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In children with impending cardiac arrest, start CPR for bradycardia

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Hospitalized children with impending cardiac arrest have better survival when cardiopulmonary resuscitation (CPR) is started during bradycardia rather than after the onset of asystole or pulseless electrical activity, according to a report in the December issue of Pediatrics.

Despite guidelines advising that CPR begin for bradycardia in these small patients, many clinicians have hesitated to perform chest compressions in children with perfusing rhythms for fear of causing atrioventricular dyssynchrony and worsening hemodynamics, the researchers say.

To address these concerns, Dr. Aaron Donoghue from the Children’s Hospital of Philadelphia and colleagues analyzed data from the National Registry of Cardiopulmonary Resuscitation on 3342 pediatric inpatients (mean age 3.2 years) who required chest compressions for > 2 minutes. None had shockable rhythms. Fifty-five percent received CPR for bradycardia with pulses.

Among those with bradycardia/poor perfusion, CPR produced a return of spontaneous circulation in 75%. At 24 hours, 57% were alive, and 41% survived to discharge. In those who received CPR for asystole/pulseless electrical activity, 53% had a return of spontaneous circulation, 36% were alive at 24 hours, and 25% survived to discharge (p < 0.001 for all outcomes).

After controlling for patient, event, and clinical variables, as well as processes of care during resuscitation, CPR for bradycardia/poor perfusion remained significantly associated with survival to discharge (adjusted odds ratio, 1.57).

However, the authors note, there was no significant difference between groups among children older than 8 years.

The authors conclude: “These data provide support for the Pediatric Advanced Life Support recommendations to initiate chest compressions for the pediatric patient when bradycardia and poor perfusion persist despite adequate oxygenation and ventilation, before progression to a pulseless cardiac arrest.”

Pediatrics 2009.