Sinus Bradycardia and Sick Sinus Syndrome

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CC (0): Glenlarson

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 ACLS Bradycardia W/ Pulse
Assess. HR < 50 bpm. Has
Pulse.
Identify and treat underlying cause
• Maintain patient airway,
• O2 if hypoxemic
• Vitals: Cardiac monitor, BP, pulse ox
• IV access
• If available and fast => 12-lead EKG

Persistent bradyarrhythmia causing:

• Hypotension
• Altered mental status
Monitor
• Signs of shock
and
• Ischemic chest pain
observe
• Acute heart failure

Atropine. If ineffective:
• Transcutaneous pacing OR Dopamine OR
Epinephrine

• Expert consult
• Transvenous
pacing

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 Bradycardia and Sick Sinus

Bradycardia

CC (0): Glenlarson

Sick Sinus Syndrome

CC (3.0): Steven Fruitsmaak CC (3.0): Steven Fruitsmaak

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 Sinus Bradycardia
• Presentation: Asymptomatic athlete (most common)
• Lightheadedness
• Presyncope/syncope
• Worsening of angina (especially if comorbid heart disease)
• Hemodynamic instability

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 Sinus Bradycardia
• Pathophysiology: High vagal tone (e.g. athletes, during sleep)
• Sick sinus syndrome (early)
• MI
• OSA
• Increased intracranial pressure
• Hypothyroidism
• Anorexia nervosa

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 Sinus Bradycardia
• Dx: HR < 60 bpm (of sinus origin)
• Upright P waves in lead II

CC (0): Glenlarson

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 Sinus Bradycardia
• Mgmt: If asymptomatic => Assess and address underlying causes
• If hemodynamically unstable => Atropine 0.5 mg
• Repeat 0.5 mg dose every 3-5 minutes up to 3.0 mg
• If no response to initial Atropine dose:
• Transcutaneous cardiac pacing
• IV dopamine
• IV epinephrine

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ACLS Bradycardia W/ Pulse

© Adobe Stock / rumruay.

Modified.

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 Sick Sinus Syndrome
• Presentation: Older patient w/ multiple comorbidities
• Intermittent symptoms that ↑ in frequency/severity:
• Dizziness
• Presyncope/syncope
• SOB on exertion
• Angina
• Fatigue
• Palpitations

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 Sick Sinus Syndrome
• Pathophysiology: Dysfunction of the SA node
• Senescence
• Medications
• Ischemia
• Hypothyroidism

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 Sick Sinus Syndrome
• Dx: Association of EKG abnormalities w/ symptoms
• Severe bradycardia (<50 bpm)
• Development of tachyarrhythmias over time
• Alternating between bradycardia and atrial tachyarrhythmias:
• Atrial fibrillation Holter monitor
• Atrial flutter
• PSVT

CC (0) NASA

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Sick Sinus => Bradycardia

CC (3.0): Steven Fruitsmaak

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Sick Sinus => Tachycardia

CC (3.0): Steven Fruitsmaak

13
 Sick Sinus Syndrome
• Mgmt: If asymptomatic => Address underlying causes
• If hemodynamically unstable => Atropine 0.5 mg
• Repeat 0.5 mg dose every 3-5 minutes up to 3.0 mg
• If no response to Atropine:
• Transcutaneous cardiac pacing
• IV dopamine
• IV epinephrine
• IV isoproterenol

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 Sick Sinus Syndrome
• Mgmt: If symptomatic, but stable => Pacemaker (definitive
treatment)

CC (0) NIH

15
 ACLS Bradycardia W/ Pulse
Assess. HR < 50 bpm. Has
Pulse.
Identify and treat underlying cause
• Maintain patient airway,
• O2 if hypoxemic
• Vitals: Cardiac monitor, BP, pulse ox
• IV access
• If available and fast => 12-lead EKG

Persistent bradyarrhythmia causing:

• Hypotension
• Altered mental status
Monitor
• Signs of shock
and
• Ischemic chest pain
observe
• Acute heart failure

Atropine. If ineffective:
• Transcutaneous pacing OR Dopamine OR
Epinephrine

• Expert consult
• Transvenous
pacing

16
ACLS Bradycardia W/ Pulse

© Adobe Stock / rumruay.

Modified.

17
High-Yield Summary

Sinus Bradycardia Sick Sinus Syndrome

• Presentation: Asymptomatic athlete (most common) • Presentation: Older patient w/ multiple comorbidities

• Lightheadedness • Intermittent symptoms that ↑ in frequency/severity

• Presyncope/syncope • Pathophysiology: Dysfunction of the SA node

• Pathophysiology: High vagal tone (e.g. athletes, during • Dx: Association of EKG abnormalities w/ symptoms
sleep)
• Severe bradycardia (<50 bpm)
• Dx: HR < 60 bpm (of sinus origin) • Development of tachyarrhythmias over time

• Mgmt: If asymptomatic => No intervention • Alternating between bradycardia and atrial

• If hemodynamically unstable => Atropine 0.5 mg tachyarrhythmias

• Transcutaneous cardiac pacing • Mgmt: Pacemaker. If hemodynamically unstable => Atropine

• IV dopamine 0.5 mg Transcutaneous cardiac pacing, IV dopamine, IV

epi, IV isoproterenol
• IV epinephrine

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High-Yield Summary

Bradycardia

CC (0): Glenlarson

Sick Sinus Syndrome

CC (3.0): Steven Fruitsmaak CC (3.0): Steven Fruitsmaak

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