Bradycardia

Table of Contents

Aliases

Heart block, junctional rhythm

Patient Care Goals

Maintain adequate perfusion
Treat underlying cause:
1. Hypoxia
2. Shock
3. Second or third-degree AV block
4. Toxin exposure (beta-blocker, calcium channel blocker, organophosphates, digoxin)
5. Electrolyte disorder
6. Hypoglycemia
7. Increased intracranial pressure (ICP)
8. Other

Patient Presentation

Inclusion Criteria

Heart rate less than 60 beats per minute with either symptoms (AMS, CP, CHF, seizure, syncope, shock, pallor, diaphoresis) or evidence of hemodynamic instability
The major EKG rhythms classified as bradycardia include:
1. Sinus bradycardia
2. Second-degree AV block
  1. Type I —Wenckenbach/Mobitz I
  2. Type II —Mobitz II
3. Third-degree AV block complete block
4. Ventricular escape rhythms
See additional inclusion criteria, below, for pediatric patients

Exclusion Criteria

No recommendations

Patient Management

Assessment, Treatment, and Interventions

Adult Management
1. Manage airway as necessary
2. Administer oxygen as appropriate with a target of achieving 94-98% saturation
3. Initiate cardiac monitoring and perform 12-lead EKG
4. Establish IV access
5. Check blood glucose and treat hypoglycemia per the Hypoglycemia and Hyperglycemia guidelines
6. Consider the following additional therapies if bradycardia and symptoms of hemodynamic instability continue:
  1. For any unstable bradycardia, Transcutaneous Pacing – If pacing performed, consider sedation or pain control. Choose one of the following:
    1. Fentanyl 2 mcg/kg IN/IM; max of 100 mcg
    2. Fentanyl 1 mcg/kg IV/IO; max of 100 mcg
    3. Midazolam 5 mg IN/IM
    4. Midazolam 1 mg IV/IO
  2. For wide complex bradycardia & known or strongly suggested hyperkalemia
    1. Calcium chloride 1 gram (10 mL) slow IV push
    2. Albuterol 10 mg via small volume nebulizer
  3. For Sinus Bradycardia or increased vagal tone only
    1. Atropine 0.5 mg IV every 3 minute (maximum total dose of 3 mg)
  4. Push Dose Pressors
    1. Epinephrine by push dose (dilute boluses)
      1. Prepare 10 mcg/mL by adding 1 mL of Epinephrine (0.1 mg/mL) to 9 mL normal saline, then administer 10 mcg boluses (1 mL) every 1 minutes titrated MAP greater than 65 mmHg
Pediatric Management
Treatment is only indicated for patients who are symptomatic (pale/cyanotic, diaphoretic, altered mental status, hypoxic)
1. Initiate chest compressions for heart less than 60 and signs of poor perfusion (altered mental status, hypoxia, hypotension, weak pulse, delayed capillary refill, cyanosis)
2. Manage airway and assist ventilations as necessary with minimally interrupted chest compressions using a compression to ventilation ratio 15:2 (30:2 if single provider is present)
3. Administer oxygen as appropriate with a target of achieving 94-98% saturation
4. Initiate monitoring and perform 12-lead EKG
5. Establish IV access
6. Check blood glucose and treat hypoglycemia per the Hypoglycemia guideline
7. Consider the following additional therapies if bradycardia and symptoms of hemodynamic instability continue:
  1. For any unstable bradycardia, transcutaneous pacing – If pacing performed, consider sedation or pain control. Choose one of the following:
    1. Fentanyl 2 mcg/kg IN/IM; max of 100 mcg
    2. Fentanyl 1 mcg/kg IV/IO; max of 100 mcg
    3. Midazolam 5 mg IN/IM
    4. Midazolam 1 mg IV/IO
  2. For wide complex bradycardia & known or strongly suggested hyperkalemia
    1. Calcium chloride 10% 20 mg/kg (0.2 mL/kg), max of 1 gram (10 mL) slow IV push
    2. Albuterol 10 mg via small volume nebulizer
  3. Push Dose Pressors
    1. Epinephrine by push dose (dilute boluses). Prepare 10 mcg/mL by adding 1 mL of Epinephrine (0.1 mg/mL) to 9 mL Normal Saline, then administer 0.01 mg/kg (0.1 ml/kg) maximum single dose 10 mcg (1 ml) every 1 minutes titrated to MAP greater than 65mmHg
  4. If increased vagal tone or cholinergic drug toxicity
    1. Consider atropine 0.02 mg/kg IV with dose of 0.1 – 0.5 mg, repeat every 5 mins (maximum total dose of 3 mg)

Notes – Bradycardia

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