HWN Suggests

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…

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  Dirty EPI

Mixology of the dirty epi drip... Temporize with push dose epinephrine boluses of ~20-50 mcg

  Push Dose Epi

• Take a 10 ml syringe with 9 ml of normal saline • Into this syringe, draw up 1 ml of epinephrine from the cardiac amp (Cardiac amp contains Epinephrine 100 mcg/ml) • Now you have 10 mls of Epinephrine 10 mcg/m

 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.

 Treatment of Bradycardia and Bradydysrhythmias

Suggested Treatment Algorithm for Crashing Bradycardic Patient Without an Obvious Cause...

Articles of Interest

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.

Episode 90 – Low and Slow Poisoning

One of the things we need to think about whenever we see a patient who’s going low and slow with hypotension and bradycardia is an overdose. B-blockers, calcium channel blockers (CCB) and digoxin are some of the most frequently prescribed cardiovascular drugs. And inevitably we’re going to be faced with both intentional and unintentional overdoses from these drugs in the ED.

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.