Bradycardia resident survival guide: Difference between revisions
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'''Obtain a detailed history''': <br> | '''Obtain a detailed history''': <br> | ||
❑ [[Age]] | ❑ [[Age]] - commonly seen in the elderly due to:<br> | ||
♦ Disease in the sinus node <br> ♦ AV nodal disease <br> ♦ Age-related fibrosis and sclerosis <br> ❑ Medication use <br> :: ❑ [[Beta blockers]] <br> :: ❑ [[Calcium channel blockers]] <br> :: ❑ [[Digoxin]] <br> ❑ Past medical history <br> :: ❑ [[Infection]] <br> :: ❑ Infiltrative disease <br> :: ❑ [[Increased intracranial pressure]] <br> :: ❑ [[Electrolyte disturbance]] <br> :: ❑ Toxin exposure <br> :: ❑ [[Surgery]] <br> :: ❑ [[Heart transplant]] <br> :: ❑ [[Sleep apnea]] <br> :: ❑ [[Myocardial infarction]] <br> :: ❑ [[Hypothyroidism]] <br> </div>}} | ♦ Disease in the sinus node <br> ♦ AV nodal disease <br> ♦ Age-related fibrosis and sclerosis <br> ❑ Medication use <br> :: ❑ [[Beta blockers]] <br> :: ❑ [[Calcium channel blockers]] <br> :: ❑ [[Digoxin]] <br> ❑ Past medical history <br> :: ❑ [[Infection]] <br> :: ❑ Infiltrative disease <br> :: ❑ [[Increased intracranial pressure]] <br> :: ❑ [[Electrolyte disturbance]] <br> :: ❑ Toxin exposure <br> :: ❑ [[Surgery]] <br> :: ❑ [[Heart transplant]] <br> :: ❑ [[Sleep apnea]] <br> :: ❑ [[Myocardial infarction]] <br> :: ❑ [[Hypothyroidism]] <br> </div>}} | ||
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Revision as of 17:04, 20 March 2014
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]
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
Management
Shown below is an algorithm depicting the management of bradycardia based on the 2010 AHA guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.[1]
Characterize the symptoms: ❑ Palpitations Obtain a detailed history: ♦ AV nodal disease ♦ Age-related fibrosis and sclerosis ❑ Medication use :: ❑ Beta blockers :: ❑ Calcium channel blockers :: ❑ Digoxin ❑ Past medical history :: ❑ Infection :: ❑ Infiltrative disease :: ❑ Increased intracranial pressure :: ❑ Electrolyte disturbance :: ❑ Toxin exposure :: ❑ Surgery :: ❑ Heart transplant :: ❑ Sleep apnea :: ❑ Myocardial infarction :: ❑ Hypothyroidism | |||||||||||||||||||||||||||||||||||||||||||||||||
Examine the patient: ❑ Heart rate < 50/min
❑ Signs of poor perfusion
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Identify and treat underlying cause:
❑ Maintain patent airway; assist breathing as necessary | |||||||||||||||||||||||||||||||||||||||||||||||||
Persistent bradyarrhythmia causing: ❑ Hypotension? ❑ Acutely altered mental status? ❑ Signs of shock? ❑ Ischemic chest discomfort? ❑ Acute heart failure? | |||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||
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 | ||||||||||||||||||||||||||||||||||||||||||||||||
If atropine ineffective: ❑ Proceed with transcutaneous pacing, OR ❑ Administer dopamine infusion (2-10 mcg/kg/min), OR ❑ Administer epinephrine infusion (2-10 mcg/min) | |||||||||||||||||||||||||||||||||||||||||||||||||
❑ Consider expert consultation ❑ 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 because it increases oxygen demand and could worsen the ischemia.
Don'ts
- 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.
- Avoid using 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 Type II second degree and third degree heart blocks since their management requires transcutaneous/transvenous pacing.
References
- ↑ 1.0 1.1 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
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