Bedside Snapshot
- Recognize
- Heart rate < 60/min with poor perfusion despite oxygen and ventilation
- Pulse present: check SpO₂ and EtCO₂ first
- Red Flags
- Pale, gray or mottled skin; capillary refill over 2 s
- Lethargy, weak pulses or apnea
- First Actions
- Oxygen and ventilation
- CPR if rate still under 60/min with poor perfusion
- Epinephrine 0.01 mg/kg IV/IO
- Key Doses
- Epinephrine 0.01 mg/kg (0.1 mL/kg of 0.1 mg/mL), max 1 mg, every 3–5 min
- Atropine 0.02 mg/kg, min 0.1 mg, max 0.5 mg, may repeat once
- Don't Miss
- Hypoxia treated as a rhythm problem
- Epinephrine 1 mg/mL given IV
- Atropine below 0.1 mg
- Escalate & Transport
- Call pediatric-ready transport early
- Pacing if bradycardia persists despite drugs
Overview & Pediatric Differences
Bradycardia with a pulse: the heart is slow, but it is still beating. In children that is usually a failing circulation, rather than a primary rhythm problem. Most often the cause is hypoxia, hypoventilation or shock. Your question is whether the slow rate is causing poor perfusion. Fix oxygenation and ventilation first.
CPR is not the first move. The 2025 AHA PALS algorithm starts it only when the heart rate is under 60/min and perfusion is poor despite oxygen and ventilation. Slow with good perfusion? Observe it and treat the cause.
Why Kids Are Different
- Cardiac output depends on rate: a child's stroke volume is small and limited. Slow the rate and output falls fast.
- Hypoxia is the usual cause: the heart slows late in respiratory failure. The rate is a late sign, not an early one.
- Vagal reflexes are strong: Suction, laryngoscopy, pressure on the eye or abdomen, even pain. Any of them can slow an infant's or young child's heart.
- Dosing is by kilogram: every dose is weight based. A small weight error becomes a large dose error, which is why each dose has a fixed maximum.
Recognition & Severity
Check the age-based normal ranges on the pediatric vital signs page first. A rate that looks low for age is not automatically a drug problem. Perfusion makes the call.
| Feature | Perfusion Adequate | Poor Perfusion |
|---|---|---|
| Mental status | Awake, appropriate for age | Lethargic, limp or unresponsive |
| Skin | Warm, pink | Pale, gray or mottled |
| Capillary refill | ≤ 2 s | > 2 s |
| Pulses and BP | Pulses normal for site | Weak or absent pulses; hypotension for age |
| Breathing | Adequate, no distress | Apnea, gasping, shallow or irregular breathing |
Red Flags
- Heart rate under 60/min with any of the poor-perfusion signs above.
- Bradycardia that follows suctioning, intubation or a pressure stimulus, and does not recover when the stimulus stops.
- Bradycardia with hypertension and irregular breathing (raised intracranial pressure).
Differential Diagnosis
| Condition | Distinguishing Features | Key Test or Finding |
|---|---|---|
| Hypoxia or hypoventilation | Cyanosis, apnea, noisy or slow breathing, altered mental status | SpO₂ and EtCO₂; chest rise; airway check |
| Increased vagal tone | Slow rate after suctioning, laryngoscopy, or a pressure stimulus | Rate recovers when the stimulus stops |
| Atrioventricular (AV) block | Congenital block, myocarditis, post-cardiac-surgery, post-procedure | 12-lead ECG; PR and P-wave relationship |
| Toxic bradycardia | Beta-blocker, calcium-channel blocker, digoxin or other cardiac glycoside exposure | History, medication and ingestion review; poison center. Suspected toxic cause: call poison control or toxicology early. Atropine and pacing are often ineffective; antidotes such as calcium, glucagon, high-dose insulin and digoxin Fab are guided by the agent. |
| Hypothermia or hypoglycemia | Cold skin, altered mental status, poor feeding in infants | Core temperature; point-of-care glucose |
| Raised intracranial pressure | Bradycardia with hypertension, irregular breathing, pupil changes | Neurologic exam; transport to a neurosurgical center |
Algorithm: Bradycardia with a Pulse
Work the steps in order. This algorithm fits one picture only: a pulse, a heart rate under 60/min and poor perfusion despite oxygenation and ventilation.
- Oxygenate and ventilate: give oxygen, assist ventilation with a bag-mask device, and confirm with SpO₂, EtCO₂ and chest rise. Most children with bradycardia need this step alone.
- Check perfusion: if the heart rate is still under 60/min with poor perfusion, start CPR (Paramedic/RN/CCT: per local protocol). If the child becomes pulseless, switch to the arrest pathway on the pediatric cardiac arrest page.
- Give epinephrine: 0.01 mg/kg IV/IO (0.1 mL/kg of 0.1 mg/mL), max 1 mg per dose, every 3–5 min while poor perfusion persists.
- Give atropine for vagal or AV-block causes: 0.02 mg/kg IV/IO, minimum 0.1 mg, maximum 0.5 mg per dose; may repeat once.
- Escalate to pacing: if bradycardia with poor perfusion persists despite epinephrine and atropine, pacing is considered (transcutaneous first where available, then transvenous). Pacing is mainly for known or suspected AV block or sinus node dysfunction (congenital, post-surgical or post-procedure). Don't expect it to help with hypoxic, toxic or vagal bradycardia. See transcutaneous pacing.
Treat the cause at every step: get a 12-lead ECG and a glucose. Then find and treat the reversible causes: hypoxia, hypothermia, hypoglycemia, toxins, raised intracranial pressure and electrolytes, including hyperkalemia. Suspect a toxic ingestion? Call poison control or medical direction early (see toxic ingestions). Doses and agents are protocol-dependent.
Oxygen is the first bradycardia drug: A child who slows from hypoxia usually comes back with ventilation alone. Drugs given first won't fix the lungs.
Medications & Dosing
Doses vary by protocol; follow local protocols and medical direction. Read the concentration off the label before every dose.
| Drug | Dose & Route | Max | Notes |
|---|---|---|---|
| Epinephrine High-alert | 0.01 mg/kg IV/IO = 0.1 mL/kg of 0.1 mg/mL | 1 mg per dose; every 3–5 min | First drug for bradycardia with poor perfusion after oxygenation and ventilation. The 0.1 mg/mL syringe is FDA-labeled for adult septic-shock hypotension; pediatric bradycardia use follows PALS and is off-label. |
| Atropine | 0.02 mg/kg IV/IO = 0.2 mL/kg of 0.1 mg/mL | Min 0.1 mg; max 0.5 mg per dose; may repeat once | For bradycardia from increased vagal tone or primary AV block. Do not give a dose below 0.1 mg. Protocols may switch to adult dosing in adolescents; follow local protocol and the weight-based maximum (0.5 mg) until then. |
| Dextrose | 0.5–1 g/kg IV/IO = 5–10 mL/kg of D10W (children) | Adult dose 25 g per dose | Give when glucose is low. Infants: use D10W, not D50. |
Epinephrine concentration: IV/IO doses come from the 0.1 mg/mL strength. The 1 mg/mL concentrate is for IM use, or for dilution per pharmacy or protocol. Never push it undiluted IV/IO. Give 1 mg/mL IV by mistake and it is a tenfold overdose that can cause lethal hypertension and arrhythmia.
Monitoring, Reassessment & Disposition
| Parameter | Target | Notes |
|---|---|---|
| Heart rate and perfusion | Rate above 60/min with normal perfusion | Reassess after each intervention, per protocol |
| Oxygenation and ventilation | SpO₂ and EtCO₂ per protocol | Continuous monitoring; an EtCO₂ waveform confirms the airway |
| Blood pressure | Age-appropriate per the vital-signs page | Hypotension signals poor perfusion, not a normal rate |
| Glucose | Check and correct low values | Treat with dextrose as in the table above |
- Pacing or pacing pads placed, with capture confirmed.
- Early PICU or pediatric critical-care consultation for any child who needed drugs or pacing.
Pitfalls & Safety Checks
| Pitfall | Consequence | Prevention |
|---|---|---|
| 1 mg/mL epinephrine given IV | Tenfold overdose | Use the 0.1 mg/mL IV/IO concentration; read the label |
| Drugs before ventilation | Hypoxic bradycardia persists | Oxygen, ventilation and EtCO₂ first |
| CPR for a slow rate with good perfusion | Unnecessary compressions and drugs | Apply the entry criteria: rate under 60/min with poor perfusion |
| Atropine below 0.1 mg | Dose below the PALS minimum | Use the 0.1 mg minimum per PALS and local protocol; do not give less |
| Lbs used for kg | Dose error by up to 2.2 times | Weigh in kg or use the length-based estimate on the Broselow tape |
| Pacing delayed | Prolonged low output | Pads on early in known or suspected AV block or sinus node dysfunction; not for hypoxic, toxic or vagal bradycardia |
Most catastrophic error: the 10-fold epinephrine concentration error. Before every IV/IO push, read the mg/mL on the syringe.
Special Populations
Neonates
- Neonates run on the Neonatal Resuscitation Program, and ventilation comes first. Under 100/min, ventilate first. Still under 60/min after effective ventilation? That calls for compressions. See neonatal resuscitation.
Infants
- Vagal bradycardia is common with suctioning and intubation. Take away the stimulus and ventilate before any drug goes in.
- Atropine may go in before intubation to prevent bradycardia. See the atropine page, and follow local protocol.
Adolescents
- The local protocol sets the size or pubertal threshold where adult dosing starts. Use one rule, the one in your protocol.
Children With Heart Disease
- A child after congenital heart surgery, or one with known AV block, may have a pacing wire or device. Check the device, then the cardiology plan.
Prehospital & Transport Considerations
| Level | Typical Role in This Topic |
|---|---|
| EMT | Oxygen, bag-mask ventilation, pulse and perfusion check, CPR, early call for ALS |
| AEMT | Pediatric monitoring, IV or IO access per protocol |
| Paramedic | Epinephrine and atropine by weight; transcutaneous pacing per protocol |
| RN (ED/ICU) | Drug preparation and titration with pacing and monitoring |
| Critical Care Transport | Pacing and pumps during transport; ventilation by age and weight |
- Preparation: pre-drawn epinephrine 0.1 mg/mL and atropine 0.1 mg/mL syringes, color-coded by weight, if local stock allows.
- Destination: a pediatric-ready ED or a pediatric critical-care center, early.
- Handoff: structured handoff (IMIST-AMBO or MIST), with the drugs given, times and rhythm changes.
Clinical Pearls
Ventilate before you medicate: most slow children are hypoxic. Fix the airway and breathing first. Then look at the rate and perfusion again.
Perfusion decides the next step: a slow child with good perfusion gets watched, and the cause gets treated. CPR and drugs belong to a rate under 60/min with poor perfusion.
Atropine helps the vagal child, not the hypoxic one: give it for increased vagal tone or AV block. If the lungs are the problem, expect little from it.
Pacing is for AV block and sinus node dysfunction: start it when drugs fail to hold the rate in those conditions. Then confirm capture with a pulse and a perfusion check.
References
- American Heart Association and American Academy of Pediatrics. Part 8: Pediatric Advanced Life Support: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025;152(16 suppl 2):S479–S537. https://doi.org/10.1161/CIR.0000000000001368
- Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay. Circulation. 2019;140(8):e382–e482. https://doi.org/10.1161/CIR.0000000000000628
- Hospira, Inc. Atropine sulfate injection, solution [prescribing information]. DailyMed, National Library of Medicine; revised 9/2025. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ad8916e7-206e-409e-2582-30d072845dd4
- Epinephrine injection USP, 0.1 mg/mL single-dose prefilled syringe [prescribing information]. DailyMed, National Library of Medicine; revised 12/2024. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f2b5f15b-8541-466a-a27a-ee57bc4aac67
Medical Disclaimer
- For Educational Purposes Only: This content is intended for educational reference and should not be used for clinical decision-making.
- Not a Substitute for Professional Judgment: Always consult your local protocols, institutional guidelines, and supervising physicians.
- Verify Before Acting: Users are responsible for verifying information through authoritative sources before any clinical application.
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