Pediatric Advance Life Support: Unstable Bradycardia

Search for Reversible Causes

·         Hypoxia

·         Hypothermia

·         Hyper/hypokalemia

·         Hypoglycemia

·         Tablets/toxins

·         Tension pneumothorax

·         Tamponade, cardiac

·         Thrombosis, pulmonary

Hypoxia

·         Hypoventilation and hypoxia can lead to bradycardia

·         Assess ABCs

·         Give supplemental oxygen

·         Consider advanced airway management

·         Mechanical Ventilation- DOPE mnemonic

·          

Hydrogen Ions (acidosis)

·         Assess ABGs

·         Bicarb 1mEq/kg

o   Known pre-existing bicarbonate responsive acidosis

o   Intubated patient with continued long arrest interval

o   Upon return of spontaneous circulation after long arrest interval

o   Tricyclic antidepressant or aspirin overdose

o   Known preexisting hyperkalemia

·         ·Treat respiratory acidosis with ventilation

Hyperkalemia

·         Assess serum potassium levels

·         Slow rhythm with tall T waves, widened QRS

o   3.5-5.3          Normal

o   5.3-6.0          Mild

o   6.1-7.0          Moderate

o   >7.0               Severe

·         Rule of 10

o   10ml of 10% calcium chloride or gluconate

o   10 units of regular insulin IV

o   One amp D50 over 10 minutes

·         Kayexalate upon return to ROSC

·         Lasix IV

Hyperkalemia 8.8 mEq/dl

Hypokalemia

·         Slow rhythm with ST segment depression, flattened waves, prominent U wave

·         Potassium replacement either orally or IV

·         No IV push boluses!

Tablets

·         Assess for drug overdose

·         Assess for hx of drug use

·         Consult poison control

Tablets: Calcium Channel Blockers

·         Hypotension

·         Bradycardia with variable heart block

·         Altered mental status

·         EKG: slow rate, prolonged PRI, AV blocks

·         Rx Calcium chloride 10% 1-4G slow IV

·         Fluid resuscitation, vasopressor agents, atropine, transvenous pacing

Tablets: Beta blockers

·         Hypotension

·         Bradycardia with variable heart block

·         EKG: slow rate, prolonged PRI

·         Rx Glucagon 3-10mg IV bolus followed by infusion 2-5mg/hr

Tablets: Tricyclic Antidepressants

·         Amitriptyline, Doxepine, Trazadone, Nortriptyline

·         Prolonged QT, Widened QRS

·         3Cs & 1A - Cardiac dysrhythmias, Convulsions, Coma, & Acidosis

·         Rx NaHCO3 bolus or infusions

·         Maintain pH > 7.45

Tension Pneumothorax

·         Hx trauma, recent pacemaker or central line insertion, ventilator patient

·         Assess for tracheal deviation

·         Needle decompression 2nd intercostal space midclavicular line

·         Chest tube

Thrombosis, Coronary

·         MONA

·         Follow ACS algorithm

Sources

PALS Provider Manual. American Heart Association 7272 Greenville Ave. Dallas, Tx 75231

Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL, Berg MD, de Caen AR, Fink EL, Freid EB, Hickey RW, Marino BS, Nadkarni VM, Proctor LT, Qureshi FA, Sartorelli K, Topjian A, van der Jagt EW, Zaritsky AL. Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S876–S908