PALS Algorithms

Pediatric Bradycardia - Pulse & Poor Perfusion

This algorithm provides a detailed framework for managing pediatric patients presenting with bradycardia accompanied by pulse and poor perfusion, guiding healthcare providers through the necessary steps to stabilize the child and address potential underlying causes.

Initial Assessment and Stabilization

Identify and Treat Underlying Cause: Begin by assessing and addressing any underlying causes of bradycardia as they are identified.

Maintain Patent Airway: Ensure the airway is clear. Assist breathing as necessary to maintain adequate oxygenation.

Administer Oxygen and Monitor: Provide supplemental oxygen and place the child on a cardiac monitor to continuously assess heart rhythm, blood pressure, and oximetry.

Establish IV/IO Access: Secure intravenous or intraosseous access promptly to facilitate medication administration.

12-Lead ECG: Obtain a 12-lead ECG if available to further evaluate the cardiac rhythm. Do not delay initial therapy while obtaining this diagnostic test.

Response to Signs of Cardiopulmonary Compromise

If Signs of Compromise Are Evident (e.g., hypotension, altered mental status, signs of shock):

  • CPR for Heart Rate <60/min: Initiate CPR immediately if the heart rate is less than 60/min with poor perfusion despite adequate oxygenation and ventilation.
  • Continuous Support and Monitoring: Support ABCs (Airway, Breathing, Circulation), continue oxygen, and observe the patient closely.
  • Consider Expert Consultation: Get advice from a pediatric cardiologist or critical care specialist if the bradycardia persists despite initial interventions.

Pharmacological Interventions

Administer Epinephrine: If bradycardia persists, administer epinephrine at 0.01 mg/kg (using a 1:10,000 concentration), repeating every 3-5 minutes as needed.

Administer Atropine: Use atropine (0.02 mg/kg, may repeat once) to address increased vagal tone or primary AV block. Ensure dosages respect the minimum of 0.1 mg and do not exceed a maximum single dose of 0.5 mg.

Consider Pacing: If pharmacologic interventions are ineffective, consider transthoracic or transvenous pacing to stabilize the heart rate.

Advanced Interventions and Monitoring

Treat Underlying Causes: Continue to diagnose and treat any identified underlying causes of the bradycardia.

Transition to Cardiac Arrest Algorithm: If the patient develops a pulseless arrest, immediately transition to the pediatric cardiac arrest algorithm for appropriate resuscitation measures.

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