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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==
==Differential Diagnosis==
#'''Ischemia/Infarction'''
{{Symptomatic bradycardia}}
##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==
==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'''
**{{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}}
##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
**{{MedicationDose|drug=Dopamine|dose=5-20 mcg/kg/min|route=IV drip|context=Chronotrope for bradycardia|indication=ACLS: Bradycardia|population=Adult}}
###Pad on lead V3 position and btwn L scapula and T-spine
**{{MedicationDose|drug=Dobutamine|dose=2-20 mcg/kg/min|route=IV drip|context=Chronotrope for bradycardia|indication=ACLS: Bradycardia|population=Adult}}
##Set: HR 80, pacing threshold usually btwn 40-80 mA
**{{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}}
###Look for clear QRS complex and T-wave following pacer spike
**{{MedicationDose|drug=Isoproterenol|dose=2-10 mcg/min|route=IV drip|context=Chronotrope for bradycardia|indication=ACLS: Bradycardia|population=Adult}}
###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
##Set: HR 80, start at max current output (usually 20 mA)
###Final current set to twice the threshold level for pt


===[[Antidotes]] for toxicologic causes===
*[[Beta-Blocker Toxicity]]
**{{MedicationDose|drug=Glucagon|dose=5 mg q10 min (up to 3 doses)|route=IV|context=Beta-blocker toxicity antidote|indication=ACLS: Bradycardia|population=Adult}}
**{{MedicationDose|drug=Insulin|dose=1 U/kg bolus|route=IV|context=Beta-blocker toxicity (HDIE)|indication=ACLS: Bradycardia|population=Adult}}
**[[Intralipid]] (ILE)
*[[Calcium Channel Blocker Toxicity]]
**{{MedicationDose|drug=Calcium gluconate|dose=3 g|route=IV|context=CCB toxicity antidote|indication=ACLS: Bradycardia|population=Adult}}
**{{MedicationDose|drug=Insulin|dose=1 U/kg bolus|route=IV|context=CCB toxicity (HDIE)|indication=ACLS: Bradycardia|population=Adult}}
**[[Intralipid]] (ILE)
*[[Digoxin Toxicity]]
**{{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}}


*'''Antidotes for toxicologic causes:'''
==Disposition==
**[[Beta-Blocker Toxicity]]
*Admit to telemetry/ICU for:
***glucagon 5mg IV Q10min (rpt up to 3 doses)
**Symptomatic bradycardia requiring pharmacologic or pacing intervention
**[[Calcium Channel Blocker Toxicity]]
**High-degree AV block (second-degree type II, third-degree)
***Calcium gluconate 3g OR insulin 1U/kg bolus
**Bradycardia with hemodynamic instability
**[[Digoxin Toxicity]]
**New-onset bradycardia of unclear etiology
***Dig immune Fab 10-20 vials
*Cardiology consultation for all patients requiring temporary pacing
**[[Opioid Toxicity]]
*Discharge with outpatient cardiology follow-up for:
***Nalaxone 0.4mg IV
**Asymptomatic sinus bradycardia with rate >50 in young/athletic patients
**[[Organophosphate Toxicity]]
**Known stable bradycardia at baseline
***Atropine 2mg IV OR Pralidoxime 2g IV over 10-15min


==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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