approach to bradycardia
TRANSCRIPT
ADULT BRADYCARDIA: AN OVERVIEW
Faez BaherinEmergency Physician
ED Hospital Melaka
Outline
• Introduction and definition• Bradycardia algorithm at a glance• Stable vs unstable bradycardia• Drugs in bradycardia• Transcutaneous pacing• Take-home message• New updates 2015
Introduction• heart rate of <60 beats per minute.
• when bradycardia is the cause of symptoms, the rate is generally <50 beats per minute, which is the working definition of bradycardia used in ACLS
• focuses on management of clinically significant bradycardia (ie, bradycardia that is inappropriate for the clinical condition)
Approach to bradycardia• ABC• provide supplementary oxygen if hypoxemia• hypoxemia is a common cause of bradycardia, initial evaluation of any
patient with bradycardia should focus on signs of increased work of breathing and oxyhemoglobin saturation
• Attach a monitor to the patient• evaluate blood pressure• establish IV access• 12-lead ECG to better define the rhythm• Assess stable vs unstable
Stable bradycardia
• asymptomatic or minimally symptomatic patients do not necessarily require treatment
• unless there is suspicion that the rhythm is likely to progress to symptoms or become life-threatening (eg, Mobitz type II second-degree AV block in the setting of acute myocardial infarction)
Unstable bradycardia
• identify signs and symptoms of poor perfusion and determine if those signs are likely to be caused by the bradycardia
• acute altered mental status • ischemic chest discomfort• acute heart failure • hypotension• signs of shock
Drugs in unstable bradycardia :Atropine
• first-line drug, reverses cholinergic-mediated decreases in heart rate• improved heart rate, symptoms, and signs associated with
bradycardia.• considered a temporizing measure while awaiting a transcutaneous
or trans venous pacemaker for patients with symptomatic sinus bradycardia, conduction block at the level of the AV node, or sinus arrest
Drugs in unstable bradycardia :Atropine
• 0.5 mg IV every 3 to 5 minutes, maximum total dose of 3 mg
• Avoid relying on atropine in type II second-degree or third-degree AV block, preferably treated with TCP or β-adrenergic support as temporizing measures while the patient is prepared for transvenous pacing
Drugs in unstable bradycardia :
• dopamine, epinephrine, and isoproterenol are alternatives when a bradyarrhythmia is :• unresponsive to or inappropriate for treatment with atropine, or • as a temporizing measure while awaiting the availability of a pacemaker
Dopamine: 2 to 20 mcg/kg/minOrAdrenaline: 2-10 mcg/min
Transcutaneous pacing
• initiate TCP in unstable patients who do not respond to atropine
• Immediate pacing might be considered in unstable patients with high-degree AV block when IV access is not available
• If the patient does not respond to drugs or TCP, transvenous pacing is probably indicated
Transcutaneous pacing
• Attach pads• Select mode : fixed or demand• Select rate 60-80• Select energy : step up / step down method• Look for electrical capture then feel for mechanical
capture• Increase energy by 5mAmp
• Transcutaneous pacing may be uncomfortable for the patient. Sedation should be considered.
TCP stimulus does not work through the normal cardiac conduction system but by a direct electrical stimulus of the myocardium. Therefore, a “captured" compex will resemble a PVC. Electrical capture is characterized by a wide QRS complex, with the initial deflection and the terminal deflection always in opposite directions
• Attach pads• Select mode : fixed or demand• Select rate 60-80• Select energy : step up / step down method• Look for electrical capture then feel for mechanical
capture• Increase energy by 5mAmp
• Transcutaneous pacing may be uncomfortable for the patient. Sedation should be considered.
New Updates•CPR•ACS•ACLS•Post Arrest Care
Take-home message• Memorize the algorithm • Know your drugs• Know how to operate TCP machine• Early referrals for further management – TCP is only
TEMPORARY