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Pediatric Advanced Life Support (PALS): Bradycardia Algorithm

The Pediatric Bradycardia with a pulse algorithm outlines the steps for evaluating and managing the child who presents with symptomatic bradycardia.

If there are no signs of cardiopulmonary compromise:

•Support ABC’s as needed

•Consider Oxygen

•Observe and perform frequent reassessments

•Obtain a 12-lead ECG

•Identify and treat underlying causes.

If you find signs of Cardiopulmonary compromise like the following intervention will be required:

•Acutely altered mental status

•Signs of Shock


A child with primary bradycardia may benefit from evaluation by a pediatric cardiologist but do not delay initiating emergency treatment if symptoms present.


Airway: Support the Airway and position the child or allow the child to assume a position of comfort or open the airway if needed.

Breathing: Give oxygen in high concentration like using a non-rebreather mask if available. Assist ventilations as indicated using a bag-Mask and Ensure to attach a pulse oximeter to monitor the oxygen saturation

Circulation: Check Heart rate and Blood Pressure

Attached an ECG monitor or defibrillator. In the Bradycardia case a Defibrillator with Transcutaneous pacing capability should be used if available.

Establish vascular access using IV or IO.

Perform a 12-lead ECG if available but do not delay treatment.

Obtain appropriate laboratory studies like potassium, glucose, ionized calcium, magnesium, blood gas, and toxicology screen.

⚠️ If the Childs HR is below 60 despite good oxygenation and ventilation, and has serious signs and symptoms, immediately start with High-Quality CPR

Get an IV or IO access. If neither IV nor IO access is available for medication delivery, the Endotracheal (ET) route is the third option.

💉 Epinephrine 0.01mg/kg IV (0.1ml/kg of 0.1mg/ml)

Push Every 3-5 Minutes

ET if IV/IO not available: 0.1mg/kg (0.1ml/kg of 1mg/ml)

For persistent bradycardia, consider a continuous infusion of epinephrine- 0.1- 0.3mcg/kg per minute. A continues epinephrine infusion may be useful, particularly if the child has responded to a bolus of Epinephrine. Titrate dose against the effect.

Atropine (and pacing) are preferred over epinephrine as the first-choice treatment of symptomatic AV block due to primary bradycardia.

💉For IV/IO route, give 0.02 mg/kg; minimum 0.1 mg, maximum 0.5 mg

May repeat dose once, in 5 minutes.

🛑 Note: Larger doses may be required for organophosphate poisoning.

For ET route, give 0.04 to 0.06 mg/kg.

Note: IV/IO is preferred, but if it is not available, atropine can be administered by ET tube.

TCP or Transvenous pacing may be lifesaving in selected cases of bradycardia caused by complete heart block or abnormal sinus node function. For example, pacing is indicted for AV block after surgical correction of congenital heart disease.

Disclaimer: This video is for educational purposes only, and is not intended as medical advice. While we strive for 100% accuracy, errors may occur, and medications or protocols may change over time. #TheResuscitationCoach#PALS#PALSBradycardia



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