Pediatric Pacing

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Revised for clarity..

The other day we encountered a call with a newborn who's heart rate was 20-30 (PEA) and not breathing which got me thinking...

Per our bradycardia protocol (unrelated to this call) we initiate CPR for a heart rate of less than 60 in peds.

I am curious if anyone can provide any information on why we do not pace children in the same way we would an adult.
 
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DesertMedic66

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Pacing isn't going to do anything for PEA.
 
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Pacing isn't going to do anything for PEA.

That wasnt where my question was going really, the policy doesnt say for PEA. It just says for a heart rate below 60. I just put PEA in there for story sake.
 

Rialaigh

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That wasnt where my question was going really, the policy doesnt say for PEA. It just says for a heart rate below 60. I just put PEA in there for story sake.

Well than the infants rhythm was in fact not PEA if they had a pulse that correlated to the electrical activity shown on the monitor. And I believe the basic reason we tend not to pace children is it would be a incredibly rare anomaly for a child to have an electrical conduction problem, the vast majority of brady issues with children involve respiratory depression, drug ingestion, environmental factors. Not cardiac issues in which the pathways to the heart are having trouble conducting electricity. Therefore pacing would not cut to the core of the problem with these children and most need interventions such as O2, breathing treatments, epi, etc...
 
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Well than the infants rhythm was in fact not PEA if they had a pulse that correlated to the electrical activity shown on the monitor. And I believe the basic reason we tend not to pace children is it would be a incredibly rare anomaly for a child to have an electrical conduction problem, the vast majority of brady issues with children involve respiratory depression, drug ingestion, environmental factors. Not cardiac issues in which the pathways to the heart are having trouble conducting electricity. Therefore pacing would not cut to the core of the problem with these children and most need interventions such as O2, breathing treatments, epi, etc...

The child did not have a pulse. Just a heart rate and rhythm on the monitor.

This child's case was, as most are, respiratory. But still, the root of my question... Ignore the story i presented, its just what got me thinking. My call was PEA, in the cardiac arrest algorithm, which is the indication for CPR obviously..

My question lies in the ped bradycardia algorithm.
We do compressions because the child (any child meeting the age in the policy) has a heart rate below 60. We do this to increase pumping and perfusion.. Would pacing not do the same thing? Isn't that why we do it in adults? I'm just curious if there's a physiological reason we don't pace, or maybe the amplitude isn't accurate, and there for dangerous to a tiny heart, at those low levels.

Just curious if anyone knows why we do compressions for bradycardia in peds rather than pace.
 
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TomB

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Considering that TCP is one of the worst performed skills in the history of emergency medicine, and it would distract you from prioritizing airway and breathing, I'm delighted it's not in the pediatric bradycardia algorithm. It's also been downgraded in the adult algorithm (it used to be the only Class I intervention for symptomatic bradycardia), which suits me just fine. I would never say never, but Hs and Ts should always come first (for any ACLS algorithm).

Addendum: The 2010 AHA ECC Guidelines, Part 14: Pediatric Advanced Cardiac Life Support does list TCP as an option after oxygenation, epinephrine, and atropine for persistent bradycardia (with a pulse and poor perfusion).
 
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Rialaigh

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The child did not have a pulse. Just a heart rate and rhythm on the monitor.

This child's case was, as most are, respiratory. But still, the root of my question... Ignore the story i presented, its just what got me thinking. My call was PEA, in the cardiac arrest algorithm, which is the indication for CPR obviously..

My question lies in the ped bradycardia algorithm.
We do compressions because the child (any child meeting the age in the policy) has a heart rate below 60. We do this to increase pumping and perfusion.. Would pacing not do the same thing? Isn't that why we do it in adults? I'm just curious if there's a physiological reason we don't pace, or maybe the amplitude isn't accurate, and there for dangerous to a tiny heart, at those low levels.

Just curious if anyone knows why we do compressions for bradycardia in peds rather than pace.

I believe the physiological reason we don't pace is because generally speaking in kids there is no conduction problem. The bradycardia is caused by other issues and pacing is not a solution, and there are better temporary fixes. Pacing is used in adults generally in high degree heart blocks (implying a conduction problem) that pacing can supercede (basically) and continue to allow the heart to function.
 

Christopher

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Revised for clarity..

The other day we encountered a call with a newborn who's heart rate was 20-30 (PEA) and not breathing which got me thinking...

Per our bradycardia protocol (unrelated to this call) we initiate CPR for a heart rate of less than 60 in peds.

I am curious if anyone can provide any information on why we do not pace children in the same way we would an adult.

It would be a rare condition which required pacing in a pediatric patient. It is rare to have to pace adult patients! There is little evidence supporting the use in pediatric patients with bradycardia, and as best as I can tell the only time it would be appropriate would be in a patient with a congenital heart abnormality who is refractory to all other Rx.

I put together a short guide based on what I could find.
 

abckidsmom

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Considering that TCP is one of the worst performed skills in the history of emergency medicine, and it would distract you from prioritizing airway and breathing, I'm delighted it's not in the pediatric bradycardia algorithm. It's also been downgraded in the adult algorithm (it used to be the only Class I intervention for symptomatic bradycardia), which suits me just fine. I would never say never, but Hs and Ts should always come first (for any ACLS algorithm).

Addendum: The 2010 AHA ECC Guidelines, Part 14: Pediatric Advanced Cardiac Life Support does list TCP as an option after oxygenation, epinephrine, and atropine for persistent bradycardia (with a pulse and poor perfusion).


Could you give a quick run down on pacing? Or direct us to a blog post?
 
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