Begin CPR Immediately
The most appropriate action for a 2-year-old in shock with a heart rate of 52 beats/min is to begin CPR (Option D). 1
Clinical Rationale
A heart rate less than 60 beats per minute with signs of poor perfusion (shock) in a pediatric patient is a clear indication for immediate CPR according to the 2020 American Heart Association guidelines. 1 This represents a critical threshold where bradycardia is severe enough to compromise cardiac output and tissue perfusion, effectively functioning as a cardiac arrest equivalent in children.
Why CPR Takes Priority Over Other Options
The pediatric basic life support algorithm explicitly states: When the heart rate is less than 60 per minute with signs of poor perfusion, start CPR immediately. 1 This directive supersedes other diagnostic or therapeutic interventions because:
- Bradycardia in children typically represents hypoxia and impending cardiac arrest, not a primary cardiac conduction problem as in adults 2
- Chest compressions are necessary to maintain perfusion when the heart rate is inadequate to support circulation 1
- Delays in initiating CPR worsen outcomes - the child is already in shock, indicating inadequate tissue perfusion 3
Why Other Options Are Inappropriate
- Option A (Get an ECG): Obtaining an ECG delays life-saving intervention. The diagnosis is clinical - bradycardia with shock requires immediate action, not diagnostic testing 1
- Option B (Increase IV rate): While fluid resuscitation may be needed, it does not address the immediate problem of inadequate cardiac output from severe bradycardia 1
- Option C (Sedate the child): Sedation would be contraindicated and potentially fatal in a child with hemodynamic instability 1
Proper CPR Technique for a 2-Year-Old
Compression technique:
- Compress at least one-third of the anterior-posterior diameter of the chest 4
- Rate of 100-120 compressions per minute 4
- Allow complete chest recoil after each compression 4
Compression-to-ventilation ratio:
Critical Pitfalls to Avoid
Do not delay CPR for any reason when a pediatric patient in shock has a heart rate <60/min. 1 The most common error is hesitation or attempting other interventions first, which worsens outcomes. 3
Recognize that pediatric cardiac arrest differs from adult arrest: Most pediatric arrests result from progressive respiratory failure and shock, not primary cardiac arrhythmias. 2 The bradycardia represents end-stage cardiovascular collapse requiring immediate intervention.
Continue CPR until: The heart rate improves to >60/min with adequate perfusion, advanced life support providers take over, or the child shows signs of recovery. 1