Management of bradycardia

Last updated: August 2, 2022

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Bradycardia is generally defined as a heart rate of < 60/min. The most important step in the acute management of bradycardia is determining if the patient is unstable, in which case atropine should be administered immediately. If IV access is not available and the patient is unstable, transcutaneous pacing should be initiated. The management of symptomatic, stable bradycardia is similar but should be tailored to the suspected cause of the bradycardia. Asymptomatic, stable bradycardia typically does not require treatment. Definitive management depends on the underlying cause of the bradycardia.

See also overview of cardiac arrhythmias, sick sinus syndrome, and atrioventricular block.

1. ABCDE survey [1]

2. Determine if the patient is stable or unstable [1]

Obtaining an ECG to identify the rhythm should not delay the acute management of unstable patients.

3. Determine if the patient is symptomatic or asymptomatic

4. Subsequent management

  • Perform a focused history and examination.
  • Identify and treat the underlying cause (see causes of bradycardia).
  • Consult cardiology and consider indications for permanent pacemaker (e.g., third-degree AV block).

Overview of bradycardia based on ECG findings

Signs of unstable bradycardia

Initial management [1]

Transcutaneous pacing

  • Consider procedural sedation.
  • Place the leads in the anteroposterior position.
  • Set output to a level that is likely to result in capture.
    • Unconscious patient: Start at 160–180 mA and decrease output if possible.
    • Conscious patient: Start at a low output (e.g., 10 mA) and gradually increase until capture is seen.
  • Set pacing rate to 60–80/min.
  • Set a backup rate at a low level to avoid unnecessary pacing (e.g., 30/min).
  • Verify ventricular capture by checking the patient's pulse manually or with pulse oximetry.

Subsequent management

Most patients can be observed and will not require intervention; only patients with high-grade AV block or severe symptoms should be treated.

Initial management [2]

Special considerations [2]

Avoid atropine in patients with myocardial infarction or a recent heart transplant.

Subsequent management

  • Cardiology consult
  • Identify and treat the underlying cause (see causes of bradycardia).
  • Consider TTE and further imaging.
  • Consider admission to ICU or CCU.

Consider pacing therapy even in asymptomatic patients with second-degree AV block, Mobitz II, or third-degree AV block.

Cause [2][4][5]

Increased vagal tone

Degeneration of the conducting system
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