PALS Bradycardia Algorithm

Pediatric bradycardia refers to a heart rate that is slower than the normal range for a child’s age, differing among infants, younger children, to adolescents. It results from several causes that may be heart-related or other underlying issues, such as low oxygen level (hypoxia), hypothermia, hypotension, or electrolyte imbalance.

The treatment of pediatric bradycardia is streamlined by a systematic approach called the PALS Bradycardia Algorithm. It helps pediatric healthcare providers with early assessment and identification of symptoms, facilitates appropriate medical interventions, and provides ongoing monitoring and support for improved recovery outcomes.

Bradycardia in children is of two types:

1. Primary Bradycardia
A heart block or sick sinus syndrome, which is caused due to cardiac problems resulting from congenital abnormalities, or any injury to heart cells, is generally regarded as a primary bradycardia. The treatment for this type of bradycardia includes atropine and, permanent pacemaker.

2. Secondary Bradycardia
Secondary bradycardia is a more common type of bradycardia in infants and toddlers, caused by non-cardiac problems such as hypoxemia, acidosis, or hypothermia. Pediatric patients with secondary bradycardia are treated by maintaining proper body temperature, oxygen, and acid levels.

Pediatric Age-specific Bradycardia Heart Rate

Pediatric bradycardia varies among infants, younger children, to adolescents as follows:

Pediatric Age-group Bradycardic Heart rate (bpm)

0-3 years <100

3-9 years <60

9-16 years <50

Step-By-Step Pediatric Bradycardia Algorithm

1. Evaluation of Clinical Findings

Proper evaluation and analysis of electrocardiogram readings is the first step in the PALS bradycardia algorithm. It helps identify bradyarrhythmias with the help of ECG rhythm findings.

1. Sinus Bradycardia: Sometimes, sinus bradycardia may be just a normal response of our body to our physical inputs, such as in sports. But, underlying causes such as hypoxia, toxins, electrolyte imbalance, hypotension, and acidosis result in symptomatic bradycardia, which needs immediate medical intervention.

2. AV Blocks: AV Blocks means the disruption of the electrical conduction system through the atrioventricular (AV) node. Ranging from a healthy presence to a severe cardiac crisis, it can be of various types:
• First-degree AV block
• Second-degree AV block
Type I —Wenckebach/Mobitz I
Type II —Mobitz II
• Third-degree AV block (Complete Heart Block)

2. Recognizing Bradycardia Symptoms

Check if there is cardiopulmonary compromise or look for the signs of shock as follows:
• Poor perfusion,
• Pale or cold skin
• Hypotension
• Altered mental status
• Reduced urine output
• Pain or discomfort in the chest

3. Immediate Medical Intervention

1. Maintain ABC (manage patent airway, assist breathing, ventilation, and oxygenation).
2. Check for a cardiac monitor for rhythm identification.
3. Monitor blood pressure and pulse oximetry
4. Access Intravenous (IV) or Intraosseous (IO) access
5. Obtain a 12-lead electrocardiogram (ECG)

4. Identification of Underlying Cause

When medications are not improving the condition, it suggests the underlying causes, mainly low oxygen (hypoxia), a drop in body temp (hypothermia), toxins, electrolyte imbalance, and heart block. These causes should be identified and managed on time to prevent further damage.

5. Ongoing Monitoring and Evaluation

1. Check for the pulse every 2 minutes.
2. If no improvement is shown and instead the heart rate declines to below 60 bpm, initiate CPR immediately.

6. Advanced Treatment

1. Atropine: If bradycardia is due to increased vagal tone or primary atrioventricular (AV) block, consider atropine (0.02 mg/kg).
2. Epinephrine: Administer epinephrine boluses (0.01 mg/kg) IV or IO every 3-5 minutes. Alternatively, it can be administered using an endotracheal tube (ET).
3. Dopamine: If epinephrine is ineffective, provide dopamine (intrope and chronotrope) 2-20mcg/kg/min with titration.
4. Transcutaneous pacing: If medication like epinephrine, atropine, or dopamine is ineffective, follow the protocol and initiate transcutaneous pacing (TP) accordingly.

Special Considerations in PALS Bradycardia Treatment Algorithm

For the effective implementation of the PALS Bradycardia Treatment Algorithm, health professionals should be extra cautious to avoid any risks and complications. Here are the special considerations for this algorithm:

1. The treatment requirements vary from child to child. That’s why the medical intervention should be patient-specific.
2. The initial focus should be to maintain the cardiac output by increasing the heart rate.
3. Closely monitoring the patient’s response to ongoing medical intervention before initiating advanced treatment.
4. Administer atropine as the first-line treatment for symptomatic AV Block, but if dealing with secondary bradycardia, epinephrine is the priority.
5. At any point of treatment, if pulseless arrest develops, immediately implement the Cardiac Arrest Algorithm.

Bradycardia Treatment Algorithm for Children

The PALS Bradycardia Treatment Algorithm gives pediatric healthcare professionals a clear and structured guide to assess and manage slow heart rhythms or bradycardia in children. It focuses on early recognition, identifying reversible causes, and providing timely interventions. It helps prevent deterioration and improves survival chances and full recovery.

A PALS certification includes different treatment algorithms, like the PALS bradycardia algorithm and the PALS Cardiac Arrest Algorithm. It equips learners with the hands-on skills needed to act confidently and effectively during real pediatric emergencies.

If you are a pediatric healthcare provider or working in childcare settings and want to be AHA PALS certified, our training center, CPR VAM, offers comprehensive PALS certification classes. With expert instructors, practical simulations, and the latest evidence-based courses, you’ll gain the confidence and competence to handle when children are in life-threatening conditions.

Contact or visit us near you to get enrolled today!

FAQs for PALS Bradycardia Algorithm

1. What Heart Rate is Considered Pediatric Bradycardia?

A heart rate below 100 for ages 0-3 years, below 60 for ages 3-9 years, and below 50 for ages 9-16 years is considered pediatric bradycardia.

2. What is the First Drug for Bradycardia in PALS Algorithm?

Atropine is the first drug for bradycardia in PALS algorithm. It helps increase the heart rate by blocking the parasympathetic influence on the heart. In case atropine is effective, other medical interventions are considered, such as epinephrine, dopamine, and transcutaneous pacing.

3. Can Dehydration Cause Bradycardia?

Yes, severe dehydration can cause bradycardia as it causes the volume of blood circulation throughout the body to decrease, and it can also lead to an electrolyte imbalance.

4. Which Symptoms Indicate an Unstable Bradycardia?

Symptoms like chest pain or discomfort, altered mental condition (shock, confusion, or reduced consciousness), and low blood pressure (hypotension) indicate an unstable bradycardia. Immediate medical interventions are crucial for unstable symptomatic bradycardia.

5. What Are the Preventive Measures for Bradycardia?

The preventive measures for bradycardia are stress control, avoiding smoking, drugs, alcohol, caffeine, maintaining a healthy weight, blood pressure, and cholesterol level, and managing existing heart issues immediately.