Pediatric Sinus Bradycardia

Sinus Bradycardia

 

Pediatric cardiac issues can make even the most experienced EM MD have axillary perspiration more than normal.  We have covered many cardiac entities in the Morsels (Hypercyanotic Spells, Heart Failure, HTN, Coaractation, Fontan Complications, PGE1, Syncope, and Kawasaki Disease) as these are conditions that are not encountered everyday and, therefore, it is good to remind ourselves of them so we don’t get too sweaty when dealing with them. We are likely more comfortable with arryhthmias than structural heart disease. SVT can even be fun to manage.  The question I have is, what am I supposed to do with asymptomatic SINUS BRADYCARDIA? Do I need to get sweaty and nervous and can I be mellow and cool?

Arrhythmias in Kids

  • Arrhythmias due to a primary cardiac condition are rare in kids in the pediatric ED.
  • Arrhythmias are rarely the initial presentation of structural heart disease in children.
    • Most children with structural heart disease will present with signs of heart failure or cyanosis.
    • One study showed that only 7% of pediatric cardiology patients had a primary arrhythmia.
  • Incidence of arrhythmia in the Ped ED has a BiModal distribution.
    • Infancy
      • Most infant tachyarrhythmias resolve within 1st year of life
    • Adolescence
      • Heart size increases – thought to increase risk of developing re-entrant pathways.
      • Older kids are also able to describe symptoms better.
      • Higher likelihood of medication or illicit substance related arrhythmias.

Sinus Bradycardia

  • Sinus Bradycardia is almost never due to a primary cardiac issue in children.
  • Defined as:
    • < 100 bpm in kids 0-3 years old
    • < 60 bpm in kids 3-9 years old
    • < 50 bpm in kids 9-16 years old
  • Kids with benign sinus bradycardia are asymptomatic and have benign clinical courses.

Sinus Bradycardia Evaluation

  1. Dont’ get ahead our yourself… is this Sinus?  Remember “Worst First.
    • Is the patient hemodynamically stable?  If not, fix the problem!
    • Look closely for evidence of AV-Blocks (1st, 2nd, 3rd degree?).
    • Consider “sick sinus syndrome”
      1. An irregular tachycardia followed by a slowed SA node discharge.
      2. Will have a failure of HR to increase in response to exercise or stress.
      3. Usually seen in kids s/p operative repair of congenital heart disease.
  2. Ask yourself, “Why?
    1. Since Sinus Bradycardia is generally not a primary cardiac etiology, so it’d be good to consider other causes.
    2. Consider the follow:
      1. Things we often think of, but generally are obvious (the H’s and T’s):
        1. Hypoxia
        2. Heart Block
        3. H+ ions
        4. Hypothermia
        5. Hyperkalemia/Hypokalemia
        6. Trauma (Increased ICP)
        7. Toxins (Lithium, digoxin, Beta-blockers, Ca-Channel Blockers, Clonidine)
      2. Things to not under-appreciate (also known as things that I need to remember, cuz I keep forgetting them):
        1. Hypoglycemia
        2. Hypothyroidism
        3. Malnutrition
        4. Anorexia Nervosa

 

So, while the overall clinical course of Pediatric Sinus Bradycardia is benign and reassuring, take the opportunity to consider other entities, particularly eating disorders.  Many times the child with sinus bradycardia is athletic and we are eager to attribute the sinus bradycardia to the athletic conditioning; however, recall that eating disorders can also be associated with athletes … both males and females!!

 

 

References

Chiu SN, Lin LY, Wang JK, Lu CW, Chang CW, Lin MT, Hua YC, Lue HC, Wu MH. Long-term outcomes of pediatric sinus bradycardia. J Pediatr. 2013 Sep;163(3):885-9. PMID: 23623512. [PubMed] [Read by QxMD]

Egan KR, Ralphe JC, Weinhaus L, Maginot KR. Just sinus bradycardia or something more serious? Case Rep Pediatr. 2013;2013:736164. PMID: 23476865. [PubMed] [Read by QxMD]

Doniger SJ, Sharieff GQ. Pediatric dysrhythmias. Pediatr Clin North Am. 2006 Feb;53(1):85-105, vi. PMID: 16487786. [PubMed] [Read by QxMD]

Sacchetti A, Moyer V, Baricella R, Cameron J, Moakes ME. Primary cardiac arrhythmias in children. Pediatr Emerg Care. 1999 Apr;15(2):95-8. PMID: 10220076. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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10 Responses

  1. sam says:

    how and what can you do to treat a bradycardia in a teen with a eating disorder ?

    • Sean Fox says:

      Sam,
      Generally, it is just supportive… their bradycardia does not typically lead to hemodynamic instability, unless there is significant electrolyte derangements. Therapy should be directed toward correcting those derangements (although do so carefully).
      Thank you,
      sean

  2. Mark Roth says:

    I am a nurse/paramedic. My son was recently seen for a sinus infection at our PCP office by one of his NP’s. My son’s heart rate was 50. He was asymptomatic. He recently complained of a dizzy spell after running for some distance in gym class which resolved quickly with rest. My son never sits. He plays several sports many of them overlap. He has never had any sign or symptom during any of these sporting events like he did that day at school. Other than checking his pulse and recording it for several days at interval times is there anything else we should be doing. I am cautiously concerned but his Mother is ready for a cardiology consult. Any thoughts.

    • Sean Fox says:

      Obviously, I am unable to give any specific medical advice out over the Internet, but I would say that it sounds like you are doing a great job and discuss this further with his primary care doctor (and perhaps get an ECG).
      Thank you, sean

  3. Juanica says:

    My 16 year old son was diagnosed with sinus bradycardia and he is not atheletic at all and has never been on medications other than some antibiotics and. Does this mean he either he has a heart blockage or his natural pacemaker is not working and will probably in the end need a pacemaker put in

    • Sean Fox says:

      Juanica,
      I am, naturally, unable to give out medical advice over the internet, so would encourage you to discuss these concerns with your child’s primary care doctor. I will say that this can be a normal finding in a lot of children.
      Thank you,
      sean

  1. November 20, 2013

    […] Sinus bradycardia is probably the most common thing in paeds that we are asked to review on the ward, and a frequent (incidental) finding in ED. Sean Fox writes a great morsel on this at PED EM Morsels. [TRD] […]

  2. August 22, 2014

    […] are less dramatic.  Patients with Eating Disorders can often present with subtle cues (see Bradycardia) and if you are vigilant, you can make a profound difference — just like you always wanted to […]

  3. February 26, 2016

    […] population that requires special consideration of the differences in anatomy and physiology (ex, Sinus Bradycardia, Aortic Trauma, Back Pain, Traumatic Pneumothorax).  What is equally important to remember is that […]

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