# Bradycardia Management

## Overview

This module describes the emergent management of bradycardia, where the patient has a palpable pulse.

## Indications

1. Bradycardia with a palpable pulse

## Contraindications

1. Pulseless patients regardless of electrical activity on the monitor—treat according to cardiac arrest algorithms

## Patient information & consent

The management of bradycardia requires monitoring, administration of medication, and possibly transcutaneous pacing. Ensure that you explain your findings and decisions to the patient as you go along. Some patients may be haemodynamically unstable and unable to understand; communicate with family members if present. See Transcutaneous Pacing for specific patient information.

## Preparation

Bradycardia management may be an emergency procedure. Always:

1. Know where defibrillators, transcutaneous pads, and red trolleys are kept. Know the relevant staff and keep your seniors’ contact details close at hand.
2. Familiarise yourself with the defibrillators in your work area. Check that they are maintained regularly and have pads and the correct connections.
3. Keep unstable patients in resuscitation bays with continuous monitoring.

## Site & Positioning

The patient should be lying flat on their back on a firm surface. There should be space behind the head of the bed for staff to stand to give rescue breaths if the patient deteriorates.

## Procedure

Follow medical asepsis with non-sterile gloves.

1. Hazards
   Hazards

   Look for any body fluid spills, trip hazards etc. which is more likely in out-of-hospital scenarios. Put on gloves. Follow Transmission-Based Precautions as required.

2. Hello

   1. Tap the patient’s shoulder and call hello. Look for a response.
   2. Feel and listen for breathing with your ear close to the patient’s mouth. Look for chest rise. Don’t take more than 10 seconds.
   3. Feel for a carotid pulse. Don’t take more than 10 seconds. Identify bradycardia.
3. Help
   Help

   Call for assistance from other healthcare workers. Get someone to bring a defibrillator. Get someone more senior than yourself involved.

4. Airway: open and maintain as indicated.

5. Breathing: administer oxygen/ventilation as indicated.

6. Circulation: attach BP cuff and cardiac monitoring. Determine if the patient is stable or

   unstable
   unstable

   Signs of instability are ischaemic chest pain, acute heart failure, hypotension, signs of shock, or acutely altered mental state.

   . Obtain a 12-lead ECG as soon as possible.

7. Consider and correct

   contributing causes
   contributing causes
   - Hypoxia
   - Hypothermia
   - Head Injury
   - Hyperkalaemia
   - Heart Block
   - Hydrogen Ion (acidosis)
   - Hypotension
   - Toxins (such as organophosphates)
   - Therapeutic Agents(such as Beta Blocker or Ca Channel Blocker overdose)

   (Hs and Ts).

8. Unstable adult:

9. Unstable child with heart rate under 60/minute: start CPR if unresponsive. Administer adrenaline first, then try atropine.

   Dosages
   Dosages

   Adrenaline

   0.1ml/kg IV of 1:10 000 dilution to max dose of 1 mg every 3-5 minutes

   Atropine:

   0.02mg/kg IV to max dose of 0.5 mg

   . Consider transcutaneous pacing.

10. Stable patient: no emergency intervention. Refer to cardiology.

## Troubleshooting

I am unfamiliar with or unsure about transcutaneous pacing.

Call a senior for assistance. Refer to Transcutaneous Pacing for guidance.

## Risks

1. Conversion to pulseless rhythm; death
2. Hypoxic injury
3. Drug reactions
4. Pain
5. Burns

## References

1. Resuscitation Council of Southern Africa. Bradycardia Management Algorithm. 2021.