BRADYCARDIA
Inclusion Criteria: Patients with a heart rate less than 60 beats per minute. These guidelines are not intended for patients with compensated bradycardia who exhibit signs of increased intracranial pressure (refer to STROKE or TRAUMA Guidelines). Consider drug or other overdose, and refer to the ALTERED LOC Guidelines.
SPECIAL NOTE: In young, generally healthy patients, bradycardia may result from hypoxia. DO NOT use these guidelines unless hypoxia has been treated or excluded from the differential diagnosis.
Basic Level
- Assess and support ABCs.
- Place the patient in a position of comfort. If there is evidence of shock, place the patient supine with the feet elevated and closely monitor airway status.
- Administer oxygen, as needed, to maintain a SpO2 of at least 94%.
- If chest pain is present or develops, treat the pain under the CHEST PAIN Guidelines while continuing these guidelines.
- Once advanced level care arrives on scene, give report and transfer care.
Advanced Level
- Continuous ECG monitoring. Use capnography if the patient is hypotensive. Obtain a 12-Lead ECG and consult with BioTel, as needed. (Do NOT delay care of the unstable patient to obtain a 12-lead ECG.)
- Establish IV/IO access at a TKO rate or use a saline lock. (Do not delay care of the unstable patient to initiate vascular access.)
A. For Stable Patients
- Monitor vital signs, neurologic status, and ECG, and transport as soon as possible.
- For additional patient care considerations not covered under standing orders, consult BioTel.
B. For Unstable Patients (low BP, altered LOC, shock, chest pain, acute heart failure):
- If signs or symptoms of hypoperfusion are present or develop:
Adult
Begin transcutaneous pacing (TCP) immediately for 3rd-degree heart block.
- Do NOT pace 1st- or 2nd-degree heart block, unless the patient shows signs and symptoms of hypoperfusion.
- Refer to the Guidelines below (next page) for sedation and for pacer settings.
Pediatric
- Ventilate with 100% oxygen for one full minute at 12-20 breaths per minute. Avoid over-ventilation.
- If the pulse rate is still less than 60 after adequate ventilation, perform chest compressions and administer:
- Epinephrine (1:10,000) 0.01 mg/kg IV/IO push (0.1 mL/kg).
- Consider atropine 0.02 mg/kg (minimum dose 0.1 mg) IV/IO push (0.2 mL/kg).
- May repeat once to a maximum cumulative dose of 1 mg.
Transcutaneous Pacemaker Guidelines - ADULTS ONLY (Contact BioTel for pediatric patients.)
- If the patient is conscious, administer:
- Diazepam 2.5 mg – 5 mg slow IV/IO/IM/IN prior to pacing. May repeat once. OR
- Midazolam 2.5 mg – 5 mg slow IV/IO/IM/IN prior to pacing. May repeat once.
- Contact BioTel for additional dosing authorization.
- Set TCP rate at 60 beats per minute.
- Set TCP milliamps. Increase until electrical capture achieved. Evaluate for mechanical capture (palpable carotid pulse). Once capture is achieved, increase milliamp setting by 5 milliamps. If TCP is unsuccessful, turn off TCP and continue this treatment guideline.
- Continuously monitor vital signs, neurologic status, ECG, SPO2, and ETCO2, and transport.
- For additional patient care considerations not covered under standing orders, consult BioTel.
C. FOR PATIENTS WITH BRADYCARDIA SUSPECTED OF BEING CAUSED BY OVERDOSE OF A BETA-BLOCKER OR CALCIUM CHANNEL-BLOCKER:
- If altered mental status with bradycardia caused by beta-blocker toxicity, administer:
Adult
- Glucagon 1 mg – 2 mg IVP/IO over 2 to 5 min, OR 1 mg IM or IN.
- May repeat once after 20 minutes.
Pediatric
- Glucagon 0.5 mg (under age 1 yr) or 1 mg (at least one year of age) IV/IO, IM, or IN.
- May repeat once after 20 minutes.
- If altered mental status with bradycardia caused by calcium-channel blocker toxicity, administer:
Adult
- Calcium chloride, 10 – 15 mg/kg slow IVP/IO. (optional medication)
Pediatric
- Contact BioTel for authorization and dosing (risk of phlebitis). (optional medication)
- Monitor vital signs, neurologic status, ECG, SpO2, ETCO2, and transport.
- For additional patient care considerations not covered under standing order, consult BioTel.
- Additional information on these agents may be found in the PHARMACOLOGY section.