PALS | Pedi Bradycardia and Tachycardia Management Extended

80/20 Summary: Pediatric Arrhythmia Management & Algorithms[1]

1. Core Assessment & Stability Principles

• Hemodynamic Instability: Recognized by respiratory failure, shock with poor end-organ perfusion (with or without hypotension), altered mental status/irritability, chest pain, or sudden collapse[1].
• Initial Actions: Support ABCs, give high-concentration O₂, attach ECG/oximetry/BP monitor, obtain IV/IO access, and record a 12-lead ECG without delaying emergency care[1].

2. Pediatric Bradycardia Algorithm (With Pulse & Poor Perfusion)

• Primary Trigger: HR < 60/min with poor perfusion despite adequate oxygenation and ventilation[2][4].
• Immediate Action (CPR): Start high-quality CPR (100–120 compressions/min; depth ≥1/3 AP chest diameter: ~2 in [5 cm] in children, ~1.5 in [4 cm] in infants; complete recoil; minimal interruptions)[2][4].
• Medications for Persistent Bradycardia:
  • Epinephrine: 0.01 mg/kg IO/IV (0.1 mL/kg of 0.1 mg/mL); repeat every 3–5 min. (ET dose: 0.1 mg/kg)[2][5].
  • Atropine: 0.02 mg/kg IO/IV (min 0.1 mg, max single dose 0.5 mg; repeat once in 5 min) for increased vagal tone or primary AV block[2].
  • Cardiac Pacing: Consider for complete AV block or sinus node dysfunction[2][6].
  • Pulseless Arrest: If pulses are lost, switch immediately to the Cardiac Arrest Algorithm[7].

3. Pediatric Tachycardia Algorithm (With Pulse)

Classify by QRS width: Narrow (≤0.09 sec) vs Wide (>0.09 sec)[8][9].

A. Narrow QRS (≤0.09 sec)

• Sinus Tachycardia (ST): HR <220/min (infants) or <180/min (children); P waves present; variable R-R[8][9]. Action: Treat underlying cause (fever, pain, dehydration)[8][9].
• Supraventricular Tachycardia (SVT): HR ≥220/min (infants) or ≥180/min (children); P waves absent/abnormal; abrupt onset[8][9].
  • Stable SVT:
    1. Vagal Maneuvers: Ice bag to upper face (15–20 sec) or straw blowing[10][11].
    2. Adenosine: 0.1 mg/kg IV/IO rapid bolus (max 1st dose: 6 mg) via 2-syringe flush. 2nd dose: 0.2 mg/kg (max: 12 mg)[8][11].
  • Unstable SVT: Synchronized Cardioversion at 0.5–1 J/kg (up to 2 J/kg). If IV/IO available, give adenosine first without delaying shock[12].

B. Wide QRS (>0.09 sec)

• Ventricular Tachycardia (VT):
  • Unstable VT: Synchronized Cardioversion at 0.5–1 J/kg (up to 2 J/kg)[12].
  • Stable VT: Expert consult. Amiodarone 5 mg/kg IV/IO over 20–60 min OR Procainamide 15 mg/kg IV/IO over 30–60 min (do not combine)[15]. Adenosine may be tried if monomorphic[11][13]. Magnesium for Torsades de Pointes[19].