Advanced Cardiac Life Support (ACLS): Bradycardia
ACLS: Bradycardia
1. Initial evaluation is as follows: [1, 2, 3, 4, 5]
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Assess appropriateness for clinical condition (pulse present and unstable).
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Heart rate typically less than 50 bpm in bradyarrhythmia
2. Initial intervention is as follows:
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Maintain patent airway and assist breathing, as needed.
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Administer oxygen if hypoxemic.
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Attach monitor/defibrillator.
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Monitor blood pressure and oximetry.
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Obtain intravenous (IV)/intraosseous (IO) access.
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Perform 12-lead electrocardiography (ECG); do not delay therapy.
3. Assess for signs of poor perfusion, as follows:
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Hypotension (systolic blood pressure [SBP] < 90 mm Hg)
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Acutely altered mental status
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Signs of shock
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Ischemic chest discomfort
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Acute heart failure
4. Therapeutic intervention is as follows:
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If poor perfusion present, administer atropine.
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If adequate perfusion present, monitor and observe.
5. Measures if atropine is ineffective are as follows:
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Transcutaneous pacing OR dopamine infusion OR epinephrine infusion
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Consider expert consultation and transvenous pacing.
Drug Therapy
Drug therapy is as follows:
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Atropine 1 mg IV q3-5min; maximum dose, 3 mg NOTE: This is changed from the 2015 guidelines.
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Dopamine 2-20 μg/kg/min infusion; titrate to patient response; taper slowly.
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Epinephrine 2-10 μg/min infusion; titrate to patient response.
Atropine
Considerations for atropine administration are as follows:
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Not reliable for third-degree block or second-degree type II block
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Could potentially exacerbate the block by increasing sinoatrial (SA) node activation
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May be ineffective in patients after heart transplantation
Most Recent Guideline Changes
Changes from the 2015 guidelines include the following:
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The 2020 adult bradycardia algorithm increased the atropine dose to 1 mg (from 0.5-1 mg) but the frequency of dosing remains the same at every 3-5 minutes with a maximum of 3 mg.
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