Bradycardia with haemodynamic compromise in children: A scoping review

Abstract

BACKGROUND: Bradycardia with haemodynamic compromise is the most common in-hospital cardiac arrest initial rhythm in children. There are knowledge gaps in the efficacy of several treatments. This scoping review, part of the International Liaison Committee on Resuscitation continuous evidence evaluation process, sought to identify the literature on treatments for children with bradycardia and haemodynamic compromise.We searched Medline, EMBASE, and Cochrane (inception-August 19, 2025) for studies involving children with bradycardia (<60 beats per minute or low for age) and haemodynamic compromise (age-based hypotension, altered mental status, or signs of shock or cardiac arrest). Data extracted included study design, population, interventions, comparators, and outcomes.We screened 5392 titles and included 27 observational studies. In twenty-six studies, children with bradycardia with haemodynamic compromise who received CPR as part of a comprehensive protocol of drugs, airway support, and chest compressions had higher survival rates when compared with children receiving the same care for a pulseless rhythm. Three studies reported conflicting associations between clinical outcomes (progression to pulselessness, return of circulation, survival) with epinephrine use during CPR. Two studies reported atropine use in patients with haemodynamic compromise, one with CPR and one without. No studies assessed oxygen administration, assisted ventilation, or transcutaneous pacing. CONCLUSIONS: There is insufficient evidence to move to a systematic review for any treatment strategy for paediatric bradycardia with haemodynamic compromise. Current guidelines are based on limited evidence and expert opinion. Comparative trials evaluating possible treatments for children with bradycardia with haemodynamic compromise are needed.