Page 52 - 2023 SMOG Digital

Cardiac

BRADYCARDIA with PULSE

Signs and Symptoms: Differential Diagnosis:
• HR <50bpm • Acute MI
• Chest Pain • Hypoxia
• Respiratory Distress • Hypothermia
• Hypotension/Shock • Sinus Bradycardia
• Altered Mentation • Physiologic Bradycardia (Athletes)
• Syncope • Stroke
• Spinal Cord Lesion
• Toxin/Medications (B-blockers)
• AV Block/Sick Sinus Syndrome
Universal Patient Care Guideline Indicators of Instability:
O2 (if Hypoxemic) • Blood Pressure low (hypotension)
IV/IO Guideline • Altered mental status
Monitor and 12-Lead ECG (ASAP) • S/ /Sx of shock
x
S
• Ischemic chest pain
Place PACER PADS • Congestive heart failure (acute)
• Heart block (Mobitz 2 and complete)
No Signs of Hemodynamic YES
Compromise
Unstable without Block
Unstable with or with 1° (PR>.2) or 2° type
Observe 2 ° type 2 (nml P, occasional dropped I (PR gets longer until drops
Reassess q5min QRS) or 3 ° block (nml P but unrelated to QRS) AVB
QRS)
Transcutaneous Pacing Atropine IV / IO
(Consider sedation: 1mg IVP
Midazolam 2-5mg IV/IO) Repeat q3–5min
(MAX 3mg)
No improvement
Transcutaneous Pacing
Continuous Monitoring (Consider sedation:
Midazolam 2-5mg IV/IO)
OR
“OVERDOSE” treatable causes: Dopamine IV/IO
• B-blocker (atenolol, metoprolol, labetalol): 5–20mcg/kg/min
o Glucagon 0.05mg/kg (3–10mg) IV–pretreat with
ondansetron for nausea if possible OR
• Calcium channel blocker (diltiazem, verapamil, nifedipine): Epinephrine IV/IO
o Calcium gluconate 10% 1000mg (1amp) slow IV 2–10mcg/min
push (1-1.5mL per minute; not exceeding 200mg/
min) (profound bradycardia or
hypotension)
Pearls:
• Decompensation at any time (e.g., altered MS, hypotension) should prompt treatment as unstable patient.
• All bradycardic patients should have pacer pads in place after initial evaluation.
• Epinephrine infusion for refractory bradycardia: 2–10mcg/min or 0.1–0.5mcg/kg/minute (7–35mcg/min in a
70kg patient)
o 1mg 1:10,000 in 250mL D5W/NS = 4mcg/mL concentration
• Evaluate for treatable causes of bradycardia (B–blockade, Ca Channel blockade).
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