For a pediatric patient with a heart rate greater than 60 bpm, which intervention is commonly used first?

• A. Epinephrine 0.01 mg/kg IV/IO
• B. NS or LR Bolus 20 mL/kg
• C. Atropine 0.02 mg/kg IV
• D. Transcutaneous Pacing

Answer: (B)

When a pediatric patient is tachycardic and showing signs of poor perfusion, the priority is to restore circulating volume. The fastest way to do that is a rapid isotonic fluid bolus. Give 20 mL/kg of normal saline or lactated Ringer’s solution via IV or IO, then reassess perfusion (heart rate, blood pressure if available, capillary refill, mental status, urine output). If perfusion remains inadequate, repeat the bolus up to a total of about 40–60 mL/kg, while continuing to monitor for signs of fluid overload.

Medications like epinephrine or atropine, and interventions such as transcutaneous pacing, are reserved for other scenarios (such as bradycardia or arrest) and are not the first step when hypovolemia or distributive shock is suspected in a tachycardic child. The fluid bolus directly addresses the likely cause—reduced circulating volume—before moving on to other treatments.