Drug of Choice in Pediatric Bradycardia
Epinephrine is the drug of choice for pediatric bradycardia with poor perfusion that is unresponsive to adequate ventilation and oxygenation. 1
Initial Management Algorithm
The first and most critical intervention for pediatric bradycardia is not pharmacologic—it is ensuring adequate oxygenation and ventilation, as most pediatric bradycardia results from hypoxia rather than primary cardiac pathology. 1, 2
Step 1: Assess and Support Airway/Breathing
- Provide supplemental oxygen and ensure adequate ventilation first 1
- If heart rate remains <60 bpm with signs of poor perfusion despite adequate oxygenation and ventilation, begin chest compressions 1
Step 2: Pharmacologic Intervention - Epinephrine First-Line
Epinephrine should be administered to infants and children with bradycardia and poor perfusion that is unresponsive to ventilation and oxygenation. 1
- Standard dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) IV/IO 2, 3
- Consider higher doses (0.1-0.2 mg/kg) if standard dose is ineffective 2, 3
- Epinephrine remains the most effective resuscitation adjunct despite theoretical superiority of other alpha-adrenergic agents 2, 3
Role of Atropine - Context-Specific, Not First-Line
Atropine is reasonable for bradycardia caused by increased vagal tone or anticholinergic drug toxicity, but it is NOT the primary drug for most pediatric bradycardia. 1
When to Use Atropine:
- Vagally-mediated bradycardia (e.g., during intubation, suctioning) 1, 4
- Anticholinergic drug toxicity 1
- NOT for hypoxia-induced bradycardia (the most common pediatric scenario) 2
Atropine Dosing in Pediatrics:
- 0.02 mg/kg IV/IO 4
- Minimum dose: 0.1 mg 4
- Maximum single dose: 0.5 mg in children, 1.0 mg in adolescents 4
- Can repeat every 5 minutes to maximum total: 1 mg (children), 2 mg (adolescents) 4
Critical Caveat:
There is insufficient evidence to support or refute the routine use of atropine for pediatric cardiac arrest. 1 The 2020 International Consensus guidelines explicitly state this limitation, and a 2022 evidence update found that recent studies showed either worse outcomes or no difference with epinephrine use (though epinephrine remains recommended due to lack of alternatives). 1
Common Pitfalls to Avoid
Pitfall #1: Using Atropine for Hypoxic Bradycardia
Most pediatric bradycardia is caused by hypoxia, not increased vagal tone. 2 Atropine is ineffective for hypoxia-induced bradycardia—improved oxygenation is the intervention of choice. 2 Administering atropine delays the appropriate treatment (ventilation/oxygenation and epinephrine).
Pitfall #2: Inadequate Doses
- Atropine doses <0.5 mg may paradoxically cause further slowing of heart rate 5
- The minimum pediatric dose of 0.1 mg exists to prevent this paradoxical bradycardia 4
Pitfall #3: Undertreating Prehospital Bradycardia
A 2023 multi-agency analysis found that pediatric bradycardia is significantly undertreated in prehospital settings, with variable adherence to PALS guidelines. 6 Providers must recognize bradycardia early and intervene aggressively with appropriate therapies.
Special Considerations
Emergency Transcutaneous Pacing
- May be lifesaving in complete heart block or sinus node dysfunction 1
- NOT helpful in bradycardia secondary to post-arrest hypoxic/ischemic myocardial insult or respiratory failure 1
- Not effective for asystole 1
Vascular Access
Intraosseous access should be considered early when venous access is not readily available—it is superior to endotracheal drug administration. 1, 3 The endotracheal route is not reliable and requires larger doses. 3
Summary of Evidence Quality
The recommendations are based on 2020 International Consensus guidelines from ILCOR published in Circulation, representing the highest quality guideline evidence available. 1 These recommendations remain unchanged from 2010 due to insufficient new evidence, as confirmed by 2022 evidence updates. 1 The evidence base is limited, with no randomized controlled trials identified in recent systematic reviews. 1