ACLS: Bradycardia: Difference between revisions
ClaireLewis (talk | contribs) |
|||
(43 intermediate revisions by 7 users not shown) | |||
Line 1: | Line 1: | ||
''This page is for bradycardia with a pulse; for bradycardia without a pulse (i.e. PEA) see [[Adult pulseless arrest]]'' | |||
==Background== | ==Background== | ||
* | *HR < 60 | ||
*Intervention only necessary if patient is symptomatic (hypotension, altered mental status, chest pain, pulmonary edema) | |||
==Categories== | ==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> | |||
**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''' | |||
**[[Dopamine]] 2-10 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) | ||
**[[Calcium Channel Blocker Toxicity]] | **[[Insulin]] 1U/kg bolus | ||
** | **[[Intralipid]] (ILE) | ||
**[[Digoxin Toxicity]] | *[[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)]] | ||
[[Category: | ==External Links== | ||
[[Category: | *[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
- 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
- Cardiac
- Inferior MI (involving RCA)
- Sick sinus syndrome
- 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
- Infectious/Postinfectious
- Other
Management
- 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
- Dopamine 2-10 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
External Links
Video
{{#widget:YouTube|id= dKqAqC6JEYQ}}
References
- ↑ Neumar RW et al. Part 8: Adult Advanced Cardiovascular Life Support. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
- ↑ Burns, E. AV block: 3rd degree (complete heart block). http://lifeinthefastlane.com/ecg-library/basics/complete-heart-block/