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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)
*Heart rate < 60
*Intervention indicated if patient is symptomatic or experiencing symptoms of end organ damage (chest pain, altered mental status, shortness of breath, hypotension)
 
==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 type I (Wenkebach)]]
##2nd degree AV block Mobitz II
**[[2nd degree AV block type II]]
##3rd degree AV block (complete heart block)
**[[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
#Toxicologic
##B-blocker
##Ca-channel blocker
##Digoxin toxicity
##Opioids
##Organophosphates
#Infectious/Postinfectious
##Chagas dz
##Lyme dz
##Syphilis


==Treatment==
==Differential Diagnosis==
#'''Atropine'''
{{Symptomatic bradycardia}}
##Can be used as temporizing measure (while awaiting pacing and/or chronotropes)
##Use cautiously in pts w/ ongoing ischemia (tachycardia may worsen ischemia)
##0.5mg q3-5min (max 3 mg or 6 doses)
###may not work in 2nd/3rd deg HB, heart transplantTranscutaneous pacing
#'''Chronotropes'''
##Dopamine 2-10mcg/kg/min
##[[Epinephrine]] 2-10mcg/min
#'''Transcutaneous pacing'''
##Pad placement:
###Pad on apex of heart and on R upper chest
###Pad on lead V3 position and btwn L scapula and T-spine
##Set: HR 80, pacing threshold usually btwn 40-80 mA
###Look for clear QRS complex and T-wave following pacer spike
###Check pulse to confirm mechanical capture
###Final current set 5-10 mA above threshold level for pt
#'''Transvenous pacing'''
##Required if transcutaneous pacing + chronotropes is ineffective
##Set: HR 80, start at max current output (usually 20 mA)
###Final current set to twice the threshold level for pt


==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>
**{{MedicationDose|drug=Atropine|dose=1 mg q3-5 min|route=IV|context=Symptomatic bradycardia|indication=ACLS: Bradycardia|population=Adult|max_dose=3 mg|link=no}}
***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
**{{MedicationDose|drug=Dopamine|dose=5-20 mcg/kg/min|route=IV drip|context=Chronotrope for bradycardia|indication=ACLS: Bradycardia|population=Adult}}
**{{MedicationDose|drug=Dobutamine|dose=2-20 mcg/kg/min|route=IV drip|context=Chronotrope for bradycardia|indication=ACLS: Bradycardia|population=Adult}}
**{{MedicationDose|drug=Epinephrine|dose=2-10 mcg/min (0.03-0.2 mcg/kg/min)|route=IV drip|context=Chronotrope for bradycardia|indication=ACLS: Bradycardia|population=Adult}}
**{{MedicationDose|drug=Isoproterenol|dose=2-10 mcg/min|route=IV drip|context=Chronotrope for bradycardia|indication=ACLS: Bradycardia|population=Adult}}
*[[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)
**{{MedicationDose|drug=Glucagon|dose=5 mg q10 min (up to 3 doses)|route=IV|context=Beta-blocker toxicity antidote|indication=ACLS: Bradycardia|population=Adult}}
**[[Calcium Channel Blocker Toxicity]]
**{{MedicationDose|drug=Insulin|dose=1 U/kg bolus|route=IV|context=Beta-blocker toxicity (HDIE)|indication=ACLS: Bradycardia|population=Adult}}
***Calcium gluconate 3g OR insulin 1U/kg bolus
**[[Intralipid]] (ILE)
**[[Digoxin Toxicity]]
*[[Calcium Channel Blocker Toxicity]]
***Dig immune Fab 10-20 vials
**{{MedicationDose|drug=Calcium gluconate|dose=3 g|route=IV|context=CCB toxicity antidote|indication=ACLS: Bradycardia|population=Adult}}
**[[Opioid Toxicity]]
**{{MedicationDose|drug=Insulin|dose=1 U/kg bolus|route=IV|context=CCB toxicity (HDIE)|indication=ACLS: Bradycardia|population=Adult}}
***Nalaxone 0.4mg IV
**[[Intralipid]] (ILE)
**[[Organophosphate Toxicity]]
*[[Digoxin Toxicity]]
***Atropine 2mg IV OR Pralidoxime 2g IV over 10-15min
**{{MedicationDose|drug=Dig immune Fab|dose=10-20 vials|route=IV|context=Digoxin toxicity antidote|indication=ACLS: Bradycardia|population=Adult}}
*[[Opioid Toxicity]]
**{{MedicationDose|drug=Naloxone|dose=0.4 mg|route=IV|context=Opioid toxicity reversal|indication=ACLS: Bradycardia|population=Adult}}
*[[Organophosphate Toxicity]]
**{{MedicationDose|drug=Atropine|dose=2 mg, double q5-30 min until secretions controlled|route=IV|context=Organophosphate toxicity|indication=ACLS: Bradycardia|population=Adult}}
**{{MedicationDose|drug=Pralidoxime|dose=1-2 g over 15-30 min|route=IV|context=Organophosphate toxicity|indication=ACLS: Bradycardia|population=Adult}}
 
==Disposition==
*Admit to telemetry/ICU for:
**Symptomatic bradycardia requiring pharmacologic or pacing intervention
**High-degree AV block (second-degree type II, third-degree)
**Bradycardia with hemodynamic instability
**New-onset bradycardia of unclear etiology
*Cardiology consultation for all patients requiring temporary pacing
*Discharge with outpatient cardiology follow-up for:
**Asymptomatic sinus bradycardia with rate >50 in young/athletic patients
**Known stable bradycardia at baseline


==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]
*[https://emergencymedicinecases.com/treatment-bradycardia-bradydysrhythmias/ EM Cases Treatment of Bradycardia and Bradydysrhythmias]
 
==References==
<references/>
 
[[Category:Cardiology]]
[[Category:Critical Care]]
[[Category:EMS]]
[[Category:EMS]]

Revisión actual - 10:03 22 mar 2026

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

Background

  • Heart rate < 60
  • Intervention indicated if patient is symptomatic or experiencing symptoms of end organ damage (chest pain, altered mental status, shortness of breath, hypotension)

Categories

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]
    • 1 mg q3-5 min IV (max 3 mg)
      • 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

Disposition

  • Admit to telemetry/ICU for:
    • Symptomatic bradycardia requiring pharmacologic or pacing intervention
    • High-degree AV block (second-degree type II, third-degree)
    • Bradycardia with hemodynamic instability
    • New-onset bradycardia of unclear etiology
  • Cardiology consultation for all patients requiring temporary pacing
  • Discharge with outpatient cardiology follow-up for:
    • Asymptomatic sinus bradycardia with rate >50 in young/athletic patients
    • Known stable bradycardia at baseline

See Also

External Links

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/
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