ACLS: Bradycardia: Difference between revisions

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''This page is for bradycardia with a pulse; for bradycardia without a pulse see [[Adult Pulseless Arrest]] (i.e. PEA)''
''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==
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**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
**Hypoglycemia (neonates)
*'''Toxicologic'''
**B-blocker
**Ca-channel blocker
**Digoxin toxicity
**Opioids
**Organophosphates
*'''Infectious/Postinfectious'''
**Chagas dz
**Lyme dz
**Syphilis
*[[Sick Sinus Syndrome]]


==Treatment==
==Management==
*'''Atropine'''
[[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 pts w/ ongoing ischemia (tachycardia may worsen ischemia)
**Use cautiously in patients with ongoing ischemia (tachycardia may worsen ischemia)
**0.5mg q3-5min (max 3 mg or 6 doses)
**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>
***may not work in 2nd/3rd deg HB, heart transplant
**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'''
*'''Chronotropes'''
**Dopamine 2-10mcg/kg/min
**[[Dopamine]] 2-10 mcg/kg/min, max 50 mcg/kg/min
**[[Epinephrine]] 2-10mcg/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]]'''
*'''[[Transcutaneous Pacing]]'''
*'''[[Transvenous Pacing]]'''
*'''[[Transvenous Pacing]]'''
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===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)
**Insulin 1U/kg bolus
**Intralipid (ILE)
*[[Calcium Channel Blocker Toxicity]]
*[[Calcium Channel Blocker Toxicity]]
**Calcium gluconate 3g OR insulin 1U/kg bolus
**[[Calcium gluconate]] 3g  
**Insulin 1U/kg bolus
**Intralipid (ILE)
*[[Digoxin Toxicity]]
*[[Digoxin Toxicity]]
**Dig immune Fab 10-20 vials
**[[Dig immune Fab]] 10-20 vials
*[[Opioid Toxicity]]
*[[Opioid Toxicity]]
**Nalaxone 0.4mg IV
**[[Naloxone]] 0.4mg IV
*[[Organophosphate Toxicity]]
*[[Organophosphate Toxicity]]
**Atropine 2mg IV OR Pralidoxime 2g IV over 10-15min
**[[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/