ACLS: Bradycardia: Difference between revisions

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''This page is for bradycardia with a pulse; for bradycardia without a pulse (i.e. PEA) see [[Adult pulseless arrest]]''
==Background==
==Background==
*Only intervene if pt is symptomatic (hypotension, AMS, chest pain, pulm edema)
*HR < 60
*Intervention only necessary if patient is symptomatic (hypotension, altered mental status, chest pain, pulmonary edema)
 
==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 Mobitz I/Wenckebach
##2nd degree AV block Mobitz II
**2nd degree AV block Mobitz II
##3rd degree AV block (complete heart block)
**3rd degree AV block (complete heart block)


==Differential==
==Differential Diagnosis==
#'''Ischemia/Infarction'''
{{Symptomatic bradycardia}}
##Inferior MI (involving RCA)
#'''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)
##Hypothyrodism
#'''Toxicologic'''
##B-blocker
##Ca-channel blocker
##Digoxin toxicity
##Opioids
##Organophosphates
#'''Infectious/Postinfectious'''
##Chagas dz
##Lyme dz
##Syphilis
 
==Sick Sinus Syndrome==
#Collection of bradyarrhythmias with or without tachycardia<ref>Semelka, M et Al. Sick Sinus Syndrome: A Review. Am Fam Physician. 2013 May 15;87(10):691-696. http://www.aafp.org/afp/2013/0515/p691.html</ref>
##50% have alternating bradycardia and tachycardia
##Causes include:
###Intrinsic: degenerative fibrosis, infiltrative disease process, ion channel dysfunction, SA node remodeling
###Extrinsic: pharmacologic, metabolic/electrolyte disturbance, autonomic, OSA
##Clinical manifestations related to end-organ hypoperfusion
###Syncope/pre-syncope (50%)
##Dx - ECG identification, inpatient telemetry, outpatient Holter monitoring, event monitoring, loop monitoring
###ECG frequently negative for findings early in disease course
##Tx - remove extrinsic factors and/or pacemakers
###Pacemakers do not reduce mortality, only decrease symptoms
##Complications
###(50%) Tachy-brady syndrome with atrial fibrillation or atrial flutter
###(50%) AV block
 
==Treatment==
#'''Atropine'''
##Can be used as temporizing measure (while awaiting pacing and/or chronotropes)
##Use cautiously in pts w/ ongoing ischemia (tachycardia may worsen ischemia)
##0.5mg q3-5min (max 3 mg or 6 doses)
###may not work in 2nd/3rd deg HB, heart transplant
#'''Chronotropes'''
##Dopamine 2-10mcg/kg/min
##[[Epinephrine]] 2-10mcg/min
#'''[[Transcutaneous Pacing]]'''
#'''[[Transvenous Pacing]]'''


==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>
**0.5mg q3-5min (max 3mg or 6 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]] 2-10 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===
===Antidotes for toxicologic causes===
**[[Beta-Blocker Toxicity]]  
*[[Beta-Blocker Toxicity]]  
***glucagon 5mg IV Q10min (rpt up to 3 doses)
**Glucagon 5mg IV Q10min (rpt up to 3 doses)
**[[Calcium Channel Blocker Toxicity]]
**Insulin 1U/kg bolus
***Calcium gluconate 3g OR insulin 1U/kg bolus
**Intralipid (ILE)
**[[Digoxin Toxicity]]
*[[Calcium Channel Blocker Toxicity]]
***Dig immune Fab 10-20 vials
**[[Calcium gluconate]] 3g  
**[[Opioid Toxicity]]
**Insulin 1U/kg bolus
***Nalaxone 0.4mg IV
**Intralipid (ILE)
**[[Organophosphate Toxicity]]
*[[Digoxin Toxicity]]
***Atropine 2mg IV OR Pralidoxime 2g IV over 10-15min
**[[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==
==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]
 
==Video==
{{#widget:YouTube|id= dKqAqC6JEYQ}}
 
==References==
<references/>
 
[[Category:Cardiology]]
[[Category:Critical Care]]
[[Category:Critical Care]]
[[Category:EMS]]
[[Category:EMS]]
==References==
#Semelka, M et al. Sick Sinus Syndrome: A Review. Am Fam Physician. 2013 May 15;87(10):691-696.http://www.aafp.org/afp/2013/0515/p691.html#afp20130515p691-t2.

Revision as of 23:52, 8 August 2018

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

Background

  • HR < 60
  • Intervention only necessary if patient is symptomatic (hypotension, altered mental status, chest pain, pulmonary edema)

Categories

  • Sinus node dysfunction
  • AV node dysfunction
    • 1st degree AV block
    • 2nd degree AV block Mobitz I/Wenckebach
    • 2nd degree AV block Mobitz II
    • 3rd degree AV block (complete heart block)

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]
    • 0.5mg q3-5min (max 3mg or 6 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
  • Transcutaneous Pacing
  • Transvenous Pacing

Antidotes for toxicologic causes

See Also

External Links

Video

{{#widget:YouTube|id= dKqAqC6JEYQ}}

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/