Prove It: Pushing hard improves cardiac arrest outcome for pediatric patients

Push hard, push fast and push deeper to improve chance of survival for a child in cardiac arrest

Case Review

Engine and Rescue 3 respond to a report of a child not breathing. As the crews simultaneously arrive on the scene, dispatch advises they are giving compression-only CPR instructions over the phone.

Standing at the front door is a woman screaming for the team to help her baby. The team enters a small nursery to find a man performing chest compressions as the dispatcher instructs. The mom says she put the 13-month-old child down for a nap, returned about ten minutes later and found the child not breathing. The child was a full-term delivery with no medical problems or illnesses since being brought home.

Firefighters take over CPR from the father and begin delivering assisted ventilation using supplemental oxygen. Paramedic Hall determines chest compression depth is adequate. In addition, he is able to appreciate clear lung sounds and chest rise with each assisted ventilation. The ECG displays asystole and there is no evidence of trauma on the infant’s body.

Paramedic Bell quickly places an intraosseous line in the infant’s left tibia. After securing the line, she administers a dose of intravenous epinephrine. The team moves the infant to the ambulance, administers a second dose of epinephrine and prepares for transport.

At the next rhythm check, Hall notices a slow organized rhythm on the ECG screen. He asks the firefighters to hold compressions. Hall can feel a faint brachial pulse although there is no spontaneous ventilatory effort. Since the palpable pulse rate is slow, Hall asks the firefighters to continue chest compressions.

Upon arrival at the emergency department (ED), the organized rhythm has disappeared and the infant is in asystole. After an aggressive resuscitation effort, the ED team is unable to resuscitate the infant.

Later in the evening as the medics and the firefighters are having dinner, the team wonders if they had performed better CPR, if the outcome would have been different.

Study review

Researchers in Pennsylvania examined whether compliance with the chest compression depth recommendation in the 2010 American Heart Association (AHA) CPR guidelines improves survival in children over the age of one year [1]. The study was conducted at the Children’s Hospital of Philadelphia using data from the intensive care unit and the ED. In these areas, CPR quality data is captured by the monitor/defibrillator, which also provides real-time audiovisual feedback throughout the event. Real-time feedback allows the resuscitation team to make instantaneous corrections when chest compression performance does not meet some preset standard.

The team divided the first five minutes of the resuscitation effort into 30-second segments called epochs. To be classified as AHA compliant, 60 percent or more of the epochs for each case had to have an average chest compression depth of 51 mm or more. The authors chose to only use data from the first five minutes since compressions delivered early in the resuscitation attempt seem more likely to influence the outcome. Using only data from the first five minutes also allowed exclusion of compressions delivered later in the resuscitation attempt, when provider thoughts of futility could compromise compression depth efforts.

Although the variable of interest in this study was chest compression depth, the research team collected data on a number of other CPR quality measurements. The primary outcome for this study was survival at 24 hours after cardiac arrest.


There were 89 events requiring CPR during the study period. In two cases, CPR quality data was not available and the researchers excluded those cases from analysis. Of the remaining 87 cases, the researchers classified 23 (26 percent) as AHA compliant. The remaining 64 cases had an average chest compression depth lower than 51 mm and represented the comparison (control) group.

There were no significant differences in most CPR quality measurements between the study group (AHA compliant) and the control group. These included chest compression rate, chest compression faction, and leaning on the chest during recoil. There was also no correlation between chest compression depth and any of these variables.

The ages of the children in the AHA compliant group were not significantly different from the control group, 12.8 years compared to 13.7 years, respectively. Since the AHA recommends targeting adult chest compression depths when a child reaches puberty, the 51 mm cutoff for AHA compliance seems reasonable [2].

In the unadjusted analysis, 70 percent of the patients with AHA compliant chest compression depth were still alive at 24 hours after the arrest (primary study variable) compared to only 16 percent of the patients in the control group. After adjusting the analysis to control the effects of potential measured variables that could influence the outcome (confounders), the odds of survival for at least 24 hours was 10 times greater if the child received chest compressions that were AHA compliant for depth.

What this means for you

Although this was not a prehospital study, the data does have some implications for the prehospital environment. Overall, survival in children who suffer an out-of-hospital cardiac arrest is dismal [2-5]. For those who do survive, significant neurological impairment is common [6-12]. Inadequate chest compression depth frequently occurs during adult and pediatric resuscitation attempts both in and out of the hospital [13-15]. The association between providing deeper chest compressions and improved survival in the adult patient is now well established [16-22]. However, the relationship between chest compression depth and survival rates in the pediatric population is less well known.

The AHA recommends healthcare providers begin administering adult CPR to children once they reach puberty [23]. This represents the difference between pushing to a preset depth (as in an adult) instead of a depth based on the anterior-posterior diameter of the pediatric chest. In this study, the overwhelming majority of children in both the AHA-compliant group and the control group were over the age of eight years (86 percent vs. 91 percent, respectively). This explains why the research group used the adult depth recommendations rather than the pediatric depth recommendations. An additional advantage of this strategy is the relatively low number of children under the age of eight years in both groups did not contaminate the results.

One interesting point to note is the authors of this study did not observe the same inverse relationship between chest compression rate and chest compression depth frequently seen in the adult population [20,21]. It seems that when compressing the pediatric chest, increasing the rate of chest compressions did not result in more shallow chest compressions. Although there are a number of potential explanations for this discrepancy, it is possible the increased thoracic compliance inherent in the pediatric chest wall may allow the rescuer to achieve faster chest compression rates without sacrificing compression depth [24].


The CPR quality measurement instrument used in this particular study may be overestimating the actual depth of chest compression provided by the hospital staff [25-27]. Other studies have demonstrated that mattress deflection may account for as much as 13 mm of the measured compression depth, even when a backboard is used [25]. The measurements reported here did not correct for potential mattress deflection.

The authors of this study acknowledge the possibility that a number of other unmeasured variables could have accounted for the survival differences, such as whether or not the child received epinephrine or the interval from when the arrest occurred until the chest compressions began. Due to technological limitations at this facility, the authors were also unable to measure ventilation variables, many of which are known to impact survival.


Following the 2010 American Heart Association recommendation to "Push Hard and Push Fast" appears to improve survival in pediatric patients who suffer cardiac arrest. Similarly, deeper chest compressions appear to provide greater survival advantages when compared to more shallow compressions.


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