When to Start Chest Compressions on a Bradycardic Pediatric Patient
Begin chest compressions immediately when a pediatric patient has a heart rate less than 60 beats per minute WITH signs of poor perfusion (pallor, mottling, or cyanosis) despite adequate oxygenation and ventilation support. 1
Critical Decision Algorithm
Step 1: Assess Heart Rate and Perfusion Status
- Check for pulse (up to 10 seconds): brachial in infants, carotid or femoral in children 1
- Measure heart rate accurately 1
- Evaluate perfusion signs: skin color (pallor, mottling, cyanosis), capillary refill, mental status 1
Step 2: Apply the HR <60 Rule
If heart rate is <60 bpm AND signs of poor perfusion are present:
- Start chest compressions immediately 1
- This applies ONLY after ensuring adequate oxygenation and ventilation support has been provided 1
- Cardiac arrest is imminent in this scenario, and early CPR improves survival 1
If heart rate is ≥60 bpm but inadequate breathing:
- Provide rescue breaths at 12-20 breaths per minute (1 breath every 3-5 seconds) 1
- Do NOT start compressions 1
- Reassess pulse every 2 minutes 1
Step 3: Verify Prerequisites Before Starting Compressions
The bradycardia must be despite adequate support of:
This is crucial because ventilation is the key intervention in pediatric resuscitation, and most bradycardia resolves with effective ventilation alone 1.
Evidence-Based Rationale
The HR <60 threshold with poor perfusion is supported by strong outcome data. Pediatric patients who receive chest compressions for bradycardia with poor perfusion before progressing to complete pulselessness have significantly better survival to hospital discharge (40.7%) compared to those who receive CPR after developing asystole/PEA (24.5%) 2. The 2020 International Consensus reaffirmed this recommendation, noting that lower survival is associated with longer time intervals between starting CPR for bradycardia and loss of pulse 1.
Critical Pitfalls to Avoid
Do not start compressions for bradycardia alone without poor perfusion signs. 1 The absolute heart rate threshold is less important than the combination of bradycardia AND poor perfusion 1. Recent hemodynamic data shows that patients with bradycardia and preserved pulse pressure (≥20 mmHg) have better outcomes, suggesting that perfusion status matters more than heart rate alone 3.
Do not start compressions before optimizing ventilation. 1 In neonates and children, cardiac output depends heavily on heart rate, but bradycardia is usually secondary to hypoxia 1. Effective ventilation often resolves bradycardia without need for compressions 4. Starting asynchronous chest compressions prematurely may be harmful, as one pediatric study found that a third of patients receiving compressions for pulseless bradycardia progressed to complete arrest 4.
Do not delay compressions if both criteria are met. 1, 2 Once HR <60 with poor perfusion is confirmed despite adequate ventilation, immediate compressions are indicated because cardiac arrest is imminent 1.
Compression Technique Considerations
- Lone rescuer: Use 30:2 compression-to-ventilation ratio 1
- Two rescuers: Use 15:2 compression-to-ventilation ratio 1
- Infants (lone provider): 2-finger technique 1
- Infants (2 rescuers): 2-thumb encircling hands technique (produces superior coronary perfusion pressure) 1
- Compress at least 100 times per minute 1
Special Population: Neonates
While the same HR <60 with poor perfusion rule applies, neonatal resuscitation emphasizes ventilation even more strongly 4. The neonatal heart is typically healthy, and bradycardia results from asphyxia 4. Ventilation-only protocols have proven effective in reducing neonatal mortality 4. However, the 2020 guidelines maintain that compressions should still be initiated at HR <60 with poor perfusion after 30 seconds of effective ventilation 1.