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PALS Provider Course: Cardiac Arrest & Brady/Tachy Arrhythmias

PEDIATRIC BRADYCARDIA ALGORITHM (PALS GUIDELINES)

 

Bradycardia in pediatric patients is a warning sign of impending cardiac arrest. Unlike adults, in whom bradycardia may be a primary electrical abnormality, pediatric bradycardia is most commonly caused by hypoxia, acidosis, or increased vagal tone. Early intervention can prevent progression to cardiac arrest.

🚨 Key Goals of Bradycardia Management:
✅ Ensure adequate oxygenation and ventilation.
✅ Identify and treat reversible causes.
✅ Administer epinephrine and/or atropine if needed.
✅ Initiate CPR if perfusion is poor and heart rate <60 bpm.

 

1️⃣ RECOGNITION: SIGNS OF BRADYCARDIA

🚨 Age-Specific Bradycardia Thresholds:

  • Neonates (<28 days): HR <100 bpm.
  • Infants and children: HR <60 bpm (with signs of poor perfusion).

🔹 Signs of Poor Perfusion Due to Bradycardia:

  • Weak or absent pulses.
  • Delayed capillary refill (>3 sec).
  • Hypotension (late sign).
  • Altered mental status (lethargy, unresponsiveness).
  • Respiratory distress or apnea.
 

2️⃣ PEDIATRIC BRADYCARDIA MANAGEMENT ALGORITHM

 

Step 1: Ensure Oxygenation and Ventilation

✅ 100% oxygen via bag-mask ventilation (BMV) or high-flow oxygen.
✅ If apnea or respiratory failure is present, begin positive-pressure ventilation (PPV).
✅ Check pulse oximetry and capnography to confirm adequate ventilation.

🚨 Hypoxia is the most common cause of bradycardia—correct it first!

Step 2: If HR <60 bpm with Signs of Poor Perfusion, Start CPR

✅ Begin chest compressions immediately if:

  • HR remains <60 bpm despite adequate oxygenation and ventilation.
  • Poor perfusion continues (weak pulses, altered mental status).

🔹 CPR Guidelines for Bradycardia with Poor Perfusion:

  • Compression-to-Ventilation Ratio:
    ✅ Single rescuer: 30:2
    ✅ Two rescuers: 15:2
  • Compression Depth:
    ✅ Infants (<1 year): At least 1.5 inches (4 cm).
    ✅ Children (>1 year): At least 2 inches (5 cm).
  • Compression Rate: 100-120 per minute.

🚨 Do NOT delay CPR if the child remains bradycardic with poor perfusion!

Step 3: Administer Epinephrine (First-Line Medication)

✅ IV/IO Dose: 0.01 mg/kg (1:10,000 solution) every 3-5 minutes.
✅ If no IV/IO access: Epinephrine via ETT (0.1 mg/kg).

🚨 Epinephrine increases heart rate and contractility—give as soon as IV/IO access is available.

Step 4: Consider Atropine for Bradycardia Due to Vagal Stimulation or AV Block

✅ Indications for Atropine:

  • Bradycardia due to increased vagal tone (e.g., suctioning, intubation).
  • Bradycardia due to primary AV block.
    ✅ IV/IO Dose: 0.02 mg/kg (minimum dose: 0.1 mg, max: 0.5 mg per dose).
    ✅ May repeat once after 5 minutes if bradycardia persists.

🚨 Atropine is NOT first-line for bradycardia due to hypoxia—oxygenation and epinephrine should be prioritized.

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

🚨 If bradycardia persists, look for and correct underlying causes:

The H’s (Common Hypoxic/Metabolic Causes of Bradycardia)

🔹 Hypoxia → Provide oxygen, assist ventilation.
🔹 Hypovolemia → Give IV fluids (20 mL/kg NS/LR).
🔹 Hydrogen ion excess (Acidosis) → Correct with sodium bicarbonate if needed.
🔹 Hyperkalemia/Hypokalemia → Correct electrolyte imbalances.
🔹 Hypothermia → Rewarm patient.

The T’s (Cardiac Causes of Bradycardia)

🔹 Tension pneumothorax → Needle decompression.
🔹 Tamponade (Cardiac) → Pericardiocentesis.
🔹 Toxins (e.g., beta-blockers, opioids, calcium channel blockers) → Administer antidotes (e.g., naloxone, calcium gluconate).
🔹 Thrombosis (Coronary or Pulmonary) → Thrombolysis or ECMO in severe cases.

🚨 Hypoxia and acidosis are the most common treatable causes—always correct oxygenation first!

 

3️⃣ QUICK REFERENCE: PEDIATRIC BRADYCARDIA MANAGEMENT

 

StepActionKey Considerations
1Oxygenation & VentilationBag-mask ventilation (BMV), high-flow oxygen
2CPR if HR <60 bpm & Poor Perfusion30:2 (1 rescuer), 15:2 (2 rescuers), rate 100-120/min
3Epinephrine (0.01 mg/kg IV/IO q3-5 min)First-line medication for persistent bradycardia
4Atropine (0.02 mg/kg IV/IO)For vagal-mediated or AV block bradycardia
5Identify & Treat Reversible CausesCheck H’s & T’s (Hypoxia, Acidosis, Tamponade, etc.)


4️⃣ WHEN TO ESCALATE BEYOND STANDARD TREATMENT?

🚨 If bradycardia persists despite epinephrine, atropine, and CPR:

ConditionNext Steps
Persistent Severe BradycardiaConsider transcutaneous or transvenous pacing
Bradycardia due to Beta-Blocker or CCB overdoseGlucagon, Calcium Gluconate
Bradycardia with Severe AcidosisSodium Bicarbonate

🚨 Persistent bradycardia despite intervention may require ECMO in severe cases.

 

5️⃣ SIGNS OF IMPROVEMENT AFTER TREATMENT

✅ Heart rate increases to normal range for age.
✅ Strong pulses, normal capillary refill (<2 sec).
✅ Improved mental status (alert, responsive).
✅ Stable oxygenation (SpO₂ >94%).

🔹 If these signs are absent, continue resuscitation and reassess for reversible causes.

 

6️⃣ SUMMARY: WHY EARLY INTERVENTION IN PEDIATRIC BRADYCARDIA MATTERS

✅ Bradycardia in children is usually due to hypoxia—oxygenation and ventilation are first-line interventions.
✅ If HR <60 bpm and poor perfusion is present, start CPR immediately.
✅ Epinephrine is the first-line drug; atropine is only for vagal-mediated or AV block bradycardia.
✅ Identify and treat reversible causes (H’s & T’s) to optimize resuscitation success.

🚑 Takeaway: Bradycardia is a pre-arrest warning sign—early recognition and aggressive management can prevent cardiac arrest and improve survival.