, and monthly drills for healthcare providers.
Ethical considerations [63, 64]	Cultural and religious considerations in decision-making regarding resuscitation	Conflict between parents’ emotional desires and medical professionals’ recommendations	Implement shared decision-making with families, involve hospital ethics committees in culturally sensitive decisions, and promote open family-provider dialogue.
	Difficulty in obtaining informed consent due to time constraints and compromised patient capacity	Delayed decision-making, leading to suboptimal interventions or missed opportunities for resuscitation	Create structured processes for obtaining informed consent, including shared decision-making and ethics committee support.
	Inequity and unequal resource distribution for resuscitation	Potential diversion of limited resources from high-priority patients, affecting the overall system and resulting in high disparities.	Prioritize ethical resource allocation strategies to ensure that critical care resources are used effectively.

Outcomes and prognosis of pediatric cardiac arrest in low-resource settings

Pediatric cardiac arrest presents a formidable challenge in global healthcare, with marked disparities in outcomes between high-resource and low-resource settings. A systematic review of pediatric cardiac arrest outcomes highlights significant differences in survival rates and neurological outcomes depending on the availability of healthcare resources [4]. In high-income countries, survival rates for pediatric in-hospital cardiac arrest can reach 44–52%, with over 75% of survivors achieving favorable neurological outcomes [12]. However, in low-resource settings, survival rates frequently fall below 20%, and the proportion of children who achieve favorable neurological recovery is substantially lower. These poorer outcomes are often attributed to delayed access to emergency care and inadequacies in post-arrest interventions [55]. These differences are presented in Table 2, a detailed comparison of survival, ROSC, and neurological recovery rates across different settings, illustrating the impact of resource availability on outcomes.

Table 2.

Comparing survival outcomes by resource setting

Study (Author, Year)	Setting	Sample Size	Survival Rate (%)	ROSC Rate (%)	Neurological recovery (%)	Confidence Interval (95% CI) (Survival Rate)	Key Findings
Ahmad et al. 2023 [65]	Low resource (Tanzania)	120	18.3	45.0	8.5	12.5–24.1	Delayed CPR and limited access to defibrillators contributed to low survival.
Mally et al. 2024 [21]	Low resource (Uganda)	80	12.5	30.0	5.0	8.5–16.5	Limited ICU beds and delayed transfers reduced survival rates.
Yussuf et al. 2022 [3]	Low resource (Tanzania)	150	15.0	40.0	7.0	10.5–19.5	Lack of trained personnel and equipment shortages were major barriers.
Umuhoza et al. 2021 [34]	Low resource (Rwanda)	100	10.0	25.0	3.0	5.5–14.5	Community-based CPR training improved bystander response rates.
Michelson et al. 2018 [1]	High resource (USA)	450	44.0	70.0	68.0	39.5–48.5	Pediatric emergency departments had higher survival rates than general EDs.
Holmberg et al. (2019) [51]	High resource settings (USA)	10,138	38.1	72.3	34.5	36.2–40.0	“Improvement in IHCA survival over time”
Katzenschlager et al. (2023) [66]	High resource settings Germany	1,876	16.8	48.9	12.4	14.2–19.4	“Bystander CPR associated with higher ROSC”

For instance, Ahmad et al. [65] emphasized that delayed administration of cardiopulmonary Resuscitation (CPR) and adrenaline in out-of-hospital cardiac arrests results in lower rates of return of spontaneous circulation (ROSC) and survival to hospital discharge compared to in-hospital arrests [65]. Furthermore, O’Halloran et al. [67] demonstrated that factors such as age and event location influence CPR duration in pediatric in-hospital arrests, suggesting that optimal CPR duration may be critical in improving survival outcomes [68].

A systematic review by Topjian et al. [6] identifies key strategies for improving outcomes in pediatric cardiac arrest, particularly in low-resource settings. Strengthening healthcare infrastructure, especially in rural and underserved regions, is a priority. This includes developing emergency medical services and improving access to pediatric-specific resuscitation equipment. Enhanced training for healthcare providers, especially in pediatric advanced life support (PALS), is essential for elevating the standard of care. Moreover, the implementation of standardized post-arrest care protocols, adapted to the resources available in local settings, could enhance neurological outcomes. The review also highlights the potential of community-based initiatives, such as widespread CPR training and public access to defibrillators, to improve bystander response and early defibrillation rates. Importantly, the authors call for more context-specific research to develop interventions tailored to low-resource environments and advocate for international collaboration to advance research, training, and quality improvement initiatives, which could help reduce global disparities in pediatric cardiac arrest outcomes [6].

Comparative studies further underscore the importance of specialized pediatric care in improving survival rates. For example, research has demonstrated that survival from non-traumatic out-of-hospital cardiac arrest is significantly higher in pediatric emergency departments (33.8%) compared to general emergency departments (18.9%) [1]. This finding suggests that specialized pediatric care, more commonly available in high-resource settings, plays a crucial role in improving outcomes. Investing in pediatric-specific care systems in low-resource settings could, therefore, help narrow the gap in both survival and neurological outcomes for pediatric cardiac arrest patients.

Training and capacity building in low-resource settings

The successful implementation of resuscitation protocols in low-resource settings hinges on the continuous education and training of healthcare providers. Resuscitation care requires evidence-based protocols, suitable equipment, and trained personnel to deliver effective interventions. In low-resource settings, training programs that prioritize hands-on, simulation-based learning have proven effective in building capacity and improving patient outcomes.

Several examples of successful training initiatives in low-resource settings demonstrate the potential for capacity building. The Emergency Triage Assessment and Treatment (ETAT) program has been instrumental in training healthcare workers in the recognition and management of pediatric emergencies, particularly in Africa and Asia [13]. The BASIC (Basic Assessment and Support in Intensive Care) course, developed by the Chinese University of Hong Kong, provides critical care training in resource-limited environments and has been successfully implemented in multiple low-income countries [13]. Similarly, the Network for Intensive Care Skills Training (NICST) in Sri Lanka and the Pediatric Fundamentals of Critical Care Study (PFCCS) offer tailored training for healthcare workers in pediatric resuscitation and critical care [13].

Organizations such as the Essential Emergency and Critical Care (EECC) and the World Federation of Pediatric Intensive and Critical Care Societies (WFPICCS) are also playing a vital role in developing emergency and critical care guidelines for low-resource settings [13]. By providing training, resources, and mentorship, these organizations are helping to build a sustainable framework for pediatric emergency care in underserved regions.

Simulation technology is increasingly being used to train healthcare providers in low-resource settings. For example, the Helping Babies Breathe (HBB) initiative, which the American Association of Pediatrics established, uses mannequin-based simulation to teach neonatal resuscitation, significantly reducing neonatal mortality in countries like Tanzania and India. This initiative resulted in a 47% decrease in neonatal mortality in Tanzania and a significant reduction in stillbirth rates in India [69]. The SUGAR (Simulation Use for Global Away Rotations) platform and the Procedural Education for Adaptation to Resource-Limited Settings (PEARLS) website offer additional simulation-based training tools that are tailored to the unique challenges of resource-limited environments [13]. These programs provide valuable opportunities for healthcare workers to practice resuscitation techniques in realistic settings, enhancing their confidence and competence in managing pediatric cardiac arrests.

Additionally, several countries have implemented innovative solutions to combat ALS training challenges. Specific initiatives have been launched globally. For example, in Rwanda, the Initiative for Medical Equity and Global Health Equity (IMEGH) combined a Vital Anesthesia Simulation Training Course with a modified, 2-day Advanced Cardiac Life Support training, where CPR and drug administration were taught. Participants showed adequate knowledge retention three months after training, showing that teaching similar courses together can improve life support skills in low-resource countries [67, 70].

Virtual technology, particularly telemedicine, has also emerged as a key component of capacity building in low-resource settings. In Kenya, for example, the smartphone app “Daktari Popote” (Doctor Anywhere) facilitates remote consultations with medical specialists, bridging the gap between local providers and experienced clinicians [71]. Telemedicine also removes barriers to participating in international medical meetings, providing healthcare providers with access to virtual conferences and recorded resources, regardless of time zone restrictions [71].

Limitations

Despite the insights provided in this review, several limitations must be acknowledged. First, the available data on pediatric cardiac arrest in low-resource settings are limited, particularly regarding long-term outcomes and the applicability of international resuscitation guidelines. Most of the studies referenced are based on data from high-income countries, which may not accurately reflect the challenges faced by LMICs. Additionally, many of the innovations discussed, such as telemedicine, are still in the early stages of implementation, and their effectiveness in improving outcomes in low-resource settings requires further validation. The heterogeneity of healthcare systems across different regions also makes it difficult to generalize findings. Finally, this review highlights the need for more region-specific studies to address gaps in knowledge about pediatric cardiac arrest in low-resource environments.

Conclusion and future directions

Pediatric cardiac arrest in low-resource settings presents a complex set of challenges, from delayed recognition and diagnosis to inadequate resuscitation protocols and post-arrest care. Despite these challenges, promising trends and approaches can improve outcomes for children in resource-limited environments. The implementation of community-based BLS training, the use of low-cost resuscitation technologies, and the integration of telemedicine into emergency care systems have shown significant potential for improving pediatric cardiac arrest survival rates in low-resource settings.

This review underscores the need for tailored guidelines that account for the specific needs and limitations of low-resource environments. While global resuscitation guidelines provide a valuable framework for managing pediatric cardiac arrest, their successful implementation in LMICs requires adaptation to local contexts. Collaboration between international health organizations, local governments, and medical communities will be essential in developing sustainable solutions that bridge the gap between high- and low-resource settings.

Future research should focus on exploring innovative approaches to making advanced pediatric resuscitation accessible in even the most underserved regions. By investing in training, infrastructure, and the development of context-specific interventions, the global medical community can help ensure that all children, regardless of where they live, have access to life-saving care.

Abbreviations

ALS

Advanced life support

AED

Automated external defibrillator

BLS

Basic life support

CPR

Cardiopulmonary resuscitation

ECG

Electrocardiogram

ED

Emergency department

IPCA

Inpatient cardiac arrest

OHCA

Out–of–hospital cardiac arrest

LMICs

Low–and middle–income countries

PALS

Pediatric advanced life support

PCAC

Post–cardiac arrest care

PED

Pediatric emergency department

PEA

Pulseless electrical activity

PICU

Pediatric intensive care unit

ROSC

Return of spontaneous circulation

TTM

Targeted temperature management

VF

Ventricular fibrillation

VT

Ventricular tachycardia

Authors’ contributions

• Mohamed Alsabri (MA) is considered the first author and corresponding author. He proposed the project, wrote the protocol, participated in screening and selecting studies, contributed to the conception, formulation, and drafting of the article, and reviewed and revised the manuscript.

• Mayar M Aziz (MMZ)is also considered a first author and the primary corresponding author. She contributed to the article’s conception, formulation, and drafting and reviewed and revised the manuscript.

• (HAA) is considered a second author who designed the flowcharts and participated in writing and revising the final manuscript.

• Basel A. Zaben (BAZ), Mirna Hussein (MH), Rayan R. Salahaldin (RRS), Henar El Makhzangy (HEM), and Anas R. Tuqan (ART) participated in writing and revising the final manuscript.

• All authors approved the final manuscript as submitted and agree to be accountable. I declare that the work presented in this manuscript is original and has not been submitted, in whole or in part, for publication elsewhere. All authors have contributed significantly to the conception, design, execution, and interpretation of the work.

Funding

No funding was received for this research.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.