Bradycardia Algorithm Review
(includes 2010 AHA Guideline Update)
The major ECG rhythms classified as bradycardia include:
First-degree AV block
Second-degree AV block
Type I —Wenckenbach/Mobitz I
Type II —Mobitz II
Third-degree AV block complete block
(See the ECG Interpretation section for images and more detailed information on rhythms)
Bradycardia vs. Symptomatic Bradycardia
Bradycardia is defined as any rhythm disorder with a heart rate less than 60 beats per minute. (Typically it will be <50/min) This could also be called asymptomatic bradycardia. Bradycardia can be a normal non-emergent rhythm. For instance, well trained athletes may have a normal heart rate that is less than 60 bpm.
Symptomatic bradycardia however is defined as a heart rate less than 60/min that elicits signs and symptoms, but the heart rate will usually be less than 50/min. Symptomatic bradycardia exists when the following 3 criteria are present: 1.) The heart rate is slow; 2.) The patient has symptoms; and 3.) The symptoms are due to the slow heart rate.
Functional or relative bradycardia occurs when a patient may have a heart rate within normal sinus range, but the heart rate is insufficient for the patients condition. An example would be a patient with an heart rate of 80 bpm when they are experiencing septic shock.
There are 3 medications that are used in the Bradycardia ACLS Algorithm. They are atropine, dopamine (infusion), and epinephrine (infusion). More detailed ACLS pharmacology information can be found here.
2010 AHA Update: For symptomatic bradycardia or unstable bradycardia IV infusion chronotropic agents (dopamine & epinephrine) is now recommended as an equally effective alternative to external pacing when atropine is ineffective.
Atropine: The first drug of choice for symptomatic bradycardia. Dose in the Bradycardia ACLS algorithm is 0.5mg IV push and may repeat up to a total dose of 3mg.
Dopamine: Second-line drug for symptomatic bradycardia when atropine is not effective. Dosage is 2-20 micrograms/kg/min infusion.
Epinephrine: Can be used as an equal alternative to dopamine when atropine is not effective. Dosage is 2-10 micrograms/min.
The decision point for ACLS intervention in the bradycardia algorithm is determination of adequate perfusion. For the patient with adequate perfusion, you should observe and monitor. If the patient has poor perfusion, preparation for transcutaneous pacing should be initiated, and an assessment of contributing causes (H’s and T’s) should be carried out.
Transcutaneous pacing (TCP)
Preparation for TCP should be taking place as atropine is being given. If atropine fails to alleviate symptomatic bradycardia, TCP should be initiated. Ideally the patient should receive sedation prior to pacing, but if the patient is deteriorating rapidly, it may be necessary to start TCP prior to sedation.
For the patient with symptomatic bradycardia with signs of poor perfusion, transcutaneous pacing is the treatment of choice.
Do not delay TCP for the patient with symptomatic bradycardia with signs of poor perfusion. TCP rate should use 60/min as a starting rate and adjust up or down based on the patient’s clinical response. The dose for pacing should be set at 2mA (milliamperes) above the dose that produces observed capture.
TCP is contraindicated for the patient with hypothermia and is not a recommended treatment for asystole.
A carotid pulse should not be used for assessment of circulation as TCP can create muscular movements that may feel like a carotid pulse. Assess circulation using the femoral pulse.
Identification of contributing factors for symptomatic bradycardia should be considered throughout the ACLS protocal since reversing of the cause will likely return the patient to a state of adequate perfusion.