Bradycardia

 

History:

 

  • Past medical history
  • Medications
    • Beta blockers
    • Clonidine
    • Calcium channel blockers
    • Digoxin
  • Pacemaker

 

Significant findings:

 

  • HR <60
  • Acute CHF
  • Seizures
  • Chest pain
  • Respiratory distress
  • Hypotension or shock secondary to bradycardia
  • Acute altered mental status
  • Syncope

 

Differential:

 

  • Acute MI
  • Hypoxia
  • Pacemaker failure
  • Hypothermia
  • Athletes
  • Head injury (elevated ICP)
  • Stroke
  • Spinal cord lesion
  • AV blocks (1st⁰, 2nd⁰, or 3rd⁰)
  • Overdose

 

Treatment

 

  • Oxygen
  • Initiate IV/IO

 

HR <60 with signs or symptoms of poor perfusion caused by the bradycardia?

 

    • Acute AMS
    • Syncope
    • Ongoing Chest Pain
    • Shortness of Breath
    • Hypotension
    • Acute CHF
    • Seizure
    • Other signs of shock

 

  • Yes

 

    • Atropine 0.5 mg IV/IO; may repeat every 3-5 minutes; max 3 mg

 

  • No

 

    • Continue to monitor and reassess

 

Improving?

 

  • Yes

 

    • Notify receiving facility or contact Medical Control

 

  • No

 

 

 

 

    • Notify receiving facility or contact Medical Control

 

PEARLS:

 

  • If bradycardic patient is also a STEMI, follow the STEMI guidelines.
  • Transcutaneous Pacing: set rate for 70 beats per minute. Increase current (mA) until electrical and mechanical capture occure or pacing current reaches (200 mA)
  • Demand and Non-Demand Pacing
  • Conscious Sedation, Dose should be titrated to provide comfort without causing unconsciousness or respiratory failure. Be sure to monitor patient's breathing/ventilations, blood pressure and O2 saturation.
  • Pacing can be considered first for critical patients in the presence of 2nd⁰ or 3rd⁰ heart block.
  • Consider Glucagon (GlucaGen) 2 mg IV/IO, if patient is still bradycardic and on beta blockers
  • Consider Calcium Gluconate (Kalcinate) 5-20 mL IV/IO if patient is still bradycardic and on calcium channel blockers.
  • The use of Lidocaine (Xylocaine), Amiodarone (Cordarone) and calcium channel blockers in heart block can worsen bradycardia and lead to death.
  • In wide complex slow rhythm, consider hyperkalemia.