PALS Provider: Course

Pediatric Bradycardia Algorithm

Bradycardia in children is a serious warning sign, often resulting from hypoxia or acidosis. Unlike adults, pediatric bradycardia is rarely due to a primary cardiac issue. Early recognition and intervention—especially oxygenation and ventilation—can prevent cardiac arrest and improve outcomes.

Goals of Bradycardia Management

  • Ensure adequate oxygenation and ventilation.
  • Initiate CPR if perfusion is poor and heart rate remains <60 bpm.
  • Administer epinephrine (first-line); consider atropine for vagal or AV block causes.
  • Identify and treat reversible causes (H’s and T’s).

Recognition

  • Neonates (<28 days): Bradycardia = HR <100 bpm
  • Infants and Children: Bradycardia = HR <60 bpm with signs of poor perfusion

Signs of poor perfusion include:

  • Weak or absent pulses
  • Delayed capillary refill (>3 seconds)
  • Hypotension
  • Lethargy or unresponsiveness
  • Respiratory distress or apnea

Step-by-Step Algorithm

Step 1: Oxygenation & Ventilation

  • Provide 100% oxygen via bag-mask ventilation (BMV).
  • Use positive-pressure ventilation (PPV) if the patient is apneic or in respiratory failure.
  • Confirm effective ventilation using pulse oximetry and capnography.

Note: Hypoxia is the most common cause—correct it first!

Step 2: Start CPR if HR <60 bpm and Perfusion is Poor

  • Compression-to-ventilation ratio: 30:2 (1 rescuer), 15:2 (2 rescuers)
  • Compression depth: At least 1.5 inches (infants) or 2 inches (children)
  • Compression rate: 100–120 per minute

Step 3: Administer Epinephrine

  • IV/IO dose: 0.01 mg/kg of 1:10,000 every 3–5 minutes
  • ETT dose (if no access): 0.1 mg/kg

Note: Epinephrine improves heart rate and contractility. Give early once access is established.

Step 4: Consider Atropine

  • Use for: Vagal stimulation (e.g., intubation) or AV block
  • IV/IO dose: 0.02 mg/kg (minimum 0.1 mg, max 0.5 mg/dose)
  • May repeat once after 5 minutes if needed

Step 5: Identify and Treat Reversible Causes (H’s and T’s)

The H’s:

  • Hypoxia
  • Hypovolemia
  • Hydrogen ion (acidosis)
  • Hyper/hypokalemia
  • Hypothermia

The T’s:

  • Tension pneumothorax
  • Tamponade (cardiac)
  • Toxins (e.g., beta-blockers, calcium channel blockers)
  • Thrombosis (pulmonary or coronary)

Quick Reference Table

Step Action Key Considerations
1 Oxygenation & Ventilation Bag-mask ventilation, PPV as needed
2 CPR Start if HR <60 bpm with poor perfusion
3 Epinephrine 0.01 mg/kg IV/IO q3–5 min
4 Atropine For AV block or vagal-mediated bradycardia
5 Reversible Causes Correct H’s and T’s

When to Escalate Beyond Standard Treatment

  • Consider transcutaneous or transvenous pacing if bradycardia persists despite CPR and medications.
  • For overdose (e.g., beta-blockers, CCBs), administer antidotes (e.g., glucagon, calcium).
  • Persistent severe bradycardia with acidosis may require sodium bicarbonate or ECMO support.

Signs of Improvement

  • Heart rate normalizes
  • Capillary refill <2 seconds
  • Strong, palpable pulses
  • Improved mental status and oxygenation

Summary

  • Bradycardia in children is usually due to hypoxia—ventilation is your first priority.
  • If HR remains <60 bpm with poor perfusion, begin CPR.
  • Epinephrine is first-line; atropine is for AV block or vagal causes.
  • Address all possible reversible causes early.