PALS - Bradycardia 

Updated: Mar 21, 2014
  • Author: James J Lamberg, DO; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Pediatric Advanced Life Support (PALS): Bradycardia

1. Initial evaluation [1, 2, 3]

  • Assess appropriateness for clinical condition
  • Heart rate typically < 60 bpm if bradyarrhythmia

2. Initial intervention

  • Maintain patent airway
  • Assist breathing as needed
  • Administer oxygen if hypoxemic
  • Attach monitor/defibrillator
  • Monitor blood pressure and oximetry
  • Obtain intravenous (IV)/intraosseous (IO) access
  • Perform 12-lead electrocardiography (ECG); do not delay therapy

3. Check for signs of poor perfusion

  • Hypotension
  • Acutely altered mental status
  • Signs of shock

4. Intervention for poor perfusion and heart rate < 60 bpm

  • Start high-quality cardiopulmonary resuscitation (CPR)
  • Basic life support (BLS) algorithm

5. Management following resolved bradycardia

  • Support ABCs
  • Administer oxygen and observe
  • Consider expert consultation

6. Management of persistent bradycardia

  • Administer epinephrine
  • Consider atropine for increased vagal tone or primary atrioventricular block (AV) block
  • Consider transcutaneous pacing
  • Treat underlying causes

Drug therapy

See the list below:

  • Epinephrine 0.01 mg/kg IV/IO q3-5min; use 1:10000 concentration (0.1 mL/kg)
  • Epinephrine 0.1 mg/kg endotracheal tube (ETT) q3-5min; use 1:1000 concentration (0.1 mL/kg)
  • Atropine 0.02 mg/kg IV/IO; may repeat once; minimum dose, 0.1 mg; maximum dose, 0.5 mg

Reversible causes

See the list below:

  • H's: Hypovolemia, hypoxia, H+ (acidosis), hypokalemia, hyperkalemia, hypothermia, hypoglycemia
  • T's: Toxins, tamponade (cardiac), tension pneumothorax, thrombosis (pulmonary, coronary)

Atropine

See the list below:

  • Not reliable for third-degree block or second-degree type II block
  • Could potentially exacerbate the block by increasing sinoatrial (SA) node activation
  • Not useful in transplanted hearts

Hypotension definitions

See the list below:

  • Term neonates (age 0-28 days): Systolic blood pressure (SBP) < 60 mm Hg
  • Infants (age 1-12 months): SBP < 70 mm Hg
  • Children aged 1-10 years: SBP < 70 + (age in years X 2)
  • Children older than 10 years: SBP < 90 mm Hg

Normal heart rate

See the list below:

  • Newborns to age 3 months: 85-205 bpm awake, 80-160 bpm asleep
  • Children aged 3 months to 2 years: 100-190 bpm awake, 75-160 bpm asleep
  • Children aged 2-10 years: 60-140 bpm awake, 60-90 bpm asleep
  • Children older than 10 years: 60-100 bpm awake, 50-90 bpm asleep

Normal respiratory rate

See the list below:

  • Infants: 30-60 respirations/min
  • Toddlers: 24-40 respirations/min
  • Preschool-aged children: 22-34 respirations/min
  • School-aged children: 18-30 respirations/min
  • Adolescents: 12-16 respirations/min