Adult Bradycardia (Peri-arrest)

Adult Advanced Life Support Guidelines (2021)

Adult bradycardia algorithm

The first step is to determine whether the patient has ANY of the life-threatening features or not:
  • Shock – hypotension (SBP < 90 mmHg) and/or features of sympathetic compensation
  • Syncope – due to ↓ cerebral blood flow
  • Myocardial ischaemia – chest pain and/or 12-ECG findings
  • Heart failure – pulmonary oedema (LV failure) and/or raised JVP (RV failure)
Note this is the same as the peri-arrest tachycardia algorithm.

  • 1st line: atropine 500mcg IV (alternative: glycopyrrolate)
    • Repeat every 3-5 minutes, up to a maximum of 6 doses / 3mg
  • If ineffective → consider 2nd line drugs:
    • Isoprenaline
    • Adrenaline
  • If ineffective → transcutaneous pacing 
  • If ineffective → transvenous pacing 

  • Consider aminophylline if any of the following:
    • Bradycardia secondary to inferior MI
    • Bradycardia secondary to spinal cord injury
    • Patients with cardiac transplant 
  • Consider glucagon if bradycardia potentially secondary to beta blockers or calcium channel blockers

Never use DC shock in bradyarrhythmia. DC shock is only for tachyarrhythmias.

Assess risk of asystole:
  • Recent asystole
  • Second degree Mobitz II AV block
  • Complete heart block with broad QRS
  • Ventricular pause > 3 sec
Subsequent action:
  • Yes → proceed as life-threatening features are present
  • No → observe

Guidelines for non-life threatening bradycardia is not clear and a bit confusing. In exams, unlike tachycardia, stable bradycardia is rarely examined.

Author: Adams Lau
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