ACLS: bradycardia: Difference between revisions
(Add evidence-based Disposition section)
 
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*Only intervene if pt is symptomatic
''This page is for bradycardia with a pulse; for bradycardia without a pulse (i.e. PEA) see [[Adult pulseless arrest]]''
**Hypotension, AMS, chest pain, pulm edema
 
*1st Line
==Background==
**Transcutaneous pacing
*Heart rate < 60
**Chronotropes
*Intervention indicated if patient is symptomatic or experiencing symptoms of end organ damage (chest pain, altered mental status, shortness of breath, hypotension)
***Dopamine 2-10mcg/kg/min
 
***Epineprhine 2-10mcg/min
==Categories==
*2nd Line
*Sinus node dysfunction
**Atropine 0.5mg q3-5m can be given as temporizing measure
**[[Sinus bradycardia]]
***Do not give if Mobitz type II or 3rd degree block is present
**[[Sinus arrest]]
*Transvenous pacing required if transQ pacing + chronotropes is ineffective
**[[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>
**{{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
***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
**{{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=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}}
*[[Transcutaneous Pacing]]
*[[Transvenous Pacing]]
 
===[[Antidotes]] for toxicologic causes===
*[[Beta-Blocker Toxicity]]
**{{MedicationDose|drug=Glucagon|dose=5 mg q10 min (up to 3 doses)|route=IV|context=Beta-blocker toxicity antidote|indication=ACLS: Bradycardia|population=Adult}}
**{{MedicationDose|drug=Insulin|dose=1 U/kg bolus|route=IV|context=Beta-blocker toxicity (HDIE)|indication=ACLS: Bradycardia|population=Adult}}
**[[Intralipid]] (ILE)
*[[Calcium Channel Blocker Toxicity]]
**{{MedicationDose|drug=Calcium gluconate|dose=3 g|route=IV|context=CCB toxicity antidote|indication=ACLS: Bradycardia|population=Adult}}
**{{MedicationDose|drug=Insulin|dose=1 U/kg bolus|route=IV|context=CCB toxicity (HDIE)|indication=ACLS: Bradycardia|population=Adult}}
**[[Intralipid]] (ILE)
*[[Digoxin Toxicity]]
**{{MedicationDose|drug=Dig immune Fab|dose=10-20 vials|route=IV|context=Digoxin toxicity antidote|indication=ACLS: Bradycardia|population=Adult}}
*[[Opioid Toxicity]]
**{{MedicationDose|drug=Naloxone|dose=0.4 mg|route=IV|context=Opioid toxicity reversal|indication=ACLS: Bradycardia|population=Adult}}
*[[Organophosphate Toxicity]]
**{{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}}
 
==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==
*[[ACLS (Main)]]
*[[ACLS (Main)]]
*[[Bradycardia (Wide)]]


[[Category:Airway/Resus]]
==External Links==
[[Category:Cards]]
*[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]]

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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