ACLS: bradycardia: Difference between revisions
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==Background==
==Background==
*HR < 60
*Heart rate < 60
*Intervention only necessary if patient is symptomatic (hypotension, altered mental status, chest pain, pulmonary edema)
*Intervention indicated if patient is symptomatic or experiencing symptoms of end organ damage (chest pain, altered mental status, shortness of breath, hypotension)


==Categories==
==Categories==
*'''Sinus node dysfunction'''
*Sinus node dysfunction
**Sinus bradycardia
**[[Sinus bradycardia]]
**Sinus arrest
**[[Sinus arrest]]
**[[Tachy-Brady Syndrome]] ([[Sick Sinus]])
**[[Tachy-Brady Syndrome]] ([[Sick Sinus]])
**Chronotropic incompetence
**Chronotropic incompetence
*'''AV node dysfunction'''
*[[AV node dysfunction]]
**1st degree AV block
**[[1st degree AV block]]
**2nd degree AV block Mobitz I/Wenckebach
**[[2nd degree AV block type I (Wenkebach)]]
**2nd degree AV block Mobitz II
**[[2nd degree AV block type II]]
**3rd degree AV block (complete heart block)
**[[3rd degree AV block]] ([[complete heart block]])


==Differential Diagnosis==
==Differential Diagnosis==
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==Management==
==Management==
[[File:ACLS-bradycardia.png|thumb|Algorithm for bradycardia with a pulse (Adapted from ACLS 2010)]]
[[File:ACLS-bradycardia.png|thumb|Algorithm for bradycardia with a pulse (Adapted from ACLS 2010)]]
*'''[[Atropine]]'''
*[[Atropine]]
**Can be used as temporizing measure (while awaiting pacing and/or chronotropes)
**Can be used as temporizing measure (while awaiting pacing and/or chronotropes)
**Use cautiously in patients with ongoing ischemia (tachycardia may worsen ischemia)
**Use cautiously in patients with ongoing ischemia (tachycardia may worsen ischemia)
**Avoid and/or do not rely on in wide complex bradycardia, especially in setting of ischemia<ref>Neumar RW et al. Part 8: Adult Advanced Cardiovascular Life Support. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.</ref>
**Avoid and/or do not rely on in wide complex bradycardia, especially in setting of ischemia<ref>Neumar RW et al. Part 8: Adult Advanced Cardiovascular Life Support. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.</ref>
**1mg q3-5min (max 3mg or 3 doses)
**{{MedicationDose|drug=Atropine|dose=1 mg q3-5 min|route=IV|context=Symptomatic bradycardia|indication=ACLS: Bradycardia|population=Adult|max_dose=3 mg|link=no}}
***May not work in 2nd/3rd degree heart block, heart transplant
***May not work in 2nd/3rd degree heart block, heart transplant
***Priority is to use external cardiac pacemaking<ref>Burns, E. AV block: 3rd degree (complete heart block). http://lifeinthefastlane.com/ecg-library/basics/complete-heart-block/</ref>
***Priority is to use external cardiac pacemaking<ref>Burns, E. AV block: 3rd degree (complete heart block). http://lifeinthefastlane.com/ecg-library/basics/complete-heart-block/</ref>
***Block is below AV node so atropine will accelerate sinus rate, leading to worsening of block and increased fatigue of AV nodal cells
***Block is below AV node so atropine will accelerate sinus rate, leading to worsening of block and increased fatigue of AV nodal cells
*'''Chronotropes'''
*Chronotropes
**[[Dopamine]] 5-20 mcg/kg/min, max 50 mcg/kg/min
**{{MedicationDose|drug=Dopamine|dose=5-20 mcg/kg/min|route=IV drip|context=Chronotrope for bradycardia|indication=ACLS: Bradycardia|population=Adult}}
**[[Dobutamine]] 2-20 mcg/kg/min, max 40 mcg/kg/min
**{{MedicationDose|drug=Dobutamine|dose=2-20 mcg/kg/min|route=IV drip|context=Chronotrope for bradycardia|indication=ACLS: Bradycardia|population=Adult}}
**[[Epinephrine]] 2-10 mcg/min (~0.03-0.2 mcg/kg/min, max 1 mcg/kg/min)
**{{MedicationDose|drug=Epinephrine|dose=2-10 mcg/min (0.03-0.2 mcg/kg/min)|route=IV drip|context=Chronotrope for bradycardia|indication=ACLS: Bradycardia|population=Adult}}
**[[Isoproterenol]] 2-10 mcg/min
**{{MedicationDose|drug=Isoproterenol|dose=2-10 mcg/min|route=IV drip|context=Chronotrope for bradycardia|indication=ACLS: Bradycardia|population=Adult}}
*'''[[Transcutaneous Pacing]]'''
*[[Transcutaneous Pacing]]
*'''[[Transvenous Pacing]]'''
*[[Transvenous Pacing]]


===[[Antidotes]] for toxicologic causes===
===[[Antidotes]] for toxicologic causes===
*[[Beta-Blocker Toxicity]]  
*[[Beta-Blocker Toxicity]]  
**[[Glucagon]] 5mg IV Q10min (rpt up to 3 doses)
**{{MedicationDose|drug=Glucagon|dose=5 mg q10 min (up to 3 doses)|route=IV|context=Beta-blocker toxicity antidote|indication=ACLS: Bradycardia|population=Adult}}
**[[Insulin]] 1U/kg bolus
**{{MedicationDose|drug=Insulin|dose=1 U/kg bolus|route=IV|context=Beta-blocker toxicity (HDIE)|indication=ACLS: Bradycardia|population=Adult}}
**[[Intralipid]] (ILE)
**[[Intralipid]] (ILE)
*[[Calcium Channel Blocker Toxicity]]
*[[Calcium Channel Blocker Toxicity]]
**[[Calcium gluconate]] 3g
**{{MedicationDose|drug=Calcium gluconate|dose=3 g|route=IV|context=CCB toxicity antidote|indication=ACLS: Bradycardia|population=Adult}}
**[[Insulin]] 1U/kg bolus
**{{MedicationDose|drug=Insulin|dose=1 U/kg bolus|route=IV|context=CCB toxicity (HDIE)|indication=ACLS: Bradycardia|population=Adult}}
**[[Intralipid]] (ILE)
**[[Intralipid]] (ILE)
*[[Digoxin Toxicity]]
*[[Digoxin Toxicity]]
**[[Dig immune Fab]] 10-20 vials
**{{MedicationDose|drug=Dig immune Fab|dose=10-20 vials|route=IV|context=Digoxin toxicity antidote|indication=ACLS: Bradycardia|population=Adult}}
*[[Opioid Toxicity]]
*[[Opioid Toxicity]]
**[[Naloxone]] 0.4mg IV
**{{MedicationDose|drug=Naloxone|dose=0.4 mg|route=IV|context=Opioid toxicity reversal|indication=ACLS: Bradycardia|population=Adult}}
*[[Organophosphate Toxicity]]
*[[Organophosphate Toxicity]]
**[[Atropine]] 2mg IV, double dose q5-30m until secretions controlled
**{{MedicationDose|drug=Atropine|dose=2 mg, double q5-30 min until secretions controlled|route=IV|context=Organophosphate toxicity|indication=ACLS: Bradycardia|population=Adult}}
**[[Pralidoxime]] 1-2g IV over 15-30min
**{{MedicationDose|drug=Pralidoxime|dose=1-2 g over 15-30 min|route=IV|context=Organophosphate toxicity|indication=ACLS: Bradycardia|population=Adult}}
 
==Disposition==
*Admit to telemetry/ICU for:
**Symptomatic bradycardia requiring pharmacologic or pacing intervention
**High-degree AV block (second-degree type II, third-degree)
**Bradycardia with hemodynamic instability
**New-onset bradycardia of unclear etiology
*Cardiology consultation for all patients requiring temporary pacing
*Discharge with outpatient cardiology follow-up for:
**Asymptomatic sinus bradycardia with rate >50 in young/athletic patients
**Known stable bradycardia at baseline


==See Also==
==See Also==
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*[http://ddxof.com/simplified-acls-algorithms/ DDxOf: Simplified ACLS Algorithms]
*[http://ddxof.com/simplified-acls-algorithms/ DDxOf: Simplified ACLS Algorithms]
*[https://emergencymedicinecases.com/treatment-bradycardia-bradydysrhythmias/ EM Cases Treatment of Bradycardia and Bradydysrhythmias]
*[https://emergencymedicinecases.com/treatment-bradycardia-bradydysrhythmias/ EM Cases Treatment of Bradycardia and Bradydysrhythmias]
==Video==
{{#widget:YouTube|id= dKqAqC6JEYQ}}


==References==
==References==

Latest revision as of 10:03, 22 March 2026

This page is for bradycardia with a pulse; for bradycardia without a pulse (i.e. PEA) see Adult pulseless arrest

Background

  • Heart rate < 60
  • Intervention indicated if patient is symptomatic or experiencing symptoms of end organ damage (chest pain, altered mental status, shortness of breath, hypotension)

Categories

Differential Diagnosis

Symptomatic bradycardia

Management

Algorithm for bradycardia with a pulse (Adapted from ACLS 2010)
  • Atropine
    • Can be used as temporizing measure (while awaiting pacing and/or chronotropes)
    • Use cautiously in patients with ongoing ischemia (tachycardia may worsen ischemia)
    • Avoid and/or do not rely on in wide complex bradycardia, especially in setting of ischemia[1]
    • 1 mg q3-5 min IV (max 3 mg)
      • May not work in 2nd/3rd degree heart block, heart transplant
      • Priority is to use external cardiac pacemaking[2]
      • Block is below AV node so atropine will accelerate sinus rate, leading to worsening of block and increased fatigue of AV nodal cells
  • Chronotropes
  • Transcutaneous Pacing
  • Transvenous Pacing

Antidotes for toxicologic causes

Disposition

  • Admit to telemetry/ICU for:
    • Symptomatic bradycardia requiring pharmacologic or pacing intervention
    • High-degree AV block (second-degree type II, third-degree)
    • Bradycardia with hemodynamic instability
    • New-onset bradycardia of unclear etiology
  • Cardiology consultation for all patients requiring temporary pacing
  • Discharge with outpatient cardiology follow-up for:
    • Asymptomatic sinus bradycardia with rate >50 in young/athletic patients
    • Known stable bradycardia at baseline

See Also

External Links

References

  1. ↑ Neumar RW et al. Part 8: Adult Advanced Cardiovascular Life Support. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
  2. ↑ Burns, E. AV block: 3rd degree (complete heart block). http://lifeinthefastlane.com/ecg-library/basics/complete-heart-block/
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