Bradycardia

Inclusion Criteria: Patients with a heart rate less than 60 beats per minute. This guideline is not intended for patients with compensating bradycardia who exhibit signs of increased intracranial pressure (refer to Stroke or Trauma guidelines.)

          Basic Level

1. Assess and support ABCs.
   
2. Place patient in a position of comfort. If evidence of shock, place the patient supine with the feet elevated.
   
3. Administer oxygen as needed to maintain a SpO2 of at least 96%.
   
4. If chest pain is present or develops, treat the pain under the Chest Pain guidelines while continuing these guidelines.
   
5. Once advanced level care arrives on scene, give report and transfer care.
   
   Advanced Level
   
   
6. Continuous cardiac monitoring. Use capnography if the patient is hypotensive. Obtain 12-Lead ECG and consult with BioTel, as needed. (Do NOT delay care of the unstable patient to obtain a 12-lead ECG.)
   
7. Establish IV access at a TKO rate or use a saline lock. (Do not delay care of the unstable patient to initiate an IV.)
   
   FOR STABLE PATIENTS
   
8. 
   Initiate transport and monitor closely.
   
   FOR UNSTABLE PATIENTS
   
   
9. If signs or symptoms of hypoperfusion are present or develop:

   Adult    If able to achieve IV access quickly, administer 250 ml fluid boluses (maximum of 1,000 mL)         • If no response, administer atropine 0.5 mg - 1.0 mg IVP                • If no response to atropine, initiate TCP For bradycardia caused by myocardial ischemia, begin transcutaneous pacing (TCP) immediately Consider TCP first if         •  IV access is delayed OR         • The bradycardia is second-degree type II (fixed PR interval) or third-degree heart block

   Pediatric Ventilate with 100% oxygen for one full minute. Avoid overventilation. If the pulse rate is still less than 60 after adequate ventilation, perform chest compressions and administer      o  epinephrine (1:10,000) 0.01 mg/kg IV/IO push      o  atropine 0.02 mg/kg (min dose 0.1 mg) IV/IO push - may repeat once to a maximum dose of 1 mg

   
   
   

   Transcutaneous Pacemaker Guidelines - ADULTS ONLY If conscious, administer     o   diazepam in 2.5 mg - 5 mg increments slow IVP to a maximum of 10 mg, or     o   midazolam in 2.5 mg – 5 mg increments slow IVP (max 5 mg) or IN (max 10 mg)     o   NOTE: Individual departments may carry only one of these medications; they are not required to carry both. Set TCP rate at 60 beats per minute. Set TCP milliamps. Increase until electrical capture achieved. Evaluate for mechanical capture. If achieved, increase milliamp setting by 5 milliamps. If TCP is unsuccessful, turn off TCP and continue this treatment guideline.

   
   
   
10. If altered mental status or bradycardia caused by beta-blocker toxicity:

    Adult Glucagon 1 mg – 5 mg IVP over 2 - 5 min or 1 mg IM or IN

    Pediatric Requires BioTel authorization

    
    
    
11. If altered mental status or bradycardia caused by calcium-channel blocker toxicity:

    Adult Calcium chloride, 10 mg/kg – 15 mg/kg SLOW IVP (optional medication)

    Pediatric Requires BioTel authorization

    
    
    
12. For additional patient care considerations not covered under standing orders, consult BioTel.
    
    

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