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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


==Sick Sinus Syndrome==
==Management==
#Collection of bradyarrhythmias with or without tachycardia<ref>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</ref>
[[File:ACLS-bradycardia.png|thumb|Algorithm for bradycardia with a pulse (Adapted from ACLS 2010)]]
##50% have alternating bradycardia and tachycardia
*[[Atropine]]
##Causes include:
**Can be used as temporizing measure (while awaiting pacing and/or chronotropes)
###Intrinsic: degenerative fibrosis, infiltrative disease process, ion channel dysfunction, SA node remodeling
**Use cautiously in patients with ongoing ischemia (tachycardia may worsen ischemia)
###Extrinsic: pharmacologic, metabolic/electrolyte disturbance, autonomic, OSA
**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>
##Clinical manifestations related to end-organ hypoperfusion
**{{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}}
###Syncope/pre-syncope (50%)
***May not work in 2nd/3rd degree heart block, heart transplant
##Dx - ECG identification, inpatient telemetry, outpatient Holter monitoring, event monitoring, loop monitoring
***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>
###ECG
***Block is below AV node so atropine will accelerate sinus rate, leading to worsening of block and increased fatigue of AV nodal cells
##Tx - remove extrinsic factors and/or pacemakers
*Chronotropes
###Pacemakers do not reduce mortality, only decrease symptoms
**{{MedicationDose|drug=Dopamine|dose=5-20 mcg/kg/min|route=IV drip|context=Chronotrope for bradycardia|indication=ACLS: Bradycardia|population=Adult}}
##Complications
**{{MedicationDose|drug=Dobutamine|dose=2-20 mcg/kg/min|route=IV drip|context=Chronotrope for bradycardia|indication=ACLS: Bradycardia|population=Adult}}
###(50%) Tachy-brady syndrome with atrial fibrillation or atrial flutter
**{{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}}
###(50%) AV block
**{{MedicationDose|drug=Isoproterenol|dose=2-10 mcg/min|route=IV drip|context=Chronotrope for bradycardia|indication=ACLS: Bradycardia|population=Adult}}
*[[Transcutaneous Pacing]]
*[[Transvenous Pacing]]


==Treatment==
===[[Antidotes]] for toxicologic causes===
#'''Atropine'''
*[[Beta-Blocker Toxicity]]
##Can be used as temporizing measure (while awaiting pacing and/or chronotropes)
**{{MedicationDose|drug=Glucagon|dose=5 mg q10 min (up to 3 doses)|route=IV|context=Beta-blocker toxicity antidote|indication=ACLS: Bradycardia|population=Adult}}
##Use cautiously in pts w/ ongoing ischemia (tachycardia may worsen ischemia)
**{{MedicationDose|drug=Insulin|dose=1 U/kg bolus|route=IV|context=Beta-blocker toxicity (HDIE)|indication=ACLS: Bradycardia|population=Adult}}
##0.5mg q3-5min (max 3 mg or 6 doses)
**[[Intralipid]] (ILE)
###may not work in 2nd/3rd deg HB, heart transplant
*[[Calcium Channel Blocker Toxicity]]
#'''Chronotropes'''
**{{MedicationDose|drug=Calcium gluconate|dose=3 g|route=IV|context=CCB toxicity antidote|indication=ACLS: Bradycardia|population=Adult}}
##Dopamine 2-10mcg/kg/min
**{{MedicationDose|drug=Insulin|dose=1 U/kg bolus|route=IV|context=CCB toxicity (HDIE)|indication=ACLS: Bradycardia|population=Adult}}
##[[Epinephrine]] 2-10mcg/min
**[[Intralipid]] (ILE)
#'''[[Transcutaneous Pacing]]'''
*[[Digoxin Toxicity]]
#'''[[Transvenous Pacing]]'''
**{{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==
===Antidotes for toxicologic causes===
*Admit to telemetry/ICU for:
**[[Beta-Blocker Toxicity]]
**Symptomatic bradycardia requiring pharmacologic or pacing intervention
***glucagon 5mg IV Q10min (rpt up to 3 doses)
**High-degree AV block (second-degree type II, third-degree)
**[[Calcium Channel Blocker Toxicity]]
**Bradycardia with hemodynamic instability
***Calcium gluconate 3g OR insulin 1U/kg bolus
**New-onset bradycardia of unclear etiology
**[[Digoxin Toxicity]]
*Cardiology consultation for all patients requiring temporary pacing
***Dig immune Fab 10-20 vials
*Discharge with outpatient cardiology follow-up for:
**[[Opioid Toxicity]]
**Asymptomatic sinus bradycardia with rate >50 in young/athletic patients
***Nalaxone 0.4mg IV
**Known stable bradycardia at baseline
**[[Organophosphate Toxicity]]
***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: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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