View source for ACLS: Bradycardia

''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 (CASH gets the JOULES = 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 Mobitz I/Wenckebach
**2nd degree AV block Mobitz 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 (rpt 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]

==Video==

==References==
<references/>

[[Category:Cardiology]]
[[Category:Critical Care]]
[[Category:EMS]]