Dr. Peter Antevy questions the 2020 PALS guideline recommending cardiac-arrest dose epinephrine for bradycardic children with poor perfusion. A 2019 study of 7,000 children suggested withholding it may improve outcomes. He advocates for diluted "push-pressor" dosing instead, closer to adult ACLS practice.
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Hey everyone, this is Dr. Peter Entebbe with another edition of the Hentevi Minute. In the last episode, we talked about the ventilation rate in the 2020 PALS guidelines from 10 breaths per minute up to 20 to 30 breaths per minute. Today I want to talk about the second item that I have slight concern with and that has to deal with epinephrine during bradycardia with poor perfusion. For years we have known that the one difference between pals and ACLs is that in the bradycardia algorithm for kids, they want you to give a cardiac arrest dose of epinephrine. And in adults there is no cardiac arrest dose epinephrine in that algorithm. I have thought for years that this would change. Now, interestingly, in 2019, Holmberg published a great paper in resuscitation, almost 7,000 children. And they looked at what happens when you give cardiac arrest dose epinephrine to a child with bradycardia with poor perfusion. And you can see here on this graph, I'm going to go ahead and make that line where it says one red. So now anything to the left of that red line, the plot or the whiskers, if it's on the left, it favors not giving epinephrine in children. And you can see very clearly in the overall conclusion that withholding epinephrine for children with bradycardia with poor perfusion is better for them. So here we have a study, very well done. Of course it has some limitations, but.
They enrolled almost 7,000 children in the study and it clearly demonstrated that cardiac arrest dose epinephrine can be harmful when given in this patient population. While the ACLS guidelines for similar patients calls for an epinephrine infusion. This is because we want to avoid giving cardiac arrest dose EPI to adults with a pulse. Imagine this scenario. You have a 74 year old woman with symptomatic bradycardia. Is this a patient you would give cardiac arrest dose EPI to? Of course not. And I think we should be doing the same thing for kids.
Okay, so you're probably asking, well, what should we do instead of giving cardiac arrest dose epinephrine to bradycardia with poor perfusion? Well, we would recommend that you would just dilute that down similar to an epinephrine drip, but now you have it in a syringe. We call it push presser epinephrine down. In the link below, we've created a video on what exactly it is, how to make it and how to give it. If you give very small doses. You're not giving that really big peak of epinephrine. You're sparing the heart from all the deleterious effects of epinephrine, as well as the brain, and you're allowing the body to utilize that epinephrine in a much more subtle way. So I would like for the American Heart association to relook at the Holmbrook paper, evaluate all the other data that we have on epinephrine, and let's hopefully move to a place where we're in line with what we do for adults for bradycardia with poor perfusion. This has been. Dr. Peter Entebbe for another edition of the Hantevi Minute. Thank you. It.
