An 8-month-old infant who choked on a piece of apple now has slow gasping respirations and a heart rate of 48/min with weak peripheral pulses. Bag-mask ventilation with 100% oxygen has been performed for 30 seconds. What is the next step?

• A Immediate synchronized cardioversion at 0.5 J/kg
• B Administer intramuscular epinephrine 0.01 mg/kg
• C Begin chest compressions ✓
• D Continue bag-mask ventilation and recheck the heart rate after another minute

Explanation

PALS states that a heart rate below 60/min accompanied by signs of poor perfusion that does not improve promptly with effective ventilation and oxygenation is an indication to begin chest compressions, because such bradycardia presages arrest. Epinephrine is given if compressions and ventilation fail to raise the rate. Synchronized cardioversion is used for tachyarrhythmias with a pulse, not bradycardia. Waiting further risks progression to pulseless arrest.

Reference: Nelson Textbook of Pediatrics, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.