Objective: To determine the outcome and cost for children resuscitated following out-of-hospital cardiopulmonary arrest. Design: Retrospective case series. Setting: An organized prehospital emergency medical system within Birmingham, Ala, in a county with 150 493 children under the age of 15 years. Patients: Sixty-three pediatric victims of out-of-hospital cardiopulmonary arrest of any cause presenting to the emergency department of a children's hospital. Intervention: Standard resuscitative techniques were performed for all patients until resuscitative efforts were discontinued in the hospital emergency department or successful resuscitation was achieved. Main Outcome Measures: Successful resuscitation, survival to hospital discharge, neurological outcome, final disposition, and cost of hospital care. Results: Of 63 children with out-of-hospital cardiopulmonary arrest treated in the emergency department of a children's hospital, 60 were pulseless and apneic on arrival, 18 (28.6%) were successfully resuscitated and admitted to the intensive care unit, and six (9.5%) were discharged from the hospital. Five of the survivors had severe neurological deficits and one appeared normal. On follow-up, two patients had died (1 month and 7 months after discharge), three were in a vegetative state, and one was normal. The normal patient had successful defibrillation prior to arrival at the emergency department. The average inpatient charge was $10 667 per patient for those who died and $100 000 for those discharged. Conclusions: Aggressive treatment does not lead to intact survival for victims of out-of-hospital cardiopulmonary arrest who present to the pediatric emergency department with a preterminal rhythm and absence of spontaneous circulation. Resuscitation efforts in the emergency department are commonly successful but lead to death or severe neurological sequelae at discharge with extremely high cost of care. © 1995, American Medical Association. All rights reserved.