Difference between revisions of "ACLS: Bradycardia"

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''This page is for bradycardia with a pulse; for bradycardia without a pulse see [[Adult Pulseless Arrest]] (i.e. PEA)''
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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)
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*HR < 60
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*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==
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==Differential Diagnosis==
*'''Ischemia/Infarction'''
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{{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)
 
**[[Hypothyroidism]]
 
**[[Hypoglycemia]] (neonates)
 
*'''Toxicologic'''
 
**[[B-blocker]]
 
**[[Ca-channel blocker]]
 
**[[Digoxin toxicity]]
 
**[[Opioids]]
 
**[[Organophosphates]]
 
*'''Infectious/Postinfectious'''
 
**[[Chagas disease]]
 
**[[Lyme disease]]
 
**[[Syphilis]]
 
*[[Sick Sinus Syndrome]]
 
  
==Treatment==
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==Management==
#'''[[Atropine]]'''
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[[File:ACLS-bradycardia.png|thumb|Algorithm for bradycardia with a pulse (Adapted from ACLS 2010)]]
#*Can be used as temporizing measure (while awaiting pacing and/or chronotropes)
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*'''[[Atropine]]'''
#*Use cautiously in patients with ongoing ischemia (tachycardia may worsen ischemia)
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**Can be used as temporizing measure (while awaiting pacing and/or chronotropes)
#*0.5mg q3-5min (max 3mg or 6 doses)
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**Use cautiously in patients with ongoing ischemia (tachycardia may worsen ischemia)
#**may not work in 2nd/3rd degree heart block, heart transplant
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**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>
#'''Chronotropes'''
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**0.5mg q3-5min (max 3mg or 6 doses)
#*[[Dopamine]] 2-10mcg/kg/min
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***May not work in 2nd/3rd degree heart block, heart transplant
#*[[Epinephrine]] 2-10mcg/min
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***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>
#'''[[Transcutaneous Pacing]]'''
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***Block is below AV node so atropine will accelerate sinus rate, leading to worsening of block and increased fatigue of AV nodal cells
#'''[[Transvenous Pacing]]'''
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*'''Chronotropes'''
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**[[Dopamine]] 2-10 mcg/kg/min, max 50 mcg/kg/min
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**[[Dobutamine]] 2-20 mcg/kg/min, max 40 mcg/kg/min
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**[[Epinephrine]] 2-10 mcg/min (~0.03-0.2 mcg/kg/min, max 1 mcg/kg/min)
 +
**[[Isoproterenol]] 2-10 mcg/min
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*'''[[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)
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**Glucagon 5mg IV Q10min (rpt up to 3 doses)
 +
**Insulin 1U/kg bolus
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**Intralipid (ILE)
 
*[[Calcium Channel Blocker Toxicity]]
 
*[[Calcium Channel Blocker Toxicity]]
**[[Calcium gluconate]] 3g OR insulin 1U/kg bolus
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**[[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
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**[[Naloxone]] 0.4mg IV
 
**[[Naloxone]] 0.4mg IV
 
*[[Organophosphate Toxicity]]
 
*[[Organophosphate Toxicity]]
**[[Atropine]] 2mg IV OR [[pralidoxime]] 2g IV over 10-15min
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**[[Atropine]] 2mg IV, double dose q5-30m until secretions controlled
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**[[Pralidoxime]] 1-2g IV over 15-30min
  
 
==See Also==
 
==See Also==
 
*[[ACLS (Main)]]
 
*[[ACLS (Main)]]
  
[[Category:Airway/Resus]]
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==External Links==
[[Category:Cards]]
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*[http://ddxof.com/simplified-acls-algorithms/ DDxOf: Simplified ACLS Algorithms]
 +
 
 +
==Video==
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{{#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

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/