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frequent reassessment are the foundation of successful resuscitation efforts for all scenarios encountered in the ED Bradycardia With a Pulse and Poor Perfusion Bradycardia most commonly results from impending or existing respiratory failure ( Fig 9.14 ) As always, early recognition and intervention to support the respiratory system and other vital functions reduces morbidity and may be lifesaving The first step in the treatment of children with bradycardia is airway management Note that increase in heart rate is the primary mechanism by which children increase their stroke volume, so bradycardia readily leads to hypotension Begin chest compressions when perfusion is inadequate despite airway intervention, and/or when the heart rate is less than 60/min Assess the rhythm on the cardiac monitor Other causes of bradycardia include heart block, heart transplant, increased ICP, hypoglycemia, hypercalcemia, drug effect, increased parasympathetic tone, and hypothermia For most situations, epinephrine is the drug of choice; however, if the bradycardia is believed to be due to increased vagal tone or heart block, atropine is an appropriate intervention In children with heart block, cardiac pacing may be necessary Pulseless Arrest Asystole and PEA are the most common arrest scenarios encountered in children ( Fig 9.15 ) In the pulseless child, identify the rhythm to perform the correct interventions Consider primary cardiac etiologies for witness or sudden collapse arrest Standard dose epinephrine is the drug of choice for asystole and PEA Always consider treatment of reversible causes such as hypovolemia, hypothermia, electrolyte abnormalities, poisonings, tension pneumothorax, and cardiac tamponade Perform immediate CPR followed by defibrillation for pulseless VT/VF Single defibrillation is recommended instead of three successive shocks (AHA, 2005) The rationale for this recommendation is that use of biphasic defibrillators is associated with a higher first shock success rate and delivery of three successive shocks leads to delay in CPR which is associated with decreased survival Cardiac compressions are interrupted only for rhythm checks and shock delivery Standard dose epinephrine is the drug of choice if defibrillation is unsuccessful Amiodarone was the preferred drug for refractory pulseless VT/VF prior to the 2015 Guidelines Update, however the 2015 AHA guidelines allow the use of either lidocaine or amiodarone for refractory pulseless VT/VF Magnesium is indicated for torsades de pointes VT The sequence of interventions is CPR → rhythm check → resume CPR while charging defibrillator → single shock