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==
 
#Ischemia/Infarction
==Differential Diagnosis==
##Inferior MI (involving RCA)
{{Symptomatic bradycardia}}
#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
##Digoxin toxicity
#Infectious/Postinfectious
##Chagas dz
##Lyme dz
##Syphilis


==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 pts w/ ongoing ischemia (tachycardia may worsen ischemia)
**Can be used as temporizing measure (while awaiting pacing and/or chronotropes)
##0.5mg q3-5min (max 3 mg or 6 doses)
**Use cautiously in patients with ongoing ischemia (tachycardia may worsen ischemia)
###may not work in 2nd/3rd deg HB, heart transplantTranscutaneous pacing
**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'''
**0.5mg q3-5min (max 3mg or 6 doses)
##Dopamine 2-10mcg/kg/min
***May not work in 2nd/3rd degree heart block, heart transplant
##[[Epinephrine]] 2-10mcg/min
***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'''
***Block is below AV node so atropine will accelerate sinus rate, leading to worsening of block and increased fatigue of AV nodal cells
##Pad placement:
*'''Chronotropes'''
###Pad on apex of heart and on R upper chest
**[[Dopamine]] 2-10 mcg/kg/min, max 50 mcg/kg/min
###Pad on lead V3 position and btwn L scapula and T-spine
**[[Dobutamine]] 2-20 mcg/kg/min, max 40 mcg/kg/min
##Set: HR 80, pacing threshold usually btwn 40-80 mA
**[[Epinephrine]] 2-10 mcg/min (~0.03-0.2 mcg/kg/min, max 1 mcg/kg/min)
###Look for clear QRS complex and T-wave following pacer spike
**[[Isoproterenol]] 2-10 mcg/min
###Check pulse to confirm mechanical capture
*'''[[Transcutaneous Pacing]]'''
###Final current set 5-10 mA above threshold level for pt
*'''[[Transvenous Pacing]]'''
#'''Transvenous pacing'''
 
##Required if transcutaneous pacing + chronotropes is ineffective
===[[Antidotes]] for toxicologic causes===
##Set: HR 80, start at max current output (usually 20 mA)
*[[Beta-Blocker Toxicity]]
###Final current set to twice the threshold level for pt
**[[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==
==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:EMS]]
[[Category:EMS]]

Revision as of 23:34, 23 September 2019

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/