Outcome of Pediatric Bradycardia- Poor Perfusion vs PEA

July 24, 2020

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Bradycardia with poor perfusion is associated with better survival with favorable neurologic outcome than pulseless cardiac arrest in critically ill children receiving CPR.

Why does this matter?

Bradycardia is common in children, and often progresses to pulseless arrest. Even with a pulse present, CPR can give you better hemodynamics!

Slow Code | Slow? CODE!

This was a prospective multi-center observational cohort study of CPR events in the ICUs of 11 children’s hospitals from 2013 – 2016. The authors compared children with pre-existing arterial lines capturing CPR events for pulseless cardiac arrest and bradycardia with poor perfusion, hypothesizing that the latter would be associated with better outcome (spoiler alert: it was). They analyzed data from 164 patients. This was an ICU-centric study, but there are several EM-applicable pearls!

Population: Kids <1 year old were more likely to present with bradycardia. The majority had pre-existing respiratory insufficiency (82% invasive mechanical ventilation) and/or hypotension. 60% of the patients had congenital heart disease. Those who got CPR for bradycardia were more likely to have a respiratory etiology.

Pearl #1: Bradycardia is common in younger kids! (but you knew that)
Pearl #2: Anticipate bradycardia with poor perfusion when you see a kid with respiratory disease.

The CPR events themselves did not differ between groups – 90% of patients survived the events overall, 68% of them via ROSC and 22% via ECPR.

Pearl #3: Things looking really bad? Consider ECPR!!! Note, ECPR (ECMO) is controversial for out-of-hospital cardiac arrest, and information from that setting is sparse.

Events lasted 8 minutes on average, and patients got 3 doses of epinephrine on average. About half of patients got sodium bicarbonate and calcium, respectively.

About half presented in bradycardia, got CPR, and lost pulses. They had lower diastolic blood pressure during CPR. Interestingly, while those who became pulseless during CPR had lower rates of ROSC, they did not show differences in rates of survival with good neurologic outcome compared with those who were never pulseless!

Pearl #4: Don’t abandon hope if your bradycardic pediatric patient develops PEA during CPR!

Patients with initial bradycardia and poor perfusion were more likely than pulseless patients to survive to hospital discharge (54% vs. 37%, p = 0.039) and to survive with favorable neurologic outcome (50% vs. 32%, p = 0.026). The following pearl is a logical stretch that can’t technically be made with an observational study, but with that caveat:

Pearl #5: Starting CPR for bradycardia with poor perfusion BEFORE the loss of pulse is a really good idea! It’s also part of PALS, notably the bradycardia algorithm.

Source
Survival and Hemodynamics During Pediatric Cardiopulmonary Resuscitation for Bradycardia and Poor Perfusion Versus Pulseless Cardiac Arrest. Crit Care Med. 2020 Jun;48(6):881-889. doi: 10.1097/CCM.0000000000004308.

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