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In this lesson, we're going to cover bradycardia, including some things to be aware of when dealing with bradycardic pediatric patients, types of bradycardia, underlying causes, and some information on the best courses of treatment to resolve that patient's bradycardia.
It's important to understand that there are many types of bradycardia. You may recall from a previous lesson that bradycardia is defined as a slower than normal heart rate for that child's age, activity level, and their current clinical condition.
Pro Tip #1: When a pediatric patient is presenting with bradycardia and is also hypotensive, this is usually a sign that they are experiencing cardiopulmonary compromise. When this happens, that child could possibly be in cardiac arrest very soon if not provided with treatment immediately.
The two most common types of bradycardia in pediatric patients are:
The possible underlying causes of pediatric bradycardia can include:
Pro Tip #2: It's important to remember that asymptomatic sinus bradycardia can be normal, especially in athletes, and may not require treatment. However, it's also equally important to remember that if the bradycardia, regardless of the underlying cause, is causing the patient to display serious or life-threatening symptoms related to that bradycardia, the patient must be treated immediately so that symptoms can be corrected.
Identifying and treating reversible causes is the most effective treatment for resolving symptomatic bradycardia.
Symptomatic bradycardia is a heart rate slower than normal for the child's age (usually less than 60 beats per minute) associated with cardiopulmonary compromise.
Cardiopulmonary compromise is defined as hypotension, an acutely altered mental status (such as a decreased level of consciousness), and other signs of shock.
Because hypoxemia is the most common cause of bradycardia in children, it's vital to provide proper ventilation and oxygenation early. Cardiac and oxygen saturation monitoring, blood pressure, and common vitals, also need to be obtained as early as possible.
In addition, the initiation of a patent IV or IO must be a high priority. A 12-lead ECG should be done if it is available. However, it's important to not delay treatment in order to get the 12-lead.
Pro Tip #3: A 12-lead ECG displays, as the name implies, 12 leads which are derived by means of 10 electrodes. Three of these leads are easy to understand, since they are simply the result of comparing electrical potentials recorded by two electrodes – one electrode is exploring, while the other is simply a reference electrode.
If the patient isn't showing signs of hypotension or other signs of cardiopulmonary compromise, you can continue with oxygenation, continue to observe the patient, and consider further expert consultation if needed.
If the patient's bradycardia persists and there are signs of poor perfusion after oxygen treatment, the next course of action is to administer medications.
If using medications, administer epinephrine at .01mg/kg of 1:10,000 via IV or IO. This can be repeated every 3 to 5 minutes.
In cases where the patient is dealing with a primary AV block or increased vagal tone, atropine would by your drug of choice – instead of epinephrine – at .02mg/kg. This can be repeated once for a total of .04mg/kg.
Pro Tip #4: When a pediatric patient's heart rate drops below 60 beats per minute with signs of poor perfusion, such as seen with an altered mental status or other signs of shock, it's vital to begin chest compression immediately. And cardiac pacing may be considered if either epinephrine and/or atropine are not effective.
You should ask yourself the following two questions when evaluating the heart rate and rhythm in any seriously ill or injured pediatric patient:
It's important to note that children with congenital heart disease may have underlying conduction abnormalities.
Interpret the patient's heart rate and rhythm by comparing them to that child's baseline heart rate and rhythm. Pediatric patients with poor baseline cardiac function are more likely to become symptomatic from arrhythmias than those with normal cardiac function.