How to manage bradycardia (slow heart rate) in a 12-year-old child with meningitis or encephalitis?

Management of Bradycardia in a Child with Meningitis or Encephalitis

In a 12-year-old child with meningitis or encephalitis who develops bradycardia, administer atropine 0.02 mg/kg IV if the bradycardia is causing hemodynamic compromise and is unresponsive to oxygenation and ventilation. 1

Initial Assessment and Management

When bradycardia occurs in a child with meningitis or encephalitis, follow this algorithm:

1. Determine if bradycardia is causing hemodynamic compromise:

   • Check for poor perfusion, hypotension, altered mental status
   • Assess for signs of shock (delayed capillary refill, cold extremities)
   • Monitor vital signs including blood pressure

2. First-line interventions 1:

   • Ensure patent airway
   • Provide oxygen and assist ventilation as necessary
   • Attach cardiac monitor, pulse oximetry, and blood pressure monitoring
   • Establish IV/IO access

3. If bradycardia persists with poor perfusion despite effective oxygenation and ventilation:

   • Start CPR if heart rate is <60 beats per minute with poor perfusion
   • Administer epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) IV/IO

4. If bradycardia is suspected to be vagally mediated or related to increased intracranial pressure:

   • Administer atropine 0.02 mg/kg IV/IO 1
   • Minimum single dose: 0.1 mg
   • Maximum single dose: 0.5 mg for a child
   • May repeat every 5 minutes to maximum total dose of 1 mg

Special Considerations in Meningitis/Encephalitis

Increased Intracranial Pressure (ICP)

Bradycardia in meningitis or encephalitis is often a sign of increased ICP (Cushing's triad: bradycardia, hypertension, and irregular breathing) 2. Management should include:

• Position head at 30° elevation
• Maintain euvolemia - fluid restriction is NOT recommended 1
• Consider osmotic agents if cerebral edema is present 3
• Avoid routine ICP monitoring unless specifically indicated 1

Seizure Management

Seizures can affect heart rate and should be controlled:

• Use continuous EEG monitoring for ≥24 hours to detect subclinical seizures 3
• For clinical seizures, administer benzodiazepines (lorazepam 4 mg IV) as first-line treatment 3
• Consider levetiracetam (30-50 mg/kg IV) or valproate (20-30 mg/kg IV) as second-line options 3

When to Escalate Care

Involve intensive care teams early if the child has 1:

• Rapidly evolving symptoms
• GCS of 12 or less (or a drop of >2 points)
• Cardiovascular instability
• Acid/base disturbance
• Hypoxia or respiratory compromise
• Frequent seizures

Medication Cautions

• Atropine: May cause tachycardia, dry mouth, urinary retention, and confusion. Use with caution in patients with glaucoma 4
• Amiodarone: Should not be used in combination with other drugs that cause QT prolongation without expert consultation. May cause hypotension, bradycardia, heart block 1
• Avoid fluid restriction in an attempt to reduce cerebral edema, as this is not recommended and may worsen hemodynamic status 1

Monitoring

• Perform frequent neurological assessments
• Monitor vital signs continuously
• Watch for signs of clinical deterioration
• Consider continuous cardiac monitoring
• Reassess after each intervention

If bradycardia persists despite these measures, consider emergency transcutaneous pacing, though this is rarely helpful in bradycardia secondary to a hypoxic/ischemic myocardial insult or respiratory failure 1.