Difference between revisions of "ACLS: Bradycardia"

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''This page is for bradycardia with a pulse; for bradycardia without a pulse (i.e. PEA) see [[Adult pulseless arrest]]''
  
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==Background==
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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)
  
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==Categories==
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*'''Sinus node dysfunction'''
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**Sinus bradycardia
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**Sinus arrest
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**[[Tachy-Brady Syndrome]] ([[Sick Sinus]])
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**Chronotropic incompetence
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*'''AV node dysfunction'''
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**1st degree AV block
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**2nd degree AV block Mobitz I/Wenckebach
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**2nd degree AV block Mobitz II
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**3rd degree AV block (complete heart block)
  
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==Differential Diagnosis==
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{{Symptomatic bradycardia}}
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==Management==
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[[File:ACLS-bradycardia.png|thumb|Algorithm for bradycardia with a pulse (Adapted from ACLS 2010)]]
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*'''[[Atropine]]'''
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**Can be used as temporizing measure (while awaiting pacing and/or chronotropes)
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**Use cautiously in patients with ongoing ischemia (tachycardia may worsen ischemia)
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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>
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**0.5mg q3-5min (max 3mg or 6 doses)
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***May not work in 2nd/3rd degree heart block, heart transplant
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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>
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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
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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)
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**[[Isoproterenol]] 2-10 mcg/min
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*'''[[Transcutaneous Pacing]]'''
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*'''[[Transvenous Pacing]]'''
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===[[Antidotes]] for toxicologic causes===
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*[[Beta-Blocker Toxicity]]
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**[[Glucagon]] 5mg IV Q10min (rpt up to 3 doses)
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**[[Insulin]] 1U/kg bolus
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**[[Intralipid]] (ILE)
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*[[Calcium Channel Blocker Toxicity]]
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**[[Calcium gluconate]] 3g
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**[[Insulin]] 1U/kg bolus
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**[[Intralipid]] (ILE)
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*[[Digoxin Toxicity]]
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**[[Dig immune Fab]] 10-20 vials
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*[[Opioid Toxicity]]
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**[[Naloxone]] 0.4mg IV
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*[[Organophosphate Toxicity]]
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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)]]
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==External Links==
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*[http://ddxof.com/simplified-acls-algorithms/ DDxOf: Simplified ACLS Algorithms]
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==Video==
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{{#widget:YouTube|id= dKqAqC6JEYQ}}
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==References==
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<references/>
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[[Category:Cardiology]]
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[[Category:Critical Care]]
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[[Category:EMS]]

Latest 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

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/