Advanced Cardiac Life Support (ACLS): Bradycardia
1. Initial evaluation is as follows: [1, 2, 3, 4]
Assess appropriateness for clinical condition (pulse present and unstable).
Heart rate typically less than 50 bpm in bradyarrhythmia
2. Initial intervention is as follows:
Maintain patent airway and assist breathing, as needed.
Administer oxygen if hypoxemic.
Attach monitor/defibrillator.
Monitor blood pressure and oximetry.
Obtain intravenous (IV)/intraosseous (IO) access.
Perform 12-lead electrocardiography (ECG); do not delay therapy.
3. Assess for signs of poor perfusion, as follows:
Hypotension (systolic blood pressure [SBP] <90 mm Hg)
Acutely altered mental status
Signs of shock
Ischemic chest discomfort
Acute heart failure
4. Therapeutic intervention is as follows:
If poor perfusion present, administer atropine.
If adequate perfusion present, monitor and observe.
5. Measures if atropine is ineffective are as follows:
Transcutaneous pacing OR dopamine infusion OR epinephrine infusion
Consider expert consultation and transvenous pacing.
Drug Therapy
See the list below:
Atropine 0.5 mg IV q3-5min; maximum dose, 3 mg
Dopamine 2-20 μg/kg/min infusion; titrate to patient response; taper slowly.
Epinephrine 2-10 μg/min infusion; titrate to patient response.
Atropine
See the list below:
Not reliable for third-degree block or second-degree type II block
Could potentially exacerbate the block by increasing sinoatrial (SA) node activation
May be ineffective in patients after heart transplantation
Most Recent Guideline Changes
Changes from the 2010 guidelines include the following:
Simultaneous breathing and pulse check in less than 10 seconds
Administer epinephrine as soon as feasible after the onset of cardiac arrest due to an initial nonshockable rhythm.
Provide opioid overdose education, either alone or coupled with naloxone distribution and training, to persons at risk for opioid overdose.
In pregnancy, if the fundus height is at or above the level of the umbilicus, manual left uterine displacement can be beneficial in relieving aortocaval compression during chest compression.
Changes from the 2010 ACLS guidelines include the following: For simplicity, vasopressin has been removed from the adult algorithm.
References
Neumar RW, et al. Part 1: Executive Summary: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3. 132 (18 Suppl 2):S315-67. [Medline].
Kleinman ME, et al. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3. 132 (18 Suppl 2):S414-35. [Medline].
Link MS, et al. Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3. 132 (18 Suppl 2):S444-64. [Medline].
American Heart Association. 2015 Handbook of Emergency Cardiovascular Care for Healthcare Providers. ISBN 978-1-61669-397-8. November 2015
