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Symptomatic Bradycardia: The Epinephrine Era Ends

Symptomatic Bradycardia: The Epinephrine Era Ends

It’s official: the 2025 ILCOR Pediatric Life Support guidelines have removed the recommendation to administer cardiac arrest dose epinephrine for symptomatic bradycardia in children.

Hallelujah đź‘Ź

For years, the use of epinephrine in bradycardic pediatric patients receiving CPR has been embedded in resuscitation algorithms. But as many of you have long recognized, evidence—not tradition—should guide our protocols. And the evidence has spoken—again and again.

Back in 2020, Holmberg et al. published a landmark study in Resuscitation that laid the groundwork for this change. Here’s what they found:

  • Survival to hospital discharge with CPR + epinephrine was 38% versus CPR + no epinephrine at 48%.  
  • Survival to 24 hours was lower for CPR + epinephrine, RR 0.85 (0.81, 0.90) 
  • ROSC was lower with CPR + epinephrine, RR 0.94 (0.91, 0.96).
  • Favorable neurological outcome at discharge was lower with CPR + epinephrine, RR 0.76 (0.68, 0.84).  

Despite these clear findings, the recommendation persisted—until O’Halloran et al. reaffirmed the data in 2024. In their study of 452 pediatric patients with symptomatic bradycardia, 71% received early epinephrine. These patients were generally sicker, with higher pre-arrest severity and vasoactive-inotrope scores. But even accounting for that, early epinephrine showed no association with improved outcomes:

  • Early epinephrine was not associated with survival to discharge (aRR 0.97, 95% CI 0.82, 1.14) or survival with favorable neurologic outcome (aRR 0.99, 95% CI 0.82, 1.18).

This moment is more than just a guideline change—it’s a validation of the relentless pursuit of evidence over tradition. As Handtevy Instructors, you’ve been ahead of the curve, teaching with clarity, integrity, and a deep respect for what the data tells us. Now the world is catching up. Let this serve as a reminder: your voice matters, your teaching changes minds, and your dedication saves lives. Stay the course. The future of pediatric care is brighter because of you.

 

References:

  1. Holmberg MJ, Ross CE, Yankama T, et al. Epinephrine in children receiving cardiopulmonary resuscitation for bradycardia with poor perfusion. Resuscitation. 2020;149:200–207. doi:10.1016/j.resuscitation.2019.12.032
  2. O’Halloran AJ, Reeder RW, Berg RA, et al. Early bolus epinephrine administration during pediatric cardiopulmonary resuscitation for bradycardia with poor perfusion: an ICU-resuscitation study. Crit Care. 2024;28(1):242.
  3. Scholefield BR, Acworth J, Ng K-C, et al. 2025 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Pediatric Life Support. Circulation. 2025. Published online ahead of print.

 

Peter Antevy, MD

 

 

DISCLAIMER: These links  are provided for  research and do not have affiliations with Handtevy.