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PALS

Bradycardia (Unstable)

Determine Patient Stability

Patient is considered unstable if there is hypotension, poor skin signs, shortness of breath, chest pain, evidence of CHF, or decreased mentation [or any other symptom felt to be caused by the bradycardia].

  1. Evaluate ABC's
    • Stabilize Airway/Breathing
    • Apply oxygen
    • Monitors (Rhythm, Oximetry, BP)
    • Code cart
  2. Is bradycardia still causing cardiopulmonary compromise?
    2a) NO --> Continue to monitor ABC's, continue with oxygen, observe and obtain additional appropriate workup and consultation
    2b) YES --> Proceed to Step 3
  3. Bradycardia still causing cardiopulmonary compromise then:
    • Perform CPR, oxygenation, ventilation for 1-2 minutes and reassess
    • If this resolves the symptomatic bradycardia, go to Step 2a above; if not proceed to Step 4 below
  4. Bradycardia still symptomatic despite one round of CPR, Oxygenation and ventilation then:
    • Establish IV/IO (if not done already)
    • Epinephrine (dosing below)
    • Atropine (if increased vagal tone to 1st degree AV Block; dosing below)
    • May utilize transcutaneous pacing
    • Obtain 12 lead EKG

    Epinephrine Dosing (Repeat every 3-5 minutes)
    • IV/IO: 0.01 mg/kg (1:10,000 = 0.1 mL/kg)
    • ETT: 0.1 mg/kg (1:1,000 = 0.1 mL/kg)

    Atropine Dosing (May repeat × 1 in 3-5 minutes)
    • IV/IO: 0.02 mg/kg (Minimum 0.1 mg, Maximum total dose = 1 mg)

    Transcutaneous pacing
    • At any point pacing may be utilized if drugs ineffective or patient is substantially symptomatic
    • Drugs may be used in addition to pacing if needed
  5. Obtain history and perform physical examination and consider causes
    • Hypoxia
    • Hypoglycemia
    • Hypovolemia
    • Metabolic: hyper/hypokalemia, hypercalcemia, acidosis
    • Head trauma or intracerebral bleed
    • Drugs (Beta blockers, Calcium channel blockers, Digoxin)
    • Hypothermia
    • Pneumothorax or Tamponade
    • Acute myocardial infarction (esp. inferior)
    • Pulmonary embolus
    • 2nd or 3rd degree AV Block or Junctional rhythm
  6. If PEA develops, change to that protocol; monitor pulses q1-2 minutes to confirm PEA has not developed.

Source: Circulation 2005;112. 2005 AHA Guidelines for CPR and ECC.