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
• 12-Lead EKG

• 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 1 mg 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

 

• • Transcutaneous pacing

 

• • Consider conscious sedation

 

• • Consider Epinephrine Drip 2-10 mcg/min IV/IO

• • • • • OR

 

• • Consider Dopamine (Intropin) 5-20 mcg/kg/min IV/IO

 

• • 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.
• Atropine will not work on a heart transplant patient. Transcutaneous pacing and/or Epinephrine drip is indicated.
• 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.