Adult Bradycardia with a Pulse

Question 1

First steps to take when you encounter Adult Bradycardai with a Pulse

Answer 1

Assess the appropriateness for the clinical condition - maybe it’s someone with known beta blocker therapy and regularly low HR, or a triathlete 21 year old, and everything is fine!

Think of 5 H’s and 5 T’s
Think of Hypoxia (and resulting MI) as a very likely culprit. Turn FiO2 to 100%
Think of Toxicology / drug error as other main culprit - eg, CCB, BB, Digoxin
Also think electrolyte abnormalities (eg, Hyperkalemia)
Get adequate access
Order EKG! Order lytes! But don’t delay treatment waiting for EKG!

Question 2

Define UNstable Bradycardia / Hemodynamically significant bradycardia

Answer 2

Persistent Bradyarrhythmia causing:
1) HoTN
2) AMS
3) S/S Shock
4) ACS / Ischemic chest pain
5) Acute CHF

Question 3

Treatment for stable / HDS Bradycardia

Answer 3

monitor and observe. so NO treatment

Question 4

Treatment for UNstable Bradycardia

Answer 4

1. Atropine first.

If atropine ineffective, add TransCUTANEOUS pacing AND/OR [Dopamine OR Epinephrine infusions]

Can always consider Expert consultation and TransVENOUS pacing

Expert consultation never hurts

The following Tx combos are acceptable:
Atropine + Transcutaneous (or Transvenous) pacing + Dopamine
Atropine + Transcutaneous (or Transvenous) pacing + Epi
Atropine + Dopamine
Atropine + Epi

Question 5

IV Atropine dose for hemodynamically significant / UNstable bradycardia with a pulse?

Answer 5

First dose: 1mg bolus (so would be 2.5 vials of the usual 0.4mg vials)
Repeat q3-5min up to 3 times for a maximum dose of 3mg

Question 6

Transcutaneous pacing method for hemodynamically significant / UNstable bradycardia with a pulse?

Answer 6

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Question 7

Dopamine dosing for hemodynamically significant / UNstable bradycardia with a pulse?

Answer 7

Dopamine INFUSION (vs bolus for atropine) of 5-20 mcg/kg/min, titrated up to patient response, and tapered off slowly.

Remember that you try Atropine first, then you go to TransCUTANEOUS pacing AND/OR [Dopamine OR Epinephrine infusions]. Then you might even start transVENOUS pacing if transcutaneous pacing didn’t work.
So the following Tx combos are acceptable:
Atropine + Transcutaneous (or Transvenous) pacing + Dopamine
Atropine + Transcutaneous (or Transvenous) pacing + Dopamine
Atropine + Dopamine
Atropine + Epi

Question 8

Epinephrine dosing for hemodynamically significant / UNstable bradycardia with a pulse?

Answer 8

Epi INFUSION (vs bolus for atropine) of 2-10 mcg/min, titrated to patient response.
I’m used to units of mcg/kg/min and starting at Epi 0.02-0.04 mcg/kg/min

Remember that you try Atropine first, then you go to TransCUTANEOUS pacing AND/OR [Dopamine OR Epinephrine infusions]. Then you might even start transVENOUS pacing if transcutaneous pacing didn’t work.
So the following Tx combos are acceptable:
Atropine + Transcutaneous (or Transvenous) pacing + Dopamine
Atropine + Transcutaneous (or Transvenous) pacing + Dopamine
Atropine + Dopamine
Atropine + Epi