Unstable Bradycardia

Aka: Unstable Bradycardia, Sinus Arrest

1. See Also
   1. Cardiopulmonary Resuscitation
2. Signs
   1. Bradycardia
      1. Absolute Bradycardia: under 60 bpm
      2. Relative Bradycardia: inappropriately normal rate
         1. Hypotensive patient should be tachycardic
   2. Unstable: Cardiopulmonary decompensation
      1. Pediatric
         1. Poor perfusion
         2. Hypotension
         3. Respiratory distress
      2. Adult
         1. Chest Pain
         2. Shortness of Breath
         3. Decreased Level of Consciousness
         4. Hypotension and Shock
         5. Pulmonary congestion
         6. Congestive Heart Failure
         7. Acute Myocardial Infarction
3. Precautions
   1. Avoid Lidocaine
      1. Lethal if Bradycardia is ventricular escape rhythm
4. Management: Initial for both children and adults
   1. ABC Management
   2. Mnemonic: IV-O2-Monitor
      1. Obtain IV Access
      2. Oxygen Delivery
      3. Cardiopulmonary monitor
      4. Electrocardiogram
   3. Vital signs
      1. See Pediatric Vital Signs
   4. Observe closely for change in rhythm
      1. Asystole
      2. Pulseless Electrical Activity (PEA)
      3. Ventricular Fibrillation
      4. Ventricular Tachycardia
   5. Assess if patient unstable (and if so, proceed to protocols below based on age)
      1. Hypotension
      2. Shock
      3. Altered Level of Consciousness
      4. Ischemic Chest Pain
      5. Congestive Heart Failure (CHF)
5. Management: Pediatric Unstable Bradycardia
   1. Chest Compressions for Heart Rate under 60
   2. Epinephrine every 3-5 minutes
      1. IV/IO Dose: 0.01 mg/kg (0.1 ml/kg of 1:10,000)
      2. ET Dose: 0.1 mg/kg (0.1 ml/kg of 1:1000)
   3. Atropine
      1. Dose: 0.02 mg/kg IV, IO, or ET (may repeat once)
      2. Minimum Dose: 0.1 mg
      3. Maximum Dose: 0.5 mg child, 1.0 mg adolescent
   4. Consider transcutaneous pacing or transvenous pacing
6. Management: Adult Unstable Bradycardia
   1. Atropine
      1. Dose: 0.5-1.0 mg q3-5 min to max total 3 mg
      2. No response in denervated transplanted hearts
   2. Transcutaneous pacing
   3. Alternatives to transcutaneous pacing if unavailable
      1. Dopamine 2-10 mcg/kg/min
      2. Epinephrine 2-10 mcg/min
   4. Consult with local cardiology
   5. Prepare for Transvenous Pacing if indicated:
      1. Type II second degree AV Heart Block
      2. Third degree AV Heart Block
7. References
   1. Cardiopulmonary Resuscitation Guidelines
      1. http://www.circulationaha.org
      2. (2010) Guidelines for CPR and ECC
      3. (2000) Circulation, 102(Suppl I):86-9
   2. Pediatric Resucitation
      1. http://pediatrics.aappublications.org/content/126/5/e1361.full.html
      2. (2010) Pediatrics 126(5): e1361