Starting Cardiopulmonary Resuscitation with Bradycardia and Pulses Improves Outcome
Pub Date: Tuesday, January 26, 2010
Author: Arno Zaritsky, MD, FAAP, FCCM
Donoghue A, Berg RA, Hazinski MF, Praestgaard AH, Roberts K, Nadkarni VM., Cardiopulmonary resuscitation for bradycardia with poor perfusion versus pulseless cardiac arrest., Pediatrics, 124 (6) 1541-8. View in PubMed (opens in a new window)
Deciding when to begin chest compressions in critically ill infants and children remains controversial. Early initiation seems reasonable to improve outcome but could result in patient harm and produce dyssynchrony between intrinsic cardiac activity and chest compressions. To address this question, investigators analyzed more than 8 years of cardiac arrest data from the National Registry of CardioPulmonary Resuscitation (NRCPR) database. For purposes of this evaluation, event outcome was analyzed only if more than 2 minutes of cardiopulmonary resuscitation (CPR) was required (NRCPR includes patients receiving any CPR). Requiring at least 2 minutes of CPR assured that only children with severe cardiovascular compromise were included; children with return of spontaneous circulation with short-term compressions and ventilation may reflect a population who would have improved with or without chest compressions.
Of 130,722 cardiac arrests, only 4.8% were <18 years old. Of these 6,288 events, 3,342 met all inclusion criteria. Within this group, a remarkable 55% received chest compressions for bradycardia with a pulse. This is much more frequent than a previous NRCPR analysis reported in adults (2%) and children (18%). Of note, this earlier study excluded neonates whereas the current study included neonates, except for those in the delivery room. Furthermore, the current study required at least 2 minutes of CPR. Because children with a pulse receiving CPR were significantly younger than those who were pulseless (median age 0.19 vs. 1.3 years), it appears that rescuers are more willing to initiate CPR in young infants with bradycardia. Neonates contributed substantially to the higher percentage of children receiving CPR with bradycardia and a pulse because 40% of this group were newborns versus 20% in the asystole/pulseless electrical activity (PEA) group. Beginning CPR for bradycardia is emphasized in both Pediatric Advanced Life Support and Neonatal Resuscitation Program training.
Survival to hospital discharge was significantly higher in the bradycardia with pulses group (40.7%) compared with children with asystole/PEA (24.5%). These outcomes correspond to a higher likelihood of return of spontaneous circulation (75% vs. 53%) and survival for 24 hours (57% vs. 36%). For those children who survived for at least 24 hours, there was little difference in the likelihood of survival to hospital discharge between the bradycardia with pulse and pulseless groups (72% vs. 68.9%). Significant differences in survival remained after controlling for potential confounding clinical, event, and patient factors.
Survival to discharge was significantly better in neonates, infants, and children from 1 to 8 years of age, but not in children 8 or more years of age (22% vs. 17%). The latter age group had a lower overall survival rate and relatively smaller numbers of patients (603 older children vs. 1,039 neonates and 1,046 infants). Thus, a significant benefit in older children may have been missed because of relatively small numbers.
This study confirms the Pediatric Advanced Life Support and Neonatal Resuscitation Program recommendation to begin chest compressions when an infant or child has bradycardia and poor perfusion, even if a pulse is present. Note that detecting the presence of a pulse, even by health care providers, is not reliable. Thus, some of the children identified as having PEA could have experienced "pseudo-PEA" and their outcome may be better than those with PEA. Beginning chest compressions in children with a pulse did not result in adverse effects. The results from this large pediatric CPR analysis also confirmed that development of ventricular fibrillation or pulseless ventricular tachycardia during CPR, which occurred in 10% of all patients, is associated with worse outcome (14% survival to discharge vs. 35.5% without ventricular fibrillation/pulseless ventricular tachycardia). Finally, the study cannot address whether delaying chest compressions until the victim becomes pulseless is associated with a worse outcome.
- Nadkarni VM, Larkin GL, Peberdy MA, et al. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA 2006;295(1):50–57.
- Tibballs J, Russell P. Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest. Resuscitation 2009;80(1):61–64.
-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --