ACLS: Bradycardia: Difference between revisions

No edit summary
No edit summary
(15 intermediate revisions by 6 users not shown)
Line 1: Line 1:
''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==
Line 16: Line 17:
**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)
**[[Hypothyroidism]]
**[[Hypoglycemia]] (neonates)
*'''Toxicologic'''
**[[B-blocker]]
**[[Ca-channel blocker]]
**[[Digoxin toxicity]]
**[[Opioids]]
**[[Organophosphates]]
*'''Infectious/Postinfectious'''
**[[Chagas disease]]
**[[Lyme disease]]
**[[Syphilis]]
*[[Sick Sinus Syndrome]]


==Treatment==
==Management==
#'''[[Atropine]]'''
[[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)
*'''[[Atropine]]'''
#*Use cautiously in patients with ongoing ischemia (tachycardia may worsen ischemia)
**Can be used as temporizing measure (while awaiting pacing and/or chronotropes)
#*0.5mg q3-5min (max 3mg or 6 doses)
**Use cautiously in patients with ongoing ischemia (tachycardia may worsen ischemia)
#**May not work in 2nd/3rd degree heart block, heart transplant
**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>
#**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>
**0.5mg q3-5min (max 3mg or 6 doses)
#**Block is below AV node so atropine will accelerate sinus rate, leading to worsening of block and increased fatigue of AV nodal cells
***May not work in 2nd/3rd degree heart block, heart transplant
#'''Chronotropes'''
***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>
#*[[Dopamine]] 2-10mcg/kg/min
***Block is below AV node so atropine will accelerate sinus rate, leading to worsening of block and increased fatigue of AV nodal cells
#*[[Epinephrine]] 2-10mcg/min
*'''Chronotropes'''
#'''[[Transcutaneous Pacing]]'''
**[[Dopamine]] 2-10 mcg/kg/min, max 50 mcg/kg/min
#'''[[Transvenous Pacing]]'''
**[[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)
**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
Line 65: Line 52:
**[[Naloxone]] 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)]]


[[Category:Cards]]
==External Links==
[[Category:Critical Care]]
*[http://ddxof.com/simplified-acls-algorithms/ DDxOf: Simplified ACLS Algorithms]
[[Category:EMS]]
 
==Video==
{{#widget:YouTube|id= dKqAqC6JEYQ}}


==References==
==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.
<references/>
<references/>
[[Category:Cardiology]]
[[Category:Critical Care]]
[[Category:EMS]]

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/