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ACLS Bradycardia Algorithm

Emergency Protocol for Slow Heart Rate

Comprehensive ACLS bradycardia algorithm for healthcare professionals managing patients with slow heart rates and signs of poor perfusion.

Bradycardia Definition & Recognition

Definition

  • • Heart rate <60 beats per minute
  • • Inappropriate for clinical condition
  • • May be physiologically normal in some patients
  • • Consider patient's baseline and clinical context

Signs of Poor Perfusion

  • • Altered mental status
  • • Chest pain or discomfort
  • • Hypotension (SBP <90 mmHg)
  • • Signs of shock (cool, clammy skin)
  • • Acute heart failure
  • • Syncope or near-syncope

Assessment and Initial Management

Step-by-Step Assessment

  1. 1
    Assess appropriateness for clinical condition

    Consider patient's age, fitness level, medications, and baseline

  2. 2
    Identify and treat underlying causes

    Look for reversible causes (H's and T's)

  3. 3
    Maintain patent airway; assist breathing as necessary

    Ensure adequate oxygenation and ventilation

  4. 4
    Give oxygen if hypoxemic

    Target SpO2 ≥94% unless contraindicated

  5. 5
    Monitor blood pressure and oximetry

    Continuous monitoring of vital signs

  6. 6
    Establish IV access

    Prepare for medication administration

  7. 7
    12-Lead ECG if available

    Identify rhythm and look for underlying causes

Treatment Decision Tree

Does patient have signs of poor perfusion?

ACLS Bradycardia Algorithm Treatment Decision Tree flowchart showing symptomatic vs asymptomatic patient pathways

YES - Symptomatic Bradycardia

Immediate Actions:
  1. 1. Atropine 1 mg IV push
  2. 2. May repeat every 3-5 minutes
  3. 3. Maximum total dose: 3 mg
If Atropine Ineffective:
  • • Transcutaneous pacing
  • • Dopamine 5-20 mcg/kg/min
  • • Epinephrine 2-10 mcg/min
  • • Consider transvenous pacing

NO - Asymptomatic

Continue Monitoring:
  • • Observe for changes
  • • Monitor vital signs
  • • Identify underlying causes
  • • Prepare for intervention if needed
Consider:
  • • Expert consultation
  • • Cardiology evaluation
  • • Medication review
  • • Electrolyte correction

Medication Protocols

Atropine

Dosing:

  • • First dose: 1 mg IV push
  • • Repeat: 1 mg every 3-5 minutes
  • • Maximum total: 3 mg
  • • Minimum dose: 0.5 mg (avoid paradoxical bradycardia)

Mechanism:

Blocks vagal stimulation, increases SA node firing rate and AV conduction

Contraindications:

  • • Hypothermic bradycardia
  • • Second or third-degree AV block with wide QRS
  • • Transplanted heart

Alternative Treatments

Dopamine Infusion:

  • • Dose: 5-20 mcg/kg/min
  • • Titrate to adequate perfusion
  • • Monitor for arrhythmias

Epinephrine Infusion:

  • • Dose: 2-10 mcg/min
  • • Alternative to dopamine
  • • Titrate to effect

Transcutaneous Pacing:

  • • Consider early if atropine unlikely to work
  • • Use analgesics/sedation if conscious
  • • Verify mechanical capture

Reversible Causes of Bradycardia

H's (Hypoxia, Hypovolemia, etc.)

  • • Hypoxia: Ensure adequate oxygenation
  • • Hypovolemia: IV fluid resuscitation
  • • Hydrogen ions (acidosis): Correct pH
  • • Hyperkalemia/Hypokalemia: Correct electrolytes
  • • Hypothermia: Rewarm gradually
  • • Hypoglycemia: Give glucose if indicated

T's (Toxins, Tamponade, etc.)

  • • Toxins: Consider antidotes (digoxin, beta-blockers, calcium channel blockers)
  • • Tamponade: Pericardiocentesis if indicated
  • • Tension pneumothorax: Needle decompression
  • • Thrombosis (coronary): Consider PCI/thrombolytics
  • • Thrombosis (pulmonary): Anticoagulation/embolectomy
  • • Trauma: Address underlying injuries

Special Considerations

Pediatric Considerations

  • • Bradycardia in children is usually due to hypoxia
  • • Focus on airway and breathing first
  • • CPR if HR <60 with poor perfusion
  • • Epinephrine is first-line drug

Drug-Induced Bradycardia

  • • Beta-blockers: Consider glucagon
  • • Calcium channel blockers: Consider calcium, glucagon
  • • Digoxin: Consider digoxin-specific antibodies
  • • Clonidine: Supportive care

When to Avoid Atropine

  • • Hypothermic patients
  • • Heart transplant recipients
  • • High-degree AV blocks with wide QRS
  • • May worsen ischemia in some cases

Transcutaneous Pacing

Indications

  • • Symptomatic bradycardia unresponsive to atropine
  • • High-degree AV block
  • • Bradycardia with escape rhythms
  • • Overdose of calcium channel blockers or beta-blockers
  • • Immediately available when atropine is unlikely to be effective

Procedure

  1. 1. Apply pacing pads (anterior-posterior preferred)
  2. 2. Set rate to 60-70 bpm
  3. 3. Set output to 2 mA above threshold
  4. 4. Verify electrical and mechanical capture
  5. 5. Provide analgesia/sedation if conscious
  6. 6. Prepare for transvenous pacing if prolonged

Key Clinical Points

Remember:

  • • Not all bradycardia requires treatment
  • • Treat the patient, not the monitor
  • • Address underlying causes first
  • • Consider expert consultation early

Critical Actions:

  • • Ensure adequate oxygenation
  • • Establish IV access early
  • • Monitor for deterioration
  • • Prepare for transcutaneous pacing

Master ACLS Bradycardia Management

Bradycardia management requires quick assessment and appropriate intervention. Get certified in ACLS to confidently manage these critical situations.

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