Pediatric Bradycardia (age <14) Administrative Guideline

Question 1

History

Answer 1

• Past medical history
• Foriegn body aspiration
• Respieratory distress
• Apnea
• Possible toxic exposiue or ingestion
• Congenital diseases
• Medication (maternal or infant)

Question 2

Signs and symptoms

Answer 2

• Decreased heart rate
• Delayed capillary refill or cyanosis
• Mottled, cool skin
• Hypotension or arrest
• Altered level of consciousness

Question 3

Differential

Answer 3

• Respiratory failure
• Foreign body/secretions
• Infection (croup, epiglottitis)
• Hypovolemia (dehydration)
• Congenital heart disease
• Trauma
• Hypothermia
• Toxin, medication
• Hypoglycemia

Question 4

Bradycardia (HR<60)
causing ALOC, hypotension,
poor perfusion, or shock (usually <50 BPM)

Answer 4

Open airway
Provide supplemental oxygenation and ventilation as indicated
FSBG analysis
Search for reversible causes (see differential above)

IV/IO access, pulsox, cardiac monitor
12 lead ECG (do not delay initiating treatment)

Question 5

Bradycardia (HR<60)
causing ALOC, hypotension,
poor perfusion, or shock despite adequate
oxygenation and ventilation

Age > 1yr

Answer 5

First line: administer epinephrine (1mg/10 mL) 0.01 mg/kg IV/IO
Max single dose 1 mg
May repeat every 3-5 minutes
Or
If vagally mediated: administer atropine sulfate: 0.02 mg/kg IV/IO rapid push
(min dose 0.1 mg) max initial dose 0.5 mg
May repeat every 3-5 minutes
Max total dose 3 mg
Administer NS/LR 20 mL/kg IV/IO fluid bolus, assess for signs of fluid overload

Question 6

Bradycardia (HR<60)
causing ALOC, hypotension,
poor perfusion, or shock despite adequate
oxygenation and ventilation

Answer 6

Age <28 days begin
chest compressions and
refer to Neonatal
Resuscitation AG
<1 yr begin chest
compressions and refer to
Cardiac Arrest AG

Question 7

Continued bradycardia (after epi) causing ALOC, hypotension, poor perfusion, or shock (usually <50 BPM)

Answer 7

Begin chest compressions

and do more epi

and Transport according to SAEMS Critical Pediatric Triage Protocol
and Notify Receiving Facility or Contact Medical Direction

Question 8

Do we pace kids?

Answer 8

Transcutaneous pacing:

• Indicated if bradycardia is due to complete heart block or other AV blocks which are not responsive to oxygenation, ventilation, chest compressions, or medications. Indicated with known congenital or acquired heart disease.
• Transcutaneous pacing is not indicated for asystole or bradycardia due to postarrest hypoxic / ischemic myocardial insult or respiratory failure. Do not delay therapy when bradycardia is evident and no ECG monitor is available.

Question 9

What is the drug choice for persistent, symptomatic bradycardia in pediatric patients?

Answer 9

Epi

Question 10

What is the second drug choice for persistent, symptomatic bradycardia in pediatric patients?

Answer 10

• Atropine:
• Although atropine is effective in a broader range of patients and provides a greater amount of hemodynamic support, it can cause or worsen bradycardia.
• It is second choice unless there is evidence of increased vagal tone or a primary AV conduction block.
• The paradoxical effects are the reason for the minimum dose and recommendation for rapid administration.