ACLS Bradycardia

  1. What are the main players in symptomatic brady?
    • Atropine
    • Epi
    • Dopamine
    • Trancutaneous Pacing / Transvenous Pacing
  2. Patient presents with HR < 60.
    Brady recognized.

    Is the patient having SYMPTOMS caused by bradycardia?

    • Ssx of bradycardia
    • Chest sx
    • Sob
    • Altered
    • Weak/fatigue
    • Lightheaded/dizzy
    • Presyncope/syncope

    • Hypotensive or orthostatic hypo
    • Pulm congestion/edema (on cxr or exam)
    • CHF
    • Freq PVC, VT
  3. patient has HR < 50, and altered....
    next move

    • Check
    • Airway : open? head tilt and chin lift
    • Breathing: adequate? need to intubate? put on bag mask
    • pt has it plugged?
    • Circulation: pulse?
    • put pt on monitor, check for working IV access
  4. pt HR < 60, altered
    ABC's intact, now what
    Check monitor: what kind of brady is pt in?

    • *if sinus brady or 1st degree block:
    • give Atropine 0.5 mg IV (rpt 3-5 min, up to 3 mg, 6 doses)

    • if 2 degree Mobitz Type II AV block or 3 degree block,
    • start TCP!
  5. pt HR < 50, altered...
    ABCs checked
    1st doses of Atropine not working...
    start pacing or if still waiting for pacer

    • consider INFUSIONS of epi or dopamine
    • at 2-10 micrograms/min infusion.
  6. Pt HR < 50, altered
    Atropine, Epi and Dopamine not working
    • Get that TCP started!
    • Call cardiology for consult on TransVenous pacing.
  7. Patient stabilized...
    How do you know?
    • Check for improved clinical status.
    • Second, improved heart rate.

    • Patient not HR 65 on TCP.
    • More alert, no CP.....
    • You win :)
  8. Why is symptomatic brady dangerous?
    These pt are PRE-CARDIAC ARREST!

    • When the HR falls, the unstable ventricle may have escape rhythms that often fails to drugs.
    • Ventricle rhythms can become WIDE COMPLEX and turn into VT/VF then ASYSTOLE.
  9. What is the first line Tx in pts with symptomatic bradycardia without evidence of heart blocks?
    Symptomatic Brady first line treatment

    • Atropine 0.5 mg IV q 3-5 min
    • May repeat x 6 doses for max of 3mg.
  10. What are Unstable pt with symptomatic Brady?
    WHat are these first line tx?
    Unstable Pts are

    • 2nd Degree Mobitz type II AV block
    • 3rd Degree AV Block
    • Wide QRS

    • Must start TCP first.
    • Atropine wont help (pt has heart blocks, increasing HR wont do no good)
  11. Atropine Precaution in
    • ACS or AMI pts.
    • These pts have injured myocardium.
    • Atropine will increase HR and worsen ischemia.
    is really the tx of choice.
    Atropine just buys you time.

    What does TCP do?
    TCP paces the heart, like a temporary pacemaker.

    TCP delivers pacing impulses to heart thro skin using cutaneous electrodes.
  13. Indications for TCP
    • *Hemodynamically Unstable Brady Pts
    • (decrease BP, altered, angina, pulm edema)
    • *High degree heart blocks
    • (2nd degree Mobitz II or 3rd degree AV blocks)
    • *New L, R or alternating BBB
    • *Bifascicular Blocks
    • *Sympt Brady with Ventricular Escape Beats
  14. TCP Precautions
    • hypothermia
    • asystole
  15. Always give what with TCP
    • Pain meds or Benzos in stable pts
    • TCP hurts
  16. TCP: How do you do it?
    • 1. Place electrodes
    • 2. Turn on
    • 3. Set demand rate 60/min (can adjust)
    • 4. Set current output: 2mA above dose where consistent capture observed
  17. Where should you not check for TCP capture?
    • Do not check carotid pulse for TCP capture.
    • Electrical stimulus can cause muscle jerks that look like a pulse.
  18. Standby TCP pacing for
    Anticipate clinical DETEROATION in pts with AMI and

    • *symptomatic brady
    • *Asympt 2nd degree Mobitz II and 3rd degree AV block
    • *New L, R or alternating BBB
    • *bifascicular blocks in setting of AMI.
  19. Brady tx in a nutshell
    • 1. ABCs!
    • 2. Does pt have ssx of adequate perfusion? Brady causing these symptoms?
    • If no and no worrisome EKGs : monitor

    • If yes with worrisome EKGs
    • TCP

    • if yes with no worrisome EKGs
    • Atropine 0.5 mg IV q 3-5 min, up to 3mg
    • Start TCP
    • consider adding Epi or Dopamine if above fail or still waiting for TCP
    • dose (2-10 microgram/kg/min)

    Cardiac consult for Trans Venous Pacing!
Card Set
ACLS Bradycardia
ACLS Provider Manuel 2006