The major ECG rhythms classified as bradycardia include:
- Sinus Bradycardia
- First-degree AV block
- Second-degree AV block
- Type I —Wenckenbach/Mobitz I
- Type II —Mobitz II
- Third-degree AV block complete block
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.
Click below to view the bradycardia algorithm diagram. When finished, click again to close the diagram. Bradycardia Algorithm Diagram
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 in 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 protocol since reversing of the cause will likely return the patient to a state of adequate perfusion.