A 3-year-old develops heart rate 48/min with poor perfusion and hypotension during sedation for a CT scan. Airway is patent and oxygenation is adequate. Intravenous access is present. Which drug should be administered first?

• A Atropine 0.02 mg/kg IV
• B Amiodarone 5 mg/kg IV
• C Adenosine 0.1 mg/kg IV
• D Epinephrine 0.01 mg/kg IV ✓

Explanation

PALS recommends epinephrine 0.01 mg/kg as the first-line chronotrope for symptomatic bradycardia with poor perfusion. Atropine is preferred only when bradycardia is due to suspected increased vagal tone or primary AV block, such as during laryngoscopy. Adenosine treats reentrant tachyarrhythmias and amiodarone is an antiarrhythmic, so both would worsen bradycardia here.

Reference: Nelson Textbook of Pediatrics, 21st ed.

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