ACLS: Bradycardia

This page is for bradycardia with a pulse; for bradycardia without a pulse see Adult Pulseless Arrest (i.e. PEA)

Background

• Only intervene if pt is symptomatic (hypotension, AMS, chest pain, pulm 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

• Ischemia/Infarction
  • 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)
  • Hypothyrodism
  • Hypoglycemia (neonates)
• Toxicologic
  • B-blocker
  • Ca-channel blocker
  • Digoxin toxicity
  • Opioids
  • Organophosphates
• Infectious/Postinfectious
  • Chagas dz
  • Lyme dz
  • Syphilis
• Sick Sinus Syndrome

Treatment

1. Atropine
   • Can be used as temporizing measure (while awaiting pacing and/or chronotropes)
   • Use cautiously in patients with ongoing ischemia (tachycardia may worsen ischemia)
   • 0.5mg q3-5min (max 3mg or 6 doses)
     • may not work in 2nd/3rd degree heart block, heart transplant
2. Chronotropes
   • Dopamine 2-10mcg/kg/min
   • Epinephrine 2-10mcg/min
3. Transcutaneous Pacing
4. Transvenous Pacing

Antidotes for toxicologic causes

• Beta-Blocker Toxicity
  • glucagon 5mg IV Q10min (rpt up to 3 doses)
• Calcium Channel Blocker Toxicity
  • Calcium gluconate 3g OR insulin 1U/kg bolus
• Digoxin Toxicity
  • Dig immune Fab 10-20 vials
• Opioid Toxicity
  • Nalaxone 0.4mg IV
• Organophosphate Toxicity
  • Atropine 2mg IV OR pralidoxime 2g IV over 10-15min

See Also

• ACLS (Main)
• Bradycardia (Wide)

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.