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
   • Place transcutaneous pacing (TCP) pads and start pacing if situation critical
   • Establish IV
   • Monitors (Rhythm, Oximetry, BP)
   • Obtain 12 lead EKG
   • Code cart
2. Initial treatment of circulation/rhythm
   1. 1^st degree AV block: Atropine
   2. 2^nd degree AV block: Pacing or trial of atropine
   3. 3^rd degree AV block/Junctional: Pacing
   4. Transplanted heart: Pacing, Dopamine and/or Epinephrine infusion
   
   Atropine Dosing
   0.5 mg IVP every 3-5 minutes (Maximum cumulative dose is 3 mg)
   Dopamine Dosing
   2-10 mcg/minute IV infusion
   
   Epinephrine Dosing
   2-10 mcg/minute IV infusion
3. Subsequent treatment of circulation/rhythm
   • If atropine given and ineffective, add either dopamine and/or epinephrine infusion
   • 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
4. Obtain history and perform physical examination and consider causes
   • Acute myocardial infarction (esp. inferior)
   • Drugs (Beta blockers, Calcium channel blockers, Digoxin)
   • 2^nd or 3^rd degree AV Block or Junctional rhythm
   • Head trauma or intracerebral bleed
   • Hypovolemia
   • Hypoxia
   • Hypothermia
   • Metabolic: hyper/hypokalemia, hypercalcemia, acidosis, thyroid disease
   • Hypoglycemia
   • Pulmonary embolus
   • Pneumothorax or Tamponade
5. Cardiology consultation.

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