PALS Bradycardia Algorithm

1. Identifying the Bradycardia

Healthcare providers begin assessment by measuring the child’s heart rate and comparing it to age-appropriate normal ranges. The provider team evaluates whether the bradycardia causes symptoms such as altered mental status, poor feeding, or decreased activity levels. This initial step determines the urgency of intervention and guides the treatment decisions. Recognition of symptomatic versus asymptomatic bradycardia also determines the entire management approach.

2. Assessing the Cardiopulmonary Compromise

Healthcare professionals evaluate the patient for signs of cardiopulmonary compromise, including hypotension, altered mental status, and poor perfusion. The assessment focuses on identifying shock, respiratory failure, or cardiovascular instability that requires immediate intervention. Signs of compromise include shortness of breath, chest pain, dizziness, and changes in skin color. This critical determination divides patients into two distinct management pathways.

When Cardiopulmonary Compromise is Present

Assessment and Support

Medical teams immediately establish and maintain patent airways while providing positive pressure ventilation with supplemental oxygen as needed. Continuous cardiac monitoring identifies the underlying rhythm, while pulse oximetry and blood pressure monitoring track the patient’s physiologic response. IV or IO access becomes a priority for medication administration. These foundational steps stabilize the patient before specific bradycardia interventions.

Start CPR

Healthcare providers initiate chest compressions when the heart rate falls below 60 beats per minute despite adequate oxygenation and ventilation efforts. High-quality CPR maintains circulation and perfusion to vital organs during severe bradycardia. The compression-to-ventilation ratio follows standard pediatric guidelines while the team prepares for medication administration. CPR continues until the heart rate improves or advanced interventions take effect.

Evaluating the Bradycardia

A. If Bradycardia Persists: The medical team continues CPR while establishing vascular access through IV or IO routes for medication delivery. Epinephrine administration follows standard dosing protocols to stimulate cardiac contractility and improve heart rate. Atropine becomes the preferred choice for bradycardia caused by increased vagal tone or primary AV blocks. Healthcare providers check for pulse presence every 2 minutes during ongoing resuscitation efforts. If the pulse remains present, the team continues with CPR, medications, and pacing considerations while treating reversible causes. If a pulse is absent, providers immediately transition to the pediatric cardiac arrest algorithm for pulseless management.

B. If Bradycardia Doesn’t Persist: Providers maintain airway, breathing, and circulation support while closely monitoring the patient’s clinical status and vital signs. Supplemental oxygen administration continues based on oxygen saturation levels and clinical appearance of respiratory distress. A 12-lead ECG provides detailed rhythm analysis and helps identify underlying cardiac abnormalities or conduction disorders. The team focuses on identifying and correcting reversible causes while preparing for potential deterioration.

When Cardiopulmonary Compromise is Not Present

Medical teams provide supportive care by maintaining airway patency and ensuring adequate breathing while closely monitoring vital signs. Oxygen administration depends on saturation levels and clinical assessment of respiratory status and perfusion. A 12-lead ECG helps identify the underlying rhythm and potential cardiac abnormalities requiring specific treatment approaches. The primary focus remains on identifying and treating reversible causes while observing for clinical deterioration that would require escalation.