Bradycardia resident survival guide: Difference between revisions
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</div></div> | </div></div> | ||
*[[Sick sinus syndrome]] | *[[Sick sinus syndrome]] | ||
* [[Hypovolemia]] | |||
* [[Hypoxia]] | |||
* [[Acidosis]] | |||
* [[Hypokalemia]] | |||
* [[Hyperkalemia]] | |||
* [[Hypoglycemia]] | |||
* [[Hypothermia]] | |||
* [[Toxins]] | |||
* [[Cardiac tamponade]] | |||
* [[Tension pneumothorax]] | |||
* [[Thrombosis]] | |||
==Diagnosis== | ==Diagnosis== | ||
===First Initial Rapid Evaluation of Suspected Bradycardia=== | ===First Initial Rapid Evaluation of Suspected Bradycardia=== | ||
Shown below is an algorithm for the First Initial Rapid Evaluation (FIRE) of suspected [[bradycardia]].<br> | Shown below is an algorithm for the First Initial Rapid Evaluation (FIRE) of suspected [[bradycardia]].<ref name="Neumar-2010">{{Cite journal | last1 = Neumar | first1 = RW. | last2 = Otto | first2 = CW. | last3 = Link | first3 = MS. | last4 = Kronick | first4 = SL. | last5 = Shuster | first5 = M. | last6 = Callaway | first6 = CW. | last7 = Kudenchuk | first7 = PJ. | last8 = Ornato | first8 = JP. | last9 = McNally | first9 = B. | title = Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal = Circulation | volume = 122 | issue = 18 Suppl 3 | pages = S729-67 | month = Nov | year = 2010 | doi = 10.1161/CIRCULATIONAHA.110.970988 | PMID = 20956224 }}</ref> <br> | ||
<span style="font-size:85%">Boxes in red signify that an urgent management is needed.</span> | <span style="font-size:85%">Boxes in red signify that an urgent management is needed.</span> | ||
{{familytree/start}} | {{familytree/start}} | ||
{{familytree | | | | | | | | | B01 | | | | | |B01=<div style="float: left; text-align: left; line-height: 150% ">'''Identify cardinal signs and symptoms that increase the pretest probability of bradycardia''' <br> ❑ [[Heart rate]] < 50 beats/min <br> ❑ [[altered mental status|Acute altered mental status]] <br> ❑ [[chest pain|Severe ischemic chest pain]] <br> ❑ [[heart failure|Acute heart failure]] <br> ❑ [[Hypotension]] <br> ❑ [[Syncope]] <br> ❑ [[shock|Signs of shock | {{familytree | | | | | | | | | B01 | | | | | |B01=<div style="float: left; text-align: left; line-height: 150% ">'''Identify cardinal signs and symptoms that increase the pretest probability of bradycardia''' <br> ❑ [[Heart rate]] < 50 beats/min <br> ❑ [[altered mental status|Acute altered mental status]] <br> ❑ [[chest pain|Severe ischemic chest pain]] <br> ❑ [[heart failure|Acute heart failure]] <br> ❑ [[Hypotension]] <br> ❑ [[Syncope]] <br> ❑ [[shock|Signs of shock]]</div>}} | ||
{{familytree | | | | | | | | | |!| | | | | | | | }} | {{familytree | | | | | | | | | |!| | | | | | | | }} | ||
{{familytree | | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; line-height: 150% ">'''Identify alarming signs and symptoms of hemodynamic instability'''<br> ❑ [[Shock]] <br> ❑ [[Altered mental status]] <br> ❑ [[Hypotension]] <br> ❑ [[Hypothermia]] <br> ❑ [[Oliguria]] </div>}} | {{familytree | | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; line-height: 150% ">'''Identify alarming signs and symptoms of hemodynamic instability'''<br> ❑ [[Shock]] <br> ❑ [[Altered mental status]] <br> ❑ [[Hypotension]] <br> ❑ [[Hypothermia]] <br> ❑ [[Oliguria]] </div>}} | ||
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{{Family tree/start}} | {{Family tree/start}} | ||
{{family tree | | | | V01 | | | | | | | | | | | | | | | | | | |V01= <div style="float: left; text-align: left; line-height: 150% ">'''Characterize the symptoms:''' <br> | {{family tree | | | | V01 | | | | | | | | | | | | | | | | | | |V01= <div style="float: left; text-align: left; line-height: 150%; width: 22em">'''Characterize the symptoms:''' <br> | ||
❑ [[Palpitations]] <br> ❑ [[Lightheadedness]] or [[Dizziness]] <br> ❑ [[Dyspnea]] <br> ❑ [[Chest pain]] <br> ❑ [[Altered mental status]] <br> | ❑ [[Palpitations]] <br> ❑ [[Lightheadedness]] or [[Dizziness]] <br> ❑ [[Dyspnea]] <br> ❑ [[Chest pain]] <br> ❑ [[Altered mental status]] <br> | ||
❑ [[Syncope]] <br> ❑ [[Fatigue]] <br> ❑ [[Exercise intolerance]]<br> | ❑ [[Syncope]] <br> ❑ [[Fatigue]] <br> ❑ [[Exercise intolerance]]<br> | ||
'''Obtain a detailed history''': <br> | '''Obtain a detailed history''': <br> | ||
❑ [[Age]] - commonly seen in the elderly due to:<br> | ❑ [[Age]] - commonly seen in the elderly due to:<br> | ||
: | :❑ Disease in the sinus node | ||
: | :❑ AV nodal disease | ||
: | :❑ Age-related fibrosis and sclerosis <br> | ||
❑ Medication use <br> | ❑ Medication use <br> | ||
: | :❑ [[Beta blockers]] | ||
: | :❑ [[Calcium channel blockers]] | ||
: | :❑ [[Digoxin]] <br> | ||
❑ Past medical history <br> | ❑ Past medical history <br> | ||
: | :❑ [[Infection]] | ||
: | :❑ [[Increased intracranial pressure]] | ||
: | :❑ [[Electrolyte disturbance]] | ||
: | :❑ [[Toxin|Exposure to toxins]] | ||
: | :❑ [[Surgery]] | ||
: | :❑ [[Heart transplant]] | ||
: | :❑[[Sleep apnea]] | ||
: | :❑ [[Myocardial infarction]] | ||
: | :❑ [[Hypothyroidism]]</div>}} | ||
{{family tree | | | | |!| | | | | | | | | | | | | | | | | | | | }} | {{family tree | | | | |!| | | | | | | | | | | | | | | | | | | | }} | ||
{{Family tree | | | | A01 | | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Examine the patient:'''<br> | {{Family tree | | | | A01 | | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em; width: 22em"> '''Examine the patient:'''<br> | ||
'''Vitals'''<br> | '''Vitals'''<br> | ||
❑ [[Pulse]] <br> | ❑ [[Pulse]] <br> | ||
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:❑ Rhythm <br> | :❑ Rhythm <br> | ||
::❑ Slow regular <br> | ::❑ Slow regular <br> | ||
::❑ Irregularly pulse of varying intensity <br> | ::❑ Irregularly pulse of varying intensity (as in the 2nd and 3rd degrees of [[AV block]]) <br> | ||
❑ [[Respiration]] <br> | ❑ [[Respiration]] <br> | ||
:❑ [[Tachypnea]] <br> | :❑ [[Tachypnea]] <br> | ||
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:❑ [[Rales]] - uncommon <br> | :❑ [[Rales]] - uncommon <br> | ||
'''Cardiovascular examination'''<br> | '''Cardiovascular examination'''<br> | ||
❑ Auscultation <br> | ❑ Auscultation <br> | ||
:❑ [[Heart sounds]] | :❑ [[Heart sounds]] | ||
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❑ Percussion<br> | ❑ Percussion<br> | ||
:❑ Dullness - [[ascites]] (uncommon)<br> | :❑ Dullness - [[ascites]] (uncommon)<br> | ||
'''Extremities'''<br> | '''Extremities'''<br> | ||
❑ Inspection/palpation <br> | ❑ Inspection/palpation <br> | ||
:❑ Lower extremity edema (uncommon)</div>}} | :❑ Lower extremity edema (uncommon)</div>}} | ||
{{Family tree | | | | |!| | | | | }} | {{Family tree | | | | |!| | | | | }} | ||
{{family tree | | | | P01 | | | |P01=<div style="float: left; text-align: left; line-height: 150% ">'''Consider alternative diagnosis''':<br> ❑ [[Ventricular bigeminy]] <br> ❑ [[premature ventricular contraction|Frequent premature ventricular contractions (PVCs)]] <br> ❑ [[Atrial fibrillation]] <br> ❑ [[premature atrial contraction|Blocked premature atrial contractions (PACs)]] <br> ❑ [[Cardiac tamponade]] </div>}} | {{family tree | | | | P01 | | | |P01=<div style="float: left; text-align: left; line-height: 150%; width: 22em">'''Consider alternative diagnosis''':<br> ❑ [[Ventricular bigeminy]] <br> ❑ [[premature ventricular contraction|Frequent premature ventricular contractions (PVCs)]] <br> ❑ [[Atrial fibrillation]] <br> ❑ [[premature atrial contraction|Blocked premature atrial contractions (PACs)]] <br> ❑ [[Cardiac tamponade]] </div>}} | ||
{{Family tree | | | | |!| | | | | }} | {{Family tree | | | | |!| | | | | }} | ||
{{family tree | | | | R01 | | | |R01=<div style="float: left; text-align: left; line-height: 150% ">'''Order tests''':<br> '''First initial test''' <br> | {{family tree | | | | R01 | | | |R01=<div style="float: left; text-align: left; line-height: 150%; width: 22em">'''Order tests''':<br> '''First initial test''' <br> | ||
❑ [[ECG|12-lead ECG]] | ❑ [[ECG|12-lead ECG]] (to determine rhythm) | ||
[[Image:Sinusbradycardia.png| | [[Image:Sinusbradycardia.png|300px|center|thumb|12-lead [[ECG]] showing sinus bradycardia]]<br> | ||
'''Other initial tests''' <br> | '''Other initial tests''' <br> | ||
❑ [[Holter monitoring]]- to evaluate <br> | ❑ [[Holter monitoring]]- to evaluate <br> | ||
: | :❑ Severe [[sinus bradycardia]] <br> | ||
: | :❑ Sinus pauses <br> | ||
: | :❑ Sinus arrest <br> | ||
: | :❑ Second-or third-degree [[AV block]] <br> | ||
❑ [[Exercise stress testing]] | ❑ [[Exercise stress testing]] (for diagnoses of [[sick sinus syndrome]] and [[ischemic heart disease]]) <br> | ||
❑ [[Carotid sinus massage]] | ❑ [[Carotid sinus massage]] (to evaluate [[carotid sinus hypersensitivity]]) <br> | ||
❑ [[Echocardiogram]] | ❑ [[Echocardiogram]] (to evaluate [[valvular heart disease]]) <br> | ||
'''Laboratory tests''' <br> | '''Laboratory tests''' <br> | ||
❑ [[Thyroid function tests]] | ❑ [[Thyroid function tests]] (elevated [[TSH]] in [[hypothyroidism]]) <br> | ||
❑ [[Basic metabolic panel]] | ❑ [[Basic metabolic panel]] (to determine [[electrolyte disturbances]]) <br> | ||
❑ [[Cardiac enzymes]] | ❑ [[Cardiac enzymes]] ([[creatine kinase]], [[CK-MB]] and [[troponin]]) <br> | ||
❑ [[creatinine|Serum creatinine]] | ❑ [[creatinine|Serum creatinine]] (elevated in renal impairment) <br> | ||
❑ Serum digoxin - for junctional bradycardia<br> | ❑ Serum digoxin - for junctional bradycardia<br> | ||
'''Other Investigations''' <br> | '''Other Investigations''' <br> | ||
❑ [[Tilt-table testing]] | ❑ [[Tilt-table testing]] (to evaluate autonomic system and diagnosis of [[neurocardiogenic syncope]]) <br> | ||
❑ [[Electrophysiologic testing]] | ❑ [[Electrophysiologic testing]] (to evaluate [[bradyarrhythmias]])</div>}} | ||
{{family tree/end}} | {{family tree/end}} | ||
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{{Family tree | E03 | | | | E03='''Secondary treatment options'''<br>'''If atropine ineffective:'''<br><div style="float: left; text-align: left; line-height: 150% "> ❑ Administer [[dopamine]] infusion (2-10 mcg/kg/min) <br> OR <br> ❑ Administer [[epinephrine]] infusion (2-10 mcg/min) <br> OR <br> ❑ Proceed with [[transcutaneous pacing]]</div>}} | {{Family tree | E03 | | | | E03='''Secondary treatment options'''<br>'''If atropine ineffective:'''<br><div style="float: left; text-align: left; line-height: 150% "> ❑ Administer [[dopamine]] infusion (2-10 mcg/kg/min) <br> OR <br> ❑ Administer [[epinephrine]] infusion (2-10 mcg/min) <br> OR <br> ❑ Proceed with [[transcutaneous pacing]]</div>}} | ||
{{family tree | |!| | | | | | | | }} | {{family tree | |!| | | | | | | | }} | ||
{{family tree | F01 | | | | | | |F01=<div style="float: left; text-align: left; line-height: 150% "> ❑ Consult | {{family tree | F01 | | | | | | |F01=<div style="float: left; text-align: left; line-height: 150% "> ❑ Consult a cardiologist <br> ❑ Consider [[transvenous pacing]] </div>}} | ||
{{Family tree/end}} | {{Family tree/end}} | ||
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* Prepare for transcutaneous pacing if perfusion is poor. | * Prepare for transcutaneous pacing if perfusion is poor. | ||
* Consider using sodium bicarbonate for severe metabolic acidosis. | * Consider using sodium bicarbonate for severe metabolic acidosis. | ||
* Use atropine with caution in the presence of myocardial ischemia because it increases oxygen demand and could worsen the ischemia. | * Use atropine with caution in the presence of [[myocardial ischemia]] and [[acute coronary syndrome]] because it increases oxygen demand and could worsen the [[ischemia]] and increase infarction size.<ref name="Neumar-2010">{{Cite journal | last1 = Neumar | first1 = RW. | last2 = Otto | first2 = CW. | last3 = Link | first3 = MS. | last4 = Kronick | first4 = SL. | last5 = Shuster | first5 = M. | last6 = Callaway | first6 = CW. | last7 = Kudenchuk | first7 = PJ. | last8 = Ornato | first8 = JP. | last9 = McNally | first9 = B. | title = Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal = Circulation | volume = 122 | issue = 18 Suppl 3 | pages = S729-67 | month = Nov | year = 2010 | doi = 10.1161/CIRCULATIONAHA.110.970988 | PMID = 20956224 }}</ref> | ||
* Consider immediate pacing in unstable patients with high degree [[AV block]] when IV access isn't available.([[ACC AHA guidelines classification scheme|Class IIb, level of evidence C]])<ref name="Neumar-2010">{{Cite journal | last1 = Neumar | first1 = RW. | last2 = Otto | first2 = CW. | last3 = Link | first3 = MS. | last4 = Kronick | first4 = SL. | last5 = Shuster | first5 = M. | last6 = Callaway | first6 = CW. | last7 = Kudenchuk | first7 = PJ. | last8 = Ornato | first8 = JP. | last9 = McNally | first9 = B. | title = Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal = Circulation | volume = 122 | issue = 18 Suppl 3 | pages = S729-67 | month = Nov | year = 2010 | doi = 10.1161/CIRCULATIONAHA.110.970988 | PMID = 20956224 }}</ref> | |||
==Don'ts== | ==Don'ts== | ||
* Do not treat asymptomatic or minimally symptomatic patients, unless the rhythm is likely to progress to symptoms or become life threatening.<ref name="Neumar-2010">{{Cite journal | last1 = Neumar | first1 = RW. | last2 = Otto | first2 = CW. | last3 = Link | first3 = MS. | last4 = Kronick | first4 = SL. | last5 = Shuster | first5 = M. | last6 = Callaway | first6 = CW. | last7 = Kudenchuk | first7 = PJ. | last8 = Ornato | first8 = JP. | last9 = McNally | first9 = B. | title = Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal = Circulation | volume = 122 | issue = 18 Suppl 3 | pages = S729-67 | month = Nov | year = 2010 | doi = 10.1161/CIRCULATIONAHA.110.970988 | PMID = 20956224 }}</ref> | |||
* Do not delay pacing if the rhythm is Mobitz type II second degree block or third-degree [[AV block]] even if the patient is asymptomatic. | * Do not delay pacing if the rhythm is Mobitz type II second degree block or third-degree [[AV block]] even if the patient is asymptomatic. | ||
* | * Do not use atropine in hypothermic patients with either bradycardia or Mobitz type II second degree AV block. | ||
* Do not use [[atropine]] to treat bradycardia in [[cardiac transplant]] patients. | * Do not use [[atropine]] to treat bradycardia in [[cardiac transplant]] patients as the transplanted heart lacks vagal innervation.<ref name="Neumar-2010">{{Cite journal | last1 = Neumar | first1 = RW. | last2 = Otto | first2 = CW. | last3 = Link | first3 = MS. | last4 = Kronick | first4 = SL. | last5 = Shuster | first5 = M. | last6 = Callaway | first6 = CW. | last7 = Kudenchuk | first7 = PJ. | last8 = Ornato | first8 = JP. | last9 = McNally | first9 = B. | title = Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal = Circulation | volume = 122 | issue = 18 Suppl 3 | pages = S729-67 | month = Nov | year = 2010 | doi = 10.1161/CIRCULATIONAHA.110.970988 | PMID = 20956224 }}</ref> | ||
* Do not use [[atropine]] to treat | * Do not use [[atropine]] to treat type II second degree and third degree [[heart block]]s since their management requires transcutaneous/[[transvenous pacing]]. | ||
==References== | ==References== |
Revision as of 19:37, 3 April 2014
Bradycardia Resident Survival Guide Microchapters |
---|
Overview |
Causes |
Diagnosis |
Treatment |
Do's |
Don'ts |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]: Associate Editor(s)-in-Chief: Ogheneochuko Ajari, MB.BS, MS [2]; Vidit Bhargava, M.B.B.S [3]
Overview
Bradycardia is defined as a sinus rhythm with a rate < 60 beats per minute. A heart rate of < 50 beats per minute is used as a working definition of bradycardia causing symptoms.[1]. The evaluation of bradycardia includes assessment of heart rhythm, symptoms and associated medical conditions. Symptomatic bradycardias are treated by removal of underlying causes, medications (e.g. the use of atropine) or insertion of temporary or permanent pacemaker. Nevertheless, some asymtomatic bradycardias may require treatment to prevent complications.
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
Common Causes
- Sick sinus syndrome
- Hypovolemia
- Hypoxia
- Acidosis
- Hypokalemia
- Hyperkalemia
- Hypoglycemia
- Hypothermia
- Toxins
- Cardiac tamponade
- Tension pneumothorax
- Thrombosis
Diagnosis
First Initial Rapid Evaluation of Suspected Bradycardia
Shown below is an algorithm for the First Initial Rapid Evaluation (FIRE) of suspected bradycardia.[1]
Boxes in red signify that an urgent management is needed.
Identify cardinal signs and symptoms that increase the pretest probability of bradycardia ❑ Heart rate < 50 beats/min ❑ Acute altered mental status ❑ Severe ischemic chest pain ❑ Acute heart failure ❑ Hypotension ❑ Syncope ❑ Signs of shock | |||||||||||||||||||||||||||||||||||||||||||||
Identify alarming signs and symptoms of hemodynamic instability ❑ Shock ❑ Altered mental status ❑ Hypotension ❑ Hypothermia ❑ Oliguria | |||||||||||||||||||||||||||||||||||||||||||||
Unstable patient | Stable patient | ||||||||||||||||||||||||||||||||||||||||||||
Identify and treat underlying cause ❑ Maintain patient airway ❑ Assist breathing if required ❑ Give supplemental oxygen ❑ Monitor blood pressure ❑ Give atropine 0.5 mg IV bolus and repeat every 3-5 mins with a maximum dose of 3 mg | |||||||||||||||||||||||||||||||||||||||||||||
❑ If atropine ineffective administer
| |||||||||||||||||||||||||||||||||||||||||||||
If signs of poor perfusion or shock still persist ❑ Consult a cardiologist and ❑ Prepare patient for transvenous pacing | |||||||||||||||||||||||||||||||||||||||||||||
Complete Diagnostic Approach to Bradycardia
Shown below is an algorithm summarizing the diagnostic approach to bradycardia based on the 2010 and 2005 AHA guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.[1][2]
Characterize the symptoms: ❑ Palpitations
❑ Medication use ❑ Past medical history | |||||||||||||||||||||||||||||||||||||||||||||||||
Examine the patient: Vitals
Skin
❑ Palpation
Neck
Respiratory examination
❑ Auscultation
Cardiovascular examination
Abdominal examination
Extremities
| |||||||||||||||||||||||||||||||||||||||||||||||||
Consider alternative diagnosis: ❑ Ventricular bigeminy ❑ Frequent premature ventricular contractions (PVCs) ❑ Atrial fibrillation ❑ Blocked premature atrial contractions (PACs) ❑ Cardiac tamponade | |||||||||||||||||||||||||||||||||||||||||||||||||
Order tests: First initial test ❑ 12-lead ECG (to determine rhythm) Other initial tests
❑ Exercise stress testing (for diagnoses of sick sinus syndrome and ischemic heart disease) | |||||||||||||||||||||||||||||||||||||||||||||||||
Treatment
Shown below is an algorithm depicting the treatment of bradycardia based on the 2010 AHA guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.[1]
Bradycardia confirmed Bradyarrhythmia seen with heart rate < 50/min | |||||||||||||||||||
Identify and treat underlying cause
❑ Maintain patent airway; assist breathing as necessary | |||||||||||||||||||
Symptomatic bradyarrhythmia ❑ Hypotension ❑ Acutely altered mental status ❑ Signs of shock ❑ Ischemic chest discomfort ❑ Acute heart failure | |||||||||||||||||||
Yes | No | ||||||||||||||||||
Primary treatment option Atropine
❑ Administer a first dose 0.5 mg IV bolus ❑ Repeat every 3-5 minutes ❑ Administer a maximum dose of 3 mg | ❑ Monitor and observe | ||||||||||||||||||
Secondary treatment options If atropine ineffective: ❑ Administer dopamine infusion (2-10 mcg/kg/min) OR ❑ Administer epinephrine infusion (2-10 mcg/min) OR ❑ Proceed with transcutaneous pacing | |||||||||||||||||||
❑ Consult a cardiologist ❑ Consider transvenous pacing | |||||||||||||||||||
Do's
- Prepare for transcutaneous pacing if perfusion is poor.
- Consider using sodium bicarbonate for severe metabolic acidosis.
- Use atropine with caution in the presence of myocardial ischemia and acute coronary syndrome because it increases oxygen demand and could worsen the ischemia and increase infarction size.[1]
- Consider immediate pacing in unstable patients with high degree AV block when IV access isn't available.(Class IIb, level of evidence C)[1]
Don'ts
- Do not treat asymptomatic or minimally symptomatic patients, unless the rhythm is likely to progress to symptoms or become life threatening.[1]
- Do not delay pacing if the rhythm is Mobitz type II second degree block or third-degree AV block even if the patient is asymptomatic.
- Do not use atropine in hypothermic patients with either bradycardia or Mobitz type II second degree AV block.
- Do not use atropine to treat bradycardia in cardiac transplant patients as the transplanted heart lacks vagal innervation.[1]
- Do not use atropine to treat type II second degree and third degree heart blocks since their management requires transcutaneous/transvenous pacing.
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Neumar, RW.; Otto, CW.; Link, MS.; Kronick, SL.; Shuster, M.; Callaway, CW.; Kudenchuk, PJ.; Ornato, JP.; McNally, B. (2010). "Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation. 122 (18 Suppl 3): S729–67. doi:10.1161/CIRCULATIONAHA.110.970988. PMID 20956224. Unknown parameter
|month=
ignored (help) - ↑ "Part 7.3: Management of Symptomatic Bradycardia and Tachycardia". Circulation. 112 (24_suppl): IV-67–IV-77. 2005. doi:10.1161/CIRCULATIONAHA.105.166558. ISSN 0009-7322.