ACLS: Bradycardia: Difference between revisions

Latest revision as of 20:55, 10 December 2025

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)

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
  - Myxedema coma
- Hypoglycemia (neonates)
Toxicologic
Infectious/Postinfectious
Other
- Brash syndrome

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]
- 1mg q3-5min (max 3mg or 3 doses)
  - 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, max 50 mcg/kg/min
- Dobutamine 2-20 mcg/kg/min, max 40 mcg/kg/min
- Epinephrine 2-10 mcg/min (~0.03-0.2 mcg/kg/min, max 1 mcg/kg/min)
- Isoproterenol 2-10 mcg/min
Transcutaneous Pacing
Transvenous Pacing

Antidotes for toxicologic causes

Beta-Blocker Toxicity
- Glucagon 5mg IV Q10min (repeat up to 3 doses)
- Insulin 1U/kg bolus
- Intralipid (ILE)
Calcium Channel Blocker Toxicity
- Calcium gluconate 3g
- Insulin 1U/kg bolus
- Intralipid (ILE)
Digoxin Toxicity
- Dig immune Fab 10-20 vials
Opioid Toxicity
- Naloxone 0.4mg IV
Organophosphate Toxicity
- Atropine 2mg IV, double dose q5-30m until secretions controlled
- Pralidoxime 1-2g IV over 15-30min

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/

Authors:

[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/

[1]

[2]

@@ Line 1: / Line 1: @@
+''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]]'''
+**[[1st degree AV block]]
+**[[2nd degree AV block type I (Wenkebach)]]
+**[[2nd degree AV block type II]]
+**[[3rd degree AV block]] ([[complete heart block]])
+==Differential Diagnosis==
+{{Symptomatic bradycardia}}
+==Management==
+[[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)
+**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>
+**1mg q3-5min (max 3mg or 3 doses)
+***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>
+***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, max 50 mcg/kg/min
+**[[Dobutamine]] 2-20 mcg/kg/min, max 40 mcg/kg/min
+**[[Epinephrine]] 2-10 mcg/min (~0.03-0.2 mcg/kg/min, max 1 mcg/kg/min)
+**[[Isoproterenol]] 2-10 mcg/min
+*'''[[Transcutaneous Pacing]]'''
+*'''[[Transvenous Pacing]]'''
+===[[Antidotes]] for toxicologic causes===
+*[[Beta-Blocker Toxicity]]
+**[[Glucagon]] 5mg IV Q10min (repeat up to 3 doses)
+**[[Insulin]] 1U/kg bolus
+**[[Intralipid]] (ILE)
+*[[Calcium Channel Blocker Toxicity]]
+**[[Calcium gluconate]] 3g
+**[[Insulin]] 1U/kg bolus
+**[[Intralipid]] (ILE)
+*[[Digoxin Toxicity]]
+**[[Dig immune Fab]] 10-20 vials
+*[[Opioid Toxicity]]
+**[[Naloxone]] 0.4mg IV
+*[[Organophosphate Toxicity]]
+**[[Atropine]] 2mg IV, double dose q5-30m until secretions controlled
+**[[Pralidoxime]] 1-2g IV over 15-30min
 ==See Also==
 *[[ACLS (Main)]]
+==External Links==
+*[http://ddxof.com/simplified-acls-algorithms/ DDxOf: Simplified ACLS Algorithms]
+*[https://emergencymedicinecases.com/treatment-bradycardia-bradydysrhythmias/ EM Cases Treatment of Bradycardia and Bradydysrhythmias]
+==References==
+<references/>
+[[Category:Cardiology]]
+[[Category:Critical Care]]
+[[Category:EMS]]