2020 Bradycardia algorithm review | ACLS-Algorithms.com

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  1. Vivire says

    I had a patient, symptomatic bradycardia. Fully conscious and alert,talking,not in respiratory distress BP 100/80 (he known hypertensive). And had complete heart block. He presented with multiple syncopal attack.he had 2 episodes of syncope and near syncope in ED (witnessed). My question is, between chemical pacing and TCP, which is superior /preferred . Can we do simultaneous pacing? (Both chemical and tcp). Thank you

      • Jeff with admin. says

        PubMed would be the place to look for these types of studies. You would be wading through a lot of literature to get your answers. This is why AHA does a lot of this work for us, and then develops guidelines. AHA makes their guidelines after a regular and thorough review of the medical literature. The AHA now states that chemical pacing is just as effective as an alternative to TCP. Personally, I like electrical pacing. It seems to me like it can be more closely regulated and easily discontinued. However, their literature review seems to indicate that chemical pacing is just as good.

        In the situation you experienced something like demand pacing for a heart rate less than 50 or 60 many have been the right way to go especially with complete block.

        If you were to attempt chemical pacing, you would probably want to infuse to maintain a HR greater than 60 or 70 and keep the patient free of symptoms until a pacemaker could be placed.

        I’m not an expert in this area, and I imagine that even most internal med residents and such would get with a cardiologist rather quickly on cases like this.

        Hope this helps.

        Kind regards,
        Jeff

  2. fitri says

    i had a patient with blackout,airway n breathing was clear, BP 90/60,HR 40x,what should i do first?sugestion please..i decided to iv line loading RL n epineprine 0,5 im is that correct?

    regards

    • Jeff with admin. says

      Considering that the Heart rate was 40 and the patient was symptomatic AHA ACLS guidelines would have directed toward IV, EKG, atropine 0.5mg IV push. You would also want to immediately start looking for the cause of the bradycardia and also ensure that the bradycardia was the cause of the blackout.

      Kind regards,
      Jeff

  3. Nicola says

    Today we witnessed a cardiac arrest where the patient was experiencing a palpable beat centrally at an irregular rate of approximately 6 per minute; for a sustained period of approximately 25 minutes. Could you please tell me if there is a minimum heart rate for atropine to be successful in raising the heart rate?

    Thank you!

    • Jeff with admin. says

      You cannot have cardiac arrest and bradycardia at the same time. Most likely, this irregular beat was chaotic and should not be considered a perfusion generating pulse.
      If the patient was in cardiac arrest then atropine would not be appropriate. By definition cardiac arrest means that the heart is no longer providing effective perfusion to the vital organs. CPR would be the appropriate action in this case. It is not uncommon to think that a pulse if felt or to feel a random pulse. The fall back would be to obtain a peripheral blood pressure. If you cannot obtain a blood pressure then you have no effective perfusion. In this case, CPR Should be performed and the pulseless arrest algorithm should be used.
      You also would need to look for the cause of this arrest. Understanding why the arrest is very important so that any reversible causes can be addressed.
      Kind regards,
      Jeff

  4. melsa says

    is there any limit for the heart rate in asymptomatic sinus bradicardiab that should given atropine 0,5 mg? thx

    • Jeff with admin. says

      If a patient is asymptomatic with a heart rate of 30 and they are not an athlete, it would be surprising. Atropine should be used when a pt. has symptoms. If the HR is low and there is no reason and the patient is asymptomatic, they should probably should have a cardiology evaluation. Also, they probably would become symptomatic with activity.

      Anyway, if they are severely bradycardic but asymptomatic, they should be evaluated by a cardiologist. I do not think it would be recommended to use atropine unless they are symptomatic.

      Kind regards,
      Jeff

  5. Pacer says

    We were wondering if pacing is less invasive than IO atropine. As in you can not get an IV not serious signs and systems but deteriorating. Would it be better to pace or IO atropine.

    • Jeff with admin. says

      IO is really only used in emergencies. If the above scenario occurred in an ER, I think that most ER physicians would get a quick central line in if possible. If this were not possible, I think that most ER physicians would go with TCP and then get a line once pacing was initiated. Pacing is very non-invasive with minimal complications, and it can be discontinued easily.

      Kind regards,
      Jeff

    • gACLS says

      Also I was looking for something on transplanted hearts. Are there any exceptions to the algorithms for transplanted hearts?

      • Jeff with admin. says

        I could not find anything stating that the treatment of patients with heart transplants would be any differently during cardiac arrest.
        I did find this article that speaks specifically to CPR and this issue.

        I have sent an e-mail to my brother who has more experience in this area. If I find out any other information, I will let you know.

        Kind regards,
        Jeff

    • Jeff with admin. says

      Although Isoprel is no longer a first-line medication in the ACLS bradycardia algorithm, it is still can be used. Here is a quote from AHA 2010 guidelines on this issue:
      “Although not first-line agents for treatment of symptomatic bradycardia, dopamine, epinephrine, and isoproterenol are alternatives when a bradyarrhythmia is unresponsive to or inappropriate for treatment with atropine, or as a temporizing measure while awaiting the availability of a pacemaker. Alternative drugs may also be appropriate in special circumstances such as the overdose of a β-blocker or calcium channel blocker.” Here is the link to the AHA article.

      Kind regards,
      Jeff

  6. Carmesuze Joseph says

    I have such a hard time differentiate between a complete blocks ,Sinus exit block and sinus pause Cant get them straight…..please help!

    • Jeff with admin. says

      The easiest why I explain it is as follows.
      In a 3rd degree heart block is a persistent rhythm having P waves and QRS complexes that are not associated with one another. Further, the P waves march out with one another as do the QRS complexes.

      Sinus Arrest/Pause is not a persistent rhythm/ It’s intermittent. P waves and QRSs are associated with one another. i.e you have a PR interval except for when you have sinus arrest, then you just have no electrical impulse for a beat.

      Does that make since. Here is a great sight to view and study 12 lead ECGs
      Hope this helps.
      Kind regards,
      Chris

  7. nizam says

    There are some statement said, we cannot give IV atropine less than 0.5mg. it may cause paradoxically result in further slowing the heart rate. Can you elaborate more thank you

  8. dalal alhasan says

    Hello,
    1.do we have to give atropine to all symptomatic bradycardia patients even if mobtiz II and 3rd degree heart blocks? if no what should bemy first action?
    2. in mobtiz II or 3rd degree heart block and un available TCP is it safe to give dopamine or adrenaline?

    • Jeff with admin. says

      1. “Do not rely on atropine in Mobitz type II or 3rd degree AV Block or in patient with 3rd degree AV block with a new wide QRS complex.”
      Therefore if a patient is unstable, in this situation, it is ok to go to electrical pacing.
      2. Yes, dopamine and epinephrine infusions are acceptable replacements for electrical pacing.
      Kind regards,
      Jeff

  9. chibi says

    hi, im just confused, if patient is with stable bradycardia, should the patient still be given the first line drug atropine or the dopamine/ epinephrine? or should the patient be monitored and observed only?

    • Jeff with admin. says

      For the patient with stable bradycardia, the patient would be monitored and observed. Common practice would be to admit the patient to an ICU or telemetry unit and consult with cardiology.

      Kind regards,
      Jeff

  10. Blazegirl1 says

    Why is pacing contraindicated in hypothermia?

    Great site…huge help in studying for recert!!
    I’m a Navy veteran myself, so thank you for your service and sacrifice!

    • Jeff with admin. says

      Bradycardia may be physiologic in the hypothermic patient. This type of bradycardia is an appropriate response to the decreased metabolic rate that normally occurs with hypothermia. Also the hypothermic ventricle is more prone to fibrillation with any sort of irritation. Thus the irritation of TCP could induce VF. Once the hypothermic ventricle begins to fibrillate, it is more resistant to defibrillation.

      Kind regards,
      Jeff

  11. riyas says

    How long we should wait and see whether 1st line management is working. ….and before giving atropine can we give a sympathetic stimulation and see whether it’s increasing or not….and my another question is I had seen lot of cases with patient who is coming with heart rate of 40 and some odd , so that occasion is it mandator to give some intervention especially if patient is under spinal anaesthesia

    • Jeff with admin. says

      Atropine should have it affect within 30 seconds after administration. If you do not see an improvement in the patients condition within 1-2 minutes max., You should through the bradycardia algorithm. Atropine blocks the action of the vagus nerve, a part of the parasympathetic system of the heart whose main action is to decrease heart rate. You should see a direct effect on the rate of the heart. If the heart rate does not improve and the patients symptoms do not improve, you should move on.
      I do not understand what you are trying to ask in your second question.
      Kind regards,
      Jeff

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