Pediatric Bradycardia with Pulse Algorithm

Initial Assessment and Stabilization

• The initial evaluation of a pediatric patient with a rhythm disturbance must focus on the child's heart rate, rhythm, and clinical hemodynamic status.
• Bradycardia is defined as a heart rate slower than normal for the patient's age.
• The emergency management of bradycardia is dictated by its hemodynamic consequences.
• If bradycardia causes cardiorespiratory compromise, the initial step is to support the airway, breathing, and circulation (ABC) as required, administer supplemental oxygen, and attach a cardiac monitor or defibrillator.
• After securing the ABCs, the clinician must reassess the patient; if pulses, perfusion, and respirations normalize, no immediate emergency treatment is required, and the child should be continuously monitored while proceeding with further evaluation.
• If at any point the patient loses their pulse and develops pulseless arrest, the provider must immediately initiate cardiopulmonary resuscitation (CPR).

Management of Bradycardia with Poor Perfusion

• If the heart rate remains $<60$ beats per minute and is associated with poor systemic perfusion despite effective ventilation and oxygen administration, the provider must immediately start chest compressions.
• During this phase, it is critical to continue supporting the airway, maintaining ventilation, and providing oxygenation alongside chest compressions.

Pharmacological Interventions

• Epinephrine is the primary drug of choice for pediatric bradycardia associated with poor perfusion that does not respond to oxygenation and ventilation.
• Atropine is specifically indicated when bradycardia is caused by increased vagal tone (e.g., vagal stimulation) or a primary atrioventricular (A-V) block.
• If the bradycardia persists or responds only transiently to bolus medications, a continuous infusion of Epinephrine ($0.1-0.3$ $\mu$g/kg/min) or Isoproterenol should be considered.

Advanced Interventions (Pacing)

• Emergency transcutaneous cardiac pacing can be a life-saving measure if the bradycardia is caused by complete heart block or sinus node dysfunction that remains unresponsive to ventilation, oxygenation, chest compressions, and medications.
• Pacing is particularly useful when the condition is associated with congenital or acquired heart disease.
• Cardiac pacing is not effective and is not indicated for asystole or for bradycardia that is secondary to a post-arrest hypoxic/ischemic myocardial insult or respiratory failure.

Identification and Treatment of Reversible Causes

• While actively managing the bradyarrhythmia, the clinician must continuously look for and treat any underlying contributing factors, which are easily remembered by the "Hs" and "Ts" mnemonic.