Bradyarrhythmias
Not all bradycardias were created equal - Winny Li
image by: Fikri El Tahir Abdalla
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Managing unstable bradycardia
Key step 1: Temporarily increase the heart rate
This can be done either pharmacologically (using dopamine or epinephrine) or electrically (starting with transcutaneous pacing). In the past, I was confused about the order in which these interventions should be tried. My approach now is simple: start both at the same time. Transcutaneous pacing frequently fails and is not a long term solution, so starting a chronotropic medication right away makes sense. However, it takes time to get a drip started and titrated to effect, so an early attempt at transcutaneous pacing is important. Arranging the team so that both of these interventions are implemented in parallel rather than in series…
Resources
Bradycardia
EKG: Focus on three things: Rhythm diagnosis (e.g., sinus bradycardia vs. heart block). Signs of hyperkalemia (e.g., peaked T-waves). Signs of ischemia.
Emergency Department Bradydysrhythmias
Even if the patient appears asymptomatic now and a majority of the beats are being conducted, remember that, in certain settings, second-degree type II blocks can rapidly degrade to complete heart block. Strongly consider admitting the patient to an intensive care unit for closer monitoring.
4-Step Approach to Bradycardia and Bradydysrhythmias
It is important to determine if the bradycardia is causing symptoms (an older patient with underlying cardiac disease with chest pain and syncope), or if symptoms are the cause for bradycardia (vasovagal bradycardia), as this will direct management.
An Approach to Bradycardia in the Emergency Department
The differential for symptomatic bradycardia is broad. One way to look at the differential is by broad categories which includes but is not limited to: structural/electrophysiological, infectious, endocrine, toxicology/iatrogenic, and other.
Approach to Bradycardia and the BRADI Mnemonic
Bradycardia/blocks range from normal variants to life threatening emergencies.
Approach to the Bradycardic Patient
The approach to ACLS bradycardia differs slightly from the tachycardia algorithm in that the first and only branch point is stable vs unstable (aka symptomatic bradycardia).
Bradycardia Basics
3g calcium gluconate (treats hyperK & increases inotropy). 20-40 mcg IV (EMCRIT recommended dose using push dose epi).
Bradycardia DDx
The underlying causes of bradycardia are legion...
Bradycardia: A Common Cause of Many ECG Findings
A common cause of many ECG findings is ischemic heart disease. If you come across an unusual ECG finding, look up the potential causes to help you home in on the correct diagnosis.
Pediatric Sinus Bradycardia
Pediatric cardiac issues can make even the most experienced EM MD have axillary perspiration more than normal.
Unstable Bradycardia
Not all bradycardia is bad and scary, some presentations are benign and asymptomatic.
Managing unstable bradycardia
In bradycardic patients, immediate and effective management of airway and breathing is essential, because hypoxia is a potential cause of bradycardia.1,2 However, airway management in the setting of cardiogenic shock is fraught with difficulty.
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