2020 Bradycardia algorithm review | ACLS-Algorithms.com


  1. Pietro Bocchi says

    Good Morning Jeff, I have a question.

    What is the diluition of dopamine in bradycardia algorithm?

    Thank you
    Best Regards

  2. Yvette Konemann says

    Do you know why the dosing for atropine changed from the 2015 guidelines? Unable to find. Thank you!

    • ACLS says

      I have searched for an answer to that question for quite some time. I have reviewed all of the American heart Association primary literature and I cannot locate a reason and rationale for the change.

      They did something similar previously with the dosing of adenosine and I never could find a specific reason for that either.

      Sorry I do not have a specific answer for your question.

      Kind regards,

      • Jasmine says

        Atropine dose equals or less than 0.5mg may cause slower heart rate to bradycardia patient. The resource is from Heartcode ACLS Online Course. They have a question about it in the test.

  3. Kerin says

    Hi – I had a question about profound sinus bradycardia hypotension (70/40) with hypothermia (28C) and sepsis. I was trying to find journal articles concerning fluid use. My practice has been to judiciously use fluids due to the bradycardia. Give a fluid boluses and continuous fluids but not reflexive 30cc/kg bolus. I’m having trouble finding any articles discussing evidence based fluid use. Any thoughts?

    • ACLS says

      This question is beyond the scope of my experience and beyond the scope of ACLS. I have dealt very little with sepsis and hypothermia along with the use of fluids in these situations. The more variables you add to situations like this when trying to find research the less likely you’re going to be able to find specifics. What I would recommend is searching keyword subject two word Key word phrases then searching back two or three pages in the search. You often times will stumble upon what you’re looking for when you do this. Kind regards, Jeff

  4. breeana says

    Hi if I have a first degree heart block or even a second degree type 1 with poor perfusion do I TCP or always atropine first even if the vitals are unstable?

    • ACLS says

      Atropine should be attempted while setting up TCP. Atropine is the first-line medication for the treatment of symptomatic bradycardia.

      If atropine fails then move directly to TCP.

      If for some reason you already would have had TCP attaches to the patient then it would be appropriate to begin TCP ASAP.

      Kind regards,

  5. Kaes says

    I had a patient presented with sonis bradycardia heart rate 30 BPM, he is alert and conscious, no dyspnea or chest pain, BP 124/85 mmHg, looks unaffected.., he is using beta blockers, I choosed to stop net blockers and observe patient with no intervention… is it OK..

    • ACLS says

      Sounds like a wise conservative choice. The patient was stable and this was most likely related to the beta blocker.

      How did things turn out?

      Kind regards, Jeff

  6. Rubén says

    Hi Jeff,
    completely agree in the management but just one doubt: we still use isoproterenol in patientes with brady without HDN compromise with good results (24-48 hours), while waiting pacemaker implant . Any place nowadays…

  7. metwally says


  8. Gavin Grant says

    Why is dopamine used instead of norepinephrine? yes norepinephrine on its own causes reflex bradycardia but if you use atropine before it, which blocks the activation of the vagal nerve then your good. I’ve read many studies that have said dopamine causes more arrhythmias than norepinephrine so why is dopamine preferred?
    Thank you , Gavin

    • ACLS says

      Norepinephrine has less of an effect on the heart rate and has a greater effect on vasoconstriction. Dopamine is the choice for bradycardia because it’s effects on heart rate are more profound than its affects on vasoconstriction.

      Kind regards,

      • Eleni says

        I have observed that noradrenaline increases HR and many times when we have an unstable , tachycardic , intubated pt, an increase in e.g Levophed in order to raise BP almost always requires an increase in dose of e.g. Brevibloc (esmolol) . I have almost never experienced bradycardia after higher noradrenaline doses. Anybody else agree?

  9. Carrie Miller says

    If you immediately start pacing a highly unstable patient in 3rd degree block, how will you then know if the block and instability was caused by a STEMI? Wouldn’t you want to ideally want an EKG first? ACLS says not to delay therapy if the patient is very unstable.

    • ACLS says

      It would be ideal to get a 12 lead EKG prior to starting pacing.  If this is not possible, you could begin pacing and then when and EKG is available, momentarily stop pacing to perform the 12 lead EKG.
      Kind regards, Jeff

  10. Karol says

    witam, czy w wolnym migotaniu przedsionków można podać Atropinę ? czy ona w ogóle zadziała w takim rytmie ? Przyspiesza rytm zatokowy czyli działa w bradykardii zatokowej ale jeśli mamy wolne AF ? pozdrawiam

    • ACLS says

      Yes, atropine can be given for bradycardia with atrial fibrillation. However, if the patient is unstable, it may be better to use transdermal stimulation or intravenous epinephrine infusion. Kind regards, Jeff

  11. Koh Jiyoon says

    Jeff, I hav a qusetion
    I met a patient, whose heart rate was 30-40 / min, and Juctional Bradycardia. Initial blood pressure was 60/40mmHg. His mental status was Drowsiness.
    We used transcutaeneous pacing, and his rate was controlled, but his blood pressure was not controlled(after pacing, his blood pressure was 70/45mmHg).
    In this case, should I use vasoconstricotors like dopamine or epinephrine? Or should I use bolus fluid to maintain blood pressure?
    I will wait for your answer. Thank you for your writing.

    • ACLS says

      Depending on the circumstances you would probably use both. If the patient has a history of fluid overload related to heart failure then fluid blouses should be used very cautiously.

      A fluid challenge of 500 ml would probably be appropriate, and see how the BP responds. It would be appropriate to use epi or dopamine to help improve and maintain the patient’s BP.

      The main caution is not to worsen any ongoing fluid overload related to heart failure.

      Kind regards,

  12. Martin says

    What other type of hypothermias are there? Can you explain? Is it because the heart is not beating fast enough that hypothermia results and makes it different from just being hypothermic because of weather?

    • Jeff with admin. says

      Primary Hypothermia is typically caused by excessive exposure to environmental conditions that cause a reduction in the core temperature of the body.

      Secondary hypothermia is a result of disease, trauma, surgery, or drug-induced alteration in heat production and thermoregulation of the body.

      When Hypothermia occurs, it results in decreased depolarization of cardiac pacemaker cells which can cause bradycardia.

      Kind regards, Jeff

  13. Donald Redford says

    In the bradycardia section it states that the infusion dosage of Dopamine is weight dependent and Epinephrine is not weight dependent, and this is the case under dosing on the Bradycardia algorithm, yet on the post-cardiac arrest algorithm under the IV Bolus and IV meds instructions it indicates Epinephrine 0.1 -0.5 mcg/kg/min. Is this an error? Thanks, Don

    • Jeff with admin. says

      Is not an error.

      The bradycardia algorithm uses weight dependent dosing for dopamine and not for epinephrine.

      The post cardiac arrest algorithm uses weight-based dosing for both epinephrine and dopamine.

      Unfortunately, the American heart Association has not developed a consistent dosing method that can match across both algorithms.

      Kind regards,

  14. Peter Feliciano says

    Hi Jeff!

    Your site is very helpful to medical professionals. My question is, I’ve read somewhere (I forgot the source/article) that you should never delay electrical therapy for patients who are severely symptomatic. But I read somewhere here from the comments’ section that Atropine, TCP and Dopamine/Epi infusions all have equal effects/possibilities to return the patient’s rhythm to normal. My understanding is that you never delay electrical therapy since using the medication will take more time (absorption and all) compared to electricity which gives you the best possible outcome for the unstable patient.


    Peter Feliciano

    • Jeff with admin. says

      Epi and dopamine are now considered equally effective alternatives to TCP. This is because they are as effective. If TCP is not available or not readily available they may be used.

      All of these medications have a rapid onset and a very short half-life. Atropine is the first-line medication for symptomatic bradycardia and should be used if MI is not suspected.

      If you have attempted atropine, and it is it effective the best alternative is TCP but Epi and dopamine may be used as equally effective alternatives.

      In my humble opinion, if a patient is symptomatic and atropine is not effective use TCP if it is available. Easy to start, easy to stop, minimally invasive.

      Kind regards,

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