Management of Bradycardia with Hemodynamic Compromise
Red Cross Guidelines
- For infants and children with bradycardia with inadequate perfusion, assurance of adequate oxygenation and ventilation must be the initial intervention. REAFFIRMED
- For infants and children with bradycardia with inadequate perfusion and a heart rate of 60 beats per minute or less despite adequate oxygenation and ventilation, chest compressions should be initiated. REAFFIRMED
- For infants and children with bradycardia with inadequate perfusion that is unresponsive to oxygenation and ventilation and requiring chest compressions, drug therapy may begin with epinephrine. Follow standard cardiac arrest guidelines and algorithms.
- For selected cases of infants and children with bradycardia with inadequate perfusion induced by poisoning (e.g., beta-blockers [β-blockers], calcium channel blockers, clonidine, cardiac glycosides, organophosphates and carbamates) or in the setting of increased vagal tone or atrioventricular (AV) block, it may be reasonable to administer atropine. (Good practice statement)
- Transcutaneous pacing may be considered in infants and children for some types of bradycardia and poor perfusion, such as in the setting of AV nodal block, β-blocker- or calcium channel blocker-induced bradycardia or failed permanent pacemaker. (Good practice statement)
Insights
Severe bradycardia in children is most often caused by hypoxia, usually secondary to respiratory failure. If not promptly corrected, it can lead to hemodynamic compromise and progress to pulseless electrical activity (PEA) or cardiac arrest. Past guidelines recommended epinephrine for bradycardia with poor perfusion unresponsive to ventilation and oxygenation, atropine for bradycardia due to increased vagal tone or anticholinergic drug toxicity, and pacing in selected cases such as complete heart block or sinus node dysfunction. A recent systematic review, however, found no direct evidence to support epinephrine, atropine, or pacing for pediatric bradycardia, and the International Liaison Committee on Resuscitation therefore issued no treatment recommendation or good practice statement for their use.
Indirect evidence shows that children receiving cardiopulmonary resuscitation (CPR) for bradycardia with hemodynamic compromise have better survival rates than those with asystole or PEA. Thus, delaying CPR when oxygenation and ventilation fail to reverse bradycardia may result in pulselessness and worse outcomes. The Red Cross guidelines recommend that CPR should be prioritized when severe bradycardia with poor perfusion does not respond to oxygenation and ventilation. In addition, the Red Cross continues to support guidance for the selective use of pharmacologic or pacing interventions in very specific situations. Although no direct pediatric trial evidence exists, atropine may be reasonable in cases of bradycardia due to poisonings (e.g., digoxin, diltiazem, organophosphates) or excessive vagal tone. Likewise, temporary transcutaneous pacing may be considered in atrioventricular nodal block, failing permanent pacemaker, or life-threatening bradyarrhythmias resulting from poisoning with β-blockers, calcium channel blockers, cardiac glycosides or local anesthetics.