Unstable Bradycardia

Aka: Unstable Bradycardia, Sinus Arrest, Symptomatic Bradycardia

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II. Signs

  1. Bradycardia
    1. Absolute Bradycardia: under 60 bpm
    2. Relative Bradycardia: inappropriately normal rate
      1. Hypotensive patient should be tachycardic
  2. Unstable: Cardiopulmonary decompensation
    1. Pediatric
      1. Poor perfusion
      2. Hypotension
      3. Respiratory distress
    2. Adult
      1. Chest Pain
      2. Shortness of Breath
      3. Decreased Level of Consciousness
      4. Hypotension and Shock
      5. Pulmonary congestion
      6. Congestive Heart Failure
      7. Acute Myocardial Infarction

III. Precautions

  1. Avoid Lidocaine
    1. Lethal if Bradycardia is Ventricular Escape Rhythm

IV. Management: Initial for both children and adults

  1. ABC Management
  2. Mnemonic: IV-O2-Monitor
    1. Obtain IV Access
    2. Oxygen Delivery
    3. Cardiopulmonary monitor
    4. Electrocardiogram
  3. Vital Signs
    1. See Pediatric Vital Signs
  4. Observe closely for change in rhythm
    1. Asystole
    2. Pulseless Electrical Activity (PEA)
    3. Ventricular Fibrillation
    4. Ventricular Tachycardia
  5. Assess if patient unstable (and if so, proceed to protocols below based on age)
    1. Hypotension
    2. Shock
    3. Altered Level of Consciousness
    4. Ischemic Chest Pain
    5. Congestive Heart Failure (CHF)

V. Management: Pediatric Unstable Bradycardia

  1. Chest Compressions Indications
    1. Heart Rate under 50 bpm AND
    2. Poor perfusion despite oxygenation and ventilation
  2. Epinephrine every 3-5 minutes
    1. IV/IO Dose: 0.01 mg/kg (0.1 ml/kg of 1:10,000)
    2. ET Dose: 0.1 mg/kg (0.1 ml/kg of 1:1000)
  3. Atropine
    1. Dose: 0.02 mg/kg IV, IO, or ET (may repeat once)
    2. Minimum Dose: 0.1 mg
    3. Maximum Dose: 0.5 mg child, 1.0 mg adolescent
  4. Consider pacing
    1. Transcutaneous Pacing
    2. Transvenous pacing

VI. Management: Adult Unstable Bradycardia

  1. Atropine
    1. Dose: 0.5-1.0 mg q3-5 min to max total 3 mg
    2. No response in denervated transplanted hearts
    3. Avoid Atropine in Mobitz II AV Block
      1. Atropine may increase degree of Mobitz 2 block (e.g. from 2:1 to 4:1)
      2. Mobitz II AV Block is an infranodal disorder, that does not respond to Atropine
  2. Transcutaneous Pacing
  3. Alternatives to Transcutaneous Pacing if unavailable or ineffective
    1. Epinephrine 2-10 mcg/min
    2. Dopamine 5-20 mcg/kg/min
  4. Consult with local cardiology
  5. Prepare for Transvenous Pacing if indicated:
    1. Type II second degree AV Heart Block
    2. Third degree AV Heart Block

VII. References

  1. Cardiopulmonary Resuscitation Guidelines
    1. http://www.circulationaha.org
    2. (2010) Guidelines for CPR and ECC [PubMed]
    3. (2000) Circulation, 102(Suppl I):86-9 [PubMed]
  2. Pediatric Resucitation
    1. http://pediatrics.aappublications.org/content/126/5/e1361.full.html
    2. (2010) Pediatrics 126(5): e1361 [PubMed]

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