What are the first actions for a 2-year-old male patient with respiratory arrest and bradycardia after choking?

Immediate Management of Pediatric Respiratory Arrest with Bradycardia After Choking

Start CPR immediately—a heart rate of 30 beats per minute with respiratory arrest represents profound bradycardia with inadequate perfusion requiring chest compressions without delay. 1, 2

Initial Actions in Sequence

Scene Safety and Assessment (First 10 Seconds)

• Verify the scene is safe before approaching 1
• Confirm the child is unresponsive (already established—unconscious) 1
• Shout for help and activate emergency response system immediately 1
• Simultaneously assess for breathing (absent or only gasping) and check pulse within 10 seconds 1

Immediate CPR Initiation

Because the heart rate is 30 bpm (well below the critical threshold of 60 bpm) with respiratory arrest, begin chest compressions immediately—this supersedes all other interventions. 2

• The American Heart Association mandates starting CPR when heart rate is <60 bpm with signs of poor perfusion, as bradycardia at this level compromises cardiac output and tissue perfusion 2
• In this scenario with HR of 30 and respiratory arrest, the child has profound circulatory compromise requiring immediate compressions 2

CPR Technique Specifics

Compression-to-Ventilation Ratio

• If you are alone: Perform 30 compressions followed by 2 breaths 1
• When a second rescuer arrives: Switch immediately to 15 compressions followed by 2 breaths (the pediatric two-rescuer ratio) 1, 2

Compression Quality Parameters

• Compress at least one-third of the anterior-posterior diameter of the chest 2
• Maintain a rate of 100-120 compressions per minute 2
• Allow complete chest recoil after each compression 2
• Minimize interruptions in compressions 2

Airway Management Considerations

Foreign Body Obstruction

• Since this is a choking event, be prepared to visualize and remove any visible foreign body during airway opening 1
• Do not perform blind finger sweeps 1
• If the child becomes responsive during CPR and begins coughing effectively, allow spontaneous coughing efforts 1

Advanced Airway (If Available)

• Once an advanced airway (endotracheal tube) is placed, switch to continuous compressions at 100-120/minute with 1 breath every 6 seconds (10 breaths/minute) without pausing compressions 1
• Confirm tube placement with clinical assessment and exhaled CO2 detection 3

Medication Administration

Epinephrine Dosing

• Administer epinephrine 0.01 mg/kg IV/IO as soon as vascular access is obtained 4
• Repeat every 3-5 minutes during ongoing CPR 4
• Do not use atropine—it is not recommended for pediatric cardiac arrest and delays appropriate epinephrine administration 4, 5

Critical Pitfalls to Avoid

Do Not Delay CPR

• Never delay chest compressions for any reason when a pediatric patient has HR <60/min with signs of poor perfusion—delays worsen outcomes 2
• Do not waste time attempting to establish IV access before starting compressions 2
• Do not attempt defibrillation unless a shockable rhythm (VF/pulseless VT) is confirmed—this child likely has bradycardia/asystole from hypoxia, which requires CPR and epinephrine, not defibrillation 4

Avoid Excessive Ventilation

• Do not hyperventilate—excessive ventilation decreases venous return and cardiac output 6
• Deliver breaths over 1 second, just enough to produce visible chest rise 1

When to Continue vs. Reassess

Pulse Checks

• Reassess pulse and rhythm every 2 minutes (after each CPR cycle) 1
• Continue CPR until heart rate improves to >60/min with adequate perfusion, advanced life support providers take over, or the child shows signs of recovery 2

Duration of Resuscitation

• In pediatric cardiac arrest, particularly with witnessed arrest and initial pulse present (as in this choking case), prolonged resuscitation efforts are justified 7, 8
• Intact survival has been reported following prolonged resuscitation even after multiple doses of epinephrine 3
• The presence of any pulse at any point during evaluation strongly supports continuing CPR efforts 8