Bradycardia refers to a slow heart rate that falls below the normal range for a patient’s age. In children, this condition is often a sign of low oxygen levels (hypoxia) and can be a critical warning that may precede cardiac arrest, particularly in infants and young kids. It should be treated timely, particularly if associated with poor perfusion signs like weak pulses, altered mental status, or hypotension. In PALS (Pediatric Advanced Life Support), bradycardia is generally defined as a heart rate below the expected range for age. For example, a heart rate less than 100 bpm in infants, less than 80 bpm in toddlers, less than 70 bpm in school-aged children, and less than 60 bpm in adolescents.
The PALS Bradycardia Algorithm plays a critical role in guiding the rapid assessment and management of abnormally slow heart rates in pediatric emergencies. It assists healthcare providers in quickly identifying reversible causes and determining when to start interventions such as oxygen, chest compressions, or medication to stabilize the child’s condition. Effective team coordination is essential in emergencies to ensure timely, organized, and accurate patient care. It helps reduce errors, improve communication, and improve the overall outcome for critically ill patients.
We classify PALS bradycardia into two types based on its underlying cause and physiological response.
|
Types |
Primary Bradycardia | Secondary Bradycardia |
|
Definition |
An underlying cardiac condition, like heart block or sick sinus syndrome. |
It is caused by non-cardiac problems, such as hypoxemia, acidosis, or hypothermia. |
|
Reasons |
Myocarditis, surgical injury, cardiomyopathy, and congenital heart defects. |
Hypoxia, acidosis, hypotension, hypothermia, and medication side effects. |
|
Cure |
Cured by involving medication like atropine or placement of a permanent pacemaker. |
Cured by treating causes like giving oxygen, correcting acidosis, or managing temperature. |
Note: In children (infants and babies, especially premature babies), secondary bradycardia is more common than primary bradycardia. This simply means that the sinus node is firing at a slow rate. It is caused by something outside of the heart.
The PALS Bradycardia Algorithm helps healthcare providers quickly recognize and treat dangerously slow heart rates in children. Here’s why this algorithm is so important:
The PALS Bradycardia Algorithm with a pulse helps healthcare providers assess and manage pediatric patients who are experiencing slow heart rates but still have a pulse. It’s a critical tool for guiding treatment decisions to stabilize the child and ensure proper circulation while addressing the underlying causes of bradycardia.
01.
Bradycardia happens when a child's heart beats slower than what's normal for their age. It's important to catch it early and take the right actions to address it.
02.
When evaluating a patient with bradycardia, it is essential to evaluate for signs of cardiopulmonary compromise. Key indicators include acutely altered mental status, such as confusion, boredom, or unresponsiveness; signs of shock, like cold skin or body, delayed capillary refill, weak pulses, and poor perfusion; and hypotension, which indicates inadequate cardiac output. The presence of any of these signs alongside bradycardia suggests an unstable condition that requires immediate intervention to support airway, breathing, and circulation while identifying and treating the underlying cause.
03.
During assessment and support, ensure the airway is patent and provide positive pressure ventilation and oxygen as needed. Use a cardiac monitor to assess the rhythm and continuously monitor vital signs, including pulse, blood pressure (BP), and oxygen saturation (SpO2). This helps guide further interventions and ensures optimal patient care.
04.
If the heart rate stays below 60 bpm even after providing oxygen and ventilation, begin CPR right away to help support circulation and stop things from getting worse.
05.
In kids, persistent bradycardia points to a serious underlying problem that needs quick attention. Acting fast with the right assessment and treatment is key to controlling complications and keeping circulation stable.
06.
If a patient experiences a heart rate less than 60 bpm, continue CPR. Establish intravenous (IV) or intraosseous (IO) access for medication administration. Administer epinephrine to help support circulation, and consider atropine if the issue is due to increased vagal tone or primary AV block. If necessary, consider transthoracic or transvenous pacing to restore a normal heart rate. Finally, it’s crucial to identify and treat any underlying causes contributing to bradycardia.
07.
Check the patient’s pulse every 2 minutes to keep an eye on their circulation and look for any changes.
08.
If a pulse is not present, the healthcare provider should continue with the step-by-step approach outlined in the Pediatric Cardiac Arrest Algorithm. This includes delivering high-quality CPR, performing early defibrillation if a shockable rhythm is identified, and administering epinephrine promptly.
09.
Support the ABCs: Airway, Breathing, and Circulation. If the patient needs it, go ahead and give oxygen, and keep a close eye on how they're doing. It’s also important to run a 12-lead ECG to check their heart rhythm. From there, try to quickly pinpoint and treat whatever’s causing the problem, so you can stabilize the patient and decide on the next steps.
Medications for managing bradycardia in children are all about boosting the heart rate and stabilizing circulation. Each medication has a key role in handling specific situations.
This medicine helps to speed up the heart rate when it’s too slow. It works by blocking certain signals that slow the heart down, allowing the heart to beat faster. Atropine IV/IO dose: 0.02 milligram per kilogram. May repeat once. The minimum dose is 0.1 mg, and the maximum single dose is 0.5 mg.
Epinephrine is a medicine used when the heart rate is very slow and atropine doesn’t work. It helps by making the heart pump stronger and faster, and it also improves blood flow to vital organs. Epinephrine IV/IO dose: 0.01 milligram per kilogram (0.1 milliliter per kilogram of the 0.1 mg per ml concentration). Repeat every 3 to 5 minutes. If IV/IO access is not available but an endotracheal tube is in place, you may give an endotracheal tube dose of 0.1 mg per kilogram (0.1 ml per kilogram of the 1 mg per ml concentration).
Dopamine is a medication that helps to improve the heart’s ability to pump blood when the heart rate is low. It also supports blood pressure, ensuring that blood gets to all parts of the body, especially important organs like the brain and kidneys.
Note: Healthcare providers give these medications in different situations based on the severity of the bradycardia (slow heart rate) and the child’s response.
In short, the PALS Bradycardia Algorithm is key in quickly assessing and managing bradycardia in kids. It helps healthcare providers identify reversible causes of slow heart rates, preventing cardiac arrest. The algorithm guides clinicians through checking airway, breathing, and circulation, and outlines steps like starting CPR if the heart rate drops below 60 bpm and giving medications like atropine and epinephrine. By providing a clear, structured approach, the PALS Bradycardia Algorithm improves outcomes and survival rates for critically ill children.
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