I. Problem. A 9-month-old infant is brought to the emergency department with acute bronchiolitis. The infant's heart rate has decreased to 58 beats/min.

Immediate Questions

A. Is the heart rate abnormal? Heart rate varies with age and is greatly influenced by factors such as crying, anxiety, fever, and activity. Table I-7 lists normal heart rate ranges in infants and children. See Appendix H, p. 768, for other age-specific heart rate values.

B. Is patient hemodynamically compromised? Assess the following:

1. Level of consciousness. Remember the mnemonic AVPU: Alert, responsive to Voice, responsive to Pain, Unresponsive.

2. Peripheral pulses. Normal, thready, or absent?

3. Skin perfusion a. Color. Pink, mottled, gray, or blue?

b. Temperature. Warm, cool, or cold?

c. Capillary refill. Normal (< 2 seconds) or delayed (> 2 seconds)?

4. BP. Differentiates extent of shock. (See Table I—12 in Chapter 52, Hypotension ... for estimates of the lower limit [fifth percentile] of systolic BP based on age. For other age-specific BP values, refer to Appendix B, p. 759).

a. Compensated (early) shock. Normal BP, poor systemic perfusion.

b. Decompensated (late) shock. Hypotension, weak central pulses, decreased level of consciousness.

5. Clinically significant bradycardia is defined as heart rate < 60 beats/min associated with hemodynamic compromise and shock.

C. Does patient have a history of cardiac anomaly or disease? If so, prompt cardiac consultation is required.

III. Differential Diagnosis. As a mnemonic remember the 6 H's and a

T: Hypoxemia, High (metabolic) acid, (intracranial) Hypertension, Hypothyroidism, Hypothermia, Heart condition, and Toxins.

A. Hypoxemia.

B. High Acid (Metabolic Acidosis). Any condition causing shock and lactic acidosis can result in bradycardia. This often precedes asystole and needs to be treated emergently.



Heart Rate (beats/min)



1 wk-3 mo


3 mo-2 y


2-10 y


10 y—adult


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