Pediatric Advanced Life Support (PALS): Bradycardia 

PALS: Bradycardia

1. The initial evaluation is as follows:[1, 2, 3, 4]

• Assess appropriateness for clinical condition (pulse present and unstable).
• The heart rate is typically less than 60 bpm if bradyarrhythmia.

2. The initial intervention is as follows:

• Maintain patent airway and 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, as follows:

• Hypotension
• Acutely altered mental status
• Signs of shock

4. Intervention for poor perfusion and heart rate less than 60 bpm, despite oxygenation and ventilation, is as follows:

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

5. Management following resolved bradycardia (cardiopulmonary compromised resolved) is as follows:

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

6. Management of persistent bradycardia, as follows:

• Administer epinephrine.
• Consider atropine for increased vagal tone or primary atrioventricular block (AV) block.
• Consider transcutaneous pacing or transvenous 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), not preferred route
• Atropine 0.02 mg/kg IV/IO; may repeat once; maximum single dose, 0.5 mg

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
• May be ineffective in patients after heart transplantation

Hypotension Definitions

See the list below:

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

Normal Heart Rate

See the list below:

• Neonate: 100-205 bpm awake, 90-160 bpm asleep
• Infants: 100-180 bpm awake, 90-160 bpm asleep
• Toddlers: 98-140 bpm awake, 80-120 bpm asleep
• Preschool-aged children: 80-120 bpm awake, 65-100 bpm asleep
• School-aged children: 75-118 bpm awake, 58-90 bpm asleep
• Adolescents: 60-100 bpm awake, 50-90 bpm asleep

Normal Respiratory Rate

See the list below:

• Infants: 30-53 respirations/min
• Toddlers: 22-37 respirations/min
• Preschool-aged children: 20-28 respirations/min
• School-aged children: 18-25 respirations/min
• Adolescents: 12-20 respirations/min

Most Recent Guideline Changes

Changes from the 2010 guidelines include the following:

• Simultaneous breathing and pulse check in less than 10 seconds
• Administer epinephrine as soon as feasible after the onset of cardiac arrest due to an initial nonshockable rhythm.
• Provide opioid overdose education, either alone or coupled with naloxone distribution and training, to persons at risk for opioid overdose.

Changes from the 2010 PALS guidelines include the following:

• Amiodarone or lidocaine is equally acceptable for the treatment of shock-refractory VT/VF in children.
• There is no evidence to support the routine use of atropine as a premedication to prevent bradycardia in emergency pediatric (age >1 year) intubations.
• For septic shock, the initial fluid bolus is 20 mL/kg.
• For children who are comatose in the first several days after cardiac arrest, fever should be treated aggressively.
• For comatose children resuscitated from out-of-hospital cardiac arrest (OHCA), maintain either 5 days of normothermia or 2 days of initial continuous hypothermia (32˚C-34˚C) followed by 3 days of normothermia.