ACLS: bradycardia: Difference between revisions
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==Categories== | ==Categories== | ||
* | *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]] | ||
**[[1st degree AV block]] | **[[1st degree AV block]] | ||
**[[2nd degree AV block type I (Wenkebach)]] | **[[2nd degree AV block type I (Wenkebach)]] | ||
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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]] | ||
**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) | ||
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***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 | ||
**{{MedicationDose|drug=Dopamine|dose=5-20 mcg/kg/min|route=IV drip|context=Chronotrope for bradycardia|indication=ACLS: Bradycardia|population=Adult}} | **{{MedicationDose|drug=Dopamine|dose=5-20 mcg/kg/min|route=IV drip|context=Chronotrope for bradycardia|indication=ACLS: Bradycardia|population=Adult}} | ||
**{{MedicationDose|drug=Dobutamine|dose=2-20 mcg/kg/min|route=IV drip|context=Chronotrope for bradycardia|indication=ACLS: Bradycardia|population=Adult}} | **{{MedicationDose|drug=Dobutamine|dose=2-20 mcg/kg/min|route=IV drip|context=Chronotrope for bradycardia|indication=ACLS: Bradycardia|population=Adult}} | ||
**{{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}} | **{{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}} | ||
**{{MedicationDose|drug=Isoproterenol|dose=2-10 mcg/min|route=IV drip|context=Chronotrope for bradycardia|indication=ACLS: Bradycardia|population=Adult}} | **{{MedicationDose|drug=Isoproterenol|dose=2-10 mcg/min|route=IV drip|context=Chronotrope for bradycardia|indication=ACLS: Bradycardia|population=Adult}} | ||
* | *[[Transcutaneous Pacing]] | ||
* | *[[Transvenous Pacing]] | ||
===[[Antidotes]] for toxicologic causes=== | ===[[Antidotes]] for toxicologic causes=== | ||
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**{{MedicationDose|drug=Atropine|dose=2 mg, double q5-30 min until secretions controlled|route=IV|context=Organophosphate toxicity|indication=ACLS: Bradycardia|population=Adult}} | **{{MedicationDose|drug=Atropine|dose=2 mg, double q5-30 min until secretions controlled|route=IV|context=Organophosphate toxicity|indication=ACLS: Bradycardia|population=Adult}} | ||
**{{MedicationDose|drug=Pralidoxime|dose=1-2 g over 15-30 min|route=IV|context=Organophosphate toxicity|indication=ACLS: Bradycardia|population=Adult}} | **{{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== | ||
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
- Sinus node dysfunction
- Sinus bradycardia
- Sinus arrest
- Tachy-Brady Syndrome (Sick Sinus)
- Chronotropic incompetence
- AV node dysfunction
Differential Diagnosis
Symptomatic bradycardia
- Cardiac
- Inferior MI (involving RCA)
- Sick sinus syndrome
- Neurocardiogenic/reflex-mediated
- Increased ICP
- Vasovagal reflex
- Hypersensitive carotid sinus syndrome
- Intra-abdominal hemorrhage (i.e. ruptured ectopic)
- Metabolic/endocrine/environmental
- Hyperkalemia
- Hypothermia (Osborn waves on ECG)
- Hypothyroidism
- Hypoglycemia (neonates)
- Toxicologic
- Infectious/Postinfectious
- Other
Management
- 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
- Dopamine 5-20 mcg/kg/min IV drip
- Dobutamine 2-20 mcg/kg/min IV drip
- Epinephrine 2-10 mcg/min (0.03-0.2 mcg/kg/min) IV drip
- Isoproterenol 2-10 mcg/min IV drip
- Transcutaneous Pacing
- Transvenous Pacing
Antidotes for toxicologic causes
- Beta-Blocker Toxicity
- Glucagon 5 mg q10 min (up to 3 doses) IV
- Insulin 1 U/kg bolus IV
- Intralipid (ILE)
- Calcium Channel Blocker Toxicity
- Calcium gluconate 3 g IV
- Insulin 1 U/kg bolus IV
- Intralipid (ILE)
- Digoxin Toxicity
- Dig immune Fab 10-20 vials IV
- Opioid Toxicity
- Naloxone 0.4 mg IV
- Organophosphate Toxicity
- Atropine 2 mg, double q5-30 min until secretions controlled IV
- Pralidoxime 1-2 g over 15-30 min IV
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
- ↑ Neumar RW et al. Part 8: Adult Advanced Cardiovascular Life Support. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
- ↑ Burns, E. AV block: 3rd degree (complete heart block). http://lifeinthefastlane.com/ecg-library/basics/complete-heart-block/