Pediatric Advanced Life Support (PALS): Bradycardia
PALS: Bradycardia
1. The initial evaluation is as follows [1, 2, 3, 4, 5] :
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Assess appropriateness for clinical condition (pulse present and unstable).
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The heart rate is typically less than 60 bpm if bradyarrhythmia.
2. The initial intervention is as follows:
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Maintain patent airway and assist breathing, as needed.
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Administer oxygen if hypoxemic.
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Attach monitor/defibrillator.
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Monitor blood pressure and oximetry.
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Obtain intravenous (IV)/intraosseous (IO) access.
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Perform 12-lead electrocardiography (ECG); do not delay therapy.
3. Check for signs of poor perfusion, as follows:
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Hypotension
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Acutely altered mental status
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Signs of shock
4. Intervention for poor perfusion and heart rate less than 60 bpm, despite oxygenation and ventilation, is as follows:
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Start high-quality cardiopulmonary resuscitation (CPR).
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Basic life support (BLS) algorithm
5. Management following resolved bradycardia (cardiopulmonary compromised resolved) is as follows:
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Support ABCs.
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Administer oxygen and observe.
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Consider expert consultation.
6. Management of persistent bradycardia, as follows:
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Administer epinephrine.
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Consider atropine for increased vagal tone or primary atrioventricular block (AV) block.
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Consider transcutaneous pacing or transvenous pacing.
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Treat underlying causes.
Drug Therapy
Drug therapy includes the following:
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Epinephrine 0.01 mg/kg IV/IO q3-5min; use 1:10000 concentration (0.1 mL/kg)
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Epinephrine 0.1 mg/kg endotracheal tube (ETT) q3-5min; use 1:1000 concentration (0.1 mL/kg), not preferred route
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Atropine 0.02 mg/kg IV/IO; may repeat once; maximum single dose, 0.5 mg
Atropine
Considerations regarding atropine administration include the following:
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Not reliable for third-degree block or second-degree type II block
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Could potentially exacerbate the block by increasing sinoatrial (SA) node activation
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May be ineffective in patients after heart transplantation
Hypotension Definitions
Pediatric hypotension definitions are as follows:
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Term neonates (aged 0-28 days): Systolic blood pressure (SBP) less than 60 mm Hg
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Infants (aged 1-12 months): SBP less than 70 mm Hg
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Children aged 1-10 years: SBP less than 70 + (age in years X 2)
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Children older than 10 years: SBP less than 90 mm Hg
Normal Heart Rate
Normal pediatric heart rates are as follows:
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Neonate: 100-205 bpm awake, 90-160 bpm asleep
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Infants: 100-180 bpm awake, 90-160 bpm asleep
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Toddlers: 98-140 bpm awake, 80-120 bpm asleep
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Preschool-aged children: 80-120 bpm awake, 65-100 bpm asleep
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School-aged children: 75-118 bpm awake, 58-90 bpm asleep
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Adolescents: 60-100 bpm awake, 50-90 bpm asleep
Normal Respiratory Rate
Normal pediatric respiratory rates are as follows:
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Infants: 30-53 respirations/min
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Toddlers: 22-37 respirations/min
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Preschool-aged children: 20-28 respirations/min
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School-aged children: 18-25 respirations/min
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Adolescents: 12-20 respirations/min
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