ACLS Drugs for Bradycardia
When bradycardia is being treated in ACLS, if an underlying cause cannot be identified and corrected, medications are indicated.
There are three medications used in the bradycardia algorithm: atropine, epinephrine, and dopamine. Each drug and its use within the bradycardia algorithm is explained below.
Atropine
Atropine is the first drug used to treat bradycardia in the bradycardia algorithm. It is classified as an anticholinergic drug and increases firing of the SA Node by blocking the action of the vagus nerve on the heart resulting in an increased heart rate.
Atropine should be used cautiously in the presence of myocardial ischemia and hypoxia since it increases oxygen demand of heart and can worsen ischemia.
The dosing for Atropine is 0.5 mg IV every 3-5 minutes as needed, and the maximum total dosage that can be give is 3 mg.
Atropine should be avoided in hypothermic bradycardia and it will not be effective for Mobitz type II/Second Degree Block Type 2.
You may have read that Atropine is not effective for Mobitz II (2nd degree block type II) and Complete Heart Block (3rd degree block)
Click here to find out why
Epinephrine and Dopamine
Epinephrine and dopamine are second-line drugs for symptomatic bradycardia. They are both used as infusions in the bradycardia algorithm if atropine is ineffective.
ACLS guidelines state that if bradycardia is unresponsive to atropine, an equally effective alternative to transcutaneous pacing is the use of an IV infusion of the beta-adrenergic agonists (dopamine or epinephrine).
Dosing:
Begin the epinephrine infusion at 2 to 10 mcg/min and titrate to patient’s response.
The goal of therapy is to improve the patient’s clinical status rather than target an exact heart rate.
Begin the dopamine infusion at 2 to 20 mcg/kg/min and titrate to the patient’s response.
Precautions
Prior to use of ACLS drugs in the treatment of symptomatic bradycardia, contributing factors of the bradycardia should be explored then ruled out or corrected.
Return to main ACLS Pharmacology page.
First let’s look at atropine and how it works. Atropine increases firing of the sinoatrial node (atria) and conduction through the atrioventricular node (AV) of the heart by blocking the action of the vegus nerve.
With 3rd degree block there is a complete block and disassociation of the electrical activity that is occurring in the atria and ventricles. Since atropine’s affect is primarily on the SA node in the atria, 3rd degree block would prevent its affect on the SA node from influencing the rate of ventricular contraction which is needed to improve perfusion.
With Mobitz-II, aka, Second-degree AV Block Type II, the situation is similar. There is a partial block in the electrical impulses from the atria (SA) to the ventricles, and thus the affects of atropine would not significantly change the status of the ventricles.
This block can also rapidly progress to 3rd degree block.
To summarize, Atropine may speed the firing rate of the SA node (atria), but the ventricles are not responding to anything the atria (SA node) puts out. Thus, the heart rates will not increase.
There may be some action at the AV-node with atropine, but the effect will be negligible and typically not therapeutic. Atropine in most cases will not hurt the patient with 3rd degree block unless they are unstable and you delay pacing to give atropine.
It is important to note that Mobitz II and Complete Heart Block may be associated with acute myocardial ischemia. In this case, if atropine is used and it increases the heart rate there is a high potential for worsening of the myocardial ischemia due to the increased oxygen consumption. The increased heart rate will also reduce diastolic filling time which may worsen coronary perfusion.
Since new onset mobitz II and Complete Heart Block are commonly associated with myocardial infarction, it would be ideal to keep the HR slow (50-60) to increase diastolic filling time. Anytime you increase HR, the diastolic filling time is what takes the biggest hit.
Transcutaneous Pacing should be the first line in symptomatic Mobitz II and Symptomatic Complete Heart Block. It is very safe & less painful than in previous times due to technology improvements. Research has shown that most individuals can tolerate > 15min of transcutaneous pacing without too much difficulty.
Hilgendh says
What’s the major differences between Dopamine and Epinephrine besides the dose ranges? In my readings, i see that dopamine is a precursor to epi, and that both have a Beta- effect at low doses and an increasing Alpha effect at higher doses. Why is epinephrine prefered for everything? What would be reasons to choose one over another?
Thanks!!!
Jeff with admin. says
For the treatment of bradycardia, dopamine or epinephrine infusions are both classified equal in their effect (Class IIb LOE B) and either choice would be equally acceptable for the treatment of symptomatic bradycardia.
The major difference would be that if you have a patient who is hypotensive along with the bradycardia, epinephrine would probably be a better choice to start with. This is due to the fact that epinephrine can simultaneously increase the heart rate and blood pressure. Whereas with dopamine, you have to titrate different doses to achieve either an increase in heart rate or increased blood pressure.
I would not say that epinephrine is always preferred for everything. I have often seen a physicians first choice for hypotension or bradycardia be dopamine.
Kind regards, Jeff
SheilaK says
The dopamine infusion rate – on the algorithm chart it states 2-10 mcg/kg/mn but on the information above in bold it states 2-20mcg/kg/mn. Which is the correct dose?
Jeff with admin. says
Can you please let me know which “algorthm chart” you are asking about? The correct dosing is 2-20 mcg/kg/min.
Is the 2-10 mcg/kg/min dosing you referenced from this website or another chart you are looking at?
Kind regards,
Jeff
Ellen Mosca says
On the AHA ACLS Bradycardia Algorithm listed on this site
Jeff with admin. says
If you can provide the link to the algorithm you are looking at that would be great. I cannot locate any bradycardia algorithm on the site that lists dopamine infusion for bradycardia at 2-10 mcg/kg/min. The correct dosing is 2-20 mcg/kg/min. Kind regards, Jeff
Ren says
EPI is for if BP >100 systolic
Dopamine is used if BP <100 systolic
That is, if TCP is unavailable or treatment is contraindicated.
Brenna says
why give dopamine for bradycardia???????
Jeff with admin. says
At intermediate rates (2-10 mcg/kg/min), dopamine acts to stimulate the beta1-adrenoceptors, resulting in improved myocardial contractility, increased SA rate and enhanced impulse conduction in the heart (i.e. increased heart rate and improved contraction). Kind regards, Jeff
Monthe Kofos says
Brilliant response!
I am watching a Blacklist episode right now where they are doing ACLS and trying to figure out why they were giving dopamine and I completely forgot about the three different responses. Thank you so much for reminding me! This is going to help me on my medical school boards now.
Monthe Kofos says
Just to elaborate a little more, at low levels dopamine activates the D1 and D2 receptors, at middle doses dopamine activates the B1 and B2 receptors, and at high doses dopamine activates the alpha 1 and Alpha 2 receptors. It is one of those weird drugs where the actual dosing effects what receptor is being involved. I hope this helps!
Ren says
Because dopamine has some alpha effects
Carol L says
Is there a place on your site where you talk about and explain about transcutaneous pacing (for someone who knows very little about it) or a website you would recommend to increase my understanding of what exactly it is and does?
Thanks!
Jeff with admin. says
The following link is just as good an explanation as any on the web: Transcutaneous pacing. Kind regards, Jeff
malinarose says
Ok just a checking…because Mobiz II and 3 rd degree HR block are located below the SA node Atropine probably won’t help in this problem? But in the brady alogrithm we start with atropine even in these conditions (Mobiz II and 3 rd Degree HR block) until we can get pacing ready.
If you know it is a Mobiz II and a 3 rd degree should you not use atropine at all?
If you see that the patient is having a septal MI on a 12 lead if you have one is it best to not use Atropine since it might decrease the preload?
Jeff with admin. says
In the case where you are dealing with symptomatic bradycardia and an ongoing MI, atropine would be contraindicated and should not be given.
In general, the use of atropine with Mobitz II and third-degree block should not be depended upon and would be a discretion call by the emergency team running the code.
Kind regards,
Jeff
rob says
So atropine is not to be used in a bradyarrhythmia when the etiology is presumed to be an AMI. How often is a bradycardic rhythms’ etiology not AMI. What are other causes of symptomatic bradycadia? Also could you direct me towards some literature that supports withholding atropine in the presence of bradycardia secondary to AMI. Thanks!
Jeff with admin. says
It can be used but you should use it with caution. Here is the AHA quote and link to the reference:
“Avoid relying on atropine in type II second-degree or third-degree AV block or in patients with third-degree AV block with a new wide-QRS complex where the location of block is likely to be in non-nodal tissue (such as in the bundle of His or more distal conduction system). These bradyarrhythmias are not likely to be responsive to reversal of cholinergic effects by atropine and are preferably treated with TCP or b-adrenergic support as temporizing measures while the patient is prepared for trans-venous pacing.” Reference: Pg. S749-750 Circulation Journal Nov. 2nd 2010
Mo says
Pt coded and has a breathing rate of 8 per minute. Common causes of bradycardia? Hypoglycemia, overdose, vagal. So, you should give D50W, atropine, narcan.
goar0701 says
I am a little confused here, please some help!!!
For the treatment of Hypotension (Just for ACLS purpose), can we use:
Dopamine infusion of 10-20 mcg/kg/min. OR,
Epinephrine infusion of 0.1-0.5 mcg/kg/min OR,
Epinephrine infusion of 2 – 10 mcg/min.
Thanks for your help!
Jeff with admin. says
Treat hypotension as follows:
Epinephrine 0.1-0.5 mcg/kg/min
Dopamine 5-10 mcg/kg/min
For chemical pacing with bradycardia:
Epinephrine: Initiate at 2-10 mcg/min and titrate to response
Dopamine: Initiate at 2-20 mcg/kg/min and titrate to response
Kind regards,
Jeff