PALS Bradycardia With a Pulse 4 — Questions and Answers
Question 1: A 9-year-old athlete has a resting heart rate of 48 bpm with no symptoms and normal BP. What is the most appropriate management?
- Immediate atropine administration
- Transcutaneous pacing
- Observation — this is likely physiologic bradycardia (Correct answer)
- Emergent cardiology consult for pacemaker
Correct answer: Observation — this is likely physiologic bradycardia
Well-trained athletes commonly have sinus bradycardia at rest due to high vagal tone; without symptoms or hemodynamic compromise, no intervention is needed.
Question 2: Which of the following signs indicates that bradycardia is causing hemodynamic compromise in a pediatric patient?
- Heart rate below 100 bpm
- Mottled skin, hypotension, and decreased consciousness (Correct answer)
- Presence of P waves on the ECG
- SpO2 of 96% on room air
Correct answer: Mottled skin, hypotension, and decreased consciousness
Mottling, hypotension, and altered mental status are clinical signs of poor perfusion indicating hemodynamically significant bradycardia.
Question 3: A 2-year-old ingested an unknown medication and presents with bradycardia, miosis, excessive secretions, and bronchospasm. Which antidote is indicated?
- Flumazenil
- Naloxone
- Atropine (Correct answer)
- N-acetylcysteine
Correct answer: Atropine
This is a classic cholinergic toxidrome (organophosphate or carbamate poisoning); atropine reverses muscarinic effects including bradycardia.
Question 4: In the PALS bradycardia algorithm, what is the correct sequence after identifying bradycardia with a pulse AND cardiopulmonary compromise?
- Cardioversion → Drugs → Airway
- Airway/Oxygenation → Drugs → CPR if unresponsive → Pacing (Correct answer)
- Pacing → Airway → Drugs
- Drugs → CPR → Pacing → Airway
Correct answer: Airway/Oxygenation → Drugs → CPR if unresponsive → Pacing
PALS bradycardia sequence is: support airway and oxygenation first, then drugs (atropine/epinephrine), then CPR if needed, then consider pacing.
Question 5: A 12-year-old presents with bradycardia following a head injury with increased intracranial pressure. Which triad of findings should be recognized?
- Fever, tachycardia, and hypotension
- Bradycardia, hypertension, and irregular respirations (Cushing's triad) (Correct answer)
- Bradycardia, hypotension, and tachypnea
- Tachycardia, wide pulse pressure, and bradypnea
Correct answer: Bradycardia, hypertension, and irregular respirations (Cushing's triad)
Cushing's triad (bradycardia, hypertension, irregular respirations) signals severely elevated ICP and impending herniation.
Question 6: How does hypoxia cause bradycardia in infants, and why does this differ from adults?
- Infants have less vagal tone, so hypoxia triggers adrenergic responses instead
- Infants respond to hypoxia with vagal stimulation causing bradycardia, unlike adults who initially tachycardia (Correct answer)
- Adult hearts are more sensitive to oxygen deprivation than infant hearts
- Bradycardia from hypoxia only occurs in neonates, not older infants
Correct answer: Infants respond to hypoxia with vagal stimulation causing bradycardia, unlike adults who initially tachycardia
Infants primarily respond to hypoxia with vagally mediated bradycardia, making hypoxia a leading cause of pediatric bradycardia that must be corrected first.
Question 7: When using the IO route for epinephrine in a bradycardic child, what should immediately follow drug administration?
- Wait 5 minutes for the drug to take effect before reassessing
- Flush with 5–10 mL of normal saline to ensure delivery into circulation (Correct answer)
- Apply a tourniquet proximal to the IO site
- Switch to IV access before flushing
Correct answer: Flush with 5–10 mL of normal saline to ensure delivery into circulation
All IO medications must be flushed with normal saline (5–10 mL) to clear the bone marrow cavity and deliver the drug into systemic circulation.
PALS Bradycardia With a Pulse 4
A 9-year-old athlete has a resting heart rate of 48 bpm with no symptoms and normal BP.
What is the most appropriate management?