Adult Bradycardia Administrative Guideline (Age ≥ 14)

Question 1

History

Answer 1

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

Question 2

Signs and symptoms

Answer 2

• Chest pain
• Respiratory distress
• Hypotension or Shock
• Altered mental status
• Syncope
• Lightheadedness/Dizziness

Question 3

Differential

Answer 3

• Acute myocardial infarction
• Hypoxia / Hypothermia
• Pacemaker failure
• Sinus bradycardia
• Head injury (elevated ICP) or Stroke
• Spinal cord lesion
• Sick sinus syndrome
• AV blocks (1°, 2°, or 3°)
• Overdose

Question 4

Bradycardia with hemodynamic instablity is…

Answer 4

Hypotension with evidence of poor perfusion and end
organ compromise (chest pain, shortness of breath,
altered mental status, etc.)
Do not delay transcutanous pacing in patients
with severe instability (poor perfusion and altered
LOC)

Question 5

If hemodynamically instability is present

Answer 5

Consider transcutaneous pacing if refractory to
medical management or in patients with poor
perfusion and altered LOC

Consider sedation or pain control as blood
pressure allows
Midazolam 0.1 mg/kg IV/IO slowly (max single
dose 2 mg) - May repeat every 2-3 minutes, max
total dose 5 mg

Question 6

Symptomatic bradycardia is

Answer 6

chest pain, shortness of breath, lightheadedness

Question 7

1st treatment for bradycardia

Answer 7

Administer 20 mL/kg NS/LR fluid bolus (unless
signs of fluid overload).
May repeat x 1

Question 8

2nd line treatment for bradycardia

Answer 8

Administer atropine sulfate 1 mg rapid push
IV/IO
May repeat every 3-5 minutes to a max total dose
of 3 mg
For wide complex bradycardia and history of renal
failure, consider hyperkalemia and administer
calcium chloride 1g IVP

Question 9

3rd line treatment for bradycardia

Answer 9

Consider Dopamine 2-10 mcg/kg/min IVPB

Titrate to HR >60 and SBP >90

Question 10

Bradycardia signs and symptoms

Answer 10

altered mental status, chest pain, congestive heart failure, seizure,
syncope, shock, pallor, diaphoresis, or evidence of hemodynamic instability

Question 11

Treatable causes of bradycardia

Answer 11

• Common causes: electrolyte abnormalities (e.g. hyperkalemia), myocardial ischemia, medication
  overdose (see below for more details), infections, hypoxemia, and hypothyroidism
• Consider hyperkalemia in patients with ECG evidence of wide complex bradycardic rhythms. Administer
  calcium chloride 1 g IV/IO for suspicion of hyperkalemia.
• Hypoxemia is a common cause of bradycardia. Ensure oxygenation and support respiratory efforts.

Question 12

TCP tips

Answer 12

• Immediately utilize TCP in patients with evidence of poor perfusion or with high-degree AV block (2nd or
  3rd degree) without IV/IO access.
• If time allows, transport to a cardiac receiving center because transcutaneous pacing is a temporizing
  measure.
• Consider sedation or pain control for TCP
• Use EtCO2 for all patients receiving sedation

Question 13

Bradycardia secondary to overdose

Answer 13

• Bradycardia is a consequence of medication overdoses, including beta blockers, calcium channels, and
  alpha-2 agonists (Clonidine)
• In Clonidine overdoses, avoid use of atropine in the setting of normotension, as atropine may cause reflex
  hypertension in this unique setting