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Acute Adult Bradycardia (With Pulse) Algorithm

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Bradycardia is any rhythm with a heart rate < 50 beats per minute. Symptoms of Bradycardia may include respiratory distress or failure, decreased systolic blood pressure, ECG changes, diminished or absent peripheral pulses, cool and pale skin, and syncope or decreased level of consciousness.

Bradycardia Sequence

  1. Attempt to identify and treat the underlying cause of the bradycardia but do NOT delay treatment of the bradycardia.

    1. Hypoxia – Supplemental oxygen

    2. Acidosis – Ventilation; consider sodium bicarbonate for severe metabolic acidosis

    3. Hyperkalemia – Ensure a normal potassium

    4. Hypothermia – Rewarm the patient but avoid hyperthermia

    5. Heart block – Consider atropine, chronotropic drugs, and external pacemaker.

    6. Toxins/Overdoses – Supportive care and antidote specific to the drug or toxin

    7. Trauma – Oxygenation and ventilation; bradycardia in head trauma must be treated aggressively to avoid increased intracranial pressure.

  2. Establish the airway and assist breathing if necessary;

  3. Monitor heart rate and rhythm and blood pressure.

  4. Monitor pulse oximetry or waveform capnography if available.

  5. Establish an IV or IO access.

  6. If the patient is not hypotensive or exhibiting signs of shock, continue to support oxygenation and monitor the patient; call for consults.

  7. If the patient is hypotensive or exhibiting signs of shock, administer Atropine 0.5 mg bolus and repeat every 3-5 minutes to a maximum dose of 3 mg.

    1. If atropine is not effective, consider trancutaneous pacing while continuing to identify and treat the cause

    2. –OR- begin a Dopamine infusion at 2-10 mcg/kg/minute

    3. –OR- begin an Epinephrine infusion at 2-10 mcg per minute