BRADYARRYTHMIA

• Any rhythm disorder with a heart rate less than 60/min

• When bradycardia is the cause of symptoms, the rate is
generally less than 50/min.
• Most commonly caused by failure of impulse formation (SA
node dysfunction) or by failure of impulse conduction over the
AV node/ His-Purkinje system.
CLASSIFICATION
SA Node dysfunction AV conduction
Abnormalities
Sinus bradycardia 1st degree heart block
Sinus arrest 2nd degree heart block
SA exit block • Mobitz type I
• Mobitz type II
Tachycardia-bradycardia • 2:1 AV Block
syndrome
3rd degree heart block
CLINICAL PRESENTATION
Symptoms include: • presyncope or syncope
• chest discomfort or pain
• shortness of breath Signs include
• decreased level of consciousness • hypotension
• weakness • drop in blood pressure on standing
• fatigue (orthostatic hypotension)
• light-headedness • diaphoresis
• dizziness • pulmonary congestion on physical
exam or chest x-ray
• frank congestive heart failure or PE
MANAGEMENT
• A symptomatic bradycardia exists when 3 criteria are present:
1.The heart rate is slow (LESS THAN 5O bpm)
2.The patient has symptoms.
3.The symptoms are due to the slow heart rate.
1. Identification of Bradycardia
2. Perform the Primary Assessment, including the following:
• A – Maintain patent airway
• B – Assist breathing as needed, give oxygen in case of hypoxemia,
monitor oxygen saturation.
• C – Monitor blood pressure and heart rate: obtain and review a
12-lead ECG; establish IV access.
• D – Conduct a problem-focused history and physical
examination; search for and treat possible contributing factors.
3. Treatment Sequence Summary
• Give atropine as first-line treatment
• IV Atropine 0.5 mg– to a total dose of 3 mg. [repeat the dose every 3
to 5 minutes]
• If atropine is ineffective
• Begin transcutaneous pacing or
• Dopamine 2 to 20 mcg/kg per minute (chronotropic or heart rate dose)
• Epinephrine 2 to 10 mcg/min
 Transcutaneous Pacing (TCP)
Indications for Transcutaneous Pacing
• Hemodynamically unstable
bradycardia (eg, hypotension, acutely
altered mental status, signs of shock,
ischemic chest discomfort, acute heart
failure [AHF] hypotension)
• For pacing readiness in the setting of
AMI as follows:
• Symptomatic sinus bradycardia
• Mobitz type II second-degree AV
block
• Third-degree AV block
• New left, right, or alternating
bundle branch block or
bifascicular  block
Technique: • Contraindicated in severe
hypothermia
• Conscious patients require analgesia
• Step 1: Place pacing electrodes on the
for discomfort
chest
• Do not assess the carotid pulse to
• Step 2: Turn the Pacer on.
confirm mechanical capture; eletrical
• Step 3: Set the demand rate to
stimulation causes muscular jerking
approximately 60/min. This rate can
that may mimic the carotid pulse.
be adjusted up or down (based on
patient clinical response) once pacing
is established.
• Step 4: Set the current milliamperes
output 5 mA at which consistent
capture is observed (safety margin).
• Step 5: Check pulse for mechanical
capture.
• Step 6: increase by a further 5mA
after capture
• Most patients will improve with a rate
of 60 to 70/min
REFERENCES
• https://www.acls-pals-bls.com/algorithms/acls/
• Tintinalli (2010) Emergency Medicine, McGraw Hill