Advanced Cardiac Life Support (ACLS): Bradycardia

Updated: May 10, 2018
  • Author: James J Lamberg, DO; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Advanced Cardiac Life Support (ACLS): Bradycardia

ACLS: Bradycardia

1. Initial evaluation is as follows: [1, 2, 3, 4]

  • Assess appropriateness for clinical condition (pulse present and unstable).
  • Heart rate typically less than 50 bpm in bradyarrhythmia

2. Initial intervention is as follows:

  • Maintain patent airway and assist breathing, as needed.
  • Administer oxygen if hypoxemic.
  • Attach monitor/defibrillator.
  • Monitor blood pressure and oximetry.
  • Obtain intravenous (IV)/intraosseous (IO) access.
  • Perform 12-lead electrocardiography (ECG); do not delay therapy.

3. Assess for signs of poor perfusion, as follows:

  • Hypotension (systolic blood pressure [SBP] < 90 mm Hg)
  • Acutely altered mental status
  • Signs of shock
  • Ischemic chest discomfort
  • Acute heart failure

4. Therapeutic intervention is as follows:

  • If poor perfusion present, administer atropine.
  • If adequate perfusion present, monitor and observe.

5. Measures if atropine is ineffective are as follows:

  • Transcutaneous pacing OR dopamine infusion OR epinephrine infusion
  • Consider expert consultation and transvenous pacing.

Drug Therapy

See the list below:

  • Atropine 0.5 mg IV q3-5min; maximum dose, 3 mg
  • Dopamine 2-20 μg/kg/min infusion; titrate to patient response; taper slowly.
  • Epinephrine 2-10 μg/min infusion; titrate to patient response.


See the list below:

  • Not reliable for third-degree block or second-degree type II block
  • Could potentially exacerbate the block by increasing sinoatrial (SA) node activation
  • May be ineffective in patients after heart transplantation

Most Recent Guideline Changes

Changes from the 2010 guidelines include the following:

  • Simultaneous breathing and pulse check in less than 10 seconds
  • Administer epinephrine as soon as feasible after the onset of cardiac arrest due to an initial nonshockable rhythm.
  • Provide opioid overdose education, either alone or coupled with naloxone distribution and training, to persons at risk for opioid overdose.
  • In pregnancy, if the fundus height is at or above the level of the umbilicus, manual left uterine displacement can be beneficial in relieving aortocaval compression during chest compression.

Changes from the 2010 ACLS guidelines include the following: For simplicity, vasopressin has been removed from the adult algorithm.